Answers to frequently asked questions about medical provider networks (MPNs)
A: A medical provider network (MPN) is a network of medical service providers created to provide medical treatment for work injuries of employees in California. Self-insured employers, workers' compensation insurers, or entities providing physician network services may establish an MPN. An MPN must be approved by the California Division of Workers' Compensation (DWC) before it can be used. Unless exempted by law or the employer, all medical care for workers injured on the job whose employer has an approved MPN will be handled and provided through the MPN.
Q: Where can I find the regulations pertaining to MPNs?
A: The MPN regulations are found in Title 8, California Code of Regulations, sections 9767.1 - 9767.19 (MPN regulations).
Q: Are MPNs mandatory after Jan. 1, 2005?
A: No. Each eligible employer or insurer may decide if they want to establish and use an MPN to treat employees' industrial injuries or conditions.
Q: Who is covered by an MPN?
A: All employees of an employer using an approved and implemented MPN are required to receive medical treatment through the MPN for work injuries, EXCEPT:
- Those employees who properly pre-designate a physician any time before an injury occurs, even if the pre-designated physician is a provider in the MPN's network;
- Those employees with injuries prior to the effective date of the MPN whose care has not been transferred into the MPN; and
- Those employees who are otherwise exempted from the MPN.
Q: Who can apply for an MPN?
A: A workers' compensation insurer, self-insured employer, joint powers authority, the State of California, California Insurance Guarantee Association (CIGA), State Compensation Insurance Fund (SCIF), a group of self-insured employers and an entity that provides physician network services.
Q: How do I apply for an MPN?
A: Submit an MPN application with the information required by the current MPN regulations. Include a completed "MPN Cover Page for Medical Provider Network Application or Plan for Reapproval" (Cover Page) with a signature by the MPN applicant's Authorized Individual who is an officer or employee of the MPN applicant with the authority to act on behalf of the MPN applicant.
Q: Where do I send my completed MPN application?
A: Submit two copies of the completed, signed Cover Page, the completed MPN Application Plan in compact discs or flash drives by mail to:
|California Department of Industrial Relations
Division of Workers' Compensation
P.O. Box 71010
Oakland, CA 94612
|Or by overnight delivery to:||California Department of Industrial Relations
Division of Workers' Compensation
1515 Clay St., 17th floor
Oakland, CA 94612
Q: Who is responsible for the MPN?
A: The MPN applicant is responsible for compliance with the MPN statutes and regulations, regardless of any delegated authority given to a third party to administer an MPN, including the MPN liaison.
Q: Can we submit our MPN application, Material Modification, or Plan for reapproval via email?
A: No. Currently, the DWC is not accepting MPN applications, material modifications, nor plans for reapproval via email.
Q: Who must sign the MPN application?
A: The MPN Authorized Individual who is an officer or employee of the eligible MPN applicant must sign the mandatory MPN cover page.
Q: I've seen more than one version of the mandatory cover page for the MPN application. Which one should I use?
A: Make sure you use the MPN cover page which is included in the regulations. Do not use any earlier version of this form.
Q: What is the deadline for applying to be an MPN?
A: There is no deadline for applying for an MPN.
Q: What providers should be included in an MPN?
A: Licensed physicians and providers of medical services are to be included in the MPN. These providers include, but are not limited to, physicians, surgeons, psychologists, acupuncturists, optometrists, dentists, podiatrists, and chiropractic practitioners. The MPN provider network may also include ancillary service providers such as physical therapists, providers of durable medical equipment and supplies, and diagnostic services. The name of the licensed physician, ancillary service provider, or the entity legally authorized to render the medical services, shall be listed in the MPN provider listing. To be included in an MPN, all MPN providers must have a contractual agreement to treat workers' compensation injuries in compliance with Labor Code section 4609.
Q: Can DWC add a provider to an MPN network?
A: No. The MPN applicants determine which providers will be in their provider networks.
Q: If I am a provider, how do I get added to an approved MPN network?
A: As a provider, you need to contact the MPN applicants to offer your services as a network provider. You can also contact organizations which contract with MPN applicants to provide network providers such as PPOs, HCOs, HMOs or other network entities.
Note: A memorandum for providers interested in joining an MPN network is located on the DWC website.
Q: Should chiropractors and acupuncturists be included in our MPN network?
A: MPNs must include acupuncturists and chiropractors as providers if they are commonly used by the employees being treated.
Q: How must we submit our provider list?
A: Under the current regulations, you must submit your provider listing in compact discs or flash drives as a Microsoft Excel spread sheet with your MPN application.
Q: We are planning to use the provider network of a certified Health Care Organization (HCO) as the deemed network for our MPN. Can we change some of the providers in the HCO network?
A: If you are using an HCO network as a “deemed entity” MPN network, you must use the entire list of HCO providers exactly as certified under the HCO and you may not make any modifications to the provider list. If you make any changes to an HCO's provider listing, you are no longer filing as a "deemed entity," and must file your entire provider list in an Excel spread sheet with your submission. If you have questions about using the network of a deemed entity, discuss these issues with that entity before submitting your MPN application.
Note: If the MPN applicant is providing ancillary services within the MPN in addition to the services provided by a deemed entity, the additional ancillary service providers shall be set forth in an Excel spread sheet submitted with the application.
Q: Does DWC have a ratio of necessary physicians to the expected number of injury cases for an MPN?
A: No. There is no specific ratio of physicians to expected injuries. In order to establish that your MPN has a sufficient number and type of providers, here are some things you may want to consider:
- Number of employees to be covered;
- Geographic service area to be covered;
- Number and types of injuries expected;
- Number and types of providers needed to accommodate an injured workers' right to change physicians and to support the second and third opinion processes;
- Estimated number and type of providers needed to meet the MPN access standards for Primary Treating Physician, specialist, and hospital access.
However, a minimum of three primary treating physicians and three providers for each commonly used specialty within the access standards must be available to employees.
Q: What kind of MPN provider directory is required to be given to covered employees upon their request?
A: If the MPN provider directory is available on a website, the URL shall be provided, as well as sufficient information to allow an employee to access the provider directory online. If the MPN provider directory is not available on a website, at a minimum, a written regional area listing of all MPN providers within the mileage or the county requested by the covered employees shall be provided. It is not acceptable to only provide a select list of five or ten providers, as that does not constitute a complete regional area listing.
Q: If a worker or a worker's representative requests a complete provider directory listing in writing, must it be provided?
A: Yes. If a worker or a worker's legal representative requests a complete provider directory listing of all providers in the MPN, it is to be made available in writing.
Q: What can I do to increase my chances of getting my MPN application approved more quickly?
A: Read and carefully follow the current MPN regulations.
Before submitting your application to the DWC, make sure that it is complete by double checking that it has all the required information, including:
- A cover page signed by the applicant's Authorized Individual;
- The correct legal name as verified or certified by the Office of Self Insurance Plans (OSIP) or the Department of Insurance (DOI) or the California Secretary of State;
- The correct tax ID number for the MPN applicant;
- The number of estimated number of claims for the MPN;
- Copy of documented proof showing current eligibility of an MPN applicant;
- MPN Medical Access Assistants’ toll-free number, email address, fax number, and days and times of availability;
- Physician listings in Excel spread sheets with the eight required columns; physician’s name, medical specialty, physical office address, city, state, zip code, and medical group affiliations if applicable, and an assigned provider code for each physician listed.
- Ancillary service provider listing in Excel spread sheets with the six required columns; name of ancillary service provider who is actually providing the medical service or goods, type of ancillary service, physical address, city, state, and zip code.
- Geocoding results in Excel spread sheets;
- Include a copy of the signed cover page, application plan in word-searchable PDF format, and Excel spread sheets.
Q: Is there any information that MPN applicants often forget to include in their applications?
A: Yes. Remember to include the following information in your application:
- An MPN contact name and toll-free phone number;
- Statements disclosing that a copy of the entire continuity of care policy (COC) and the transfer of care (TOC) policy are available upon request;
- A valid MPN website address providing the MPN general information, at a minimum, how to contact the MPN Contact and MPN Medical Access Assistants, and how to obtain a copy of any MPN notification required for covered employees.
- A valid MPN provider listing URL address providing covered employees access to the roster of all treating physicians in the MPN.
- A description of any alternative rural access policy, if applicable;
- A written policy for covered employees working or living outside the MPN geographic service area who need non-emergency medical care;
NOTE: Also, under the current MPN regulations, a toll-free phone number is to be included in the employee notification for employees to obtain assistance from the MPN Medical Access Assistants, and if the MPN geographic service area covers more than one area code a toll-free phone number for the MPN Contact.
Q: What if my MPN application is incomplete?
A: If your application is determined to be "incomplete," DWC will send you a letter identifying the area(s) in which the application is incomplete. It is then up to you, the MPN applicant, to resubmit materials to ensure that your application is complete. No further action will be taken by the DWC on an incomplete submission and the regulatory review deadline does not begin until the submission is deemed complete.
Q: How do I find out the status of my MPN application?
A: DWC does not give status updates on applications. However, after receipt of your initial application and determination that all required information has been submitted, you will receive a letter of completeness. The letter of completeness will also include a log number which will allow you and DWC to identify and track the application.
All complete applications are processed for full review and are reviewed in the order received. Within 60 days of DWC's receipt of a complete application, you will be sent a decision letter stating whether the application has been approved or disapproved.
Note: The decision letter will be sent to the MPN liaison by regular mail and to the email address provided on the Cover Page.
Q: What are common deficiencies seen in MPN applications that can lead to disapproval?
A: Some common problems identified in MPN applications are:
- The imposition of additional or different time frames not required by the regulations. For example, imposing deadlines not in the regulations to respond or object to transfer of care determinations by the MPN applicant;
- Failure to include all required information in the complete employee notification (i.e. instructions to access the MPN provider directory);
- Attempting to list the name of a medical service organization rather than the name of the licensed physician, ancillary service provider, or the entity legally authorized to render the professional service. Only providers who are actually providing the medical service will be allowed to be listed in an MPN;
- Having an insufficient number or type of providers to meet the access standards;
- Changes made to the transfer of care dispute resolution process that are not allowed by the regulations;
- The use of vague terminology that does not reflect the requirements under the regulations, such as referring to "a specified time frame" or "specified circumstances";
- Failure to clearly inform a worker of the 60-day deadline for a waiver of the second or third opinion;
- Inconsistency between the same policies stated in the MPN application.
Q: How do I find out if my MPN application is disapproved?
A: Your MPN liaison receive a disapproval letter identifying the deficiencies in your application.
Q: What do I do if my MPN application is disapproved?
A: If your application is disapproved:
- Your MPN liaison will receive a disapproval letter stating the deficiencies found in the application. Carefully review the letter detailing the deficiencies in the application, and revise the application accordingly.
- Follow the instructions in the disapproval letter to prepare your resubmission.
- Submit an original and a copy of the revised application in word-searchable PDF format in two compact discs or flash drives. If the employee notification or transfer of care or continuity of care materials, have been revised, submit a copy of the entire revised materials in English and in Spanish.
- Include a newly signed cover page.
Q: Do I have to include a newly signed cover page when I submit my revised MPN application?
A: Yes. All resubmissions to an MPN application must be accompanied by a newly signed cover page. No application will be approved without a signed cover page by the MPN applicant's Authorized Individual indicating that the MPN applicant has read the revised application and verified the contents of the revised application as true and correct. Resubmitting the original signed cover page with the initial application will not suffice.
Q: How long does it take to get my revised and resubmitted MPN application reviewed?
A: Although the 60-day review period restarts upon resubmission of an application, resubmitted applications are considered a priority for review and will be expedited to the extent possible.
Q: How can I find out what MPNs have been approved?
A: A list of approved MPNs are posted on the DWC MPN webpage and is updated on a quarterly basis.
Q: What is the "MPN Identification Number"?
A: Upon approval of your MPN plan, the Log ID Number initially assigned by the DWC to each new MPN application will become the MPN Identification Number of each approved MPN. This unique MPN Identification Number shall be used to specifically identify that MPN. If an MPN applicant creates multiple MPNs, each one will have its own unique MPN Identification Number.
After approval: Filing a notice of plan modification for an approved MPN
Q: If I have an approved MPN and I want to make changes to the MPN, what do I need to do?
A: For most changes, you will need to submit a Notice of MPN Plan Modification. Changes which require a material modification include, but are not limited to, the following:
- Change in the eligibility status of the MPN Applicant;
- Change in employee notification materials, including changes in contact information for the MPN Contact and MPN Medical Access Assistant, and change of MPN website address for MPN general information and provider directory listing;
- Change in the economic profiling policy, including instituting an economic profiling policy when the original application stated that economic profiling was not performed;
- Change in the continuity of care (COC) policy and/or the transfer of care (TOC) policy;
- Update of the entire MPN plan to comply with the current regulations effective 1/1/2016 (SB542);
- A change in the name of the MPN;
- A change in the geographic service area of the MPN, within the state of California;
- A change in how the MPN complies with the access standards;
- A change in the DWC liaison person for the MPN or Authorized Individual for the MPN (NOTE: either change must be reported to DWC within fifteen business days of the change taking place)
You will need to fill out and submit the material modification form and submit a copy of any proposed modified policies or employee notification.
Q: After I file the Notice of MPN Plan Modification, can I go ahead and implement the changes in the MPN?
A: No. Unless it is a change of the DWC liaison or a change of the Authorized Individual, DWC must review and approve the proposed changes to the MPN plan before the changes can be implemented. DWC will review your notice of plan modification and issue a decision on the plan modification within 60 days of receipt of a complete plan modification submission. You may institute the changes to your plan only after theDWC issues its approval, or after 60 days if DWC fails to issue a decision on the plan modification within that time frame.
Q: What do we need to do if our company has an approved MPN and we decide to change carriers, third-party administrators (TPAs) or MPN networks?
A: When changing partners involved in an MPN contractual arrangement it is critical that you plan ahead to avoid any unnecessary disruption of MPN coverage for your employees. Even with careful planning it is possible that there could be some interruption of MPN coverage when changing TPAs, MPN networks or insurance carriers if enough time is not allowed for plan modification review and approval. Consult with DWC's MPN staff as early as possible for guidance on implementing such a change as smoothly as possible.
Q: What happens if I have an approved MPN through my insurance carrier and I decide to become self-insured for workers' compensation?
A: Once your company becomes self-insured, new workers’ compensation injuries will no longer be covered by your former carrier's MPN. Employees with old injuries which occurred while you were covered by the carrier's MPN will stay in that carrier's MPN as long as it is being used by that carrier. As a self-insured employer, you will need to decide to either file a new application for an MPN of your own, or use your third-party administrator’s MPN. Please consult with DWC MPN staff as early as possible to determine what will happen and how best to make the change from one MPN to another or to end coverage under the MPN.
Q: What happens if I am a self-insured employer and I decide to change TPAs?
A: It depends on how the original MPN was structured. If the MPN design, provider listings and contracts, notices and policies were created by the TPA you are leaving, you may need to file a completely new MPN application with the new TPA’s MPN information. In other situations, you may only need to file a notice of MPN plan modification. Please consult with DWC MPN staff as early as possible to determine what will happen and how best to make the change to reduce the impact on covered injured workers.
Q: What should I do if I have an approved MPN under one insurance carrier and want to switch to a different MPN under a different carrier?
A: Before changing carriers, you should talk to the new carrier about how to ensure that your employees' coverage gets transitioned to the new MPN. This will most likely involve a new employee notification using the new carrier's MPN employee notification materials. It is possible that you could have an interruption of MPN coverage unless this change in carriers is carefully planned well before the effective date of the new policy. Please consult with DWC MPN staff as early as possible to determine what will happen and how best to make the change.
Q: What do I do if I have questions about the new employee hire pamphlet, the claim form, or the workers’ compensation poster?
A: Contact an Information and Assistance (I&A) officer at your nearest DWC district office.
The contact information of your nearest DWC’s I&A offices are accessible by:
- Going to the I&A Unit of the DWC’s website
- Calling I&A Unit at toll free phone number 1-800-736-7401
- Press Option 1 (English) or 2 (Spanish), Option 9, Option 1, and enter your 5-digit zip code]
Q: What is SB537 and the MPN requirement effective July 1, 2021?
4616(a)(4)(A)(i) Commencing July 1, 2021, every medical provider network shall post on its internet website a roster of all participating providers, which includes all physicians and ancillary service providers in the medical provider network, and shall update the roster at least quarterly. Every network shall provide to the administrative director the internet website address of the network and of its roster of participating providers. The roster of participating providers shall include, at a minimum, the name of each individual provider and their office address and office telephone number. If the ancillary service is provided by an entity rather than an individual, then that entity’s name, address, and telephone number shall be listed.
- Labor Code section 4616(a)(4)(A)(i) requires all MPNs to add a Roster of All Participating Providers into their MPN website.
Q: How does SB537 affect MPN Applications, MPN Material Modifications, and MPN Plans for Reapproval filed with the DWC?
A: Any MPN filing (new application, material modification, or plan for reapproval) received by the DWC on or after July 1, 2021 must include, at a minimum, the following in order to be Complete:
- An application description statement with information regarding the MPN internet website containing the Roster of All Participating Providers in the MPN; and
- The MPN internet website shall have the Roster of All Participating Providers in the MPN.