California Medical Provider Networks (MPN)

What is a Medical Provider Network?

A Medical Provider Network (MPN) is a network of medical service providers established by employers or insurers to provide medical treatment for work-related injuries in California. Under Labor Code Section 4616, self-insured employers, workers' compensation insurers, or entities providing physician network services may establish an MPN.

An MPN must be approved by the California Division of Workers' Compensation (DWC) before it can be used. The MPN program became effective January 1, 2005. All employees of an employer using an approved MPN are required to receive medical treatment through the network for work injuries, with limited exceptions.

Who Can Establish an MPN?

Under California regulations, the following entities may establish a Medical Provider Network:

• Workers' compensation insurers
• Self-insured employers
• Joint powers authorities
• The State of California
• California Insurance Guarantee Association (CIGA)
• State Compensation Insurance Fund (SCIF)
• Groups of self-insured employers
• Entities that provide physician network services

MPNs are not mandatory - each eligible employer or insurer may decide whether to establish and use an MPN to treat employees' industrial injuries.

Your Right to Change Treating Physicians

Under CCR Section 9767.6(e), at any point after your initial medical evaluation with an MPN physician, you have the right to select a different physician of your choice from within the MPN.

Key Points About Changing Doctors

• You can change providers within the MPN for any reason
• The new provider you choose should be appropriate to treat your specific injury
• Your employer or insurer must provide you with access to the MPN provider directory
• You may request assistance from the MPN's medical access assistants to find a physician or schedule appointments

Predesignation Exception

Under Labor Code Section 4600(d), if you properly pre-designate a personal physician before an injury occurs, you can treat with that physician even if your employer has an established MPN. To pre-designate:

• You must have health coverage at the time of injury
• Your personal physician must agree to be pre-designated
• Pre-designation must be in writing before the injury

MPN Independent Medical Review (IMR)

If you still disagree with the diagnosis or treatment after receiving a third opinion, you have the right to request an MPN Independent Medical Review under CCR Section 9768.9.

IMR Process

1. At the time of the third opinion selection, your MPN Contact must notify you about the IMR process and provide an IMR Application form
2. Complete and submit the Independent Medical Review Application
3. When you receive the name of the Independent Medical Reviewer, schedule an appointment within 60 days
4. The Independent Medical Reviewer must schedule an appointment within 30 days

Transfer of Care into an MPN (CCR Section 9767.9)

If you are being treated outside of an MPN for an occupational injury that occurred before the MPN's coverage, you may be entitled to continue treatment under certain conditions:

Conditions Allowing Continued Treatment Outside MPN

General Transfer Rule

If your condition does not meet one of the above categories, you may be transferred into the MPN for medical treatment, unless otherwise authorized by your employer or insurer.

Employee Notification Requirements (CCR Section 9767.12)

Employers and insurers are required to provide you with written notification about the MPN:

Required Notifications

• Initial notification when an injury is reported or when you are transferred into an MPN
• Implementation notice to all employees before implementing an approved MPN
• New hire notification at the time of hire
• Notification must be provided in English and Spanish (if employee primarily speaks Spanish)

Notification Must Include

• How to access initial and subsequent medical care
• How to contact medical access assistants for help finding physicians or scheduling appointments
• Description of transfer of care and continuity of care policies
• Information about second and third opinion rights
• Information about the MPN Independent Medical Review process

MPN Provider Directory Requirements

Under Labor Code Section 4616(a)(4)(A)(i), effective July 1, 2021, every MPN must:

• Maintain a website with a roster of all participating providers
• Include all physicians and ancillary service providers in the network
• Update the roster at least quarterly
• Ensure all listed physicians have valid and current California licenses
• Ensure ancillary providers have current valid licenses or certifications

Treatment Outside the MPN

In certain circumstances, you may be entitled to receive treatment outside the MPN:

• Access standard failure: If you cannot obtain reasonable and necessary treatment within the applicable access standards and required timeframes
• Predesignation: If you properly pre-designated your personal physician before the injury
• Emergency treatment: Emergency care is always covered regardless of MPN status
• Continuity of care: Under qualifying conditions when being transferred into an MPN
• Employer authorization: If your employer or insurer agrees to allow treatment outside the MPN

The MPN must have a written policy permitting treatment outside the network when access standards cannot be met.

Telehealth Services in MPNs

California regulations address telehealth services within Medical Provider Networks:

• If you consent to telehealth services, telehealth-only physicians count toward the MPN's access standards
• If you do not consent or withdraw consent to telehealth before treatment, the telehealth physician does not count toward access standards
• You have the right to choose between in-person and telehealth appointments when both are available

Key Legal References

Medical Provider Networks in California are governed by:

Labor Code

• Labor Code Section 4616 - Establishment of MPNs
• Labor Code Section 4616.2 - Continuity of care
• Labor Code Section 4616.3 - Second and third opinions
• Labor Code Section 4600(d) - Predesignation of physician

California Code of Regulations, Title 8

• Section 9767.1 - MPN Definitions
• Section 9767.3 - MPN Plan Requirements
• Section 9767.5 - Access Standards
• Section 9767.6 - Treatment and Change of Physicians Within MPN
• Section 9767.7 - Second and Third Opinions
• Section 9767.9 - Transfer of Ongoing Care into MPN
• Section 9767.12 - Employee Notification
• Section 9768.9 - MPN Independent Medical Review