Transfer of care-requirements/exceptions (California)

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Transfer of care-requirements/exceptions (California)

Postby wcscout on Fri Jun 28, 2013 2:23 pm

As far as transfer of care requirements, is an english/spanish letter to applicant, attorney, and physician stating that the injured worker does not qualify for exceptions sufficient to warrant transfer of care? Does anything more formal need to happen?

As far as exceptions, can someone explain the surgery exception, does it only happen if its recommended w/in 180 days from MPN inception?
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Re: Transfer of care-requirements/exceptions (California) (Calif

Postby Barney5 on Fri Jun 28, 2013 4:55 pm

There is more to it than a surgery request within 180 days for an exception, another would be if the injured workers condition is chronic. MANY injured workers could fall under this label, and could be eligible for continued care with their doctor for up to one year. Also know, if your injured worker, or their treating doctor disagrees with your determination that he cannot continue treating with their current doctor, they CAN continue to treat with them until this dispute is resolved, under Labor Code section 4616.2(d)(3).

http://www.dir.ca.gov/t8/9767_9.html

(2) A serious chronic condition. For purposes of this subdivision, a serious chronic condition is a medical condition due to a disease, illness, catastrophic injury, or other medical problem or medical disorder that is serious in nature and that persists without full cure or worsens over 90 days and requires ongoing treatment to maintain remission or prevent deterioration. Completion of treatment shall be authorized for a period of time necessary, up to one year: (A) to complete a course of treatment approved by the employer or insurer; and (B) to arrange for transfer to another provider within the MPN, as determined by the insurer or employer. The one year period for completion of treatment starts from the date of the injured covered employee's receipt of the notification, as required by subdivision (f), of the determination that the employee has a serious chronic condition
"§9767.10. Continuity of Care Policy. http://www.dir.ca.gov/t8/9767_10.html


(a) At the request of a covered employee, an insurer or employer 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 or insurer 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.

(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 the injured covered employee shall continue to treat with the terminated provider until the dispute is resolved. " Labor Code section 4616.2(d)(3),
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