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 9767.1 - Medical Provider Networks - Definitions

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a) As used in this article:
(1) "Ancillary services" means any provision
					 of medical services or goods as allowed in Labor Code section
					 4600 by a
					 non-physician, including, but not limited to, interpreter services, physical
					 therapy and pharmaceutical services.
(2) "Covered employee" means an employee or
					 former employee whose employer has ongoing workers' compensation obligations
					 and whose employer or employer's insurer is using a Medical Provider Network
					 for the provision of medical treatment to injured employees unless:
(A) the injured employee has properly
					 designated a personal physician pursuant to Labor Code section
					 4600(d)
					 by notice to the employer prior to the date of injury, or;
(B) the injured employee's employment with
					 the employer is covered by an agreement providing medical treatment for the
					 injured employee and the agreement is validly established under Labor Code
					 section
					 3201.5,
					 3201.7 or
					 3201.81.
(3) "Division" means the Division of Workers'
					 Compensation.
(4) "Economic
					 profiling" means any evaluation of a particular physician, provider, medical
					 group, or individual practice association based in whole or in part on the
					 economic costs or utilization of services associated with medical care provided
					 or authorized by the physician, provider, medical group, or individual practice
					 association.
(5) "Emergency health
					 care services" means health care services for a medical condition manifesting
					 itself by acute symptoms of sufficient severity such that the absence of
					 immediate medical attention could reasonably be expected to place the patient's
					 health in serious jeopardy.
(6)
					 "Employer" means a self-insured employer, the Self-Insurer's Security Fund, a
					 group of self-insured employers pursuant to Labor Code section
					 3700(b)
					 and as defined by Title 8, California Code of Regulations, section
					 15201(s), a joint
					 powers authority, or the state.
(7)
					 "Entity that provides physician network services" means a legal entity
					 employing or contracting with physicians and other medical providers or
					 contracting with physician networks, and may include but is not limited to
					 third party administrators and managed care entities, to deliver medical
					 treatment to injured workers on behalf of one or more insurers, self-insured
					 employers, the Uninsured Employers Benefits Trust Fund, the California
					 Insurance Guaranty Association, or the Self-Insurers Security Fund, and that
					 meets the requirements of this article, Labor Code 4616 et seq., and
					 corresponding regulations.
(8)
					 "Geocoding" means the mapping of addresses within specific geographic
					 location(s) or coordinate space.
(9) "Group Disability Insurance Policy" means
					 an entity designated pursuant to Labor Code section
					 4616.7(c).
(10) "Health Care Organization" means an
					 entity designated pursuant to Labor Code section
					 4616.7(a).
(11) "Health Care Service Plan" means an
					 entity designated pursuant to Labor Code section
					 4616.7(b).
(12) "Health care shortage" means a situation
					 in a geographical area in which the number of physicians in a particular
					 specialty who are available and willing to treat injured workers under the
					 California workers' compensation system is insufficient to meet the Medical
					 Provider Network access standards set forth in 9767.5(a) through (c) to ensure
					 medical treatment is available and accessible at reasonable times. A lack of
					 physicians participating in an MPN does not constitute a health care shortage
					 where a sufficient number of physicians in that specialty are available within
					 the access standards and willing to treat injured workers under the California
					 workers' compensation system.
(13)
					 "Insurer" means an insurer admitted to transact workers' compensation insurance
					 in the state of California, California Insurance Guarantee Association, or the
					 State Compensation Insurance Fund.
(14) "Medical Provider Network" ("MPN") means
					 any entity or group of providers approved as a Medical Provider Network by the
					 Administrative Director pursuant to Labor Code sections
					 4616 to
					 4616.7 and this
					 article.
(15) "Medical Provider
					 Network Identification Number" means the unique number assigned by DWC to a
					 Medical Provider Network upon approval or within ninety (90) days of the
					 effective date of these regulations and used to identify each approved Medical
					 Provider Network.
(16) "Medical
					 Provider Network Medical Access Assistant" means an individual in the United
					 States provided by the Medical Provider Network to help injured workers with
					 finding available Medical Provider Network physicians of the injured workers'
					 choice and with scheduling provider appointments.
(17) "Medical Provider Network Geographic
					 Service Area" means the geographic area within California in which medical
					 services will be provided by the Medical Provider Network.
(18) "Medical Provider Network Plan" means an
					 employer's, insurer's, or entity that provides physician network services'
					 detailed description for a Medical Provider Network contained in a complete
					 application submitted according to the requirements of this article to the
					 Administrative Director by an MPN Applicant.
(19) "MPN Applicant" means an insurer or
					 employer or an entity that provides physician network services as defined in
					 this section who is legally responsible for the Medical Provider
					 Network.
(20) "MPN Contact" means
					 an individual(s) designated by the MPN Applicant in the employee notification
					 who is responsible for responding to complaints, for answering employees'
					 questions about the Medical Provider Network and for assisting the employee in
					 arranging for an MPN independent medical review pursuant to Labor Code section
					 4616.4.
(21) "Occupational Medicine" means the
					 diagnosis or treatment of any injury or disease arising out of and in the
					 course of employment.
(22) "Primary
					 treating physician" means a primary treating physician within the medical
					 provider network and as defined by section
					 9785(a)(1).
(23) "Probation" means a Medical Provider
					 Network's approval is conditioned on the completion of specified actions within
					 a stated time frame as required by the Administrative Director for the Medical
					 Provider Network to comply with the requirements of this article and Labor Code
					 sections
					 4616 et
					 seq.
(24) "Provider" means a
					 physician as described in Labor Code section
					 3209.3 or other
					 practitioner as described in Labor Code section
					 3209.5.
(25) "Regional area listing" means either:
(A) a listing of all MPN providers within a
					 15-mile radius of an employee's worksite or residence; or
(B) a listing of all MPN providers in the
					 county where the employee resides or works if
1. the employer or insurer cannot produce a
					 provider listing based on a mile radius
2. or by choice of the employer or insurer,
					 or upon request of the employee.
(C) If the listing described in either (A) or
					 (B) does not provide a minimum of three physicians of each specialty, then the
					 listing shall be expanded by adjacent counties or by 5-mile increments until
					 the minimum number of physicians per specialty are met.
(26) "Residence" means the covered employee's
					 primary residence.
(27)
					 "Revocation" means the permanent termination of a Medical Provider Network's
					 approval.
(28) "Second Opinion"
					 means an opinion rendered by a medical provider network physician after an in
					 person examination to address an employee's dispute over either the diagnosis
					 or the treatment prescribed by the treating physician, pursuant to Labor Code
					 section
					 4616.3.
(29) "Suspension" means the temporary
					 discontinuance of MPN coverage for new claims within a specified period as
					 required by the Administrative Director.
(30) "Taft-Hartley health and welfare fund"
					 means an entity designated pursuant to Labor Code section
					 4616.7(d).
(31) "Termination" means the permanent
					 discontinued use of an implemented MPN that ceases to do business.
(32) "Third Opinion" means an opinion
					 rendered by a medical provider network physician after an in person examination
					 to address an employee's dispute over either the diagnosis or the treatment
					 prescribed by either the treating physician or physician rendering the second
					 opinion, pursuant to Labor Code section
					 4616.3.
(33) "Treating physician" means any physician
					 within the MPN applicant's medical provider network other than the primary
					 treating physician who examines or provides treatment to the employee, but is
					 not primarily responsible for continuing management of the care of the
					 employee.
(34) "Withdrawal" means
					 the permanent discontinuance of an approved MPN that was never
					 implemented.
(35) "Workplace" means
					 the geographic location where the covered employee is regularly
					 employed.