Medical Provider Network

A Medical Provider Network is a collection of health care professionals that have been certified by the California Department of Workers’ Compensation to treat injured workers. Health Provider Networks include physicians specializing in general fields of medical care as well as those specializing in work-related injuries. A Stockton workers’ compensation lawyer will explain the Medical Provider Network’s rules to you. Contact the Stockton Workers’ Compensation Attorneys, P.C., today so we can help you understand how your work-related injury will affect your case.

What are the access standards for a Medical Provider Network?

Medical Provider NetworkMedical 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 who specializes in work-related injuries. The Medical Provider Network must locate the physician no more than 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 before the accident, the employee had chosen a doctor. Another exception occurs in situations where 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 personal 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 personal 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 you think your Medical Provider Network is not following the rules, you can file a written complaint with the Medical Provider Network’s contact. The written complaint must contain the following details as well as a description of the alleged violations. 

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

The Medical Provider Network has 30 days from the date of receipt of the complaint to respond. 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 their dispute. The Division of Workers’ Compensation has its own 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 was more serious and resulted in an immediate threat to the worker’s life. 

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

When you’re trying to get medical attention for your workers’ compensation case, it can be challenging to understand medical provider networks. Please contact StocktonWorkers’ Compensation Attorneys, P.C., to learn more about your rights. We will 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.