Current through Register 2024 Notice Reg. No. 38, September 20, 2024
(a)
Any aggrieved person or entity may file a petition appealing a determination of
the Administrative Director to:
(1) Deny a
medical provider network (MPN) application;
(2) Revoke or suspend an MPN plan;
(3) Place an MPN plan on probation;
(4) Deny a petition to revoke or suspend an
MPN plan; or
(5) Impose
administrative penalties relating to an MPN.
(b) The petition shall be filed only as
follows:
(1) The petition shall be filed no
later than 20 days after the date of service of the Administrative Director's
determination. An untimely petition may be summarily dismissed.
(2) Notwithstanding any other provision of
these rules or of Administrative Director rules 9767.8(i), 9767.13(f) and
9767.14(f), the petition shall be filed solely in paper form directly with the
Office of the Commissioners of the Workers' Compensation Appeals
Board.
(3) The petition shall not
be submitted to any district office of the Workers' Compensation Appeals Board,
including the San Francisco District Office, and it shall not be submitted
electronically.
(4) A petition
submitted in violation of this subdivision shall neither be accepted for filing
nor deemed filed and shall not be acknowledged or returned to the submitting
party.
(c) The caption of
the petition shall identify it as a "Petition Appealing Administrative
Director's Medical Provider Network Determination."
(d) The caption of the petition shall
include:
(1) The name of the MPN or MPN
applicant;
(2) The identity of the
petitioner; and
(3) The case number
assigned by the Administrative Director to the MPN
determination.
(e) The
petition shall include a copy of the Administrative Director's determination
and proof of service of that determination.
(f) The petition shall comply with each of
the following provisions:
(1) The petition
may appeal the Administrative Director's determination upon one or more of the
following grounds and no other:
(A) The
determination was without or in excess of the Administrative Director's
powers;
(B) The determination was
procured by fraud;
(C) The evidence
does not justify the determination;
(D) The petitioner has discovered new
material evidence, which the petitioner could not, with reasonable diligence,
have discovered and presented to the Administrative Director prior to the
determination; and/or
(E) The
Administrative Director's findings of fact do not support the
determination.
(2) The
petition shall set forth specifically and in full detail the factual and/or
legal grounds upon which the petitioner considers the determination of the
Administrative Director to be unjust or unlawful, and every issue to be
considered by the Workers' Compensation Appeals Board. The petitioner shall be
deemed to have finally waived all objections, irregularities and illegalities
concerning the Administrative Director's determination other than those set
forth in the petition appealing.
(3) The petition shall comply with the
requirements of rules 10945(a) and (c), and 10972. It shall also comply with
the provisions of rule 10940, including but not limited to the 25-page
restriction.
(4) Any failure to
comply with the provisions of this subdivision shall constitute valid ground
for summarily dismissing or denying the petition.
(g) A copy of the petition shall be
concurrently served on the Division of Workers' Compensation, Medical Provider
Network Unit (MPN Unit).
(h) The
petition shall be assigned to a panel of the Appeals Board in accordance with
Labor Code section
115.
(i) Within 30 days after the filing of an
answer or the lapse of the time allowed for filing one, the Appeals Board shall
issue a notice for an evidentiary hearing regarding the petition. The
evidentiary hearing shall be set for the purposes of specifying the issue(s) in
dispute and any stipulations, taking testimony, and listing and identifying any
documentary evidence offered. The proceedings shall be transcribed by a court
reporter, which the Appeals Board in its discretion may order the petitioner to
provide. The Appeals Board also may order the petitioner to pay the costs of
the transcript(s) of the evidentiary hearing.
(j) In its discretion, the Appeals Board may
provide that the evidentiary hearing shall be conducted by:
(1) One or more commissioners of the Appeals
Board; or
(2) A workers'
compensation judge appointed under Labor Code section 5309(b) for the sole
purpose of holding hearings and ascertaining facts necessary to enable the
Appeals Board to render a decision on the petition; a workers' compensation
judge appointed for this purpose shall not render any factual determinations,
but may make a recommendation regarding the credibility of any witness(es)
presented.
The time, date, length and place of the evidentiary
hearing shall be determined by the Appeals Board in its
discretion.
(k)
The assigned panel of the Appeals Board shall determine when the petition is
submitted for decision. Within 60 days after submission, the panel shall render
a decision on the petition unless, within that time, the panel orders that the
time be extended so that it may further study the facts and relevant
law.
(l) Where a timely request to
the Administrative Director for a re-evaluation of an initial determination is
filed in accordance with rules 9767.8(f), 9767.13(c), and 9767.14(c), the
following procedures shall apply:
(1) If a
request for re-evaluation is made to the Administrative Director prior to
filing a petition with the Office of the Commissioners of the Appeals Board,
the time for filing such a petition shall be tolled until the Administrative
Director files and serves a decision and order regarding the request for
re-evaluation.
(2) If a request for
re-evaluation is made to the Administrative Director after a petition appealing
the Administrative Director's initial determination is filed with the Office of
the Commissioners of the Appeals Board, the petitioner shall file a copy of the
re-evaluation request with the Office of the Commissioners in accordance with
subdivisions (b)(2) and (b)(3), together with a cover letter requesting that
its petition be dismissed without prejudice. A copy of the cover letter and
request for re-evaluation shall be concurrently served on the Division of
Workers' Compensation MPN Unit.
1.
Amendment filed 12-19-2002; operative 1-1-2003. Submitted to OAL for printing
only pursuant to Government Code section
11351
(Register 2002, No. 51).
2. Renumbering of former section 10580 to
section 10672 and renumbering and amendment
of former section
10959 to section 10580 filed
12-17-2019; operative 1-1-2020. Submitted to OAL for printing only pursuant to
Government Code section
11351
(Register 2019, No. 51).
Note: Authority cited: Sections
133,
5307,
5309 and
5708, Labor
Code. Reference: Sections 4616 et seq., 5300(f), 5309 and 5900 et seq., Labor
Code.
