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 9767.8 - Modification of Medical Provider Network Plan
Current through Register 2024 Notice Reg. No. 38, September 20, 2024
(a) The MPN applicant shall serve the Administrative Director with two copies of the completed, signed Notice of MPN Plan Modification and any necessary documentation in compact discs or flash drives in word-searchable PDF format. The hard copy of the original signed Notice of Medical Provider Network Plan Modification form and any necessary documentation 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. The MPN applicant shall serve these documents with the Administrative Director within the stated time frames or if no time frame is stated, then before any of the following changes occur:
(b) Failure to file a material modification within the requisite time frame may result in administrative actions pursuant to sections 9767.14 and/or 9767.19.
(c) The modification must be verified by an officer or employee of the MPN 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 notice and know the contents thereof, and verify that, to the best of my knowledge and belief, the information included in this modification is true and correct."
(d) Within 60 days of the Administrative Director's receipt of a Notice of MPN Plan Modification, the Administrative Director shall approve or disapprove the plan modification based on information provided in the Notice of MPN Plan Modification. The Administrative Director shall approve or disapprove a plan modification based on the requirements of Labor Code section 4616 et seq. and this article. If the Administrative Director has not acted on a plan within 60 days of submittal of a Notice of MPN Plan Modification, it shall be deemed approved. Except for subdivisions (a)(2), (a)(3) and (b) of this section, modifications shall not be made until the Administrative Director has approved the plan or until 60 days have passed, whichever occurs first. If the Administrative Director disapproves of the MPN plan modification, he or she shall serve the MPN applicant with a Notice of Disapproval within 60 days of the submittal of a Notice of MPN Plan Modification.
(e) A MPN applicant denied approval of a MPN plan modification may either:
(f) Any MPN applicant may request a re-evaluation of the denial by submitting with the Division, within 20 days of the issuance of the Notice of Disapproval, a written request for a re-evaluation with a detailed statement explaining the basis upon which a re-evaluation is requested. The request for re-evaluation shall be accompanied by supportive documentary material relevant to the specific allegations raised and shall be verified under penalty of perjury. The MPN application and modification at issue shall not be refiled; they shall be made part of the administrative record by incorporation by reference.
(g) The Administrative Director shall, within 45 days of the receipt of the request for a re-evaluation, either:
(h) The Administrative Director may extend the time specified in subdivision (g) within which to act upon the request for a re-evaluation for a period of 30 days and may order a party to submit additional documents or information.
(i) An MPN applicant may appeal the Administrative Director's decision and order regarding the MPN by filing, within twenty (20) days of the issuance of the decision and order, a "Petition Appealing Administrative Director's Medical Provider Network Determination" with the Workers' Compensation Appeals Board pursuant to WCAB Rule 10959. A copy of the petition shall be concurrently served on the Administrative Director.
(j) The MPN applicant shall use the following Notice of MPN Plan Modification form:
| For DWC only: MPN Identification Number | Date Notice Received: / / |
| Notice of Medical Provider Network Plan Modification § 9767.8 | |
| 1. Legal Name of MPN Applicant___________________________ | |
| 2. Name of MPN and MPN Identification Number:___________________________ | |
| 3. MPN Applicant Address | 4. Tax Identification Number |
| ___________________________ | __ __--__ __ __ __ __ __ __ |
| ___________________________ |
| ___________________________ | |||
| Name of Authorized Individual | Title | Organization | |
| ___________________________ | |||
| Phone | |||
| ___________________________ | |||
| Signature of Authorized Individual | Date Signed | ||
| ___________________________ | |||
| Name | Title | Organization | |
| ___________________________ | |||
| Phone | |||
| ___________________________ | |||
| Address | Fax number | ||
___________________________
___________________________
___________________________
[] Change of MPN name or MPN Applicant name: Provide new name and plan sections affected by the change within fifteen (15) business days of the change.
[] Change in MPN Applicant eligibility status. Provide date of change in eligibility and reason for change. Must file within fifteen (15) business days of change in status.
[] Change of Division Liaison or Authorized Individual: Provide the name and contact information within fifteen (15) business days of change.
[] Change in MPN Service Area: Provide documentation in compliance with section 9767.5.
[] Change in continuity of care policy: Provide a copy of the revised written continuity of care policy.
[] Change in transfer of care policy. Provide a copy of the revised written transfer of care policy.
[] Change in Economic Profiling policy used by MPN Applicant or any entity contracted with MPN: Provide a copy of the revised policy or procedure.
[] Change in how the MPN complies with the access standards: Explain what change has been made and describe how the MPN still complies with the access standards.
[] Change in employee notification materials, including a change in MPN contact or Medical Access Assistants contact information, or a change in provider listing access or MPN website information: Provide a copy of the revised notification materials.
[] Change in use of one of the following Deemed Entities: Health Care Organization (HCO), Health Care Service Plan, Group Disability Insurer, or Taft-Hartley Health and Welfare Trust Fund.
Please state change: ________________________________________ From To ________________________________________
[] Revision of any plan section(s) required by sections 9767.3(d)(8) or 9767.3(e) resulting from a change of any MPN administrator(s) listed in the MPN Plan. Please include complete sections revised.
[] Replacement of entire plan application. Please state why and include entire revised plan.
[] Update of MPN plan to the current regulations pursuant to section 9767.15. Please include entire updated plan.
Submit two copies of the completed, signed Notice of MPN Plan Modification and any necessary documentation in compact discs or flash drives in word-searchable PDF format to the Division of Workers' Compensation. Mailing address: DWC, MPN Application, P.O. Box 71010, Oakland, CA 94612.
[DWC Mandatory Form -- Section 9767.8 -- 5/14]
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. Change without regulatory effect
amending form filed 5-23-2007 pursuant to section
100, title 1, California Code of
Regulations (Register 2007, No. 21).
6. Amendment of subsections
(a)(5)-(6) and (a)(9), new subsections (a)(10)-(13) and amendment of
subsections (b)-(d), (g)(2) and (j) filed 8-9-2010; operative 10-8-2010
(Register 2010, No. 33).
7. Amendment of section, including
amendment of DWC Mandatory Form -- Section 9767.8, 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).
8. Governor Newsom issued Executive Order
N-63-20 (2019 CA EO 63-20), dated May 7, 2020, which extended certain deadlines
for action on Medical Provider Network applications or requests for
modifications or reapprovals, due to the COVID-19
pandemic.
Note: Authority cited: Sections 133, 4616(h) and 5300(f), Labor Code. Reference: Sections 3700, 3743, 4616, 4616.2 and 4616.5, Labor Code.
