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

Current through Register 2024 Notice Reg. No. 28, July 12, 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.