Subchapter 1. Administrative Director--Administrative Rules
Article 3.5. Medical Provider Networks
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§ 9767.17. Petition for Suspension or Revocation of a Medical Provider Network.
(a) The DWC Petition for Suspension or Revocation of a Medical Provider Network Form 9767.17.5, as contained in title 8, California Code of Regulations, section 9767.17.5, may be filed with the Division of Workers' Compensation by any person who can show:
(1) The employer, insurer or entity that provides physician network services failed to maintain its qualifying status to have an MPN, or
(2) That an MPN has systematically failed to meet access standards under 9767.5, at minimum, on more than one occasion in at least two specific access locations within the MPN geographic service area. Additionally, the MPN failed to ensure in each instance that a worker received necessary medical treatment within the MPN or failed to authorize treatment outside of the MPN within the required time frames and access standards.
(b) The failure of an MPN to accept or retain a particular provider in its network shall not be grounds to file a DWC Petition for Suspension or Revocation of a Medical Provider Network.
(c) The petitioner shall complete the DWC Petition for Suspension or Revocation of a Medical Provider Network Form 9767.17.5, include all supporting documentation and file the petition verified under penalty of perjury and with proof of service, directly with the Administrative Director. The petitioner shall concurrently serve a copy of the completed DWC Petition for Suspension or Revocation of a Medical Provider Network Form 9767.17.5 along with a copy of all supporting documentation on the MPN's authorized individual. The petition shall include details that show an MPN no longer meets the eligibility requirements to have a Medical Provider Network and/or an MPN systemically fails to meet the access standards. A petition for suspension or revocation of an MPN shall include but not be limited to the following:
(1) Documentation showing all attempts made to contact the MPN to address the violations that form the basis for the petition.
(2) Results of any and all attempts by petitioner to determine if the MPN has met the access standards on more than one occasion for the specific locations within the geographic service area or areas described in its plan.
(3) What, if any, impact the violation has had on injured workers.
(d) The MPN applicant has thirty (30) calendar days to respond to the petition after the date of service of the petition. The verified response shall include but not be limited to addressing the alleged violations and providing any supporting documentation to establish that no violation has occurred or that all specified violations have been remedied in a timely manner. Any response shall be served concurrently on the Administrative Director and on the petitioner.
(e) Within thirty (30) calendar days of the last day for the MPN applicant to file a response to the DWC Petition for Suspension or Revocation of a Medical Provider Network, the Administrative Director or his/her designee may make reasonable requests for information or additional evidence from the MPN or the petitioner.
(1) The MPN applicant or petitioner shall have thirty (30) calendar days from receipt of the Administrative Director's request, as determined by the parameters set forth in 9767.16(a)(2)(A) through (C), to provide DWC with the requested information or documentary evidence.
(f) Within sixty (60) calendar days of receipt of all the requested information or additional evidence, the Administrative Director shall issue an administrative Decision and Order either granting or denying the petition and setting forth the reasons for the Decision.
(g) Once the Administrative Director issues a Decision and Order, the procedures set forth in section 9767.14 and/or section 9767.19 may apply.
HISTORY
1. New section filed 8-27-2014; operative 8-27-2014 pursuant to Government Code section 11343.4(b)(3) (Register 2014, No. 35).
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