Chapter 4.5. Division of Workers' Compensation
Subchapter 1. Administrative Director--Administrative Rules
Article 4. Certification Standards for Health Care Organizations

§9771.70 Contracts with Providers.

Written contracts must be executed between the organization and each provider of workers' compensation health care which regularly furnishes health care under the organization. All contracts with providers shall be subject to the following requirements:

(a) A written contract shall be prepared or arranged in a manner which permits confidential treatment by the Administrative Director of payment rendered or to be rendered to the provider without concealment or misunderstanding of other terms and provisions of the contract.

(b) The contract shall require that the provider submit claims for workers' compensation health care services to the organization within a reasonable period of time following the delivery of health care services to an employee.

Contracts which contain the following language shall be deemed to meet the timing requirements of this subsection (b), and there shall be no other agreements or other language in the contract which negates or diminishes the effect of the following language:

“[Name of Provider] shall submit claims for the cost of workers' compensation health care services to [Organization] according to the compensation provisions of [Section and paragraph] of this agreement, within 60 days after [Name of Provider] has rendered the workers' compensation health care services to the employee. However, failure to submit claims within 60 days does not alter the obligation of the organization to pay claims of contracting providers for which the organization has received payment.”

(c) The contract shall provide that the organization shall forward claims from providers to the self-insured employer, group of self-insured employers or insurers of employers within 30 days after receipt of the claim from the provider, and that the organization shall pay the provider's claim no later than 30 days after receiving payment from the self-insured employer, group of self-insured employers or insurer of employers.

(d) The contract shall require that the provider maintain such records and provide such information to the organization or to the Administrative Director as may be necessary for compliance by the organization with the provisions of the Code and the rules thereunder, that such records will be retained by the provider for at least five years, and that such obligation is not terminated upon a termination of the agreement, whether by rescission or otherwise. (See Rule 9771.83)

Contracts which contain the following language shall be deemed to meet the requirements of this subsection (d), and there shall be no other agreements or other language in the contract which negates or diminishes the effect of the following language:

“[Name of Provider] shall maintain all books, records of account, medical records, reports and papers as may be necessary for compliance by the organization with the provisions of Labor Code Section 4600.6 and the rules thereunder. All such books, records and reports shall be available to the organization or to the Administrative Director, as necessary or required, under the Act and Rules.

All such books, records, reports and papers must be maintained for at least five years after the initial date of delivery of health care services under this Agreement. The obligation of [Name of Provider] to maintain books, records, reports and papers and to make them available shall not terminate upon the termination of [this Agreement].”

(e) The contract shall require that the organization shall have access at reasonable times upon demand to the books, records and papers of the provider relating to the workers' compensation health care provided to employees, to the cost thereof, to payments received by the provider from the organization, self-insured employer, group of self-insured employers, an insurer of an employer, employee, or from others on the behalf of the foregoing. Contracts which contain the following language shall be deemed to meet the requirements of this subsection

(e), and there shall be no other agreements or other language in the contract which negates or diminishes the effect of the following language:

“The [Organization] shall have access during regular business hours to all administrative, financial and medical books, records reports and papers relating to the delivery of workers' compensation health care to employees, and to the cost of such delivery, payments received by [the Provider] from [the Organization] and/or any self-insured employer, group of self-insured employers, or insurer of an employer, an employee, or others.”

(f) The contract shall prohibit surcharges or other payments in violation of the Labor Code for workers' compensation health care services and shall provide that whenever the organization receives notice of any such surcharge it shall take appropriate action.

(g) The contract shall disclose whether there are any other agreements between the organization and the provider, and shall incorporate by reference all such other agreements. Contracts which contain the following language shall be deemed to meet the requirements of this subsection (g):

“This [Agreement], including all addenda, supersedes any and all other agreements between [the Organization] and [the Provider] which are not attached hereto and incorporated herein and which are related to the delivery of, or to the compensation for, workers' compensation health care services. No future statements or promises relating to the delivery of workers' compensation health care services shall be valid or binding unless written and incorporated herein as addenda, subject to the approval of the Administrative Director”.

(h) The contract shall contain provisions complying with Section 4600.6(n) of the Code and shall comply with the provisions of subsection (a)(7) of Rule 9771.69.

(i) The contract shall require that the provider cooperate with the organization's quality assurance and utilization review system established pursuant to Section 4600.6(k) of the Code, and cooperate with the Administrative Director in accordance with the provisions of Section 4600.6(o) of the Code and Sections 9771.76 and 9771.77 of the Rules.

NOTE

Authority cited: Stats. 1997, Ch. 346, Section 5. Reference: Sections 4600.3, 4500.5 and 4600.6, Labor Code.

HISTORY

1. New section filed 4-15-98; operative 4-15-98. Submitted to OAL for printing only pursuant to Stats. 1997, Ch. 346, Section 5 (Register 98, No. 16).