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 4 - Certification Standards for Health Care Organizations › Section 9771.70 - Contracts with Providers

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
Written contracts must be executed between the
						organization and each provider of workers' compensation health care which
						regularly furnishes health care under the organization. All contracts with
						providers shall be subject to the following requirements:
(a) A written contract shall be prepared or
					 arranged in a manner which permits confidential treatment by the Administrative
					 Director of payment rendered or to be rendered to the provider without
					 concealment or misunderstanding of other terms and provisions of the
					 contract.
(b) The contract shall
					 require that the provider submit claims for workers' compensation health care
					 services to the organization within a reasonable period of time following the
					 delivery of health care services to an employee.
Contracts which contain the following language shall be
						deemed to meet the timing requirements of this subsection (b), and there shall
						be no other agreements or other language in the contract which negates or
						diminishes the effect of the following language:
"[Name of Provider] shall submit claims for the cost of
						workers' compensation health care services to [Organization] according to the
						compensation provisions of [Section and paragraph] of this agreement, within 60
						days after [Name of Provider] has rendered the workers' compensation health
						care services to the employee. However, failure to submit claims within 60 days
						does not alter the obligation of the organization to pay claims of contracting
						providers for which the organization has received payment."
(c) The contract shall provide that the
					 organization shall forward claims from providers to the self-insured employer,
					 group of self-insured employers or insurers of employers within 30 days after
					 receipt of the claim from the provider, and that the organization shall pay the
					 provider's claim no later than 30 days after receiving payment from the
					 self-insured employer, group of self-insured employers or insurer of
					 employers.
(d) The contract shall
					 require that the provider maintain such records and provide such information to
					 the organization or to the Administrative Director as may be necessary for
					 compliance by the organization with the provisions of the Code and the rules
					 thereunder, that such records will be retained by the provider for at least
					 five years, and that such obligation is not terminated upon a termination of
					 the agreement, whether by rescission or otherwise. (See Rule 9771.83) Contracts
					 which contain the following language shall be deemed to meet the requirements
					 of this subsection (d), and there shall be no other agreements or other
					 language in the contract which negates or diminishes the effect of the
					 following language:
"[Name of Provider] shall maintain all books, records of
						account, medical records, reports and papers as may be necessary for compliance
						by the organization with the provisions of Labor Code Section
						4600.6 and the
						rules thereunder. All such books, records and reports shall be available to the
						organization or to the Administrative Director, as necessary or required, under
						the Act and Rules.
All such books, records, reports and papers must be
						maintained for at least five years after the initial date of delivery of health
						care services under this Agreement. The obligation of [Name of Provider] to
						maintain books, records, reports and papers and to make them available shall
						not terminate upon the termination of [this Agreement]."
(e) The contract shall require that the
					 organization shall have access at reasonable times upon demand to the books,
					 records and papers of the provider relating to the workers' compensation health
					 care provided to employees, to the cost thereof, to payments received by the
					 provider from the organization, self-insured employer, group of self-insured
					 employers, an insurer of an employer, employee, or from others on the behalf of
					 the foregoing.
Contracts which contain the following language shall be
						deemed to meet the requirements of this subsection (e), and there shall be no
						other agreements or other language in the contract which negates or diminishes
						the effect of the following language:
"The [Organization] shall have access during regular
						business hours to all administrative, financial and medical books, records
						reports and papers relating to the delivery of workers' compensation health
						care to employees, and to the cost of such delivery, payments received by [the
						Provider] from [the Organization] and/or any self-insured employer, group of
						self-insured employers, or insurer of an employer, an employee, or
						others."
(f) The contract
					 shall prohibit surcharges or other payments in violation of the Labor Code for
					 workers' compensation health care services and shall provide that whenever the
					 organization receives notice of any such surcharge it shall take appropriate
					 action.
(g) The contract shall
					 disclose whether there are any other agreements between the organization and
					 the provider, and shall incorporate by reference all such other agreements.
					 Contracts which contain the following language shall be deemed to meet the
					 requirements of this subsection (g):
"This [Agreement], including all addenda, supersedes any
						and all other agreements between [the Organization] and [the Provider] which
						are not attached hereto and incorporated herein and which are related to the
						delivery of, or to the compensation for, workers' compensation health care
						services. No future statements or promises relating to the delivery of workers'
						compensation health care services shall be valid or binding unless written and
						incorporated herein as addenda, subject to the approval of the Administrative
						Director".
(h) The contract
					 shall contain provisions complying with Section
					 4600.6(n) of the
					 Code and shall comply with the provisions of subsection (a)(7) of Rule
					 9771.69.
(i) The contract shall
					 require that the provider cooperate with the organization's quality assurance
					 and utilization review system established pursuant to Section
					 4600.6(k) of the
					 Code, and cooperate with the Administrative Director in accordance with the
					 provisions of Section
					 4600.6(o) of the
					 Code and Sections
					 9771.76 and
					 9771.77 of the Rules.
1. New
						section filed 4-15-98; operative 4-15-98. Submitted to OAL for printing only
						pursuant to Stats. 1997, Ch. 346, Section
						5 (Register 98, No.
						16).
Note: Authority cited: Stats. 1997, Ch. 346, Section
						  5. Reference: Sections
						  4600.3,
						  4500.5 and
						  4600.6, Labor
						  Code.