Continuity of Care Policy

MPN Applicant will provide all employees entering the workers’ compensation system with notice of its written continuity of care policy and with information regarding the process for an employee to request a review under the policy. MPN Applicant will also provide, upon request, a copy of the written policy to any employee.

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Procedure:   

  1. Completion of treatment by a terminated medical provider. MPN Applicant will, at the request of an injured employee, provide the completion of treatment as set forth in this exhibit by a terminated medical provider.
    • The treatment being provided by a medical provider whose membership in the MPN terminates will be provided by a terminated medical provider to an injured employee who, at the time of the contract’s termination, was receiving services from that provider for one of the conditions described in paragraph b i-b iv) below.
    • MPN Applicant will provide for the completion of treatment for the following conditions subject to coverage through the workers’ compensation system before transferring further medical treatment to a physician in the MPN. At that time, the employee will have the same rights to select a new physician or contest the opinion of the primary treating physician as has been previously described:
      • An acute condition. An acute condition is a medical condition that involves a sudden onset of symptoms due to an illness, injury, or other medical problem that requires prompt medical attention and that has a duration of less than ninety (90) days. Completion of treatment shall be provided for the duration of an acute condition.
      • A serious chronic condition. A serious chronic condition is a medical condition due to a disease, illness, or other medical problem or medical disorder that is serious in nature and that persists without full cure or worsens over a period of at least ninety (90) days or requires ongoing treatment to maintain remission or prevent deterioration. Completion of treatment shall be provided for a period of time necessary to complete a course of treatment and to arrange for a safe transfer to another provider, as determined by the insurer or employer in consultation with the injured employee and the terminated provider and consistent with good professional practice. Completion of treatment under this paragraph shall not exceed 12 months from the contract termination date.
      • A terminal illness. A terminal illness is an incurable or irreversible condition that has a high probability of causing death within one year or less. There will be no transfer of care in such circumstances, and completion of treatment will be provided for the duration of a terminal illness.
      • Surgery or other procedure. Performance of surgery or other procedure  that is authorized by the Employer/Insurer 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.
  2. Contractual terms and conditions. MPN Applicant may require the terminated medical provider whose services are continued beyond the contract termination date pursuant to this section, to agree in writing to be subject to the same contractual terms and conditions that were imposed upon the provider prior to termination. If the terminated medical provider does not agree to comply or upon agreement does not comply with these contractual terms and conditions, then MPN Applicant is not required to continue the provider’s services beyond the contract termination date.
  3. Compensation. Unless otherwise agreed by the terminated medical provider and MPN Applicant, the services rendered pursuant to this section will be compensated at rates and methods of payment similar to those used by MPN Applicant for currently contracted providers providing similar services who are practicing in the same or a similar geographic area as the terminated medical provider. MPN Applicant is not required to continue the services of a terminated medical provider if the provider does not accept the payment rates provided for in this paragraph.
  4. Termination for medical disciplinary cause or reason. This policy will not require Applicant to provide for completion of treatment by a provider whose contract with MPN Applicant has been terminated or not renewed for reasons relating to a medical disciplinary cause or reason, as defined in paragraph (6) of subdivision (a) of Section 805 of the Business and Profession Code, or fraud or other criminal activity.
  5. Continuity of care beyond requirements. Nothing in this exhibit will preclude Applicant from providing continuity of care beyond the requirements of this exhibit.
  6. Dispute resolution process.
    • Following Applicant’s determination of the injured covered employee’s medical condition, Applicant 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 residence 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.
    • 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 described in paragraphs b) i – iv. The treating physician shall provide the report to the covered employee within 20 calendar days of the request. If the treating physician fails to issue the report within 20 days, then the determination made by MPN Applicant shall apply.
    • If MPN Applicant 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.
    • If the treating physician agrees with MPN Applicant’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), then the employee shall choose a new provider from within the MPN during the dispute resolution process.
    • If the treating physician does not agree with MPN Applicant’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.
  7. Replacement of continuity of care policy. MPN Applicant will file a revision of the continuity of care policy with the Administrative Director if it makes a material change to this policy.