Section 4616.2 Of Article 2.3. Medical Provider Networks From California Labor Code >> Division 4. >> Part 2. >> Chapter 2. >> Article 2.3.
4616.2
. (a) A medical provider network shall file a written
continuity of care policy with the administrative director.
(b) If approved by the administrative director, the provisions of
the written continuity of care policy shall replace all prior
continuity of care policies. A medical provider network shall file a
revision of the continuity of care policy with the administrative
director if it makes a material change to the policy.
(c) The medical provider network shall provide all employees
entering the workers' compensation system notice of the medical
provider network's written continuity of care policy and information
regarding the process for an employee to request a review under the
policy and, upon request, a copy of the medical provider network's
written continuity of care policy.
(d) (1) At the request of an injured employee, completion of
treatment shall be provided by a terminated provider as set forth in
this section.
(2) The completion of treatment shall be provided by a terminated
provider to an injured employee who, at the time of the contract's
termination, was receiving services from that provider for one of the
conditions described in paragraph (3).
(3) The employer or its claims administrator shall provide for the
completion of treatment for the following conditions subject to
coverage through the workers' compensation system:
(A) An acute condition. An acute condition is a medical condition
that involves a sudden onset of symptoms due to an illness, injury,
or other medical problem that requires prompt medical attention and
that has a limited duration. Completion of treatment shall be
provided for the duration of the acute condition.
(B) A serious chronic condition. A serious chronic condition is a
medical condition due to a disease, illness, or other medical problem
or medical disorder that is serious in nature and that persists
without full cure or worsens over an extended period of time or
requires ongoing treatment to maintain remission or prevent
deterioration. Completion of treatment shall be provided for a period
of time necessary to complete a course of treatment and to arrange
for a safe transfer to another provider, as determined by the
employer or its claims administrator in consultation with the injured
employee and the terminated provider and consistent with good
professional practice. Completion of treatment under this paragraph
shall not exceed 12 months from the contract termination date.
(C) 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. Completion of treatment shall be provided
for the duration of a terminal illness.
(D) Performance of a surgery or other procedure that is authorized
by the employer or its claims administrator 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.
(4) (A) The employer or its claims administrator may require the
terminated provider whose services are continued beyond the contract
termination date pursuant to this section to agree in writing to be
subject to the same contractual terms and conditions that were
imposed upon the provider prior to termination. If the terminated
provider does not agree to comply or does not comply with these
contractual terms and conditions, the employer or its claims
administrator is not required to continue the provider's services
beyond the contract termination date.
(B) Unless otherwise agreed by the terminated provider and the
employer or its claims administrator, the services rendered pursuant
to this section shall be compensated at rates and methods of payment
similar to those used by the medical provider network for currently
contracting providers providing similar services who are practicing
in the same or a similar geographic area as the terminated provider.
The employer or its claims administrator is not required to continue
the services of a terminated provider if the provider does not accept
the payment rates provided for in this paragraph.
(5) An employer or its claims administrator shall ensure that the
requirements of this section are met.
(6) This section shall not require an employer or its claims
administrator to provide for completion of treatment by a provider
whose contract with the medical provider network has been terminated
or not renewed for reasons relating to a medical disciplinary cause
or reason, as defined in paragraph (6) of subdivision (a) of Section
805 of the Business and Professions Code, or fraud or other criminal
activity.
(7) Nothing in this section shall preclude an employer or its
claims administrator from providing continuity of care beyond the
requirements of this section.