California Medical Provider Network Employer Implementation Packet
The information and forms in this packet will assist you in implementing and administering the Liberty Mutual Medical Provider Network (”MPN”). The forms contained in this packet are: 1. MPN Employer Packet overview 2. MPN Frequently Asked Questions (“FAQ”) 3. Employee Cover Memo Sample 4. MPN Notification Letter (English and Spanish) 5. Employee Notification Confirmation Form 6. Provider Referral Services Access Information-English 7. Provider Referral Services Access Information-Spanish 8. California Predesignation Forms (English and Spanish)
After reviewing the information in this packet, please let us know if you have questions about implementing or administering the MPN. Thank you,
Golden Eagle InsuranceTM Workers’ Compensation Claims Department
(800) 603-6438
April 2009
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California Medical Provider Network Employer Packet Overview
We are pleased to inform you that Golden Eagle InsuranceTM has a state approved Medical Provider Network (MPN) to assist you in managing your California workers’ compensation claims. In 2005 California’s workers’ compensation statute was changed to allow insurers and self‐insured employers to create medical provider networks (MPN) to which they may direct injured employees to for medical treatment. Since Golden Eagle Insurance is a member of the Liberty Mutual Group, we will be able to utilize the Liberty Mutual MPN for new policies written on or after 6/1/2009. The CA MPN consists of a network of medical providers contracted through Blue Cross of California and Kaiser On‐the Job (KOJ). We feel this network will provide injured employees with high quality medical care while managing medical costs. Use of the MPN allows employers to exercise greater control of the medical direction of care on workers’ compensation injuries. By referring all industrial injuries to providers within the MPN, you will realize the benefits of keeping medical treatment with MPN medical providers. This will help control medical claims costs and should also work to help injured employees return to work sooner. There are several steps that you, as an employer, need to take to prepare your organization and your employees in order to implement the Liberty Mutual Group MPN. What an Employer Must Do To Implement the CA MPN ‐ Employee Notification: Letter #1 ‐ Golden Eagle Insurance CA MPN Employee Notification Letter (Mandatory): The MPN Employee Notification letter is a mandatory letter that must be provided in both English and Spanish to all CA employees. This letter, approved by the CA Department of Workers’ Compensation, outlines the MPN regulations and includes information on: pre‐designation, access standards, changing physicians, transfer of care, obtaining referrals to specialists, and second and third opinion procedures. Distribution: All current employees – upon receipt of this letter All future employees – at the time of hire Any employee transferring into a California location, or otherwise moving into the California Workers’ Compensation jurisdiction Additional Information to Assist with the MPN Implementation: 1. MPN Employee Cover Memo (Optional): This is a one page form and can be used as a cover memo to letter #1 ‐ MPN Initial Employee Notification letter. You should edit the memo to fit your company structure (Human Resources or Management), add contact information, revise the date and add your company logo. 2. Form B – MPN Employee Notification Confirmation (Optional): This form is provided in both English and Spanish and may be used to confirm that the employee has received notification on the CA MPN. You may use this or you may have other ways of tracking and verifying the MPN Employee Notification letter was issued and/or received. In the
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event employee notification is questioned at a later date, when a claim is made, we do recommend this form or other tracking be utilized. 3. Provider Referral Services (PRS) Access Information (Optional): Access to the MPN list of providers is critical and is an essential part of the MPN regulation. This document, provided in both English and Spanish, may be provided to employees and will walk them through accessing the MPN either; (1) internet access by using the URL address: http://www.talispoint.com/liberty/goldeneagle/ext or (2) calling the Provider Referral Service hot line phone number: (800) 944‐0443 or (3) calling the employee’s claim handler. 4. California Predesignation Of Personal Physician DWC Form 9783 (English and Spanish): This is not a MPN mandatory form but there is a reference to this form outlined in the MPN Initial Employee Notification letter. This form may be used, or other similar Predesignation notification information can be used. All CA employees must receive notification of the right to predesignate a physician at the time of their employment starts or when they transfer to CA. This CA state form outlines how an employee may predesignate his/her regular physician to be the primary treating physician for a workers’ compensation claim; the form must be signed by both the employee and his/her treating physician or the physicians designated representative and returned to the employee’s employer. This form, if completed, will be required by the Liberty Mutual claims case manager, when a loss is reported. If the notification of Predesignation has not previously been provided, we recommend it be done as part of the MPN notification process, as not doing so may allow an injured employee the right to select a provider from outside the MPN. 5. Employer Medical Provider Network Frequently Asked Questions: This document “MPN FAQ” is intended for management and human resources staff only and will help answer the majority of questions that may come from employees when the MPN is being rolled out. If any questions do come up that are not addressed, feel free to contact Golden Eagle Claims at 1‐800‐603‐6438. 6. New Employee Hire Packet: Letter #1 ‐ CA MPN Employee Notification letter must be provided to all new employees as part of their new hire employee packet. Additionally, any employee that transfers to CA must also receive this letter. After All CA Employees are Notified of the CA MPN: Document in each employee’s personnel file that they have received the required Employee Notification Send an email to GEIC‐
[email protected] with the following information: o Policy Number o Policyholder (Company) Name o Date the MPN notification was completed for all existing employees o Confirmation that all new employees will be notified as part of their new hire employee packet
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When the CA MPN takes effect: The MPN will become effective 30 days after you notify your California employee per state regulation. When an employee is injured: A requirement of the MPN is that after an injury is reported an employee must be provided with another copy of Letter #1 ‐ CA MPN Employee Notification letter. Employers may provide this document. If your company has completed its MPN employee notification and advised us of the implementation date, Golden Eagle InsuranceTM will send this letter at the time a claim is reported to our office. Employer Direction of Medical Care: As a result of the implementation of the MPN, employers will need to validate that their current Work Site Poster contains certified MPN providers. Employers can validate a provider’s inclusion in the MPN via the PRS website: http://www.talispoint.com/liberty/goldeneagle/ext An employer may also call the PRS Hotline at 1‐800‐944‐0443, or call the Golden Eagle InsuranceTM Claims Department at 1‐800‐603‐6438. The PRS Hotline can also be used to locate an MPN provider geographically convenient to an employer’s location and to generate new worksite posting notices. If you need assistance generating updated worksite posters you can contact the Golden Eagle InsuranceTM Claims Department at 1‐800‐603‐6438. If you currently use a provider that has not been certified on the CA MPN, you can contact the Golden Eagle Insurance Claims Department for possible contracting into the MPN. Your claim handler or other representative in the Golden Eagle claims department will forward all nominations to the Liberty Mutual Regional Network Coordinator, to manage the process. Because of the more stringent requirements of the MPN, not all providers will be considered for inclusion. If you choose to continue using the non‐MPN provider, you will lose your ability to direct injured employees to the MPN and the injured employees’ medical services may not be covered, under the MPN. As California allows you to direct an injured employee’s initial care, we strongly encourage you to comply with this requirement and post the Work Site Poster in a prominent location. It is important to note that, as of certification of the CA MPN, as an employer you are only able to direct the initial treatment, after which the injured employee may choose any provider from within the MPN for subsequent treatment. Transfer of Care: Employees who were injured before the implementation of the MPN may be moved to an MPN provider for treatment, unless one of the following conditions applies: − An acute condition that is defined as treatment that will resolve within 90 days − A serious chronic condition, for which treatment shall be provided for a period of time up to one year − A terminal illness, as defined as an incurable or irreversible condition that has a high probability of causing death within one year or less − A surgical or other procedure that is authorized by the insurer or employer as a course of treatment that is to occur within 180 days of the MPN effective date
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The Golden Eagle InsuranceTM process for claims handling is to review each injured employees claim, on a case‐by‐case basis, to determine if the best overall outcome will be to either; 1) allow the employee to continue treatment with their primary treating physician or 2) to move the medical treatment within the MPN. Also, employees that have properly designated a personal physician by notice to the employer prior to the date of injury (see Labor Code 4600(d) for specifications) may treat outside the MPN. Continuity of Care: This process covers employees whose treating physician has either left the MPN or whose contract with the MPN has been terminated. In this circumstance, injured employees may be moved to another provider within the MPN for treatment, unless one of the following conditions applies: − An acute condition resolving within 90 days − A serious chronic condition, for which treatment shall be provided for a period of time up to one year − A terminal illness, as defined as an incurable or irreversible condition that has a high probability of causing death within one year or less − A surgical or other procedure that is authorized by the insurer or employer as a course of treatment that is to occur within 180 days of the MPN effective date. Employer MPN Questions: We are here to help in any way we can. Please contact your California claim handler or call the Golden Eagle InsuranceTM Claims Department at 1‐800‐603‐6438.
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California Medical Provider Network Frequently Asked Questions 1.
What is California SB899? SB899 refers to workers’ compensation legislation in California. This legislation changed California’s workers’ compensation regulations to allow insurers and self‐insured employers to direct injured employees to a medical provider network (MPN) for medical treatment if they receive state approval for their MPN.
2.
What is a medical provider network (MPN)? Simply put, a medical provider network, or MPN, is a network of physicians that is used to help manage medical costs by directing injured employees to a select group of providers with expertise in treating workers’ compensation injuries. More specifically, the medical provider network relates to wording in SB899 that allows insurers and self‐insured employers to direct injured employees to a medical provider network (MPN) for medical treatment if they receive state approval for the network. Insurers or self‐ insured employers (as defined in the Labor Code, section 4616.5) must create this network and submit it to the State for approval before injured employees can be directed for care.
3.
What is the Employer’s role in implementing the Liberty Mutual Group MPN plan? The employer must notify all California existing employees, in writing. It is strongly encouraged that the employer carefully and deliberately document when, how, and to whom the “employee notification” was distributed. Employers will also need to provide the MPN notification letter as part of their new hire packet to all new employees hired after the after the rollout of the MPN.
4. Must the MPN employee notification be provided in both English and Spanish? Yes. This is a mandatory requirement under the MPN regulation. 5. When all CA employees are notified, is there a 30‐day waiting period before the MPN can be implemented? Yes. Customers that implement the MPN by providing their CA employees with the MPN notification letter will have a 30 day waiting period from the date they complete their employee notification. 6. How was the Liberty MPN created? In creating the network the following criteria were taken into consideration: • Volume of a provider’s workers’ compensation experience • Network quality indicators such as billing and chiropractic and physical therapy treatment or referral • Medical cost per service and case In addition, Liberty Mutual claims and Managed Care professionals reviewed over 17,000 provider locations for inclusion or suppression from the network. Based on their experience with these providers, they identified a significant number of providers for suppression as well as a number of providers with whom Liberty Mutual has had positive results for inclusion. 7. What does Liberty’s MPN look like?
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The California MPN network of providers is contracted through Blue Cross of California and Kaiser On‐ the‐Job (KOJ). Blue Cross of California is a part of WellPoint, Inc., the largest health care company in the United States. Additionally, we have national contracts with vendors for durable medical equipment (DME), pharmacy (retail and home delivery), and transportation that are in the Liberty Mutual Group MPN. 8.
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Does the MPN regulation outline physician access standards? Yes and the Liberty Mutual Group MPN includes a minimum of six primary treating physicians, six specialists and two other provider specialties in each zip code. The selection logic ensures that there will be at least two orthopedic surgeons, neurologists, physical medicine specialists and neurosurgeons wherever possible. For all other specialties, at least one of each specialty type occurring within each zip code. In order to meet regulatory requirements, 25% of the providers are engaged in non‐occupational medicine. It is possible that a specialty provider an employer is currently using is not in the Liberty MPN. If this is the case, the employee will be able to choose an appropriate provider from within the MPN. Does the MPN apply to employees with claims prior to 1/1/05? Yes, the MPN applies to all dates of loss (see section 9767.9, Transfer of Ongoing Care into the MPN). However, there are certain exceptions that include: − An acute condition resolving within 90 days − A serious chronic condition, for which treatment shall be provided for a period of time up to one year − A terminal illness, as defined as an incurable or irreversible condition that has a high probability of causing death within one year or less − A surgical or other procedure that is authorized by the insurer or employer as a course of treatment that is to occur within 180 days of the MPN effective date.
Also, employees that have properly designated a personal physician by notice to the employer prior to the date of injury (see Labor Code 4600(d) for specifications) may treat outside the MPN. 10. Does the insurer have to pay for treatment rendered outside the MPN? If an injured employee treats outside the MPN and self‐procures the treatment, the treatment will only be covered if he or she has authorization from his or her Claims handler. Without authorization, treatment outside the MPN may not be covered under the accepted workers’ compensation claim. 11. Can an employee choose any provider from the MPN? Yes, however, the insurer/employer is able to direct the initial treatment to a provider within the MPN. After initial treatment, the injured employee can choose a provider from within the MPN for subsequent treatment. In addition, the regulations indicate that a request for a change of physician within the MPN still takes place under Labor Code 4601. 12. As employees have the ability to choose providers from within the MPN, does the claims handler lose the ability to “direct” the employee to specialists? Although not specifically stated in the regulations, the publicly held assumption is that the claims case manager can continue to direct the employee to ancillary services such as MRI’s, physical therapy, etc. 13. Is there a geographic mileage requirement in the MPN for access to care? Yes, Section 9767.5, Access Standards states that a covered employee must have a residence or workplace within 30 minutes or 15 miles of an MPN primary care physician or hospital. For all other occupational
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heath services and specialist referrals, the requirement is 60 minutes or 30 miles from the residence or workplace. 14. Are there appointment standards? Yes, for non‐emergency services the MPN shall ensure that an appointment for initial treatment is available within 3 business days of the receipt of request for treatment. For non‐emergency specialist services to treat common injuries, the MPN shall ensure that an appointment is available within 20 business days of the receipt of referral to a specialist. 15. If the employee pre‐designates a treating provider, does it have to be from the employer’s group health plan? Although this was the intent of Labor Code 4600(d), it has never been clarified. However, in order for an employee to be able to pre‐designate their treating physician, their employer must provide group health coverage. Additionally, the personal physician must agree to be predesignated and confirmation must be provided to the employer, in writing, prior to the industrial injury. Only pre‐ designations submitted to the employer in compliance with L.C. 4600(d) will be reviewed for validity. 16. Who will monitor the pre‐designations to verify that the provider has treated the employee in the past and agrees to treat the employee for WC injuries? Although not addressed in the Labor Code, the employer should do this when they receive the employee’s pre‐designation. It is then Liberty’s intent to have its Claims staff, at the time an injury occurs, verify with the pre‐designated physician that the injured employee has treated with them previously and the physician agrees to treat the employee for his/her workers’ compensation illness or injury. 17. What happens when a pre‐designation is determined to be invalid or the provider does not agree to be pre‐designated? The injured employee must receive medical treatment from providers within the MPN. 18. Can a chiropractor or acupuncturist be a pre‐designated provider? No, however, they can be a Primary Treating Physician chosen from the MPN. 19. How does an employer or employees know which providers are part of the Liberty Mutual Group MPN? Access to the MPN is maintained through Liberty’s Provider Referral Service (PRS). You or your employee’s may access PRS using this URL: http://www.talispoint.com/liberty/goldeneagle/ext You may choose either a radius or a specific city to create the directory.
We recommend customers review all worksite posters, sometimes referred to as “Posting Notices.” Provider lists and posting notices should be updated to reflect the MPN list of providers. Customer Service Managers can assist employers to identify non‐network providers treating injured employees and suggesting alternative providers based on the new MPN. 20. How can an employer recommend providers for the MPN? Advise your customer service manager or claim service team the name, address, phone number and provider type. FOR ADDITIONAL INFORMATION: The MPN Labor Code is Labor Code section 4616 – 4616.7, and is available at the State’s DWC web site: http://www.leginfo.ca.gov/cgi‐bin/displaycode?section=lab&group=04001‐05000&file=4616‐4616.7
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The MPN rulemaking regulations can be viewed at the DWC Forum site: http://www.dir.ca.gov/dwc/DWCPropRegs/MPNReg.htm
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Employee Cover Memo Sample
MEMORANDUM To:
Covered Employees
From:
Human Resources
Date:
Re:
CALIFORNIA WORKERS’ COMPENSATION
California’s workers’ compensation law allows employers and their claim administrators to implement and direct injured employees to a Medical Provider Network (MPN) for medical care. Our claim administrator, Golden Eagle InsuranceTM, has implemented the Liberty Mutual Group MPN for workers’ compensation claims. There are over 54,000 MPN providers in the Liberty Group MPN. This is similar to group health networks but specifically designed for work-related injuries. Attached, please find the California MPN Employee Notification letter. As required by the CA MPN regulation, this is being provided in both English and Spanish. This letter provides a description of how medical treatment for work-related injuries will be handled under the MPN. The description was prepared by Liberty Mutual and approved by the State of California. Outlined below are a few key elements of the MPN arrangement and your responsibilities if you experience a work-related injury or illness. Please refer to the attached documents for complete information. ¾
If you have a new work-related injury or illness and need emergency care, go to the nearest medical facility. For all non-emergency medical care, an MPN provider can be selected from the list that is posted at the job site, provided to you by your supervisor or human resources representative. You must contact your supervisor and/or a human resources representative immediately following your injury, so that a claim can be filed with Liberty Mutual.
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Liberty Mutual provides Internet access to the list of providers in their MPN using Provider Referral Services (PRS). You can access PRS at any time to find a medical provider or specialist in your area using the following web address:
http://www.talispoint.com/liberty/goldeneagle/ext or by calling the PRS Hotline at 1-800-944-0443. ¾
In the event of a claim, if you have any questions about the providers or need a specialist referral, you should contact the Golden Eagle InsuranceTM claims handler who is assigned to your claim.
If you have any questions, please be sure to ask your supervisor or human resources representative.
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CALIFORINA MPN EMPLOYEE NOTIFICATION
Liberty Mutual Group
Medical Provider Network
For The State of California
IMPORTANT INFORMATION REGARDING YOUR WORKERS COMPENSATION BENEFITS
MEDICAL TREATMENT FOR WORK RELATED INJURIES Recent changes in California’s workers’ compensation laws now allow insurers and self-insured employers to direct injured employees to a medical provider network (MPN) for medical treatment if they receive state approval for the network. The State of California has certified the Liberty Mutual Group Medical Provider Network (MPN) under California Labor Code section 4616 et seq. and Division of Workers’ Compensation regulations to provide all necessary medical care, treatment and services for your work related injury. The goals of the MPN program are to ensure that: • You have access to prompt, efficient, and quality medical care, treatment and services for occupational injuries and illnesses. • You have increased access to occupational health services and specialists. • You receive ongoing medical review of treatment. All rendered treatment will be consistent with recommended standards set forth in the American College of Occupational and Environmental Medicine (ACOEM) Occupational Medical Practice Guidelines, evidence based medical guidelines or with guidelines adopted by the DWC Administrative Director. You may pre-designate your physician(s) prior to injury if: • You have received care with the physician, and • The physician agrees to be your primary treating physician. If your physician does not agree to participate in this capacity, you will be required to seek medical care with a MPN provider. Access to MPN Services The MPN shall ensure that a MPN primary care physician, a hospital, or a provider of all emergency health care services are located within thirty (30) minutes or fifteen (15) miles from your residence or work place. Other occupational health services and specialists must be within sixty (60) minutes or thirty (30) miles from your residence or work place. You may consult with your employer for physician, hospital or other medical care recommendations within the MPN. Should you have a work-related injury, your supervisor will help to ensure that you receive prompt initial care and medical attention through a MPN provider. •
On the job injuries must immediately be reported to your supervisor.
"Any person who makes or causes to be made any knowingly false, or fraudulent material statement or material representation for the purposes of obtaining or denying workers’ compensation benefits or payments is guilty of a felony" 1
CALIFORINA MPN EMPLOYEE NOTIFICATION • Upon being notified of an on the job injury, your supervisor will immediately direct you to a primary care MPN physician who will provide you with the necessary initial and subsequent medical care required for your injury. After your first visit with an MPN provider you have the right to be treated by a physician of your choice within the MPN. • The Liberty Mutual Group MPN physician/provider directory will be available to your employer, physician and you. You may contact your supervisor or Claims handler to request a regional and/or full listing of the MPN provider network. Your employer or Claims handler will provide you the options of receiving (a) electronic access to a regional and/or full listing of the MPN provider network via the Provider Referral Services (PRS) system, at http://www.talispoint.com/liberty/goldeneagle/ext; (b) a printed copy of the regional and/or full listing of the MPN provider network; and/or (c) a printed copy of a regional and or full listing of MPN providers by calling the Liberty Provider Referral Line, 1-800-944-0443. • If you need emergency health care services, please proceed to the nearest hospital or emergency medical facility and notify your employer. The Liberty Mutual Group MPN shall allow the emergency health care services by the hospital or medical facility until such time that your physician considers you to be in stable medical condition and recommends that you may return to your residence or your employer’s workplace. You will then continue your medical treatment with a MPN physician or provider under the provisions of the Liberty Mutual Group MPN. •
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For non-emergency services, an appointment for initial treatment with a MPN physician will be available within three (3) business days of your request for treatment. For non-emergency specialist services to treat common injuries experienced at work, an appointment with a specialist within the MPN will be available within twenty (20) business days of your request for a referral. If you are temporarily working or traveling for work and require treatment outside the MPN service area and need emergency health care services proceed as stated above. If you require non-emergency medical treatment outside of the MPN service area, you should notify your supervisor and the Claims handler of your need for medical treatment outside the MPN Service Area. The Claims handler will assist you in locating at least three physicians or other providers outside the Service Area. Primary care physicians will be located within thirty (30) minutes or fifteen (15) miles from your temporary residence or workplace. Other occupational health services and specialists will be within sixty (60) minutes or thirty (30) miles from your temporary residence or workplace. The procedures for changing physicians and obtaining a second and third opinion apply to employees who need to seek treatment outside the Service Area, see page 5.
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If you are temporarily living outside the Service Area or a covered employee, whose former employer has ongoing workers’ compensation obligations, who lives outside the Service Area please contact your Claims handler. They can provide you with, at least, three physicians outside the Service Area. Primary care physicians will be located within thirty (30) minutes or fifteen (15) miles from your residence or workplace. Other occupational health services and specialists will be within sixty (60) minutes or thirty (30) miles from your residence or workplace. The procedures for changes physicians and obtaining second and third opinions apply for treatment outside the Service Area, see page 5.
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If you require medical treatment in certain rural or unpopulated areas where health facilities are located at least 30 miles apart, you must notify your employer or Claims handler. If necessary, the Claims handler will provide you with a MPN provider directory. You may need to treat with a physician or provider outside of the MPN service area. If necessary, the Claims handler will assist you in finding a non-MPN provider.
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If your physician prescribes durable medical equipment, home health services, or medications for you, please contact your Claims handler who will contact the ancillary service provider. The service provider will contact you directly to arrange for service delivery.
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If you need transportation to your MPN physician or medical facility please contact your Claims handler who will make the necessary arrangements. The service provider will contact you directly to arrange for service delivery.
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If you need language translation services provided to you at the time of your medical appointment please contact your Claims handler who will make the necessary arrangements.
"Any person who makes or causes to be made any knowingly false, or fraudulent material statement or material representation for the purposes of obtaining or denying workers’ compensation benefits or payments is guilty of a felony" 2
CALIFORINA MPN EMPLOYEE NOTIFICATION Changing Your Treating Physician Within the MPN •
If you are not satisfied with the services of a MPN provider anytime after your initial medical evaluation, you will be allowed to change to another provider of your choice within the MPN.
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Non-emergency treatment, incurred outside of the MPN may not be paid unless the request is received by a Claims handler, in advance. This written request should also document the reason for the requested change.
Your supervisor or the Claims handler can assist you in choosing a geographically convenient provider in the MPN and will be able to assist you to ensure that you receive the appropriate medical attention needed to get you back to work. •
If you have difficulty scheduling an appointment with a MPN physician or provider you should notify the Claims handler. The Claims handler will contact the physician or provider on your behalf to schedule an appointment. If the physician or provider cannot accommodate your appointment request within the required timeframes the Claims handler will notify you and when necessary, will provide to you a full listing and/or regional MPN directory of the names of physicians or providers who are accessible to you for you to choose another physician or provider.
Treatment Provided By a Specialist If you require treatment by a specialist, you may self-select an appropriate specialist or be referred to a specialist by your physician. Your Claims handler can provide you with a full listing of the MPN provider network or a regional directory of the names of physicians or providers who are accessible to you within 60 minutes or 30 miles of your residence or workplace. Your physician has access to the MPN directory and can also refer you to a specialist within the MPN. If your primary treating physician refers you to a type of specialist not included in the MPN you may select a specialist from outside the MPN. Please contact your Claims handler for additional information on this process. Transfer of Ongoing Medical Care to MPN Provider If you are currently being treated for a work related injury or illness by a physician or other health care provider that becomes a provider in the MPN, you may continue treatment with your physician or health care provider through the MPN. If you are being treated for a work related injury or illness by a physician or other health care provider that is not in the MPN, you may continue to receive treatment from your physician or provider for the duration of any 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 the acute condition. For a serious chronic condition, you may complete treatment with your physician or other health care provider that is not in the MPN for a period of time necessary, up to one year, to complete the course of treatment approved by your insurer or employer and to arrange transfer to another provider within the MPN, as determined by your insurer or employer. A serious chronic condition is a medical condition due to disease, illness, catastrophic injury, or other medical problem or medical disorder that is serious in nature that persists without full cure or worsens over 90 days and requires ongoing treatment to maintain remission or prevent deterioration. The one year period for completion of treatment starts from the date you receive notification of the determination that you have a serious chronic condition. You will continue to have coverage and may complete treatment with your physician or other health care provider that is not in the MPN for an incurable or irreversible condition for the duration of a terminal illness which is defined as an incurable or irreversible condition that has a high probability of causing death within one year or less. You may have surgery or other procedures performed by your physician or other health care provider that is not in the MPN that were authorized by your Claims handler or employer and were recommended and documented by your physician or other health care provider to occur within one hundred and eighty (180) days from the effective date of the MPN.
"Any person who makes or causes to be made any knowingly false, or fraudulent material statement or material representation for the purposes of obtaining or denying workers’ compensation benefits or payments is guilty of a felony" 3
CALIFORINA MPN EMPLOYEE NOTIFICATION Your Claims handler or employer will notify you and your primary treating physician in writing of the determination regarding completion of ongoing treatment. You may request a report from your treating physician if you disagree with the determination regarding transfer of ongoing care. The primary treating physician report will be issued within twenty (20) calendar days from the date of your request. If the treating physician fails to issue the report, then the determination made by the employer or insurer shall apply pursuant to 8 CCR § 9767.9 (g). If you disagree with the medical determination made by your treating physician regarding transfer of care, you may file a dispute under Labor Code section 4062. The transfer of care will go forward during the dispute resolution process only if your treating physician agrees with your MPN or employer’s determination. Upon request, your Claims handler can provide you a copy of this policy. MPN Continuing Care Policy As a covered employee in the MPN you have certain rights concerning your medical care. Your rights include allowing you to receive and complete medical treatment for certain medical conditions with your physician who is no longer in the MPN if you fall within one of the following conditions: (A) Completion of treatment for an acute condition shall be provided for the duration of the 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. (B) Completion of treatment for a serious chronic condition 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 Liberty Mutual Group MPN in consultation with the injured covered employee and the terminated provider and consistent with good professional practice. Completion of treatment under this paragraph shall not exceed 12 months from the provider contract termination date. 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 that persists without full cure or worsens over a ninety (90) day period of time or requires ongoing treatment to maintain remission or prevent deterioration. (C) Completion of treatment shall be provided for the duration of 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. (D) Performance of a surgery or other procedure shall be completed that is authorized by the Liberty Mutual Group MPN as part of a documented course of treatment and has been recommended and documented by the terminated provider to occur within 180 days of the provider’s contract termination date. If you disagree with a decision made under this provision the Liberty Mutual Group MPN has the following dispute resolution process: (a) 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. (b) 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. "Any person who makes or causes to be made any knowingly false, or fraudulent material statement or material representation for the purposes of obtaining or denying workers’ compensation benefits or payments is guilty of a felony" 4
CALIFORINA MPN EMPLOYEE NOTIFICATION
(c) 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. (d) 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 Labor Code section 4616.2(d)(3), the injured covered employee shall continue to treat with the terminated provider until the dispute is resolved. A complete copy of the MPN Continuing Care Policy is available from your Claims handler. Procedures for Selecting a Physician for a Second and Third Opinion If you dispute either the diagnosis or treatment prescribed by your treating physician, you may obtain a Second Opinion and a Third Opinion from other physicians within the MPN. During this process you have the option to continue ongoing treatment with your treating physician or change to another physician of your choice within the MPN pursuant to section 9767.6 of the Department of Workers’ Compensation regulations. A Second Opinion is an opinion rendered by a MPN physician, after an in person examination, to address a dispute that you have over either the diagnosis or the treatment prescribed by your treating physician. A Third Opinion is an opinion rendered by a MPN physician, after an in person examination, to address a dispute that you have over either the diagnosis or the treatment prescribed by either your treating physician or the physician that rendered a Second Opinion. To obtain a Second Opinion, you must inform your supervisor or your Claims handler verbally or in writing by letter, fax or electronic mail that you dispute your treating physician’s opinion and are requesting a Second Opinion. You must select a physician or specialist from a regional directory of available MPN providers provided to you by your supervisor or the Claims handler. It is your responsibility to make the appointment with the Second Opinion physician within sixty (60) days and inform the Claims handler of the appointment date. The Claims handler will contact the Second Opinion provider in writing to notify that he or she has been selected for a Second Opinion, to describe the nature of the dispute, and provide necessary medical records prior to the appointment date. You will receive a copy of the letter to the Second Opinion physician. Upon your request, you may obtain a copy of your medical records. If the appointment is not made within sixty (60) days of your receipt of the directory of available MPN providers, then you may not obtain a Second Opinion for the disputed diagnosis or treatment of your treating physician. You, your treating physician, and the MPN designee will receive a copy of the Second Opinion physician’s written report within twenty (20) days of the date of your appointment or the receipt of results of any diagnostic tests made at your appointment, whichever is later. To obtain a Third Opinion, you must inform your supervisor or your Claims handler verbally or in writing by letter, fax or electronic mail that you dispute the second opinion physician’s diagnosis or treatment and are requesting a Third Opinion. You must select a physician or specialist from a regional directory of available MPN providers provided to you by your supervisor or the Claims handler. At the time of the selection of the physician for a third opinion, the Claims handler will notify you about the Independent Medical Review process and provide you with an “Application for Independent Medical Review” form as set forth in section 9768.10 of the Department of Workers Compensation regulations. The Claims handler will fill out the “MPN Contact Section” of the form and list the specialty of the treating physician and an alternative specialty, if any, that is different from the specialty of the treating physician. It is your responsibility to make the appointment with the Third Opinion physician within sixty (60) days and inform the Claims handler of the appointment date. The Claims handler will notify the Third Opinion provider in writing that he or she has been selected for a Third Opinion, describe the nature of the dispute, and provide necessary medical records prior to the appointment date. You will receive a copy of the letter to the Third Opinion physician. Upon your request, you may obtain a copy of your medical records. If the appointment is not made within sixty (60) days of your receipt of a directory of available "Any person who makes or causes to be made any knowingly false, or fraudulent material statement or material representation for the purposes of obtaining or denying workers’ compensation benefits or payments is guilty of a felony" 5
CALIFORINA MPN EMPLOYEE NOTIFICATION MPN providers, then you may not obtain a Third Opinion for the disputed diagnosis or treatment of your treating physician. You, your treating physician, and the MPN designee will receive a copy of the Third Opinion physician’s written report within twenty (20) days of the date of your appointment or the receipt of results of any diagnostic tests made at your appointment, whichever is later. If either the second or third opinion physician recommends specific treatment you may seek treatment from that physician or choose another MPN physician. If you disagree with the diagnosis or treatment recommended by the Third Opinion physician, you may file the application form with the California Division of Workers’ Compensation Administrative Director to request an Independent Medical Review. If you need assistance contact your supervisor or your Claims handler. Contact Information For questions and concerns regarding the MPN program contact your supervisor, the Claims handler, or the Liberty Mutual Group MPN Program Coordinator. The Claims handler and the MPN Program Coordinator may be contacted during normal business hours of 8:00 AM - 5:00 PM, Monday through Friday at 1-800-603-6438. The MPN Program Coordinator may be contacted at 800-331-1133.
"Any person who makes or causes to be made any knowingly false, or fraudulent material statement or material representation for the purposes of obtaining or denying workers’ compensation benefits or payments is guilty of a felony" 6
CALIFORINA MPN EMPLOYEE NOTIFICATION NOTIFICACIÓN AL EMPLEADO Liberty Mutual Group
Red de proveedores médicos
para el Estado de California INFORMACIÓN IMPORTANTE ACERCA DE LOS BENEFICIOS DE COMPENSACIÓN DE TRABAJADORES TRATAMIENTO MÉDICO PARA LESIONES RELACIONADAS CON EL TRABAJO Los recientes cambios en las leyes de compensación de trabajadores de California permiten actualmente que las aseguradoras y los empleados auto-asegurados envíen a los trabajadores lesionados a una red de proveedores médicos (MPN) para recibir asistencia médica si el estado les otorga la aprobación de dicha red. El Estado de California ha certificado a la Red de Proveedores Médicos de Liberty Mutual Group (MPN) de conformidad con el Código de Trabajo de California (California Labor Code) sección 4616 y subsecuentes y los Reglamentos de la División de compensación a Trabajadores (División of Workers´ Compensation) para proveer toda la atención médica, el tratamiento y los servicios necesarios para su lesión relacionada con el trabajo. Los objetivos del programa de la MPN son garantizar que: • Usted tenga acceso a asistencia, tratamientos y servicios médicos rápidos, eficientes y de calidad en caso de sufrir lesiones y enfermedades relacionadas con el trabajo. • Usted tenga mayor acceso a especialistas y servicios de salud ocupacional. • Usted reciba revisión constante del tratamiento. Todo tratamiento que se brinde cumplirá con los estándares recomendados según lo establecido en las Reglamentaciones de la Práctica de la Medicina Ocupacional del Colegio Americano de Medicina Ocupacional y Ambiental (American College of Occupational and Enviromental Medicine o ACOEM), de acuerdo con las normas de la medicina empírica y las disposiciones adoptadas por el Director Administrativo de la División de Compensación de Trabajadores (DWC). Usted puede designar a su/s médico/s antes de lesionarse si: • Usted ha recibido asistencia del médico y • Si el médico acepta ser su médico tratante de asistencia primaria. Si su médico no acepta participar en esta capacidad, se le solicitará que busque la asistencia médica de un proveedor de la MPN.
Acceso a los servicios de la MPN "Cualquier persona que hace o provoca conscientemente cualquier declaración o representación material falsa o fraudulenta para propósitos de obtener o de negar los beneficios de compensación o pagos de los trabajadores es culpable de un delito grave." 7
CALIFORINA MPN EMPLOYEE NOTIFICATION La MPN garantizará que haya un médico de asistencia primaria, un hospital o un proveedor de todos los servicios de asistencia médica de emergencia de la MPN ubicado a no más de treinta (30) minutos o quince (15) millas de su domicilio o lugar de trabajo. Otros especialistas y servicios de salud ocupacional deben estar a no más de sesenta (60) minutos o treinta (30) millas de su domicilio o lugar de trabajo. Puede consultar con su empleador para que le recomiende un médico, hospital u otro tipo de atención médica dentro de la MPN. Si usted tiene una lesión relacionada con el trabajo, su supervisor lo ayudará a asegurar que reciba atención médica inicial inmediata a través de un proveedor de la MPN. • Las lesiones en el trabajo deben informarse en forma inmediata a su supervisor. •
Al momento de notificarle una lesión de trabajo, su supervisor lo derivará de inmediato a un médico de atención primaria de la MPN quien le brindará la atención médica inicial y posterior necesaria para su lesión. Después de su primera visita con un proveedor de la MPN, usted tiene derecho a que le atienda un médico de su elección de la MPN.
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El directorio de médicos y proveedores de la Liberty Mutual Group MPN estará disponible para su empleador, su médico y usted. Puede comunicarse con su supervisor o con el administrador de casos de reclamos para solicitar un listado regional y/o completo de la red de proveedores de la MPN. Su empleador o administrador de casos de reclamos le brindará la opción de recibir (a) acceso electrónico al listado regional y/o completo de la red de proveedores de la MPN a través del Sistema de Servicios de Referencia a un Proveedor (Provider Referral Services o PRS), en http://www.talispoint.com/liberty/goldeneagle/extrs.com; (b) una copia impresa del listado regional y/o completo de la red de proveedores de la MPN y/o (c) una copia impresa del listado regional y/o completo de los proveedores de la MPN llamando a la Línea Liberty de Referencia (Liberty Provider Referral Line) al 1-800-944-0443.
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Si necesita servicios de atención médica de emergencia, por favor acuda al hospital o centro médico de emergencias más cercano e informe a su empleador. La MPN de Liberty Mutual Group le permitirá recibir los servicios de atención médica de emergencia en un hospital o en un centro médico hasta que su médico considere que usted se encuentra estable y le recomiende regresar a su domicilio o al lugar de trabajo de su empleador. Luego usted continuará su tratamiento con un médico o proveedor de la MPN según las disposiciones de la MPN de Liberty Mutual Group.
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Para los servicios que no sean de emergencia, se le concertará una cita para tratamiento inicial con un médico de la MPN dentro de los tres (3) días hábiles posteriores a su solicitud de tratamiento. Para los servicios de un especialista que no sean de emergencia y que tienen por objetivo tratar lesiones comunes en el trabajo, se le concertará una cita con un especialista de la MPN que estará disponible a los veinte (20) días hábiles posteriores a su solicitud de tratamiento. Si usted está trabajando temporalmente o en viaje de negocios y requiere tratamiento fuera del área de servicio de la MPN y requiere atención médica de emergencia proceda como se indicó arriba. Si usted requiere tratamiento médico que no sea de emergencia fuera del Área de servicio de la MPN, debe notificar a su supervisor y al administrador de casos de reclamos acerca de su necesidad de tratamiento médico fuera del Área de servicio de la MPN. El administrador de casos de reclamos lo asistirá al localizar al menos a tres médicos u otros proveedores que se encuentren fuera del Área de servicio. Los médicos de atención primaria deberán ubicarse a no más de (30) treinta minutos o (15) quince millas de su domicilio o lugar de trabajo temporal. Otros especialistas y servicios de salud ocupacional deberán ubicarse a no más de sesenta (60) minutos o treinta (30) millas de su domicilio o lugar de trabajo temporal. Los procedimientos para cambiar de médico y obtener una segunda y tercera opinión se aplican a empleados que necesitan someterse a un tratamiento fuera del Área de servicio, consulte la página 5.
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•
Si usted está viviendo temporalmente fuera del Área de servicio o si es un empleado asegurado y su empleador anterior tiene obligaciones continuas con respecto a su compensación y además vive fuera del Área de servicio, comuníquese con su administrador de casos de reclamos. Le podrán proporcionar al menos tres médicos que se encuentren fuera del Área de servicio. Los médicos de atención primaria serán localizados a no más de (30) treinta minutos o (15) quince millas de su domicilio o lugar de trabajo. Otros
"Cualquier persona que hace o provoca conscientemente cualquier declaración o representación material falsa o fraudulenta para propósitos de obtener o de negar los beneficios de compensación o pagos de los trabajadores es culpable de un delito grave." 8
CALIFORINA MPN EMPLOYEE NOTIFICATION especialistas y servicios de salud ocupacional deberán ubicarse a no más de sesenta (60) minutos o treinta (30) millas de su domicilio o lugar de trabajo. Los procedimientos para cambiar de médico y obtener una segunda y tercera opinión se aplican a tratamientos que se realicen fuera del Área de servicio, consulte la página 5. •
Si requiere tratamiento médico en ciertas Áreas rurales o poco pobladas donde los establecimientos médicos se encuentran a 30 millas de distancia como mínimo, usted debe notificar a su empleador o al administrador de casos de reclamos. En caso de ser necesario, el administrador de casos de reclamos le brindará un directorio de proveedores de la MPN. Es probable que necesite tratarse con un médico o proveedor fuera del Área de servicio de la MPN. En caso de ser necesario, el administrador de casos de reclamos le ayudará a encontrar un proveedor que no participe en la MPN.
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Si su médico prescribe equipo médico durable, servicios de salud a domicilio o medicamentos, comuníquese con su administrador de casos de reclamos que contactará al proveedor de servicios auxiliares. El proveedor de servicios se comunicará con usted en forma directa para acordar la entrega del servicio.
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Si necesita transporte para dirigirse al establecimiento médico o a su médico de la MPN comuníquese con su administrador de casos de reclamos quien hará los arreglos necesarios. El proveedor de servicios se comunicará con usted en forma directa para acordar la entrega del servicio.
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Si necesita servicios de traducción de idiomas al momento de su cita médica comuníquese con su administrador de casos de reclamos, quien hará los arreglos necesarios.
Cambio del médico tratante que pertenece a la red MPN •
Si usted no está satisfecho con los servicios de un proveedor de la MPN en cualquier momento posterior a su examen médico inicial, se le permitirá cambiar su médico por otro proveedor de su elección dentro de la MPN.
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El tratamiento que no sea de emergencia y que se realice fuera de la MPN puede no ser cubierto a menos que el administrador de casos de reclamos reciba la solicitud con anticipación. Dicha solicitud por escrito debe además certificar el motivo del cambio solicitado.
Su supervisor o el administrador de casos de reclamos puede asistirlo al elegir un proveedor geográficamente conveniente dentro de la MPN y podrá ayudarle a garantizar que usted reciba la atención médica adecuada que necesita para que regresar al trabajo. •
Si usted tiene alguna dificultad para concertar una cita con un médico o proveedor de la MPN deberá notificarlo al administrador de casos de reclamos. El administrador de casos de reclamos se comunicará con el médico o proveedor en su nombre para concertar una cita. Si el médico o proveedor no puede concertar su cita dentro de los límites de tiempo requeridos, el administrador de casos de reclamos se lo notificará y, si es necesario, le brindará un directorio regional y/o completo de la MPN con los nombres de los médicos o proveedores disponibles para que usted los seleccione.
Tratamiento brindado por un especialista Si usted requiere tratamiento con un especialista, podrá elegir uno adecuado o ser referido al mismo por medio de su médico. Su administrador de casos de reclamos puede brindarle un directorio completo de la red de proveedores de la MPN o un directorio regional con los nombres de médicos o proveedores que estén disponibles para usted a 60 minutos o 30 millas de su domicilio o lugar de trabajo. Su médico tiene acceso al directorio de la MPN y además puede referirlo a un especialista disponible dentro de la MPN. En caso de que su médico tratante lo refiera a un tipo de especialista que no forme parte de la MPN, usted podrá seleccionar otro especialista que no participe en la MPN. Para obtener más información sobre este proceso, comuníquese con su administrador de casos de reclamos. Transferencia de la atención médica actual a un proveedor de la MPN "Cualquier persona que hace o provoca conscientemente cualquier declaración o representación material falsa o fraudulenta para propósitos de obtener o de negar los beneficios de compensación o pagos de los trabajadores es culpable de un delito grave." 9
CALIFORINA MPN EMPLOYEE NOTIFICATION Si usted está siendo tratado actualmente por una lesión o enfermedad relacionada con el trabajo por un médico u otro proveedor de atención médica que pasa a ser un proveedor de la MPN, usted puede continuar su tratamiento con su médico o proveedor de atención médica a través de la MPN. Si usted está siendo tratado actualmente por una lesión o enfermedad relacionada con el trabajo por un médico u otro proveedor de atención médica que no forme parte de la MPN, usted puede continuar recibiendo tratamiento de su médico o proveedor mientras dure cualquier padecimiento grave. Un padecimiento grave es una condición médica que implica la aparición repentina de síntomas debido a una enfermedad, lesión u otro problema médico que requiera atención médica inmediata y que dure menos de noventa (90) días. El tratamiento se llevará a cabo mientras dure el padecimiento grave. En caso de un padecimiento crónico serio, usted puede completar el tratamiento con su médico u otro proveedor de atención médica que no forme parte de la MPN por un período de tiempo necesario, de hasta un año, a fin de completar el tratamiento aprobado por su aseguradora o su empleador y para planificar la transferencia a otro proveedor dentro de la MPN, según lo determine su aseguradora o empleador. Un padecimiento crónico serio es una condición médica que se produce debido a una afección, enfermedad, lesión grave u otro problema o trastorno médico de características serias que persiste sin curarse totalmente o empeora durante 90 días y que además requiere tratamiento continuo para mantener la remisión o prevenir el deterioro. El período de un año para completar el tratamiento comienza a partir de la fecha en que se le notifica que tiene un padecimiento crónico serio. Usted seguirá teniendo cobertura y puede completar el tratamiento con su médico u otro proveedor de atención médica que no forme parte de la MPN si usted sufre un padecimiento incurable o irreversible que tenga una alta probabilidad de causar muerte dentro de un año o antes. Usted podrá someterse a cirugía o a otros procedimientos realizados por su médico u otro proveedor de atención médica que no forme parte de la MPN, dentro de los ciento ochenta (180) días posteriores a la entrada en vigencia de la MPN. Dicho médico o proveedor debe estar autorizado por su administrador de casos de reclamos o su empleador y dichos procedimientos deben ser recomendados y certificados por su médico u otro proveedor de atención médica. Su administrador de casos de reclamos o su empleador le notificarán por escrito a usted y a su médico tratante de atención primaria acerca de la conclusión del tratamiento actual. Usted puede solicitar un informe a su médico tratante si no está de acuerdo con la decisión de la transferencia de la atención médica actual. El informe del médico tratante de atención primaria será enviado dentro de los veinte (20) días calendario posteriores a la fecha de solicitud del informe. Si el médico tratante no emite el reporte, entonces se aplicará la determinación tomada por el empleador o asegurador, de conformidad con el Código de Compensación de los Trabajadores 8 CCR sección 9767.9 (g). Si usted no está de acuerdo con la decisión que tome su médico tratante con respecto a la transferencia de la atención médica, usted puede iniciar acciones legales según el Código Laboral sección 4062. La transferencia de la atención continuará durante el proceso judicial sólo si su médico tratante está de acuerdo con la decisión de la MPN o de su empleador. A solicitud, su administrador de casos de reclamos puede proveerle una copia de esta política. Política de atención médica continua de la MPN Al ser un empleado asegurado de la MPN usted tiene ciertos derechos con respecto a su atención médica. Sus derechos le permiten recibir y terminar un tratamiento médico por ciertas condiciones médicas con el médico que ya no pertenece a la MPN si ocurre lo siguiente: (A) El tratamiento para un padecimiento grave se llevará a cabo mientras dure el mismo. Un padecimiento grave es una condición médica que implica la aparición repentina de síntomas debido a una enfermedad, lesión u otro problema médico que requiere atención médica inmediata y que dura menos de noventa (90) días.
"Cualquier persona que hace o provoca conscientemente cualquier declaración o representación material falsa o fraudulenta para propósitos de obtener o de negar los beneficios de compensación o pagos de los trabajadores es culpable de un delito grave." 10
CALIFORINA MPN EMPLOYEE NOTIFICATION (B) El tratamiento para un padecimiento crónico grave se llevará a cabo por un periodo de tiempo necesario para completar el tratamiento y para arreglar una transferencia segura con otro proveedor, según lo determine la red MPN del Grupo Liberty Mutual en consulta con el empleado lesionado asegurado y el proveedor que ya no participa y consistente con las buenas prácticas profesionales. El tratamiento según este párrafo no excederá de 12 meses a partir de la fecha de terminación de contrato del proveedor. Un padecimiento crónico serio es una condición médica que se produce debido a una afección, enfermedad u otro problema o trastorno médico de características serias que persiste sin curarse totalmente o empeora durante un periodo de noventa (90) días o que requiere tratamiento continuo para mantener la remisión o prevenir el deterioro. (C) El tratamiento se suministrará hasta su conclusión, mientras dure la enfermedad en fase terminal. Una enfermedad en fase terminal es un padecimiento incurable o irreversible que tiene altas probabilidades de causar la muerte en un periodo de un año o menos. (D) La realización de una cirugía u otro procedimiento que haya sido autorizado por la red MPN del Grupo Liberty Mutual como parte de un curso de tratamiento documentado y que haya sido recomendado y documentado por el profesional que ya no participa en la red deberá llevarse a cabo dentro de 180 días a partir de la fecha de terminación del contrato del proveedor. Si no está de acuerdo con una decisión tomada conforme a esta disposición, la red MPN del Grupo Liberty Mutual tiene el siguiente proceso de resolución de disputas: (a) Si el proveedor que ya no participa acepta continuar el tratamiento del empleado lesionado asegurado conforme a la sección 4616.2 del Código Laboral y el empleado lesionado asegurado disputa la determinación médica, el empleado lesionado asegurado debe solicitar un reporte de su médico tratante primario que determine si el empleado asegurado entra o no en cualquiera de las condiciones establecidas en la sección 4616.2(d)(3) del Código Laboral: un padecimiento grave, un padecimiento grave crónico, una enfermedad en fase terminal o la realización de una cirugía u otro procedimiento que autorice el asegurador o empleador como parte de un curso de tratamiento documentado y que el proveedor ha recomendado y documentado para que se lleve a cabo dentro de 180 días a partir de la fecha de terminación del contrato del proveedor. El médico tratante deberá proporcionar el reporte al empleado asegurado dentro de veinte días calendario a partir de la solicitud. Si el médico tratante no emite el reporte, entonces se aplicará la determinación tomada por el empleador o asegurador a la que se hace referencia en (d)(1). (b) Si el empleador o asegurador o empleado lesionado asegurado objeta la determinación médica del médico tratante, la disputa sobre la determinación médica tomada por el médico tratante respecto a la continuación de la atención debe resolverse conforme a la sección 4062 del Código Laboral. (c) Si el médico tratante está de acuerdo con la determinación del empleador o asegurador de que la condición médica del empleado lesionado asegurado no cumple las condiciones establecidas en la sección 4616.2(d)(3) del Código Laboral, el empleado escogerá un nuevo proveedor dentro de la red MPN durante el proceso de resolución de la disputa. (d) Si el médico tratante no está de acuerdo con la determinación del empleador o asegurador de que la condición médica del empleado lesionado asegurado no cumple las condiciones establecidas en la sección 4616.2(d)(3) del Código Laboral, el empleado lesionado asegurado deberá continuar su tratamiento con el proveedor que ya no participa hasta que se resuelva la disputa. Su administrador de casos de reclamos podrá brindarle una copia de la política de atención médica continua de la red MPN. "Cualquier persona que hace o provoca conscientemente cualquier declaración o representación material falsa o fraudulenta para propósitos de obtener o de negar los beneficios de compensación o pagos de los trabajadores es culpable de un delito grave." 11
CALIFORINA MPN EMPLOYEE NOTIFICATION Procedimientos para seleccionar un médico a fin de obtener una segunda y tercera opinión Si usted no está de acuerdo con el diagnóstico o el tratamiento que le prescribe su médico tratante, puede obtener una segunda y tercera opinión de otros médicos dentro de la red MPN. Durante este proceso usted tiene la opción de seguir con el tratamiento continuo por medio de su médico tratante o solicitar otro médico de su elección dentro de la MPN según la sección 9767.6 de las reglamentaciones del Departamento de Compensación de Trabajadores. Una segunda opinión es aquella suministrada por un médico de la MPN, luego de realizar un examen en persona, al no estar de acuerdo con el diagnóstico o con el tratamiento que le prescribió su médico anterior. Una tercera opinión es aquella suministrada por un médico de la MPN, luego de realizar un examen en persona, al no estar de acuerdo con el diagnóstico o con el tratamiento que le prescribió su médico anterior o el médico que le brindó una segunda opinión. Para obtener una segunda opinión, debe informar a su supervisor o a su administrador de casos de reclamos en forma verbal o mediante una carta, fax o correo electrónico su desacuerdo con respecto a la opinión de su médico del tratamiento y acerca del motivo por el cual solicita una segunda opinión. Usted debe seleccionar a un médico o especialista de un directorio regional suministrado por su supervisor o por el administrador de casos de reclamos que incluye a los proveedores disponibles en la red MPN. Usted será responsable de concertar dentro de los sesenta (60) días una cita con el médico que le brinda una segunda opinión e informar a su administrador de casos de reclamos acerca de la fecha de la cita. El administrador de casos de reclamos se comunicará por escrito con el proveedor que brinda una segunda opinión a fin de notificarle que ha sido seleccionado/a para una segunda opinión, para describirle la naturaleza de su desacuerdo y además para suministrar la historia clínica necesaria previa a la fecha de la cita. Usted recibirá una copia de la carta dirigida al médico que ofrece la segunda opinión. Si usted lo solicita, puede obtener una copia de su historia clínica. Si la cita no se realiza dentro de los sesenta (60) días luego de haber recibido la lista de proveedores de la red MPN disponibles, usted no podrá obtener una segunda opinión del diagnóstico o tratamiento de su médico anterior con el cual estaba en desacuerdo. Su médico del tratamiento, la persona designada de la red MPN y usted recibirán una copia del informe escrito del médico que le ofrece una segunda opinión dentro de los veinte (20) días posteriores a la fecha de su cita o luego de haber recibido los resultados de cualquier prueba diagnóstica a la que se haya sometido durante su cita, lo que ocurra más tarde. Para obtener una segunda opinión, debe informar a su supervisor o a su administrador de casos de reclamos en forma verbal o mediante una carta, fax o correo electrónico, acerca de su desacuerdo con respecto al diagnóstico o al tratamiento del médico que le brinda una segunda opinión y que por este motivo usted está solicitando una tercera opinión. Usted debe seleccionar a un médico o especialista de un directorio regional suministrado por su supervisor o por el administrador de casos de reclamos que incluye a los proveedores disponibles en la red MPN. Al momento de seleccionar un médico para obtener una tercera opinión, el administrador de casos de reclamos le notificará acerca del procedimiento de su examen médico independiente y le suministrará un formulario de “Solicitud de examen médico independiente” según lo establecido en la sección 9768.10 de los reglamentos del Departamento de Compensación de Trabajadores. El administrador de casos de reclamos completará la “Sección de Contacto con la red MPN” del formulario y consignará la especialidad del médico del tratamiento y una especialidad alternativa, si existiera alguna, diferente a la primera. Usted será responsable de concertar dentro de los sesenta (60) días una cita con el médico que le brinda una tercera opinión e informar a su administrador de casos de reclamos acerca de la fecha de la cita. El administrador de casos de reclamos se comunicará por escrito con el proveedor que brinda una tercera opinión a fin de notificarle que ha sido seleccionado/a para una tercera opinión, para describirle la naturaleza de su desacuerdo y además para suministrar la historia clínica necesaria previa a la fecha de la cita. Usted recibirá una copia de la carta dirigida al médico que ofrece la tercera opinión. Si usted lo solicita, puede obtener una copia de su historia clínica. Si la cita no se realiza dentro de los sesenta (60) días luego de haber recibido la lista de proveedores MPN disponibles, usted no podrá obtener una tercera opinión del diagnóstico o tratamiento de su médico anterior del cual estaba en desacuerdo. Su médico del tratamiento, la persona designada de la red MPN y usted recibirán una copia del informe escrito del médico que le ofrece una segunda opinión dentro de los veinte (20) días posteriores "Cualquier persona que hace o provoca conscientemente cualquier declaración o representación material falsa o fraudulenta para propósitos de obtener o de negar los beneficios de compensación o pagos de los trabajadores es culpable de un delito grave." 12
CALIFORINA MPN EMPLOYEE NOTIFICATION a la fecha de su cita o luego de haber recibido los resultados de cualquier prueba diagnóstica a la que se haya sometido durante su cita, lo que ocurra más tarde. Si uno de los médicos que ofrecen la segunda o la tercera opinión recomienda tratamiento específico, usted deberá someterse a tratamiento con dicho médico o podrá seleccionar otro que forme parte de la red MPN. Si usted no está de acuerdo con el diagnóstico o el tratamiento recomendado por el médico que brinda la tercera opinión, podrá presentar una solicitud al Director Administrativo de la División de Compensación de Trabajadores de California para solicitar un examen médico independiente. Si necesita ayuda comuníquese con su supervisor o su administrador de casos de reclamos. Información de contacto Si tiene alguna pregunta o inquietud con respecto al programa de la red MPN comuníquese con su supervisor, con el administrador de casos de reclamos o con el coordinador de programas de la red MPN del Grupo Liberty Mutual. Usted puede comunicarse con el administrador de casos de reclamos y con el coordinador de programas durante las horas normales de oficina de 8:00 AM a 5:00 PM, de lunes a viernes al 1-800-603-6438. Puede comunicarse con el coordinador de programas de la red MPN al 800-331-1133.
"Cualquier persona que hace o provoca conscientemente cualquier declaración o representación material falsa o fraudulenta para propósitos de obtener o de negar los beneficios de compensación o pagos de los trabajadores es culpable de un delito grave." 13
Liberty Mutual Group MPN Form B - Employee Notification Confirmation
In order to confirm that you have received appropriate notification regarding the Liberty Mutual Group Medical Provider Network (MPN) please complete and sign the attached form. This form must be returned to your employer at the time you first receive employee notification information about the MPN. This may occur at the time of your employer’s MPN presentation, at the time of hire, at the time of your report of injury or at the time you transfer into the MPN. __________________________________________ (Employee Signature)
_____________________ (Date)
_______________________________________________________________________ (Print Employee Full Name)
________________________________________________________________________________ _ (Name of Employer) Any person who makes or causes to be made any knowingly false, or fraudulent material statement or material representation for the purposes of obtaining or denying workers’ compensation benefits or payments is guilty of a felony.
Con el fin de confirmar que usted ha recibido la notificación adecuada acerca de la Red de Profesionales de Servicios Médicos del Grupo Liberty Mutual (MPN) (Liberty Mutual Group Medical Provider Network (MPN)) por favor llene y firme la forma adjunta. Esta forma debe ser entregada a su empleador al momento en que reciba información de la notificación para empleados acerca de la MPN. Esto puede ocurrir al momento de la presentación de la MPN de su empleador, al momento de la contratación, al momento de su reporte de lesión o al momento de su traslado a la MPN. __________________________________________ (Firma del empleado)
_____________________ Fecha
_______________________________________________________________________ (Nombre firma completo) ________________________________________________________________________________ _ (Nombre del empleador) Cualquier persona que hace o provoca conscientemente cualquier declaración o representación material falsa o fraudulenta para propósitos de obtener o de negar los beneficios de compensación o pagos de los trabajadores es culpable de un delito grave. 1
California Medical Provider Network Provider Referral Services (PRS) Access Information
The information outlined below provides you with instructions on how to select a provider from the Liberty Mutual Group Medical Provider Network (MPN). If you have access to the internet you may access the MPN by following these instructions. If you do not have internet access, you may contact the Liberty Mutual Provider Referral Service hot line phone number: (800) 944-0443 for provider selection or contact your claims case manager for assistance in providing a provider directory for your review.
Internet Access Instructions to the Liberty Mutual Group MPN: 1. Go to Provider Referral Services (PRS) using the following internet URL address: http://www.talispoint.com/liberty/goldeneagle/ext 2. Click on the “Provider Search” tab (top of page) 3. Enter the City and State. State is CA. Click on “Continue.” 4. The screen will change and Plan Type “Medical Provider Network (MPN)” will appear. 5. On the line “Search Distance (miles)” select a mile button. We recommend you start with a “15” mile radius from either your home or work location. You may expand this search for additional providers, if needed. Click on “Continue.” 6. Select a “Provider Type.” We suggest you select all provider types by selecting the first provider and hold down the shift key and select the last provider type. All provider types will now be selected. If you would rather select a specific provider, click on the “Specialty”. You may also select a “SubSpecialty if they are listed.” Select the provider that you feel can provide the treatment you require. Click on “Continue.” If you are unsure which provider type to select, we recommend starting with a “Primary Care Physician (PCP)” 7. You may select any of the providers listed or you may continue to review other providers that are in the MPN. 8. You will see the providers; name, address, miles, phone number and provider specialty listed. 9. To create a map and driving instructions, click on the map that is located to the right side of the provider list. You may also create driving instructions by entering the address and zip code where you are located. 10. You may create a directory of the providers listed. Click on the bottom tab “Select all providers on this page.” Click on “Create Provider Listing.” All providers will be listed. You may print or e-mail the provider list. See the bottom of the provider listing page.
Regional Directory: To create a regional directory, click on the “Directory Region” tab (top of page)
Selecting a Physician and Setting a Medical Appointment: 1. Select a physician that will be able to treat your medical condition 2. Call the physician’s office and advise the following information: I have a Workers’ Compensation claim and you are listed as a approved provider that is contracted with either Blue Cross of California and Kaiser On-the-Job (KOJ). I need to schedule an appointment. Provide your information, the claim number, the claim case managers name and phone number. 3. Call the claim case manager and advise the; name of the physician, address, phone number and date of your appointment.
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If you have any questions regarding the above information please contact your claims case manager.
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Red de Proveedores Médicos de California Información de Acceso a Servicios de Remisión a Proveedores (PRS)
La información descrita abajo le ofrece instrucciones sobre cómo seleccionar un proveedor de la Liberty Mutual Group Medical Provider Network (MPN) (Red de Proveedores Médicos del Grupo Liberty Mutual). Si usted tiene acceso a internet puede ingresar a la MPN siguiendo estas instrucciones. Si no tiene acceso a internet, puede ponerse en contacto con el Servicio de Remisión a Proveedores de Liberty Mutual en su línea telefónica de servicio: (800) 944-0443 para selección de un proveedor, o comuníquese con su gerente de casos de reclamación para solicitar asistencia con un directorio de proveedores para que pueda consultarlo.
Instrucciones de Acceso vía Internet a la MPN del Grupo Liberty Mutual: 11. Vaya a Servicios de Remisión a Proveedores (Provider Referral Services - PRS) usando la siguiente dirección URL de internet: http://www.talispoint.com/liberty/goldeneagle/ext 12. Haga clic en la pestaña de “Búsqueda de Proveedor “ (“Provider Search”) (parte superior de la página) 13. Ingrese la Ciudad y el Estado. El estado es CA. Haga clic en “Continuar” (“Continue”). 14. La pantalla cambiará y aparecerá Plan Tipo “Red de Proveedores Médicos (MPN)” (Plan Type “Medical Provider Network (MPN)”). 15. En la línea “Distancia de Búsqueda (millas)” (“Search Distance (miles)”) seleccione un botón de millaje. Le recomendamos iniciar con un radio de “15” millas ya sea desde la ubicación de su casa o de su lugar de trabajo. Puede ampliar la búsqueda para encontrar proveedores adicionales, de ser necesario. Haga clic en “Continuar” (“Continue”). 16. Seleccione un “Tipo de Proveedor” (“Provider Type”). Le sugerimos que seleccione todos los tipos de proveedores eligiendo el primer proveedor y manteniendo oprimida la tecla de mayúsculas hasta seleccionar luego el último tipo de proveedor. Así seleccionará todos los tipos de proveedores. Si prefiere seleccionar un proveedor específico, haga clic sobre la “Especialidad” (“Specialty”). También puede elegir una “Sub-Especialidad” (“Sub-Specialty) si las hay listadas. Seleccione el proveedor que usted considere puede ofrecerle el tratamiento que requiere. Haga clic en “Continuar” (“Continue”). Si no está seguro sobre qué tipo de proveedor elegir, le recomendamos iniciar con un “Médico de Atención Primaria (PCP)” (“Primary Care Physician (PCP))”. 17. Usted puede elegir cualquiera de los proveedores listados o puede continuar repasando otros proveedores que estén dentro de la MPN. 18. En el listado usted podrá ver el nombre, dirección, millas, número de teléfono y especialidad de cada uno de los proveedores. 19. Para crear un mapa y obtener instrucciones sobre cómo llegar en automóvil, haga clic en el mapa ubicado en el lado derecho del listado de proveedores. También puede crear las instrucciones para llegar en automóvil ingresando la dirección y el código postal donde usted está ubicado. 20. Usted puede crear un directorio de los proveedores listados. Haga clic sobre la pestaña inferior “Seleccionar todos los proveedores de esta página” (“Select all providers on this page”). Haga clic en “Crear Listado de Proveedores” (“Create Provider Listing”). Todos los proveedores serán listados. Puede imprimir el listado de proveedores o enviarlo por correo electrónico. Vea la parte inferior de la página del listado de proveedores.
Directorio Regional:
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Para crear un directorio regional, haga clic en la pestaña “Región del Directorio” (“Directory Region”) (parte superior de la página)
Cómo Elegir un Médico y Programar una Cita Médica: 4. Seleccione un médico que pueda tratar su afección médica 5. Llame al consultorio del médico y suministre la siguiente información: Tengo una reclamación por Indemnización Laboral y usted está listado como un proveedor aprobado contratado por la Red Blue Cross of California y Kaiser On-theJob (KOJ). Necesito programar una cita. Suministre su información, el número de la reclamación, y el nombre y número de teléfono del gerente de casos de reclamación. 6. Llame al gerente de casos de reclamación y notifíquele el nombre del médico, dirección, número de teléfono y la fecha de su cita.
Si tiene alguna pregunta sobre la anterior información le agradecemos ponerse en contacto con su gerente de casos de reclamación.
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PREDESIGNATION OF PERSONAL PHYSICIAN In the event you sustain an injury or illness related to your employment, you may be treated for such injury or illness by your personal medical doctor (M.D.), doctor of osteopathic medicine (D.O.) or medical group if: • your employer offers group health coverage; • the doctor is your regular physician, who shall be either a physician who has limited his or her practice of medicine to general practice or who is a board-certified or board-eligible internist, pediatrician, obstetriciangynecologist, or family practitioner, and has previously directed your medical treatment, and retains your medical records; • your "personal physician" may be a medical group if it is a single corporation or partnership composed of licensed doctors of medicine or osteopathy, which operates an integrated multispecialty medical group providing comprehensive medical services predominantly for nonoccupational illnesses and injuries; • prior to the injury your doctor agrees to treat you for work injuries or illnesses; • prior to the injury you provided your employer the following in writing: (1) notice that you want your personal doctor to treat you for a work-related injury or illness, and (2) your personal doctor’s name and business address. You may use this form to notify your employer if you wish to have your personal medical doctor or a doctor of osteopathic medicine treat you for a work- related injury or illness and the above requirements are met. NOTICE OF PREDESIGNATION OF PERSONAL PHYSICIAN Employee: Complete this section. To: ____________________________ (name of employer) If I have a work-related injury or illness, I choose to be treated by: _______________________________________________________________________ (name of doctor)(M.D., D.O., or medical group) ______________________________________________________(street address, city, state, ZIP) ___________________________________________(telephone number) Employee Name (please print): ________________________________________________________________________ Employee’s Address: ________________________________________________________________________ Employee’s Signature_______________________________________________Date:_____________ Physician: I agree to this Predesignation: Signature:____________________________________________________Date:__________ (Physician or Designated Employee of the Physician or Medical Group) The physician is not required to sign this form, however, if the physician or designated employee of the physician or medical group does not sign, other documentation of the physician’s agreement to be predesignated will be required pursuant to Title 8, California Code of Regulations, section 9780.1(a)(3). Title 8, California Code of Regulations, section 9783. (Optional DWC Form 9783 March 1, 2007)
DESIGNACIÓN PREVIA DE MÉDICO PARTICULAR 1
En caso de que usted sufra una lesión o enfermedad relacionada con su empleo, usted puede recibir tratamiento médico por esa lesión o enfermedad de su médico particular (M.D.), médico osteópata (D.O.) o grupo médico si: • su empleador le ofrece un plan de salud grupal • el médico es su médico familiar o de cabecera, que será un médico que ha limitado su práctica médica a medicina general o que es un internista certificado o elegible para certificación, pediátra, gineco-obstreta, o médico de medicina familiar y que previamente ha estado a cargo de su tratamiento médico y tiene su expediente médico • su "médico particular" puede ser un grupo médico si es una corporación o sociedad o asociación compuesta de doctores certificados en medicina u osteopatía, que opera un integrado grupo médico multidisciplinario que predominantemente proporciona amplios servicios médicos para lesiones y enfermedades no relacionadas con el trabajo. • antes de la lesión su médico está de acuerdo a proporcionarle tratamiento médico para su lesión o enfermedad de trabajo • antes de la lesión usted le proporcionó a su empleador por escrito lo siguente: (1) notificación de que quiere que su médico particular le brinde tratamiento para una lesión o enfermedad de trabajo y (2) el nombre y dirección comercial de su médico particular. Puede usar este formulario para notificarle a su empleador que desea que su médico particular o médico osteópata le proporcione tratamiento médico para una lesión o enfermedad de trabajo y que los requisitos mencionados arriba han sido cumplidos. NOTICIA DE DESIGNACIÓN PREVIA DE MÉDICO PARTICULAR Empleado: Rellene esta sección. A: ____________________________ (nombre del empleador) Si sufro una lesión o enfermedad de trabajo, yo elijo recibir tratamiento médico de: _______________________________________________________________________ (nombre del médico)(M.D., D.O., o grupo médico) ______________________________________________________(dirección, ciudad, estado, código postal) ___________________________________________(número de teléfono) Nombre del Empleado (en letras de molde, por favor): ________________________________________________________________________ Domicilio del Empleado: ________________________________________________________________________ Firma del Empleado_______________________________________________Fecha:_____________ Médico: Estoy de acuerdo con esta Designación Previa: Firma:____________________________________________________Fecha:__________ (Médico o Empleado designado por el Médico o Grupo Médico) El médico no está obligado a firmar este formulario, sin embargo, si el médico o empleado designado por el médico o grupo médico no firma, será necesario presentar documentación sobre el consentimiento del médico de ser designado previamente de acuerdo al Código de Reglamentos de California, Título 8, sección 9780.1(a)(3). Código de Reglamentos de California, Título 8, sección 9783. (Formulario Opcional 9783 de la DWC 1 de marzo 2007 )
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