Current through Register 2024 Notice Reg. No. 38, September 20, 2024
(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.
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).
Note: Authority cited: Sections
133 and 4616, Labor Code.
Reference: Sections 4616(b)(4) and 4616(b)(5), Labor
Code.
