Chapter 4.5. Division of Workers' Compensation
Subchapter 1. Administrative Director--Administrative Rules
Article 4. Certification Standards for Health Care Organizations

§9772. General Standards.

(a) HCOs must demonstrate that they meet the following requirements:

(1) All facilities located in this state including, but not limited to, clinics, hospitals, laboratories, and skilled nursing facilities to be utilized by the HCO for the delivery of occupational medical and health care services or other services specifically required by this article shall be licensed by the State Department of Health Services, if such licensure is required by law, and shall meet any other relevant certification requirements. Facilities not located in this state shall conform to all licensing and other requirements of the jurisdiction in which they are located.

(2) All personnel employed by or under contract to the HCO shall be licensed or certified by their respective board or agency, where such licensure or certification is required by law.

(3) All equipment required to be licensed or registered by law shall be so licensed or registered and the operating personnel for such equipment shall be licensed or certified as required by law.

(4) The HCO shall provide continuity of care and timely referral of patients to other providers in a manner consistent with professionally recognized standards of care.

(5) All services shall be available and accessible at reasonable times to all HCO enrollees.

(6) The HCO may employ and utilize allied health personnel for the furnishing of occupational health services to the extent permitted by law and provided such use is consistent with professionally recognized standards of care; however, any course of treatment beyond first aid, as defined in subdivision (c) of Section 14311, shall provide for at least one face to face visit with a primary treating physician.

(7) The HCO shall have the organizational, financial, and administrative capacity to provide services to employers, claims administrators, and HCO enrollees. The HCO shall be able to demonstrate to the Division that medical decisions are rendered by qualified providers unhindered by fiscal and administrative management, and that such decisions adhere to professionally recognized standards of care.

Any applicant that is owned in whole or in part or controlled by a workers' compensation insurer or self-insured employer shall, in addition to the requirements set forth above, further demonstrate that the organization's claims function shall have no influence or control over medical decision-making. The applicant shall further demonstrate that the clear authority of its Medical Director over all medical decisions is reflected both in its organizational chart and any internal procedure manual or other internal description of HCO operations.

(8) All contracts with claims administrators, employers, providers and other persons or entities furnishing services specifically required by this article shall be consistent with the requirements of this article and Division 4 of the Labor Code.

NOTE

Authority cited: Sections 133, 4600.5, 4603.5 and 5307.3, Labor Code. Reference: Section 4600.5, Labor Code.

HISTORY

1. New section filed 12-31-93; operative 1-1-94. Submitted to OAL for printing only pursuant to Government Code section 11351 (Register 93, No. 53).

2. Amendment of subsection (b)(7) filed 1-9-2003; operative 1-9-2003 pursuant to Government Code section 11343.4 (Register 2003, No. 2).