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

§9773. Treatment Standards.

(a) HCOs shall provide all HCO enrollees with access to all medical, surgical, chiropractic, and hospital treatment which is reasonably required to cure or relieve the effects of an injury in accordance with Section 4600 of the Labor Code. This treatment must be provided without payment of any co-payment, deductible, or premium share by an HCO enrollee. HCOs must provide a description of the method for providing treatment required under the code, including a list of its physical facilities. The description must include the occupational health care delivery capabilities of the HCO, including the number of primary treating physicians and specialists, the number and types of licensed or state-certified health care support staff, the number of hospital beds, and the arrangements and the methods by which occupational health care services will be provided, which shall include the following:

(1) Provider services, including consultation and referral. HCOs must identify the total number of full time equivalent physicians and providers of each different specialty type available to provide treatment for work injuries or illnesses on a regular basis.

(2) Inpatient hospital services, which shall include acute hospital services, general nursing care, use of operating room and related facilities, intensive care unit and services, diagnostic laboratory and x-ray services, special duty nursing as medically necessary, physical therapy, respiratory therapy, administration of blood and blood products, and other diagnostic, therapeutic and rehabilitative services as medically reasonable or medically necessary, and coordinated discharge planning including planning of such continuing care as may be necessary, both medically and as a means of preventing possible rehospitalization.

(3) Ambulatory care services, (including outpatient hospital services) which shall include diagnostic and treatment services, physical therapy, speech therapy, occupational therapy services as appropriate, and those hospital services which can reasonably be provided on an ambulatory basis.

(4) Emergency services, including ambulance services and out-of-area coverage for emergency care.

(5) Diagnostic laboratory services, diagnostic and therapeutic radiological services, and other diagnostic services.

(6) Home health service, which shall include, where medically appropriate, health services provided at the home of an HCO enrollee as provided or prescribed by a physician or osteopath licensed to practice in California. Such home health services shall be provided in the home, including nursing care, performed by a registered nurse, public health nurse, licensed vocational nurse or licensed home health aide.

(b) HCOs shall provide a description of the times, places and manner of providing services under the HCO, including a description of the geographical service area. The geographical service area shall be designated by a list of the postal zip codes in the service area, and a map indicating the type and number of facilities within the service area. The following requirements must be met unless the HCO shows that a lack of a type of provider exists in an area and that the minimum number is not available:

(1) At least one full-time equivalent primary treating physician shall be available within the geographical proximity specified in paragraph (2) for every 1,200 expected injuries or illnesses. The HCO shall provide information on expected case-load and the methodology, data and assumptions used in the calculations.

(2) HCO enrollees must have a residence or workplace within 30 minutes or 15 miles of (i) a primary treating physician or (ii) a contracting or HCO-operating hospital, or if separate from such hospital, a contracting or HCO-operated provider of all emergency health care services. Enrollees must have a residence or workplace within 60 minutes or 30 miles of all other occupational health services listed in subdivision (a).

(3) The HCO must provide a description of how access to any of the basic health services listed in subdivision (a) will be provided to HCO enrollees who reside outside the HCO's geographical service area such that the requirements of this subdivision are met.

(4) Initial treatment for non-emergency services must be made available by an HCO within 24 hours of the HCO's receipt of a request for treatment.

(5) The HCO must describe how treatment is initiated and how an HCO enrollee is assigned a primary treating physician.

(6) Enrollees shall be entitled to at least one change of physician for an injury. The HCO shall provide the employee, within five days of a request by an HCO enrollee, with a choice of any other available participating provider in the appropriate specialty.

(7) HCO enrollees shall be provided with a second opinion, upon request, from a participating provider.

(8) The HCO must describe how it will make available interpreter's services, as required, for the treatment or evaluation of patients.

(9) The HCO must describe how the HCO will treat an injury or illness pending a claims administrator's decision concerning liability for treatment.

(10) HCOs must maintain and make available or insure that their contracted medical providers maintain and make available medical records to treating or evaluating physicians in a timely manner.

(c) The HCO shall describe its process for coordinating all aspects of medical treatment, including the coordination and monitoring of referrals to consultants, therapeutic or diagnostic facilities, reporting of treatment, being responsive to the HCO patient's request for change of physician or physician referrals as may be required by this article, and for ensuring timeliness of referrals and timely response to the primary treating physician.

(d) The HCO must include at least one full-time equivalent board-certified occupational medicine employed or contracting physician to provide expertise on workplace health and safety issues and prevention and treatment of occupational injuries and illnesses. The HCO shall describe its ongoing educational program to ensure that all primary treating physicians receive education, training or experience in occupational medicine and workers compensation, including but not limited to, the following:

(1) The regulatory requirements for primary treating physicians in workers' compensation;

(2) Familiarity with workplace hazards, causes of workplace injury, work restrictions, and vocational rehabilitation;

(3) The requirements of medical-legal reports in workers compensation,

NOTE: Authority cited: Sections 133, 4600.5, 4603.5 and 5307.3, Labor Code. Reference: Sections 3209.3, 4600 and 4600.5, Labor Code.

HISTORY

1. New section filed 12-31-93; operative 1-1-94. Submitted to OAL for printing only pursuant to Government Code section 11351 (Register 93, No. 53).