California Regulations 9767.1

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§ 9767.1 Medical Provider Networks -- Definitions

History:



(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.

(2) "Cessation of use" means the discontinued use of an implemented MPN that continues to do business.

(3) "Covered employee" means an employee or former employee whose employer has ongoing workers' compensation obligations and whose employer or employer's insurer has established 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 and/or 3201.81.

(4) "Division" means the Division of Workers' Compensation.

(5) "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.

(6) "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.

(7) "Employer" means a self-insured employer, the Self-Insurer's Security Fund, a group of selfinsured 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.

(8) "Group Disability Insurance Policy" means an entity designated pursuant to Labor Code section 4616.7(c).

(9) "Health Care Organization" means an entity designated pursuant to Labor Code section 4616.7(a).

(10) "Health Care Service Plan" means an entity designated pursuant to Labor Code section 4616.7(b).

(11) "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.

(12) "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.

(13) "Medical Provider Network Plan" means an employer's or insurer's detailed description for a medical provider network contained in an application submitted to the Administrative Director by a MPN applicant.

(14) "MPN Applicant" means an insurer or employer as defined in subdivisions (7) and (11) of this section.

(15) "MPN Contact" means the individual(s) designated by the MPN Applicant in the employee notification who is responsible for answering employees' questions about the Medical Provider Network and is responsible for assisting the employee in arranging for an independent medical review.

(16) "Nonoccupational Medicine" means the diagnosis or treatment of any injury or disease not arising out of and in the course of employment.

(17) "Occupational Medicine" means the diagnosis or treatment of any injury or disease arising out of and in the course of employment.

(18) "Physician primarily engaged in treatment of nonoccupational injuries" means a provider who spends more than 50 percent of his/her practice time providing non-occupational medical services.

(19) "Primary treating physician" means a primary treating physician within the medical provider network and as defined by section 9785(a)(1).

(20) "Provider" means a physician as described in Labor Code section 3209.3 or other provider as described in Labor Code section 3209.5.

(21) "Regional area listing" means either:

A) a listing of all MPN providers within a 15-mile radius of an employee's worksite and/or residence; or

B) a listing of all MPN providers in the county where the employee resides and/or works if 1. the employer or insurer cannot produce a provider listing based on a mile radius or 2. 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.

(22) "Residence" means the covered employee's primary residence.

(23) "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.

(24) "Taft-Hartley health and welfare fund" means an entity designated pursuant to Labor Code section 4616.7(d).

(25) "Termination" means the discontinued use of an implemented MPN that ceases to do business.

(26) "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.

(27) "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.

(28) "Workplace" means the geographic location where the covered employee is regularly employed.

Authority: Sections 133 and 4616(g), Labor Code.

Reference: Sections 1063.1, 3208, 3209.3, 3209.5, 3700, 3702, 3743, 4616, 4616.1, 4616.3, 4616.5 and 4616.7, Labor Code; California Insurance Guarantee Association v. Division of Workers' Compensation (April 26, 2005) WCAB No. Misc. #249.