AB 399 California: MPN Approval, Access, and Complaints

California’s Medical Provider Network rules sit in Labor Code Section 4616 and Title 8 of the California Code of Regulations, and they cover four things that matter to anyone dealing with an MPN: how a network gets approved, how close it has to keep providers to injured workers, what rights those workers have inside the network, and what happens when the network falls short. Penalties reach $5,000 per violation, and the Division of Workers’ Compensation can put a network on probation, suspend it, or revoke its approval outright.

Who Can Set Up an MPN and How It Gets Approved

An insurer or employer may establish one or more MPNs to provide medical treatment to injured workers. A physician network services entity can also submit an application on behalf of an employer or insurer. The network has to include physicians who primarily treat occupational injuries alongside those who primarily treat nonoccupational injuries, with a goal of at least 25 percent nonoccupational providers, and enough physicians overall to deliver timely treatment given the occupations and geography involved.¹

The Administrative Director has 60 days to act on a submitted plan. If nothing happens in that window, the plan is deemed approved.¹ Approval lasts four years. Reapproval requires a complete new application filed no later than six months before the four-year expiration, and each reapproval has to meet every requirement of an original application, including updated geocoding that shows the network still satisfies access standards.²

The application itself has to affirm that the network is adequate for the expected volume of claims and explain the reasoning behind that conclusion. It also has to document how the network meets access standards, how providers are selected, and how quality is monitored.³

Access Standards

Access standards are where a lot of networks fall down. The rules draw hard geographic lines measured from each employee’s actual residence or workplace address, not from the middle of a zip code.⁴

At least three primary treating physicians available within 30 minutes or 15 miles, plus a hospital or facility for emergency care.
Occupational health specialists and specialists who treat common injuries available within 60 minutes or 30 miles.

Where a network cannot hit those distances in a particular area, it has to either obtain approval for an alternative access standard or maintain a written policy allowing out-of-network treatment there.²

Notice to Injured Workers

Once an injured worker reports the injury or files a claim, the employer must arrange an initial medical evaluation and begin treatment. The employer also has to tell the employee that an MPN exists, explain the right to change treating physicians within the network after the first visit, and describe how to see the list of participating providers.⁵

Missing that notice does not automatically free the worker to treat outside the MPN. The employee has to show that the lack of notice actually resulted in a denial of medical care.⁵

Pre-Designating a Personal Physician

Workers who want to skip the MPN entirely can pre-designate a personal physician before any injury happens. That requires written notice to the employer naming the physician and the employee’s health plan, the physician’s agreement to the pre-designation in advance, and existing health care coverage for nonoccupational injuries at the time the work injury occurs.⁶

A valid pre-designation exempts the employee from the MPN completely. Any referrals that physician makes also do not have to stay inside the network.⁶

Second and Third Opinions

A worker who disagrees with the treating physician’s diagnosis or treatment plan can request a second opinion from another physician in the MPN, and if that doesn’t resolve the disagreement, a third. Treatment continues with the current physician or another MPN physician of the worker’s choice during the process.⁷

The steps are the same at both stages:

Notify the person designated by the employer or insurer that you dispute the treating physician’s opinion. Verbal or written notification both count.
Pick a physician or specialist from the MPN provider list.
Schedule the appointment within 60 days.
Tell the designated person the appointment date.

The 60-day window is strict. Missing it waives the second or third opinion for that particular disputed diagnosis or treatment. If the third opinion still doesn’t resolve the dispute, the worker can request an MPN Independent Medical Review from the Administrative Director.⁷

Choosing a Specialist

Within the network, the choice of a treating or subsequent physician should be based on specialty or recognized expertise in the particular injury or condition. When the network does not include a physician who can provide an approved treatment, the employer or insurer may authorize an outside specialist on a case-by-case basis.⁵

Continuity of Care When a Provider Leaves the Network

Every MPN must file a written continuity of care policy with the Administrative Director. When a treating physician is removed from the network, an injured worker actively receiving treatment from that physician can request to keep seeing them in four specific situations.⁸

Acute conditions: a sudden-onset illness or injury requiring prompt attention. Treatment continues for the duration of the acute condition.
Serious chronic conditions: conditions that persist without full cure, worsen over time, or require ongoing treatment to maintain remission. Treatment continues long enough to complete a course of care and arrange a safe transfer, capped at 12 months from the contract termination date.
Terminal illness: an incurable or irreversible condition with a high probability of causing death within one year. Treatment continues for the duration of the terminal illness.
Scheduled procedures: a surgery or other procedure authorized and documented to occur within 180 days of the contract termination date.

The MPN has to notify workers entering the system about the continuity of care policy and how to request review under it, and workers can request a copy of the full policy.⁸

Independent Medical Review

Independent Medical Review resolves disputes about whether a requested medical treatment is medically necessary. When utilization review denies, delays, or modifies a treating physician’s treatment request, the injured worker can request IMR through the DWC.⁹

IMR is conducted by an independent medical review organization contracted by the DWC, not by the employer’s network physicians, and the reviewing medical professionals must meet qualification and conflict-of-interest standards.¹⁰ IMR is also the final step after a worker exhausts the second and third opinion process inside the MPN.⁷

Penalties for Non-Compliance

The Administrative Director can place an MPN on probation, suspend it, or revoke its approval when the network fails to meet Labor Code Section 4616 and the implementing regulations.¹¹ Revocation removes the network from the workers’ compensation system entirely, so the employer loses the ability to direct injured workers’ medical care through it.

For less serious violations, the Administrative Director may impose administrative penalties of up to $5,000 per violation, place the MPN on probation, or both, as an alternative to suspension or revocation.¹ The per-violation structure means a pattern of problems, like access gaps across multiple zip codes, can add up fast.

Filing a Complaint With the DWC

Injured workers, medical providers, and others who believe utilization review is not being handled according to the regulations can file a complaint with the DWC. The DWC accepts complaints about qualified medical evaluators, the utilization review process, and the way a claims administrator is handling benefits.¹²

A DWC complaint is separate from IMR. IMR resolves medical necessity for a specific treatment request. A complaint addresses broader problems, such as an MPN that consistently fails to provide timely access or a claims administrator that routinely mishandles benefit payments. Both avenues stay open, and depending on the situation an injured worker may need to use one or both.

1
California Legislative Information. California Code Labor Code 4616 – Medical Provider Networks
2
Legal Information Institute. California Code of Regulations Title 8 Section 9767.15 – Compliance with Current MPN Regulations; Reapproval
3
Department of Industrial Relations. California Code of Regulations Title 8 Section 9767.3 – Application for a Medical Provider Network Plan
4
Department of Industrial Relations. California Code of Regulations Title 8 Section 9767.5 – Access Standards
5
California Legislative Information. California Code Labor Code 4616.3
6
Department of Industrial Relations. California Code of Regulations Title 8 Section 9780.1 – Employee’s Predesignation of Personal Physician
7
Department of Industrial Relations. California Code of Regulations Title 8 Section 9767.7 – Second and Third Opinions
8
California Legislative Information. California Code Labor Code 4616.2
9
Division of Workers’ Compensation. Division of Workers’ Compensation – Independent Medical Review
10
Department of Industrial Relations. DWC Independent Medical Review FAQs
11
Department of Industrial Relations. California Code of Regulations Title 8 Section 9767.14 – Probation, Suspension or Revocation of Medical Provider Network Plan; Hearing
12
California Division of Workers’ Compensation. DWC Filing a Complaint