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 9767.9 - Transfer of Ongoing Care into the MPN

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a) If the injured covered employee's injury
					 or illness does not meet the conditions set forth in (e)(1) through (e)(4), the
					 injured covered employee may be transferred into the MPN for medical treatment,
					 unless otherwise authorized by the employer or insurer.
(b) Until the injured covered employee is
					 transferred into the MPN, the employee's physician may make referrals to
					 providers within or outside the MPN.
(c) Nothing in this section shall preclude an
					 insurer or employer from agreeing to provide medical care with providers
					 outside of the MPN.
(d) If an
					 injured covered employee is being treated for an occupational injury or illness
					 by a physician or provider prior to coverage of a medical provider network, and
					 the injured covered employee's physician or provider becomes a provider within
					 the MPN that applies to the injured covered employee, then the employer,
					 insurer, or entity that provides physician network services shall inform the
					 injured covered employee and his or her physician or provider if his/her
					 treatment is being provided by his/her physician or provider under the
					 provisions of the MPN.
(e) The
					 employer or insurer shall authorize the completion of treatment for injured
					 covered employees who are being treated outside of the MPN for an occupational
					 injury or illness that occurred prior to the coverage of the MPN and whose
					 treating physician is not a provider within the MPN, including injured covered
					 employees who pre-designated a physician and do not fall within the Labor Code
					 section
					 4600(d),
					 for the following conditions:
(1) An acute
					 condition. For purposes of this subdivision, an acute condition is a medical
					 condition that involves a sudden onset of symptoms due to an illness, injury,
					 or other medical problem that requires prompt medical attention and that has a
					 duration of less than 90 days. Completion of treatment shall be provided for
					 the duration of the acute condition.
(2) A serious chronic condition. For purposes
					 of this subdivision, a serious chronic condition is a medical condition due to
					 a disease, illness, catastrophic injury, or other medical problem or medical
					 disorder that is serious in nature and that persists without full cure or
					 worsens over 90 days and requires ongoing treatment to maintain remission or
					 prevent deterioration. Completion of treatment shall be authorized for a period
					 of time necessary, up to one year:
(A) to
					 complete a course of treatment approved by the employer or insurer;
					 and
(B) to arrange for transfer to
					 another provider within the MPN, as determined by the insurer, employer, or
					 entity that provides physician network services. The one year period for
					 completion of treatment starts from the date of the injured covered employee's
					 receipt of the notification, as required by subdivision (f), of the
					 determination that the employee has a serious chronic
					 condition.
(3) A terminal
					 illness. For purposes of this subdivision, a terminal illness is an incurable
					 or irreversible condition that has a high probability of causing death within
					 one year or less. Completion of treatment shall be provided for the duration of
					 a terminal illness.
(4) Performance
					 of a surgery or other procedure that is authorized by the insurer or employer
					 as part of a documented course of treatment and has been recommended and
					 documented by the provider to occur within 180 days from the MPN coverage
					 effective date.