Chapter 4.5. Division of Workers' Compensation
Subchapter 1. Administrative Director--Administrative Rules
Article 3.5. Medical Provider Networks

§9767.14. Probation, Suspension or Revocation of Medical Provider Network Plan; Hearing.

(a) The Administrative Director may place on probation, suspend or revoke a Medical Provider Network if:

(1) Service under the MPN is not being provided according to the terms of the approved MPN plan.

(2) The MPN fails to meet the requirements of Labor Code section 4616 et seq. and this article.

(3) The MPN fails to meet the requirements for reapproval under Labor Code section 4616 et seq. or this article.

(4) False or misleading information is knowingly or repeatedly submitted by the MPN or a participating provider or the MPN knowingly or repeatedly fails to report information required by this article.

(5) The MPN knowingly continues to use the services of a provider or medical reviewer whose license, registration, or certification has been suspended or revoked or who is otherwise ineligible to provide treatment to an injured worker under California law.

(6) The MPN applicant no longer meets the eligibility requirements to have an MPN, including but not limited to the following situations: the MPN applicant is no longer recognized as a self-insured entity with the Office of Self-Insurance Plans for any period of time during which the MPN applicant has an MPN or if the MPN applicant is no longer properly licensed to provide workers' compensation insurance by the Department of Insurance for any period of time during which the MPN applicant has an MPN or is no longer an entity that provides physician network services.

(A) Once an MPN applicant is no longer eligible to have an MPN, by operation of law, the MPN is automatically suspended and MPN coverage will not be deemed valid for new claims during the period of suspension, pending revocation by the Administrative Director. During the effective dates of suspension, any injured worker with a new claim shall be informed of the employee's right to be treated by a physician of his or her own choice or at a facility of his or her own choice within a reasonable geographic area 30 days after reporting the injury, pursuant to Labor Code section 4600(c). After a suspension has ended, any transfer of the employee's care back into the MPN shall be subject to the MPN transfer of care requirements.

(7) The MPN fails to respond to at least two or more repeated requests or inquiries by the Administrative Director to comply with the requirements of this article or Labor Code sections 4616 et seq.

(b) If one of the circumstances in subdivision (a) exists, the Administrative Director shall notify the MPN applicant in writing of the specific violations alleged. The Administrative Director shall allow the MPN applicant an opportunity to correct the violation or to respond within ten days with a plan of action to correct the violation in a timely manner. If the Administrative Director determines that the violations have not been cured in a timely manner, he or she shall issue a Notice of Action to the MPN applicant that specifies the time period in which probation, the suspension or revocation will take effect and shall transmit the Notice of Action to the MPN applicant by U.S. Mail.

(c) An MPN applicant may request a re-evaluation of the probation, suspension or revocation by submitting to the Administrative Director, within 20 days of the issuance of the Notice of Action, a written notice of the request for a re-evaluation with a detailed statement explaining the basis upon which a re-evaluation is requested.

The request for a re-evaluation shall be accompanied by supportive documentary material relevant to the specific allegations raised and shall be verified under penalty of perjury. The MPN application at issue shall not be re-filed; it shall be made part of the administrative record and incorporated by reference.

(d) The Administrative Director shall, within 45 days of the receipt of the request for a re-evaluation, either:

(1) Issue a Decision and Order affirming or modifying the Notice of Action based on a failure to meet the procedural requirements of this section or based on a failure to meet the requirements of Labor Code section 4616 et seq. and this article;

(2) Issue a Decision and Order rescinding the Notice of Action;

(e) The Administrative Director may extend the time specified in subdivision (d) within which to act upon the request for a re-evaluation for a period of 30 days and may order a party to submit additional documents or information.

(f) An MPN applicant may appeal the Administrative Director's decision and order regarding the MPN by filing, within twenty (20) days of the issuance of the decision and order, a “Petition Appealing Administrative Director's Medical Provider Network Determination” with the Workers' Compensation Appeals Board pursuant to WCAB Rule 10959. A copy of the petition shall be concurrently served on the Administrative Director.

Note: Authority cited: Sections 133, 4616(h) and 5300(f), Labor Code. Reference: Section 4616, Labor Code.

HISTORY

1. New section filed 11-1-2004 as an emergency; operative 11-1-2004 (Register 2004, No. 45). A Certificate of Compliance must be transmitted to OAL by 3-1-2005 or emergency language will be repealed by operation of law on the following day.

2. New section refiled 2-28-2005 as an emergency; operative 3-1-2005 (Register 2005, No. 9). A Certificate of Compliance must be transmitted to OAL by 6-29-2005 or emergency language will be repealed by operation of law on the following day.

3. New section refiled 6-20-2005 as an emergency; operative 6-29-2005 (Register 2005, No. 25). A Certificate of Compliance must be transmitted to OAL by 10-27-2005 or emergency language will be repealed by operation of law on the following day.

4. Certificate of Compliance as to 6-20-2005 order, including amendment of section, transmitted to OAL 7-29-2005 and filed 9-9-2005 (Register 2005, No. 36).

5. Amendment of section heading, section and Note filed 8-27-2014; operative 8-27-2014 pursuant to Government Code section 11343.4(b)(3) (Register 2014, No. 35).