Medical Provider Network

What are the access standards for a Medical Provider Network?

Medical Provider Networks adhere to strict access guidelines. The Medical Provider Network must have at least three primary treating doctors and a hospital within a 30-minute drive or 15 miles of any covered employee’s residence or workplace, according to California Code of Regulations, Title 8 Section 9767.5. The Medical Provider Network must also provide a physician specializing in work-related injuries. The Medical Provider Network must locate the physician at most a 60-minute drive or 30 miles from every covered employee’s residence or workplace.  

Are you required to see a doctor in a Medical Provider Network?

Companies are not obligated to join a Medical Provider Network, but that network must treat all workers if they do. There are a few exceptions to this rule. One such exception is that the employee had chosen a doctor before the accident. Another exception occurred when the employee was injured before the company joined the medical provider network. Lastly, there is an exception if the employer had previously removed the employee from the medical provider network due to their insurance’s exclusion.

To pre-designate your physician to treat a work-related accident, you must meet specific criteria, including the following: In the case of a work-related accident, the doctor offers to be your pre-designated physician. Before the accident, a pre-designation report with the physician’s name and address must be filed, pre-designating your doctor. You currently have health insurance that covers non-work-related diseases or accidents.

What do I do if I believe the Medical Provider Network violates the California Code of Regulations?

If your Medical Provider Network needs to follow the rules, you can file a written complaint with the Medical Provider Network’s contact. The written complaint must contain the following details and a description of the alleged violations. 

• When did the suspected breach take place? 
• Would you happen to know if the alleged breach continues to occur? 
• What has the Medical Provider Network done, if anything, to address the violation?
• If the breach harms the injured worker in some way?

The Medical Provider Network has 30 days to respond from the date of receipt of the complaint. Within those 30 days, the Medical Provider Network must either accept responsibility for the violations and correct them or contest the claim in writing. The claimant will file a formal complaint with the Division of Workers’ Compensation if the alleged breach is not resolved within those 30 days. The Medical Provider Network has submitted its dispute. The Division of Workers’ Compensation has its complaint form, which must be completed and submitted. The complainant will file a lawsuit with the Medical Provider Network and the Division of Workers’ Compensation at the same time if the breach is more severe and results in an immediate threat to the worker’s life. 

What can Stockton Workers’ Compensation Attorneys, P.C. do? 

It can take time to understand medical provider networks when trying to get medical attention for your workers’ compensation case. Please get in touch with Stockton Workers’ Compensation Attorneys, P.C., to learn more about your rights. We’ll be able to help you understand the Medical Provider Network’s access requirements, exceptions to being a member of one, and what to do if the Medical Provider Network violates the California Code of Regulations. Our Stockton workers’ compensation attorneys are ready to help you get the best out of your claim.