For all dates of injury occurring on or after January 1, 2018, emergency treatment services and medical treatment rendered for a body part or condition that is accepted as compensable by the employer and is addressed by the medical treatment utilization schedule (MTUS) adopted pursuant to Section 5307.7, by a member of the medical provider network or health care organization, or by a physician pre-designated pursuant to subdivision (d) of Section 4600, within the 30 days following the initial date of injury, shall be authorized without prospective utilization review, except as provided in subdivision (c). The services rendered under this subdivision shall be consistent with the medical treatment utilization schedule. In the event that the employee is not subject to treatment with a medical provider network, health care organization, or predesignated physician pursuant to subdivision (d) of Section 4600, the employee shall be eligible for treatment under this section within 30 days following the initial date of injury if the treatment is rendered by a physician or facility selected by the employer. For treatment rendered by a medical provider network physician, health care organization physician, a physician predesignated pursuant to subdivision (d) of Section 4600, or an employer-selected physician, the report required under Section 6409 and a complete request for authorization shall be submitted by the physician within five days following the employee’s initial visit and evaluation.
(c) Unless authorized by the employer or rendered as emergency medical treatment, the following medical treatment services, as defined in rules adopted by the administrative director, that are rendered through a member of the medical provider network or health care organization, a predesignated physician, an employer-selected physician, or an employer-selected facility, within the 30 days following the initial date of injury, shall be subject to prospective utilization review under this section:
(1) Pharmaceuticals, to the extent they are neither expressly exempted from prospective review nor authorized by the drug formulary adopted pursuant to Section 5307.27.
(2) Nonemergency inpatient and outpatient surgery, including all presurgical and postsurgical services.(3) Psychological treatment services.
(4) Home health care services.
(5) Imaging and radiology services, excluding X-rays.
(6) All durable medical equipment, whose combined total value exceeds two hundred fifty dollars ($250), as determined by the official medical fee schedule.
(7) Electrodiagnostic medicine, including, but not limited to, electromyography and nerve conduction studies.
(8) Any other service designated and defined through rules adopted by the administrative director.
Marquee MCS Medical Provider Network Consultative Services in the last 10 years, has saved our clients 20% in total claims costs
Since 2008, we’ve helped California clients develop, implement and audit customized medical provider networks achieving, on average, a 20% reduction in total claims costs.
Medical Provider Network Benefits:
- Medical control for the life of a claim
- Lower utilization review (UR) costs
- Lower litigation costs
- Reduced medical/ indemnity expenses
- Increased return to work frequency
Our staff of knowledgeable professionals understand California’s MPN process and its significant financial benefits. Our service solutions are customizable yet holistic, achieving optimal cost saving outcomes.
Here’s what we do:
- Conduct a Request for Information (RFI) from qualified Medical Provider Networks, to properly identify most qualified industry participants
- Launch a formal Request for Proposal (RFP) to both select three finalist candidates based on:
- Ability to perform listed MPN duties and responsibilities on an annual basis
- Maintain open lines of communication to program key contacts
- Provide adequate proof of insurance
- Offer competitive pricing consideration
- Perform formal implementation with finalist/selected MPN provider
- Create MPN service provider guidelines
- Provide monthly statistics and analytics to client
- Weekly evaluation and monitoring of the progress and participation of MPN provider
Learn how our MPN services can work for you!