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

§9767.15. Compliance with Current MPN Regulations; Reapproval.

(a) MPNs approved prior to January 1, 2014 that are not in compliance with the current MPN regulations must file a modification and update to comply with the current regulations no later than January 1, 2018. If the MPN is required to apply for reapproval before January 1, 2018 based on the four-year approval period, then the MPN shall update to the current regulations with its reapproval filing, whichever is sooner.

(b) The MPN applicant shall file a new complete application for reapproval no later than six months prior to the expiration of the MPN's four-year date of approval.

(1) For MPNs approved prior to January 1, 2014, the four-year date of approval begins from the most recent approved filing prior to January 1, 2014.

(2) For MPNs approved after January 1, 2014, the first four-year date of approval begins from the date the original application is approved.

(3) After an MPN has been reapproved, the expiration of reapproval will be four years from the date of the last complete plan reapproval.

(4) Each application for reapproval shall meet all requirements for a new MPN original application.

(5) Each filing for reapproval shall meet the requirements for geocoding as follows: Provide an electronic copy in Microsoft Excel format of the geocoding results of the MPN provider directory to show estimated compliance with the access standards set forth in section 9767.5. The access standards set forth in section 9767.5 are determined by the injured employee's residence or workplace address and not the center of a zip code. The geocoding results will be used by DWC in reviewing MPN plans to give an approximation of MPN compliance with the access standards set forth in section 9767.5. The geocoding results shall include the following separate files summarizing data reasonably available at the time of compilation: 1) a complete list of all zip codes within the MPN geographic service area; 2) a narrative or graphic report that establishes where there are at least three available primary treating physicians within the fifteen-mile access standard from the center of each zip code within the MPN geographic service area; 3) a narrative or graphic report that establishes where there is a hospital or an emergency health care service provider within the fifteen-mile access standard from the center of each zip code within the MPN geographic service area; 4) a narrative or graphic report that establishes-where there are at least three available physicians in each of the specialties commonly required to treat injured workers covered by the MPN within the thirty-mile access standard from the center of each zip code within the MPN geographic service area; 5) a list of all zip codes where access standards are not met in the geographic service area or areas to be served by the MPN for primary treating physicians, for acute care hospitals or emergency facilities, and for each specialty listed to treat common injuries experienced by injured workers covered by the MPN, and a narrative report explaining if medical treatment will be provided according to an approved alternative access standard or according to a written policy permitting out of MPN treatment in those areas; and 6) each physician listed in the MPN provider directory shall be assigned at least one provider code as set forth in section 9767.3(c)(2) of this section to be used in the geocoding reports.

(6) The time frames for the review process for a plan for reapproval are as stated in section 9767.2(b).

(7) If the filing for reapproval is not filed within the requisite six months prior to the expiration of approval, then the MPN may be subject to penalties or other administrative actions. If an application for reapproval is filed less than 60 days prior to the approval expiration date, then the MPN may be subject to penalties and MPN approval will be suspended after the date of expiration if the review is not completed prior to the expiration of the MPN plan's approval.

Note: Authority cited: Sections 133, 4616(h) and 5300(f), Labor Code. Reference: Sections 4609, 4616, 4616.2 and 4616.3, Labor Code.

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