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

§ 9767.16. Medical Provider Network Complaints.

(a) Any person contending a Medical Provider Network is in violation of the requirements of this article or Labor Code sections 4616 through 4616.7 shall submit a written complaint directly with the MPN Contact.

(1) The written complaint shall provide an explanation to the MPN with sufficient detail of the MPN's alleged violation under this article or any of Labor Code sections 4616 through 4616.7. The written complaint shall include, but not be limited to, the following information:

(A) Citation of the specific statutory or regulatory provision(s) violated;

(B) When the alleged violation occurred;

(C) If the alleged violation is still occurring;

(D) What attempts the complainant has made with the MPN to address the violation;

(E) What, if any, impact there has been on an injured worker; and

(F) What remedy is sought for the alleged violation.

(2) The MPN applicant shall have thirty (30) calendar days from the date the complaint was received to respond in writing to the complainant.

(A) For purposes of this section, the complaint shall be deemed to have been received by the MPN Contact by e-mail on the e-mail receipt confirmation date or on the delivery status notification date indicating successful delivery of an e-mail to the MPN Contact, whichever is earliest.

(B) Where the complaint is made by facsimile, the complaint shall be deemed to have been received by the MPN Contact on the date the receiving facsimile electronically date stamps the transmission was successfully sent. If there is no electronically stamped date recorded, then the date the request was transmitted.

(C) Where the complaint is made by mail, and a proof of service by mail exists, the request shall be deemed to have been received by the MPN Contact five (5) days after the deposit in the mail at a facility regularly maintained by the United States Postal Service. Where the complaint is delivered via certified mail, return receipt mail, the request shall be deemed to have been received by the MPN Contact on the receipt date entered on the return receipt. In the absence of a proof of service by mail or a dated return receipt, the complaint shall be deemed to have been received by the MPN Contact on the date stamped as received on the document.

(3) Within (30) calendar days from the date the complaint was received, the MPN applicant shall respond to the complainant by:

(A) Taking reasonable actions to remedy the violation in a timely manner and stating any additional actions it will be taking if more than thirty (30) calendar days are needed to address the violation, or

(B) Verifying in writing to the complainant that the MPN is disputing the complaint and denying there is a violation.

(b) If the MPN applicant has not remedied the violation or has not taken reasonable action to remedy the violation within thirty (30) calendar days from the date the complaint was received or the MPN has confirmed in writing it is disputing the complaint and denying there is a violation, the complainant may file a written complaint with the Division of Workers' Compensation against the MPN. If the complainant can show imminent and serious threat to the health of an injured worker, including but not limited to potential loss of life, limb or other major bodily function, he or she may file a written complaint with the Division of Workers' Compensation against the MPN concurrently with the written complaint under subdivision (a) submitted on the MPN.

(1) The written complaint filed with the DWC must be made on the DWC Medical Provider Network Complaint Form, as contained in title 8, California Code of Regulations, section 9767.16.5. The complainant shall provide written details of the MPN's violation along with documentary evidence that the MPN has been notified according to subdivision (a) of this section. A copy of the DWC Medical Provider Network Complaint Form 9767.16.5 shall be served on the MPN Contact.

(2) The Administrative Director shall have the discretion to limit investigations to complaints which provide credible evidence that a violation exists.

(A) The Administrative Director may make reasonable requests for information or documentary evidence from the MPN applicant or the complainant in order to conduct an investigation to determine the validity of the allegations. The MPN applicant or the complainant shall have thirty (30) calendar days from receipt of the Administrative Director's request, as determined by the parameters set forth in (a)(2)(A) through (C) of this section, to provide DWC with the requested information or documentary evidence.

(3) If the investigation confirms a violation or if other violations are found as a result of the investigation, the Administrative Director shall notify the MPN's authorized individual and MPN Contact in writing of the specific violation(s) found and shall follow the procedures set forth in §9767.14 and/or §9767.19, if the MPN fails to remedy the violation as required.

Note: Authority cited: Sections 133 and 4616, Labor Code. Reference: Sections 4616(b)(4) and 4616(b)(5), Labor Code.

HISTORY

1. New section filed 12-11-2007; operative 4-9-2008 (Register 2007, No. 50).

2. Amendment of section heading, section and Note filed 8-9-2010; operative 10-8-2010 (Register 2010, No. 33).

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