California Code of Regulations
Title 8 - Industrial Relations
Division 1 - Department of Industrial Relations
Chapter 4.5 - Division of Workers' Compensation
Subchapter 1 - Administrative Director-Administrative Rules
Article 3.5 - Medical Provider Network
Section 9767.18 - Random Reviews
Universal Citation: 8 CA Code of Regs 9767.18
Current through Register 2024 Notice Reg. No. 38, September 20, 2024
(a) The Administrative Director may conduct random reviews of any approved Medical Provider Network to determine if the requirements of this article and Labor Code sections 4616 through 4616.7 are being satisfied.
(1) An MPN will not be
randomly reviewed more than once in a two-year period. However, an MPN may be
subject to investigation for good cause.
(2) To initiate a random review, the Division
of Workers' Compensation shall:
(A) Issue a
"Notice of Random Review" to a Medical Provider Network's authorized individual
specifying the parameters of the review, including the time frame and scope of
the review.
(B) Make reasonable
requests in writing for information or documentary evidence from the MPN in
order to conduct the review. MPN applicants shall be prepared to respond to
reasonable requests for information or documentary evidence by the DWC
including, but not limited to, the following items:
(i) Documentary proof the MPN applicant meets
the eligibility requirements to have an MPN, that the MPN name or MPN applicant
name is legally correct and consistent with the approved MPN plan, or that the
MPN status is still valid and approved.
(ii) A complete copy of the MPN's most recent
approved plan submission (new MPN application, reapproval plan or modification)
including a copy of the most recent employee notification and MPN notices given
to covered employees, and a listing of all plan filings to date after the
effective date of this section.
(iii) A copy of the most recent network
provider listing, the URL address of the MPN's network provider listing,
documentary evidence of quarterly updates to the provider listing for the past
year and documentary evidence of timely corrections to the provider listing for
inaccuracies reported to the MPN within a reasonable time period.
(iv) A copy of any MPN complaints or
petitions for suspension or revocation received by the MPN and the MPN's
responses. In addition, documentation of any administrative actions taken by
the Administrative Director against the MPN within a reasonable time period may
be requested.
(v) A copy of the
telephone call logs tracking the calls and the contents of the calls made to
and by the MPN medical access assistants and the MPN Contact within a
reasonable time period.
(vi) Copies
of the written MPN physician acknowledgments.
(3) The MPN applicant 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 and or documentary
evidence.
(4) If the review reveals
that the MPN has violated or is in violation of a provision of this article or
of Labor Code sections
4616 through
4616.7, the
Administrative Director shall notify the MPN applicant in writing of the
specific violation(s) found and may follow the procedures set forth in section
9767.14 and/or section
9767.19.
1. New section 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 122 and 4616(h), Labor Code. Reference: Sections 4616(b)(4) and 4616(b)(5), Labor Code.
Disclaimer: These regulations may not be the most recent version. California may have more current or accurate information. We make no warranties or guarantees about the accuracy, completeness, or adequacy of the information contained on this site or the information linked to on the state site. Please check official sources.
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