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 9767.3 - Requirements for a Medical Provider Network Plan

Universal Citation: 8 CA Code of Regs 9767.3

Current through Register 2024 Notice Reg. No. 38, September 20, 2024

(a) As long as the application for a medical provider network plan meets the requirements of Labor Code section 4616 et seq. and this article, nothing in this section precludes an employer or insurer or entity that provides physician network services from submitting for approval one or more medical provider network applications.

(b) Nothing in this section precludes an MPN applicant from agreeing to submit for approval a medical provider network plan which meets the specific needs of an insured employer considering the experience of the insured employer, the common injuries experienced by the insured employer, the type of occupation and industry in which the insured employer is engaged and the geographic area where the employees are employed.

(c) All MPN applicants shall complete the section 9767.4 Cover Page for Medical Provider Network Application or Plan for Reapproval with an original signature, and an MPN Plan meeting the requirements of this section or the optional MPN Plan Application form. Two copies of the completed, signed Cover Page for Medical Provider Network Application or Plan for Reapproval and the complete MPN Plan shall be submitted to the DWC in compact discs or flash drives in word-searchable PDF format. The hard copy of the completed, signed original Cover Page for Medical Provider Network Application or Plan for Reapproval and the complete MPN Plan shall be maintained by the MPN applicant and made available for review by the Administrative Director upon request. Electronic signatures in compliance with California Government Code section 16.5 are accepted.

(1) An MPN applicant shall submit the MPN provider information and ancillary service provider information required in section 9767.3(d)(8)(G) and (I) in a compact disc(s) or, a flash drive(s). The information shall be submitted as a Microsoft Excel spread sheet unless an alternative format is approved by the Administrative Director. If the MPN applicant is using a valid and currently certified Health Care Organization, then this information must be noted on the application's Cover Page for Medical Provider Network or Plan for Reapproval and only a listing of any additional ancillary service providers is required to be submitted pursuant to the requirements in subsection (3) of this subdivision.

(2) The network provider information shall be submitted in a compact disc(s), or a flash drive(s), and the provider file shall have only the following eight columns. These columns shall be in the following order: (1) physician name (2) specialty (3) physical address (4) city (5) state (6) zip code (7) any MPN medical group affiliations and (8) an assigned provider code for each physician listed. If a physician falls under more than one provider code, the physician shall be listed separately for each applicable provider code. The following are the provider codes to be used: primary treating physician (PTP), orthopedic medicine (ORTHO), chiropractic medicine (DC), occupational medicine (OCCM), acupuncture medicine (LAC), psychology (PSYCH), pain specialty medicine (PM), psychiatry (PSY), neurosurgery (NSG), family medicine (GP), neurology (NEURO), internal medicine (IM), physical medicine and rehabilitation (PMR), or podiatry (DPM). If the specialty does not fall under any one of the previously listed categories, then the specialty shall be clearly identified in the specialty column and the code used shall be (MISC). By submission of its provider listing, the applicant is affirming that all of the physicians listed have been informed that the Medical Treatment Utilization Schedule ("MTUS") is presumptively correct on the issue of the extent and scope of medical treatment and diagnostic services and have a valid and current license number to practice in the State of California.

(3) If an MPN chooses to provide ancillary services, the ancillary service provider file shall have only the following six columns. The columns shall be in the following order: (1) the name of each ancillary service provider (2) specialty or type of service (3) physical address (4) city (5) state (6) zip code of each ancillary service provider. If the ancillary service or ancillary service provider is mobile, list the covered service area within California. By submission of an ancillary provider listing, the applicant is affirming that the providers listed can provide the requested medical services or goods and have a current valid license number or certification to practice, if they are required to have a license or certification by the State of California. If interpreter services are included as an MPN ancillary service, the interpreters listed must be certified pursuant to section 9795.1.6(a)(2)(A) and (B).

(4) An MPN determines which locations are approved for physicians to provide treatment under the MPN. Approved locations are listed in an MPN's provider listing; however, an MPN has the discretion to approve treatment at non-listed locations.

(5) An MPN applicant shall have the exclusive right to determine the members of its network.

(d) A Medical Provider Network application shall include all of the following information:

(1) Type of Eligible MPN applicant. Provide a description of the entity's qualifications to be an eligible MPN Applicant. Attach proof of MPN eligibility. If a self-insured employer or joint powers authority, attach a copy of the current valid certificate of self-insurance. For an insurer, attach a current valid certificate of authority. For an entity providing physician network services, attach documentation of current legal status including, but not limited to, legal licenses or certificates and affirm that the entity employs or contracts with physicians and other medical providers or contracts with physician networks.

(2) Name of MPN applicant.

(3) MPN applicant's Taxpayer Identification Number.

(4) Name of Medical Provider Network.

(5) MPN Liaison to DWC: Provide the name, title, address, e-mail address, and telephone number of the person designated as the liaison for the Division, who is responsible for receiving compliance and informational communications from the Division and for disseminating the same within the MPN.

(6) The application must be verified by an officer or employee of the MPN applicant with the authority to act on behalf of the MPN applicant with respect to the MPN. The verification by the authorized individual shall state: "I, the undersigned officer or employee of the MPN applicant, have read and signed this application and know the contents thereof, and verify that, to the best of my knowledge and belief, the information included in this application is true and correct."

(7) Nothing in this section precludes a network, entity, administrator, or other third-party, upon agreement with a MPN applicant, from preparing a MPN application on behalf of an eligible MPN applicant.

(8) Description of Medical Provider Network Plan:
(A) Affirm that the MPN network is adequate to handle the expected number of claims covered under the MPN and explain how this was determined;

(B) Describe the MPN geographic service area or areas within the State of California to be served;

(C) State the toll-free number, email address, fax number and days and times of availability to reach the MPN's medical access assistants.

(D) State the MPN website address;

(E) State the web address or URL to the roster of all treating physicians in the MPN. Affirm that secondary treating physicians who are counted when determining access standards but can only be seen with an approved referral are clearly designated "by referral only".

(F) Affirm that each MPN physician or medical group in the network has agreed to treat workers under the MPN and that the written acknowledgments are in accordance with the requirements under "Physician Acknowledgments" section 9767.5.1, and are available for review by the Administrative Director upon request;

(G) Provide a listing of the name, specialty, and location of each physician as described in Labor Code Section 3209.3, who will be providing occupational medicine services under the plan. Only individual physicians in the MPN shall be listed, but MPN medical group affiliation(s) may be included with each individual physician listed. By submission of the application, the MPN applicant is confirming that a contractual agreement exists with the physicians, providers or medical group practice in the MPN to provide treatment for injured workers in the workers' compensation system and that the contractual agreement is in compliance with Labor Code section 4609, if applicable.

(H) Provide an electronic copy in Microsoft Excel format of the geocoding results of the MPN provider directory to show estimated compliance with the access standards set forth in section 9767.5. The access standards set forth in section 9767.5 are determined by the injured employee's residence or workplace address and not the center of a zip code. The geocoding results will be used by DWC in reviewing MPN plans to give an approximation of MPN compliance with the access standards set forth in section 9767.5. The geocoding results shall include the following separate files summarizing data reasonably available at the time of compilation:
1) a complete list of all zip codes within the MPN geographic service area;

2) a narrative or graphic report that establishes where there are at least three available primary treating physicians within the fifteen-mile access standard from the center of each zip code within the MPN geographic service area;

3) a narrative or graphic report that establishes where there is a hospital or an emergency health care service provider within the fifteen-mile access standard from the center of each zip code within the MPN geographic service area;

4) a narrative or graphic report that establishes where there are at least three available physicians in each of the specialties commonly required to treat injured workers covered by the MPN within the thirty-mile access standard from the center of each zip code within the MPN geographic service area;

5) a list of all zip codes where access standards are not met in the geographic service area or areas to be served by the MPN for primary treating physicians, for acute care hospitals or emergency facilities, and for each specialty listed to treat common injuries experienced by injured workers covered by the MPN, and a narrative report explaining if medical treatment will be provided according to an approved alternative access standard or according to a written policy permitting out of MPN treatment in those areas; and

6) each physician listed in the MPN provider directory listing shall be assigned at least one provider code as set forth in subdivision (c)(2) of this section to be used in the geocoding reports.

(I) If an MPN chooses to include ancillary services in its network, a listing of the name, specialty or type of service and location of each ancillary service, other than a physician covered under subdivision (d)(8)(G) of this section, who will be providing services or goods within the medical provider network. By submission of the application, the MPN applicant is confirming that a contractual agreement exists with the ancillary service providers to provide services to be used under the MPN and that the ancillary services will be available at reasonable times and within a reasonable geographic area to covered employees;

(J) Describe how the MPN provides ancillary services to its covered employees. Set forth which ancillary services, if any, will be within the MPN. For ancillary services not able to be provided within the MPN pursuant to section 9767.5(d), affirm that referrals will be made to services outside the MPN;

(K) Describe how the MPN complies with the second and third opinion process set forth in section 9767.7;

(L) Describe how the MPN complies with the access standards set forth in section 9767.5 for all covered employees;

(M) Describe the employee notification process, and attach an English and Spanish copy of the required employee notification material and information to be given to covered employees described in section 9767.12(a).

(N) Attach a copy of the written continuity of care policy as described in Labor Code section 4616.2;

(O) Attach a copy of the written transfer of care policy that complies with section 9767.9;

(P) Attach any policy or procedure that is used by the MPN applicant or an entity contracted with the MPN or MPN applicant to conduct "economic profiling of MPN providers" pursuant to Labor Code section 4616.1 and affirm that a copy of the policy or procedure has been provided to the MPN providers or attach a statement that the MPN applicant does not conduct economic profiling of MPN providers;

(Q) Provide an affirmation that the physician compensation is not structured in order to achieve the goal of reducing, delaying, or denying medical treatment or restricting access to medical treatment; and

(R) Describe how the MPN applicant will ensure that no person other than a licensed physician who is competent to evaluate the specific clinical issues involved in the medical treatment services, when these services are within the scope of the physician's practice, will modify, delay, or deny requests for authorization of medical treatment.

(S) Describe the MPN's procedures, criteria and how data is used to continuously review quality of care and performance of medical personnel, utilization of services and facilities, and costs.

(T) Affirm that as of January 1, 2013, every contracting agent that sells, leases, assigns, transfers, or conveys its medical provider networks and their contracted reimbursement rates to an insurer, employer, or entity that provides physician network services, or to another contracting agent shall, upon entering or renewing a provider contract, disclose to the provider whether the medical provider network may be sold, leased, transferred, or conveyed to other insurers, employers, entities providing physician network services, or another contracting agent, and specify whether those insurers, employers, entities providing physician network services, or contracting agents include workers' compensation insurers.

(e) If the entity is a Health Care Service Plan, Group Disability Insurance Policy, or Taft-Hartley Health and Welfare Fund, in addition to the requirements set forth in subdivision (d) of this section, a Medical Provider Network application shall include the following information:

(1) The application shall set forth that the entity has a reasonable number of providers with competency in occupational medicine.
(A) The MPN applicant may show that a physician has competency by confirming that the physician either is Board Certified or was residency trained in that specialty.

(B) If (A) is not applicable, describe any other relevant procedure or process that assures that providers of medical treatment are competent to provide treatment for occupational injuries and illnesses.

(f) If the MPN applicant is providing for ancillary services within the MPN that are in addition to the services provided by the Health Care Organization, Health Care Service Plan, Group Disability Insurance Policy, or Taft-Hartley Health and Welfare Fund, it shall set forth the ancillary services in the application.

(g) If a Health Care Organization, Health Care Service Plan, Group Disability Insurance Policy, or Taft-Hartley Health and Welfare Fund has been approved as a MPN, and the entity does not maintain its certification or licensure or regulated status, then the entity must file a new Medical Provider Network Application pursuant to section 9767.3(d).

(h) If a Health Care Organization, Health Care Service Plan, Group Disability Insurance Policy, or Taft-Hartley Health and Welfare Fund has been modified from its certification or licensure or regulated status, the application shall comply with subdivision (d) of this section.

1. New section filed 11-1-2004 as an emergency; operative 11-1-2004 (Register 2004, No. 45). A Certificate of Compliance must be transmitted to OAL by 3-1-2005 or emergency language will be repealed by operation of law on the following day.
2. New section refiled 2-28-2005 as an emergency; operative 3-1-2005 (Register 2005, No. 9). A Certificate of Compliance must be transmitted to OAL by 6-29-2005 or emergency language will be repealed by operation of law on the following day.
3. New section refiled 6-20-2005 as an emergency; operative 6-29-2005 (Register 2005, No. 25). A Certificate of Compliance must be transmitted to OAL by 10-27-2005 or emergency language will be repealed by operation of law on the following day.
4. Certificate of Compliance as to 6-20-2005 order, including amendment of section and NOTE, transmitted to OAL 7-29-2005 and filed 9-9-2005 (Register 2005, No. 36).
5. Amendment of subsections (c)(1)-(3), (d)(6)-(7), (d)(8)(C)-(D), (d)(8)(I), (d)(8)(L), (e)(6)-(7), (e)(11), (e)(14), (f) and (i) filed 8-9-2010; operative 10-8-2010 (Register 2010, No. 33).
6. Change without regulatory effect amending subsections (c)(1), (d)(8)(I) and (e)(11) filed 9-23-2010 pursuant to section 100, title 1, California Code of Regulations (Register 2010, No. 39).
7. Amendment of section heading, section and 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(h), Labor Code. Reference: Sections 3209.3, 4609, 4616, 4616.1, 4616.2, 4616.3, 4616.5 and 4616.7, Labor Code; and Section 16.5, Government Code.

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