Unless the employer or the employer's insurer has established or contracted with a medical provider network as provided for in Section 4616, after 30 days from the date the injury is reported, the employee may be treated by a physician of his or her own choice or at a facility of his or her own choice within a reasonable geographic area. A chiropractor shall not be a treating physician after the employee has received the maximum number of chiropractic visits allowed by subdivision (c) of Section 4604.5 (Cal Lab Code § 4600(c)) If an employee has pre-designated a personal physician prior to the effective date of these regulations, such pre-designation shall be considered valid if the conditions in subdivision (a) have been met. (8 CCR 9780.1(b))
If the employee so requests, the employer shall tender the employee one change of physician. The employee at any time may request that the employer tender this one-time change of physician. (applicable during the first 30 days) (Cal Lab Code § 4601(a))
Unless the employer or the employer's insurer has established or contracted with a medical provider network as provided for in Section 4616, after 30 days from the date the injury is reported, the employee may be treated by a physician of his/her own choice or at a facility of his/her own choice within a reasonable geographic area. A chiropractor shall not be a treating physician after the employee has received the maximum number of chiropractic visits allowed by subdivision (c) of Section 4604.5(Cal Lab Code § 4600(c))
Panel Provisions,BR. See Direction of Care law.
Employer or Carrier SelectsNotwithstanding Section 4600, when a self-insured employer, group of self-insured employers, or the insurer of an employer contracts with an HCO certified pursuant to Section 4600.5 for health care services required by this article to be provided to injured employees, those employees who are subject to the contract shall receive medical services in the manner prescribed in the contract, providing that the employee may choose to be treated by a personal physician, personal chiropractor, or personal acupuncturist that he or she has designated prior to the injury, in which case the employee shall not be treated by the HCO. Every employee shall be given an affirmative choice at the time of employment and at least annually thereafter to designate or change the designation of an HCO or a personal physician, personal chiropractor, or personal acupuncturist. The choice shall be memorialized in writing and maintained in the employee's personnel records. The employee who has designated a personal physician, personal chiropractor, or personal acupuncturist may change their designated caregiver at any time prior to the injury.
Any employee who fails to designate a personal physician, personal chiropractor, or personal acupuncturist shall be treated by the HCO selected by the employer. If the HCO offered by the employer is the workers' compensation insurer that covers the employee or is an entity that controls or is controlled by that insurer, as defined by Section 1215 of the Insurance Code, this information shall be included in the notice of contract with an HCO. (Cal Lab Code § 4600.3(a))
An employee whose employer does not offer non-occupational health coverage under a plan established pursuant to collective bargaining, and does not offer to pay more than one-half the cost of non-occupational health coverage for that employee under another plan, may be treated for occupational injuries and illnesses by a physician of the employee's choosing after 90 days from the date the injury was reported. (b) An employee whose employer offers non-occupational health coverage under a plan established pursuant to collective bargaining, or offers to pay more than one-half the cost of non-occupational health coverage for that employee under another plan, may be treated for occupational injuries and illnesses by a physician of the employee's choosing after 180 days from the date the injury was reported or upon the date of contract renewal or open enrollment of the HCO, whichever occurs first, but in no case until 90 days from the date the injury was reported. (8 CCR § 9779.45(a)-(b))
An employer must provide information concerning the HCO it is offering to its employees no later than 30 days prior to the final date for enrollment. Information shall be provided in written form, in no less than twelve (12) point typeface, and in a language understandable to employees: i. the name of the HCO offered; iv. a complete listing of all primary treating physicians, specialist physicians, and clinics participating in the HCO who would be reasonably accessible to the employee for the provision of occupational health services. Primary treating physicians who are not accepting new patients must be clearly identified. (8 CCR 9779.3(a)(3))
When an injured employee requests chiropractic treatment for work-related injuries, the HCO shall provide the injured worker with access to the services of a chiropractor pursuant to guidelines for
chiropractic care established by paragraph (2). Within 5 working days of the employee's request to see a chiropractor, the HCO 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. (Cal Lab Code § 4600.5 (l)(1))
An employee enrolled in an HCO shall have the right to no less than one change of physician on request, and shall be given a choice of physicians affiliated with the health care organization. The HCO shall provide the employee a choice of participating physicians within five days of receiving a request. In addition, the employee shall have the right to a second opinion from a participating physician on a matter pertaining to diagnosis or treatment from a participating physician. (Cal Lab Code § 4600.3(e))
See Direction of Care law.
Employer or Carrier SelectsWhen the injured covered employee notifies the employer or insured employer of the injury or files a claim for workers' compensation with the employer or insured employer, the employer or insurer or entity that provides physician network services shall arrange an initial medical evaluation with a MPN physician in compliance with the access standards set forth in section 9767.5. (d) The insurer or employer shall notify the employee of his or her right to be treated by a physician of his or her choice within the MPN after the first visit with the MPN physician and the method by which the list of participating providers may be accessed by the employee (8 CCR § 9767.6(a), (d))
Where an employer or an employer's insurer has a Medical Provider Network pursuant to section 4616 of the Labor Code, an employee's pre-designation which has been made in accordance with this section shall be valid and the employee shall not be subject to the Medical Provider Network 8 CCR 9780.1(c))
When an injury is reported or an employer has knowledge of an injury that is subject to an MPN or when an employee with an existing injury is required to transfer treatment to an MPN, a complete written MPN employee notification with the information specified in paragraph (2) of this subdivision, shall be provided to the covered employee by the employer or the insurer for the employer. This MPN notification shall be provided to employees in English and also in Spanish if the employee primarily speaks Spanish. (1) A complete MPN notification with the information specified in paragraph (2) of this subdivision may be sent electronically in lieu of by mail, if the covered employee has regular electronic access to email at work to receive this notice at the time of injury or when the employee is being transferred into the MPN. If the employee cannot receive this notice electronically at work, then the employer shall ensure this information is provided to the employee in writing at the time of injury or when the employee is being transferred into the MPN. (8 CCR 9767.12(a)(1))
(2) The complete written MPN employee notification shall include the following information: (A) The unique MPN Identification number. How to contact the person designated by the employer or insurer to be the MPN Contact for covered employees to answer questions about MPNs and to address MPN problems. The employer or insurer shall provide a toll-free telephone number with access to the MPN Contact if the MPN geographical service area includes more than one area code; A toll-free number must also be listed for MPN Medical Access Assistants, with a description of the access assistance they provide, including finding available MPN physicians of the injured workers' choice and scheduling and confirming physician appointments, and the times they are available to assist workers with obtaining access to medical treatment under the MPN; (B) A description of MPN services; as well as the MPN's web address for more information about the MPN and the web address that includes a roster of all treating physicians in the MPN;(C) How to review, receive or access the MPN provider directory. An employer, insurer, or entity that provides physician network services shall ensure covered employees have access to, at minimum, a regional area listing of MPN providers in addition to maintaining and making available its complete provider directory listing in writing and/or on the MPN's website. The MPN's website address shall be clearly listed. If an employee requests an electronic provider directory listing, it shall be provided electronically on a CD, flash drive, via email or on a website. The URL address for the provider directory shall be listed with any additional information needed to access the directory online including any necessary instructions and passcodes. MPN applicants are responsible for updating an MPN's provider listings, at minimum, on a quarterly basis with the date of the last update provided on the listing given to the employee. Each provider directory listing shall include a phone number and an email address for reporting of provider listing inaccuracies. If a listed provider becomes deceased or is no longer treating workers' compensation patients at the listed address, the provider shall be taken off the provider directory within 45 days of notice to the MPN through the contact method stated on the provider directory listing to report inaccuracies. (D) How to access initial care and subsequent medical care; and how to contact the medical access assistants if an employee needs help in finding a physician or scheduling an appointment; (E) The mileage, time requirements and alternative access standards required under section 9767.5; (F) How to access treatment if (A) the employee is authorized by the employer to temporarily work or travel for work outside the MPN's geographical service area; (B) a former employee whose employer has ongoing workers' compensation obligations permanently resides outside the MPN geographical service area; and C) an injured employee decides to temporarily reside outside the MPN geographic service area during recovery;(G) How to choose a physician within the MPN;(H) What to do if a covered employee has trouble getting an appointment with a provider within the MPN and how to use the medical access assistants for help;(I) How to change a physician within the MPN;(J) How to obtain a referral to a specialist within the MPN or outside the MPN, if needed;(K) How to use the second and third opinion process;(L) How to request and receive an independent medical review; (M) A description of the standards for the transfer of care policy and a notification that a copy of the policy in English or in Spanish if the employee speaks Spanish shall be provided to an employee upon request; and (N) A description of the standards for the continuity of care policy and a notification that a copy of the policy in English or in Spanish if the employee speaks Spanish shall be provided to an employee upon request. (8 CCR 9767.12(a)(2))
At a minimum, a written regional provider listing is to be provided to covered employees. It is not acceptable to only provide a select list of 5 or 10 providers, as that does not constitute a complete regional provider listing. If the provider directory is available on a Web site, the URL shall be provided, as well as sufficient information to allow an employee to access the provider directory online. (CA Dept of IA - DWC website: http://www.dir.ca.gov/dwc/MPN/DWC_MPN_FAQ.html )
See Direction of Care law for employee notification requirements.c