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 9767.10 - Continuity of Care Policy

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a) At the request of a covered employee, an
					 insurer, employer, or an entity that provides physician network services that
					 offers a medical provider network shall complete the treatment by a terminated
					 provider as set forth in Labor Code sections
					 4616.2(d) and
					 (e).
(b) An "acute condition," as referred to in
					 Labor Code section
					 4616.2(d)(3)(A),
					 shall have a duration of less than ninety days.
(c) "An extended period of time," as referred
					 to in Labor Code section
					 4616.2(d)(3)(B)
					 with regard to a serious and chronic condition, means a duration of at least
					 ninety days.
(d) The MPN
					 applicant's continuity of care policy shall include a dispute resolution
					 procedure that contains the following requirements:
(1) Following the employer's or insurer's
					 determination of the injured covered employee's medical condition, the
					 employer, insurer, or an entity that provides physician network services shall
					 notify the covered employee of the determination regarding the completion of
					 treatment and whether or not the employee will be required to select a new
					 provider from within the MPN. The notification shall be sent to the covered
					 employee's address and a copy of the letter shall be sent to the covered
					 employee's primary treating physician. The notification shall be written in
					 English and Spanish and use layperson's terms to the maximum extent
					 possible.
(2) If the terminated
					 provider agrees to continue treating the injured covered employee in accordance
					 with Labor Code section
					 4616.2 and if
					 the injured covered employee disputes the medical determination, the injured
					 covered employee shall request a report from the covered employee's primary
					 treating physician that addresses whether the covered employee falls within any
					 of the conditions set forth in Labor Code section
					 4616.2(d)(3);
					 an acute condition; a serious chronic condition; a terminal illness; or a
					 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 of the
					 contract's termination date. The treating physician shall provide the report to
					 the covered employee within twenty calendar days of the request. If the
					 treating physician fails to issue the report, then the determination made by
					 the employer or insurer referred to in (d)(1) shall apply.
(3) If the employer or insurer or injured
					 covered employee objects to the medical determination by the treating
					 physician, the dispute regarding the medical determination made by the treating
					 physician concerning the continuity of care shall be resolved pursuant to Labor
					 Code section
					 4062.
(4) If the treating physician agrees with the
					 employer's or insurer's determination that the injured covered employee's
					 medical condition does not meet the conditions set forth in Labor Code section
					 4616.2(d)(3),
					 the employee shall choose a new provider from within the MPN during the dispute
					 resolution process.
(5) If the
					 treating physician does not agree with the employer's or insurer's
					 determination that the injured covered employee's medical condition does not
					 meet the conditions set forth in Labor Code section
					 4616.2(d)(3),
					 the injured covered employee shall continue to treat with the terminated
					 provider until the dispute is resolved.