California Labor Codes 4600.5 465

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§ Application for certification as HCO



(a) Any health care service plan licensed pursuant to the Knox-Keene Health Care Service Plan Act, a disability insurer licensed by the Department of Insurance, or any entity, including, but not limited to, workers' compensation insurers and third-party administrators authorized by the administrative director under subdivision (e), may make written application to the administrative director to become certified as a health care organization to provide health care to injured employees for injuries and diseases compensable under this article.


(b) Each application for certification shall be accompanied by a reasonable fee prescribed by the administrative director, sufficient to cover the actual cost of processing the application. A certificate is valid for the period that the director may prescribe unless sooner revoked or suspended.


(c) If the health care organization is a health care service plan licensed pursuant to the Knox-Keene Health Care Service Plan Act, the administrative director shall certify the plan to provide health care pursuant to Section 4600.3 if the director finds that the plan is in good standing with the Department of Managed Care and meets the following additional requirements: (1) Proposes to provide all medical and health care services that may be required by this article. (2) Provides a program involving cooperative efforts by the employees, the employer, and the health plan to promote workplace health and safety, consultative and other services, and early return to work for injured employees. (3) Proposes a timely and accurate method to meet the requirements set forth by the administrative director for all carriers of workers' compensation coverage to report necessary information regarding medical and health care service cost and utilization, rates of return to work, average time in medical treatment, and other measures as determined by the administrative director to enable the director to determine the effectiveness of the plan. (4) Agrees to provide the administrative director with information, reports, and records prepared and submitted to the Department of Managed Care in compliance with the Knox-Keene Health Care Service Plan Act, relating to financial solvency, provider accessibility, peer review, utilization review, and quality assurance, upon request, if the administrative director determines the information is necessary to verify that the plan is providing medical treatment to injured employees in compliance with the requirements of this code. Disclosure of peer review proceedings and records to the�administrative � director shall not alter the status of the proceedings�or � records as privileged and confidential communications pursuant to�Sections � 1370 and 1370.1 of the Health and Safety Code. � � (5) Demonstrates the capability to provide occupational medicine�and � related disciplines. � � (6) Complies with any other requirement the administrative�director � determines is necessary to provide medical services to�injured � employees consistent with the intent of this article,�including, � but not limited to, a written patient grievance policy.� �

(d) If the health care organization is a disability insurer�licensed � by the Department of Insurance, and is in compliance with�subdivision � (d) of Sections 10133 and 10133.5 of the Insurance Code,�the � administrative director shall certify the organization to provide�health � care pursuant to Section 4600.3 if the director finds that�the � plan is in good standing with the Department of Insurance and�meets � the following additional requirements:� � (1) Proposes to provide all medical and health care services that�may � be required by this article. � � (2) Provides a program involving cooperative efforts by the�employees, � the employer, and the health plan to promote workplace�health � and safety, consultative and other services, and early return�to � work for injured employees. � � (3) Proposes a timely and accurate method to meet the requirements�set � forth by the administrative director for all carriers of workers'�compensation � coverage to report necessary information regarding�medical � and health care service cost and utilization, rates of return�to � work, average time in medical treatment, and other measures as�determined � by the administrative director to enable the director to�determine � the effectiveness of the plan. � � (4) Agrees to provide the administrative director with�information, � reports, and records prepared and submitted to the�Department � of Insurance in compliance with the Insurance Code�relating � to financial solvency, provider accessibility, peer review,�utilization � review, and quality assurance, upon request, if the�administrative � director determines the information is necessary to�verify � that the plan is providing medical treatment to injured�employees � consistent with the intent of this article.� � Disclosure of peer review proceedings and records to the�administrative � director shall not alter the status of the proceedings�or � records as privileged and confidential communications pursuant to�subdivision � (d) of Section 10133 of the Insurance Code. � � (5) Demonstrates the capability to provide occupational medicine�and � related disciplines. � � (6) Complies with any other requirement the administrative�director � determines is necessary to provide medical services to�injured � employees consistent with the intent of this article,�including, � but not limited to, a written patient grievance policy.� �

(e) If the health care organization is a workers' compensation�insurer, � third-party administrator, or any other entity that the�administrative � director determines meets the requirements of Section� 4600.6, � the administrative director shall certify the organization to�provide � health care pursuant to Section 4600.3 if the director finds�that � it meets the following additional requirements:� � (1) Proposes to provide all medical and health care services that�may � be required by this article. � � (2) Provides a program involving cooperative efforts by the�employees, � the employer, and the health plan to promote workplace�health � and safety, consultative and other services, and early return�to � work for injured employees. � � (3) Proposes a timely and accurate method to meet the requirements�set � forth by the administrative director for all carriers of workers'�compensation � coverage to report necessary information regarding�medical � and health care service cost and utilization, rates of return�to � work, average time in medical treatment, and other measures as�determined � by the administrative director to enable the director to�determine � the effectiveness of the plan. � � (4) Agrees to provide the administrative director with�information, � reports, and records relating to provider accessibility,�peer � review, utilization review, quality assurance, advertising,�disclosure, � medical and financial audits, and grievance systems, upon�request, � if the administrative director determines the information�is � necessary to verify that the plan is providing medical treatment�to � injured employees consistent with the intent of this article.� � Disclosure of peer review proceedings and records to the�administrative � director shall not alter the status of the proceedings�or � records as privileged and confidential communications pursuant to�subdivision � (d) of Section 10133 of the Insurance Code. � � (5) Demonstrates the capability to provide occupational medicine�and � related disciplines. � � (6) Complies with any other requirement the administrative�director � determines is necessary to provide medical services to�injured � employees consistent with the intent of this article,�including, � but not limited to, a written patient grievance policy. � � (7) Complies with the following requirements: � � - (a) An organization certified by the administrative director under�this � subdivision may not provide or undertake to arrange for the�provision � of health care to employees, or to pay for or to reimburse�any � part of the cost of that health care in return for a prepaid or�periodic � charge paid by or on behalf of those employees. � � - (b) Every organization certified under this subdivision shall�operate � on a fee-for-service basis. As used in this section, fee for�service � refers to the situation where the amount of reimbursement�paid � by the employer to the organization or providers of health care�is � determined by the amount and type of health care rendered by the�organization � or provider of health care. � � - (c) An organization certified under this subdivision is prohibited�from � assuming risk.

� � (f) (1) A workers' compensation health care provider organization�authorized � by the Department of Corporations on December 31, 1997,�shall � be eligible for certification as a health care organization�under � subdivision (e). � � (2) An entity that had, on December 31, 1997, submitted an�application � with the Commissioner of Corporations under Part 3.2�(commencing � with Section 5150) shall be considered an applicant for�certification � under subdivision (e) and shall be entitled to priority�in � consideration of its application. The Commissioner of�Corporations � shall provide complete files for all pending�applications � to the administrative director on or before January 31,�1998.

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(g) The provisions of this section shall not affect the�confidentiality � or admission in evidence of a claimant's medical�treatment � records.

� � (h) Charges for services arranged for or provided by health care�service � plans certified by this section and that are paid on a�per-enrollee-periodic-charge � basis shall not be subject to the�schedules � adopted by the administrative director pursuant to Section� 5307.1.

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(i) Nothing in this section shall be construed to expand or�constrict � any requirements imposed by law on a health care service�plan � or insurer when operating as other than a health care�organization � pursuant to this section.

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(j) In consultation with interested parties, including the�Department � of Corporations and the Department of Insurance, the�administrative � director shall adopt rules necessary to carry out this�section.

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(k) The administrative director shall refuse to certify or may�revoke � or suspend the certification of any health care organization�under � this section if the director finds that:� � (1) The plan for providing medical treatment fails to meet the�requirements � of this section. � � (2) A health care service plan licensed by the Department of�Managed � Care, a workers' compensation health care provider�organization � authorized by the Department of Corporations, or a�carrier � licensed by the Department of Insurance is not in good�standing � with its licensing agency. � � (3) Services under the plan are not being provided in accordance�with � the terms of a certified plan.

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(l) (1) When an injured employee requests chiropractic treatment�for � work-related injuries, the health care organization shall provide�the � injured worker with access to the services of a chiropractor�pursuant � to guidelines for chiropractic care established by paragraph�(2). � Within five working days of the employee's request to see a�chiropractor, � the health care organization and any person or entity�who � directs the kind or manner of health care services for the plan�shall � refer an injured employee to an affiliated chiropractor for�work-related � injuries that are within the guidelines for chiropractic�care � established by paragraph (2). Chiropractic care rendered in�accordance � with guidelines for chiropractic care established pursuant�to � paragraph (2) shall be provided by duly licensed chiropractors�affiliated � with the plan. � � (2) The health care organization shall establish guidelines for�chiropractic � care in consultation with affiliated chiropractors who�are � participants in the health care organization's utilization review�process � for chiropractic care, which may include qualified medical�evaluators � knowledgeable in the treatment of chiropractic conditions.� � The guidelines for chiropractic care shall, at a minimum,�explicitly � require the referral of any injured employee who so�requests � to an affiliated chiropractor for the evaluation or�treatment, � or both, of neuromusculoskeletal conditions. � � (3) Whenever a dispute concerning the appropriateness or necessity�of � chiropractic care for work-related injuries arises, the dispute�shall � be resolved by the health care organization's utilization�review � process for chiropractic care in accordance with the health�care � organization's guidelines for chiropractic care established by�paragraph � (2).� � Chiropractic utilization review for work-related injuries shall � be�conducted � in accordance with the health care organization's approved�quality � assurance standards and utilization review process for�chiropractic � care. Chiropractors affiliated with the plan shall have�access � to the health care organization's provider appeals process�and, � in the case of chiropractic care for work-related injuries, the�review � shall include review by a chiropractor affiliated with the�health � care organization, as determined by the health care�organization. � � (4) The health care organization shall inform employees of the�procedures � for processing and resolving grievances, including those�related � to chiropractic care, including the location and telephone�number � where grievances may be submitted. � � (5) All guidelines for chiropractic care and utilization review�shall � be consistent with the standards of this code that require care�to � cure or relieve the effects of the industrial injury.

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(m) Individually identifiable medical information on patients�submitted � to the division shall not be subject to the California�Public � Records Act (Chapter 3.5 (commencing with Section 6250) of�Division � 7 of Title 1 of the Government Code).

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(n) (1) When an injured employee requests acupuncture treatment�for � work-related injuries, the health care organization shall provide�the � injured worker with access to the services of an acupuncturist�pursuant � to guidelines for acupuncture care established by paragraph�(2). � Within five working days of the employee's request to see an�acupuncturist, � the health care organization and any person or entity�who � directs the kind or manner of health care services for the plan�shall � refer an injured employee to an affiliated acupuncturist for�work-related � injuries that are within the guidelines for acupuncture�care � established by paragraph (2). Acupuncture care rendered in�accordance � with guidelines for acupuncture care established pursuant�to � paragraph (2) shall be provided by duly licensed acupuncturists�affiliated � with the plan. � � (2) The health care organization shall establish guidelines for�acupuncture � care in consultation with affiliated acupuncturists who�are � participants in the health care organization's utilization review�process � for acupuncture care, which may include qualified medical�evaluators. � The guidelines for acupuncture care shall, at a minimum,�explicitly � require the referral of any injured employee who so�requests � to an affiliated acupuncturist for the evaluation or�treatment, � or both, of neuromusculoskeletal conditions. � � (3) Whenever a dispute concerning the appropriateness or necessity�of � acupuncture care for work-related injuries arises, the dispute�shall � be resolved by the health care organization's utilization�review � process for acupuncture care in accordance with the health�care � organization's guidelines for acupuncture care established by�paragraph � (2).� � Acupuncture utilization review for work-related injuries shall be�conducted � in accordance with the health care organization's approved�quality � assurance standards and utilization review process for�acupuncture � care. Acupuncturists affiliated with the plan shall have�access � to the health care organization's provider appeals process�and, � in the case of acupuncture care for work-related injuries, the�review � shall include review by an acupuncturist affiliated with the�health � care organization, as determined by the health care�organization. � � (4) The health care organization shall inform employees of the�procedures � for processing and resolving grievances, including those�related � to acupuncture care, including the location and telephone�number � where grievances may be submitted. � � (5) All guidelines for acupuncture care and utilization review�shall � be consistent with the standards of this code that require care�to � cure or relieve the effects of the industrial injury.

�History: � Amended 1999, but not operative until the Governor, by�executive � order, establishes the Department of Managed�Care, � or 07/01/00, whichever occurs first.