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 9767.3 - Requirements for a Medical Provider Network Plan

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a) As long as the application for a medical
					 provider network plan meets the requirements of Labor Code section
					 4616 et seq.
					 and this article, nothing in this section precludes an employer or insurer or
					 entity that provides physician network services from submitting for approval
					 one or more medical provider network applications.
(b) Nothing in this section precludes an MPN
					 applicant from agreeing to submit for approval a medical provider network plan
					 which meets the specific needs of an insured employer considering the
					 experience of the insured employer, the common injuries experienced by the
					 insured employer, the type of occupation and industry in which the insured
					 employer is engaged and the geographic area where the employees are
					 employed.
(c) All MPN applicants
					 shall complete the section
					 9767.4 Cover Page for Medical
					 Provider Network Application or Plan for Reapproval with an original signature,
					 and an MPN Plan meeting the requirements of this section or the optional MPN
					 Plan Application form. Two copies of the completed, signed Cover Page for
					 Medical Provider Network Application or Plan for Reapproval and the complete
					 MPN Plan shall be submitted to the DWC in compact discs or flash drives in
					 word-searchable PDF format. The hard copy of the completed, signed original
					 Cover Page for Medical Provider Network Application or Plan for Reapproval and
					 the complete MPN Plan shall be maintained by the MPN applicant and made
					 available for review by the Administrative Director upon request. Electronic
					 signatures in compliance with California Government Code section
					 16.5 are
					 accepted.
(1) An MPN applicant shall submit
					 the MPN provider information and ancillary service provider information
					 required in section
					 9767.3(d)(8)(G) and
					 (I) in a compact disc(s) or, a flash
					 drive(s). The information shall be submitted as a Microsoft Excel spread sheet
					 unless an alternative format is approved by the Administrative Director. If the
					 MPN applicant is using a valid and currently certified Health Care
					 Organization, then this information must be noted on the application's Cover
					 Page for Medical Provider Network or Plan for Reapproval and only a listing of
					 any additional ancillary service providers is required to be submitted pursuant
					 to the requirements in subsection (3) of this subdivision.
(2) The network provider information shall be
					 submitted in a compact disc(s), or a flash drive(s), and the provider file
					 shall have only the following eight columns. These columns shall be in the
					 following order: (1) physician name (2) specialty (3) physical address (4) city
					 (5) state (6) zip code (7) any MPN medical group affiliations and (8) an
					 assigned provider code for each physician listed. If a physician falls under
					 more than one provider code, the physician shall be listed separately for each
					 applicable provider code. The following are the provider codes to be used:
					 primary treating physician (PTP), orthopedic medicine (ORTHO), chiropractic
					 medicine (DC), occupational medicine (OCCM), acupuncture medicine (LAC),
					 psychology (PSYCH), pain specialty medicine (PM), psychiatry (PSY),
					 neurosurgery (NSG), family medicine (GP), neurology (NEURO), internal medicine
					 (IM), physical medicine and rehabilitation (PMR), or podiatry (DPM). If the
					 specialty does not fall under any one of the previously listed categories, then
					 the specialty shall be clearly identified in the specialty column and the code
					 used shall be (MISC). By submission of its provider listing, the applicant is
					 affirming that all of the physicians listed have been informed that the Medical
					 Treatment Utilization Schedule ("MTUS") is presumptively correct on the issue
					 of the extent and scope of medical treatment and diagnostic services and have a
					 valid and current license number to practice in the State of
					 California.
(3) If an MPN chooses
					 to provide ancillary services, the ancillary service provider file shall have
					 only the following six columns. The columns shall be in the following order:
					 (1) the name of each ancillary service provider (2) specialty or type of
					 service (3) physical address (4) city (5) state (6) zip code of each ancillary
					 service provider. If the ancillary service or ancillary service provider is
					 mobile, list the covered service area within California. By submission of an
					 ancillary provider listing, the applicant is affirming that the providers
					 listed can provide the requested medical services or goods and have a current
					 valid license number or certification to practice, if they are required to have
					 a license or certification by the State of California. If interpreter services
					 are included as an MPN ancillary service, the interpreters listed must be
					 certified pursuant to section
					 9795.1.6(a)(2)(A) and
					 (B).
(4) An MPN determines which locations are
					 approved for physicians to provide treatment under the MPN. Approved locations
					 are listed in an MPN's provider listing; however, an MPN has the discretion to
					 approve treatment at non-listed locations.
(5) An MPN applicant shall have the exclusive
					 right to determine the members of its network.