IMPORTANT INFORMATION ABOUT MEDICAL CARE FOR YOUR WORK-RELATED INJURY OR ILLNESS

Transcription

1 IMPORTANT INFORMATION ABOUT MEDICAL CARE FOR YOUR WORK-RELATED INJURY OR ILLNESS MEDICAL PROVIDER NETWORK (MPN) NOTIFICATION If yu are injured at wrk, Califrnia Law requires yur emplyer t prvide and pay fr medical treatment. Yur emplyer will prvide this medical care thrugh a Wrkers Cmpensatin Medical Prvider Netwrk (MPN). This dcument includes frequently asked questins abut the prgram and yur rights in chsing treatment fr wrk-related injuries and illnesses. Yur emplyer is using the Travelers TCT CA MPN. 1. What is a Medical Prvider Netwrk (MPN)? A Medical Prvider Netwrk is a grup f health care prviders (physicians and ther types f prviders) that will manage and direct any medical care yu receive if yu are injured at wrk. The MPN als includes ancillary prviders including a pharmacy netwrk and durable medical equipment prviders. The prviders in the MPN specialize in wrk related injuries and illnesses and meet Califrnia required access t care standards. The Califrnia Divisin f Wrkers Cmpensatin (DWC) MPN access t care standards require that an MPN plan prvide: at least three physicians f each specialty expected t treat wrkers cmpensatin injuries; has primary treating prviders within 15 miles r 30 minutes and specialty care prviders within 30 miles r 60 minutes frm either yur wrk r residence; that after ntifying the emplyer abut the injury, an injured emplyee will be able t get an appintment fr the first treatment visit fr nn-emergency services within three business days; and the appintment with a specialist will be made within 20 business days fllwing the insurer s receipt f request fr treatment. Further, the regulatins require MPN prviders t use medical treatment guidelines adpted by the DWC in making any decisins related t medical care r treatment. This MPN plan cmplies with DWC requirements and in the event that yu need medical care in cnnectin with a wrkers cmpensatin claim, it is likely that yu will receive this care frm prviders within the MPN. Yu can get general infrmatin regarding the MPN frm the website In the State Resurces sectin, select Califrnia in the drp-dwn bx Click the G buttn 2. Hw d I find ut which dctrs, pharmacies r ther medical prviders are in the MPN? Yu can get a reginal list f all MPN prviders in yur area. At minimum, the reginal list must include a list f all MPN prviders within 15 miles f yur wrkplace and/r residence r a list f all MPN prviders within the cunty where yu live and/r wrk. Yu may chse which list yu wish t receive. Yu als have the right t btain a list f all the MPN prviders upn request. There are several methds fr lcating MPN prviders. Yu may: Lg n t the website at: Click the Find a Lcal Netwrk Prvider link Cntact yur Case Manager (Claim r Medical) Cntact the MPN Medical Access Assistant Cntact yur emplyer Yu can access the rster f all treating physicians in the MPN by ging t the website at

2 Click the Find a Lcal Netwrk Prvider link Click n the CA MPN Rster f Treating Physicians tab The MPN Medical Access Assistant will be able t help yu find available MPN prviders f yur chice and help yu if yu are having truble getting an appintment with an MPN prvider. The MPN Medical Access Assistant is available t schedule medical appintments during dctrs nrmal business hurs and t assist yu frm 7:00 a.m. t 8:00 p.m. Pacific time, Mnday thrugh Saturday at , r by fax at (877) , r by t CAMPN@travelers.cm. Assistance is available in English and Spanish. If yu cme acrss any inaccuracies in a prvider listing, please reprt the inaccuracies t the MPN Medical Access Assistant by calling r by t CAMPN@travelers.cm. 3. What happens if I get injured at wrk? If yu incur a wrk-related injury r illness that is an emergency either call 911 r g t the nearest emergency medical center. Yu shuld ntify yur emplyer as sn as pssible fllwing any emergency treatment. If yur injury r illness is nt an emergency, ntify yur emplyer that yu have a wrk-related injury in a reasnable time fllwing the date f injury. Yur emplyer r insurer will arrange an initial appintment with a dctr within the MPN. 4. Hw d I chse a prvider? After yur first visit with an MPN prvider t treat yur wrk-related injury r illness, yu may either cntinue treatment with this dctr r chse anther MPN prvider that is apprpriate t treat yur injury. If needed, yu may chse a specialist r ask the treating dctr t refer yu t a specialist fr treatment. Yu may cntinue t chse dctrs within the MPN fr all f yur medical care fr this injury. If yu need help in chsing an MPN dctr r have truble getting an appintment with a dctr within the MPN, please cntact yur Case Manager (Claim r Medical) r the MPN Medical Access Assistant fr help. If yu need t see a type f specialist that is nt available in the MPN, yu have the right t see a specialist utside f the MPN. 5. Can I change prviders? Yes. Yu can change prviders within the MPN fr any reasn, but the prviders yu chse shuld be apprpriate t treat yur injury. Please cntact yur Case Manager (Claim r Medical) r the MPN Medical Access Assistant if yu want t change yur treating physician. 6. What if there are n prviders in my area? The MPN has prviders available thrughut the state f Califrnia. If yu are unable t find an apprpriate treating physician r specialist available in yur area, please cntact yur Case Manager (Claim r Medical) r the MPN Medical Access Assistant fr help. If there are n MPN prviders in the apprpriate specialty available t treat yur injury within the distance and timeframe requirements, then yu will be allwed t seek the necessary treatment utside f the MPN. 7. What if I am authrized by my emplyer t temprarily wrk r travel utside f the MPN gegraphic service area? If yur emplyer has authrized yu t temprarily wrk r travel utside the MPN gegraphic service area and the need fr nn-emergency medical care arises, yu may treat with a prvider f yur chice. Yu may als cntact the MPN Medical Access Assistant r yur Case Manager (Claim r Medical). Yu will be prvided with a chice f three physicians wh are utside f the MPN gegraphic service area fr care. These prviders will be selected by either yur primary treating physician, wh is participating in the MPN, r by the MPN Medical Access Assistant. If yur injury requires emergency care, call 911 r g t the nearest emergency medical treatment center.

3 8. What if I decide t temprarily r permanently reside utside f the MPN gegraphic service area during my recvery? If yu are a current emplyee temprarily living utside the MPN gegraphic service área r are a frmer emplyee permanently residing utside f the MPN gegraphic service area and the need fr nn-emergency medical care arises, yu may treat with a prvider f yur chice. Yu may als cntact yur Case Manager (Claim r Medical) r the MPN Medical Access Assistant. Yu will be prvided with a chice f three physicians wh are utside f the MPN gegraphic service area t chse frm fr care. These prviders will be selected by yur primary treating physician, wh is participating in the MPN, yur Case Manager, r by the MPN Medical Access Assistant. If yur injury requires emergency care, call 911 r g t the nearest emergency medical treatment center. 9. What if I am already being treated fr a wrk-related injury befre the MPN begins? The MPN has a Transfer f Care plicy, which will determine if yu can cntinue being temprarily treated fr an existing wrk-related injury by a physician utside f the MPN befre yur care is transferred int the MPN. If yur current dctr is nt r des nt becme a member f the MPN, then yu may be required t see a MPN physician. Hwever, if yu have prperly predesignated a primary treating physician, yu cannt be transferred int the MPN. (If yu have questins abut predesignatin, ask yur supervisr.) If yur Case Manager (Claim r Medical) decides t transfer yu int the MPN, yu and yur primary treating physician will receive a letter ntifying yu f the transfer. If yu meet certain cnditins, yu may qualify t cntinue treating with a nn-mpn physician fr up t a year befre yu are transferred int the MPN. Yu may qualify fr cntinuing treatment with yur nn-mpn prvider thrugh transfer f care fr up t a year if yur injury r illness meets any f the fllwing cnditins: (Acute) The treatment fr yur injury r illness will be cmpleted in less than 90 days; (Serius r Chrnic) Yur injury r illness is ne that is serius and cntinues fr at least 90 days withut full cure r wrsens and requires nging treatment. Yu may be allwed t be treated by yur current treating dctr fr up t ne year, until a safe transfer f care can be made. (Terminal) Yu have an incurable illness r irreversible cnditin that is likely t cause death within ne year r less. (Pending Surgery) Yu already have a surgery r ther prcedure that has been authrized by yur emplyer r insurer that will ccur within 180 days f the MPN effective date. Yu can disagree with the decisin t transfer yur care int the MPN. If yu dn t want t be transferred int the MPN, ask yur primary treating physician fr a medical reprt n whether yu have ne f the fur cnditins stated abve t qualify fr a pstpnement f yur transfer int the MPN. Yur primary treating physician has 20 calendar days frm the date f yur request t give yu a cpy f his/her reprt n yur cnditin. If yur primary treating physician des nt give yu the reprt within 20 calendar days f yur request, yur Case Manager can transfer yur care int the MPN and yu will be required t use an MPN physician. Yu will need t give a cpy f the reprt t yur Case Manager (Claim r Medical) if yu wish t pstpne the transfer f yur care. If yu r yur Case Manager disagrees with yur dctr s reprt n yur cnditin, yu r yur Case Manager can dispute it. See the cmplete Transfer f Care plicy fr mre details n the dispute reslutin prcess.

4 Fr a cpy f the Transfer f Care plicy, in English r Spanish, ask yur Case Manager (Claim r Medical) r the MPN Medical Access Assistant. 10. What if I am being treated by a MPN dctr wh decides t leave the MPN? The MPN has a written Cntinuity f Care plicy that will determine whether yu can temprarily cntinue treatment fr an existing wrk injury with yur dctr if yur dctr is n lnger participating in the MPN. If yur Case Manager (Claim r Medical) decides that yu d nt qualify t cntinue yur care with the nn-mpn prvider, yu and yur primary treating physician will receive a letter ntifying yu f this decisin. If yu meet certain cnditins, yu may qualify t cntinue treating with this dctr fr up t a year befre yu must chse a MPN physician. Yu may qualify fr cntinuing treatment with yur nn-mpn prvider thrugh cntinuity f care fr up t a year if yur injury r illness meets any f the fllwing cnditins: (Acute) The treatment fr yur injury r illness will be cmpleted in less than 90 days; (Serius r Chrnic) Yur injury r illness is ne that is serius and cntinues fr at least 90 days withut full cure r wrsens and requires nging treatment. Yu may be allwed t be treated by yur current treating dctr fr up t ne year, until a safe transfer f care can be made. (Terminal) Yu have an incurable illness r irreversible cnditin that is likely t cause death within ne year r less. (Pending Surgery) Yu already have a surgery r ther prcedure that has been authrized by yur emplyer r insurer that will ccur within 180 days f the terminatin f cntract date between the MPN and yur dctr. Yu can disagree with yur Case Manager s decisin t deny yu Cntinuity f Care with the terminated MPN prvider. If yu want t cntinue treating with the terminated dctr, ask yur primary treating physician fr a medical reprt n whether yu have ne f the fur cnditins stated in the bx abve t see if yu qualify t cntinue treating with yur current dctr temprarily. Yur primary treating physician has 20 calendar days frm the date f yur request t give yu a cpy f his/her medical reprt n yur cnditin. If yur primary treating physician des nt give yu the reprt within 20 calendar days f yur request, yur Case Manager s decisin t deny yu Cntinuity f Care with yur dctr wh is n lnger participating in the MPN will apply, and yu will be required t chse a MPN physician. Yu will need t give a cpy f the reprt t yur Case Manager if yu wish t pstpne the selectin f anther MPN dctr fr yur cntinued treatment. If yu r yur Case Manager disagrees with yur dctr s reprt n yur cnditin, yu r yur Case Manager can dispute it. See the cmplete Cntinuity f Care plicy fr mre details n the dispute reslutin prcess. Fr a cpy f the Cntinuity f Care plicy, in English r Spanish, ask yur Case Manager (Claim r Medical) r the MPN Medical Access Assistant. 11. What if I disagree with my dctr abut medical treatment? If yu disagree with yur dctr r wish t change yur dctr fr any reasn, yu may chse anther dctr within the MPN. If yu disagree with either the diagnsis r treatment prescribed by yur dctr, yu may ask fr a secnd pinin frm anther dctr within the MPN. If yu want a secnd pinin, yu must cntact yur Case Manager (Claim r Medical) and tell them yu want a secnd pinin. The MPN shuld give yu at least a reginal MPN prvider list, based n the specialty r recgnized expertise in treating the particular injury r cnditin in questin, frm which yu can chse a

5 secnd pinin dctr. T get a secnd pinin, yu must chse a dctr frm the MPN list and make an appintment within 60 days. Yu must tell yur Case Manager (Claim r Medical) f yur appintment date, and they will send the dctr a cpy f yur medical recrds. Yu can request a cpy f yur medical recrds that will be sent t the dctr. If yu d nt make an appintment within 60 days f receiving the reginal prvider list, yu will nt be allwed t have a secnd r third pinin with regard t this disputed diagnsis r treatment f this treating physician. If the secnd-pinin dctr feels that yur injury is utside f the type f injury he r she nrmally treats, the dctr's ffice will ntify yur Case Manager (Claim r Medical) and yu. Yu will get anther list f MPN dctrs r specialists s yu can make anther selectin. If yu disagree with the secnd pinin, yu may ask fr a third pinin. If yu request a third pinin, yu will g thrugh the same prcess yu went thrugh fr the secnd pinin. Remember that if yu d nt make an appintment within 60 days f btaining anther MPN prvider list, then yu will nt be allwed t have a third pinin with regard t this disputed diagnsis r treatment f this treating physician. If yu disagree with the third-pinin dctr, yu may ask fr an MPN Independent Medical Review (IMR). Yur Claim Case Manager will give yu infrmatin n requesting an Independent Medical Review and a frm at the time yu select a third-pinin physician. If either the secnd r third-pinin dctr r Independent Medical Reviewer agrees with yur need fr a treatment r test, yu may be allwed t receive that medical service frm a prvider within the MPN r if the MPN des nt cntain a physician wh can prvide the recmmended treatment, yu may chse a physician utside the MPN within a reasnable gegraphic area. 12. What if I have a prescriptin I need t fill? The MPN includes dctrs, as well as pharmacies. If yur MPN treating physician prescribes a medicatin, yu must btain yur prescriptins thrugh a netwrk pharmacy. Healthesystems, ur Pharmacy Benefit Manager, will electrnically prcess yur prescriptin with n ut f pcket expense t yu. T access a cmplete listing f MPN pharmacies, please lg n t and click n the Find a Netwrk Prvider link. Yu can als visit the Healthesystems website at If yu need assistance finding an MPN pharmacy, please cntact yur Case Manager (Claim r Medical) r the MPN Medical Access Assistant. T assist yu and the pharmacists with prcessing yur medicatin nline yu will need the fllwing: Member ID (Claim Number + TRV) Bin Number Healthesystems Pharmacy Help desk (877) If yu have questins r cncerns regarding yur pharmacy benefits, please cntact yur case manager (Claim r Medical). 13. What if I have questins r need help understanding the MPN? Yu will need t refer t the Travelers TCT CA MPN whenever yu have questins r requests abut the MPN. Yu may always cntact yur Case Manager r the MPN Medical Access Assistant if yu need help r further explanatin abut yur medical treatment. The MPN Medical Access Assistant can be reached at:

6 The MPN Cntact is als able t answer questins abut the use f the MPN and will address any cmplaints regarding the MPN. The MPN Cntact can be reached by phne at r by at CAMPN@travelers.cm. DWC Infrmatin & Assistance Officer: If yu have cncerns, cmplaints r questins regarding the MPN, the ntificatin prcess, r yur medical treatment f a wrk-related injury r illness, yu can call the Infrmatin and Assistance Officer at the Divisin f Wrkers' Cmpensatin at Independent Medical Review: If yu have questins abut the Independent Medical Review prcess r the Independent Medical Reviewer, yu may cntact the Divisin f Wrkers Cmpensatin s Medical Unit at: Divisin f Wrkers Cmpensatin s Medical Unit P.O. Bx Oakland, CA (510) r (800)