DELOS INSURANCE COMPANY TMC SITE COORDINATOR GUIDE MEDICAL PROVIDER NETWORK (MPN)

Transcripción

1 DELOS INSURANCE COMPANY / TMC MEDICAL PROVIDER NETWORK (MPN) SITE COORDINATOR GUIDE DELOS INSURANCE COMPANY Fr questins abut the Dels Insurance Cmpany/TMC MPN, please cntact the MPN call center at , r send an t mpnhelp@aartpa.cm Dels/TMC MPN Site Crdinatr Guide Page 1 f 15

2 DELOS INSURANCE COMPANY / TOTAL MANAGED CARE MEDICAL PROVIDER NETWORK Backgrund SITE COORDINATOR GUIDE As an emplyer, we are cmmitted t the well being and safety f ur emplyees. As part f ur cmmitment, we are implementing the Dels Insurance Cmpany/TMC Medical Prvider Netwrk (MPN). Our primary gals are t make sure that every emplyee wh has a wrk-related injury btains medical care quickly, is treated apprpriately, and safely returns t wrk as sn as medically pssible. The MPN has been chsen because it wrks effectively fr wrk injuries. As a Site Crdinatr, yur rle is very imprtant t the success f the MPN. Please read this infrmatin carefully and address any questins yu may have t the MPN call center. The mst imprtant dcument in this Guide is the MPN Site Crdinatr Instructins n page 2. Our cmpany uses the Dels Insurance Cmpany/TMC MPN, created t facilitate prmpt access fr yur emplyees medical care fr any industrial injury r illness by quality medical prviders specializing in ccupatinal health care. Yur MPN Cntact Yu may direct any questins t the MPN Call Center by calling tll free (866) Yu may als send questins r cmments by t: mpnhelp@aartpa.cm. Yu may als visit ur website, The website cntains much useful infrmatin abut the Dels Insurance Cmpany/TMC MPN, including a prvider lkup feature, allwing yu the ability t lcate any medical prvider within the MPN. When Any Wrk-Related Injury r Illness Occurs Immediately cntact American All-Risk Lss Administratrs (AARLA) t reprt a wrk injury, file all the required paperwrk and frms, and direct the injured emplyee t the designated MPN prvider fr an initial medical evaluatin and treatment, if apprpriate. AARLA s cntact infrmatin can be fund in the Claims Kit which was sent ut t yur cmpany at the beginning f yur plicy term. Included in the claims kit is a MPN Prvider Supplemental t the Psting Ntice, which cntains the name, address, phne number, and a map f the emergency and nn-emergency medical clinics designated fr yur cmpany. When an Injured Emplyee May Receive Treatment Outside f the MPN frm a Nn-Netwrk Prvider/Facility Fr treatment f an injury that began prir t the cverage f the MPN fr specified cnditins. See the Dels Insurance Cmpany/TMC Transfer f Care Plicy attached. Fr emergency care When an injured wrker has pre-designated their wn persnal physician (and this pre-designatin is with a physician wh has treated the emplyee prir t the injury and wh has cnsented t treat the emplyee) When authrized treatment is nt available by r thrugh an MPN Netwrk Prvider, i.e., if a primary treater r emergency care prvider cannt be fund within 15 miles r 30 minutes r a specialist cannt be fund within 30 miles r 60 minutes frm where the emplyee lives r wrks (if this situatin arises, please refer the emplyee t the MPN Call Center). Distributin f Emplyee Infrmatin IMPORTANT!! All emplyees need t have received their individual cpy f the MPN Emplyee Handbk upn implementatin f the prgram. The MPN handbk prvides specific instructin n hw emplyees will access the MPN including changing prviders, btaining secnd and third pinins and prviding cntinuity f care if a prvider is terminated frm the MPN. Immediately upn learning abut a wrk-related injury, every time claim fr wrk injury is made, yu are respnsible fr delivering anther cpy f the MPN Emplyee Handbk t the injured emplyee. Yu will als need t advise the MPN Crdinatr that yu have given an MPN Handbk t yur emplyee. If yu have any prblems with prmpt delivery, please alert the MPN Call Center. Infrmatin abut the MPN There is additinal infrmatin yu must read t familiarize yurself with the MPN prgram, including the fllwing: Site Crdinatr Instructins Access Standards Secnd and Third Opinin Prcess Cntinuity f Care Plicy Independent Medical Review Prcess Transfer f Onging Care Plicy These dcuments are part f Dels Insurance Cmpany/TMC s MPN plan, have been apprved by the State, and must be fllwed. Fr questins abut the Dels Insurance Cmpany/TMC MPN, please cntact the MPN call center at , r send an t mpnhelp@aartpa.cm Dels/TMC MPN Site Crdinatr Guide Page 2 f 15

3 DELOS INSURANCE COMPANY / TOTAL MANAGED CARE MEDICAL PROVIDER NETWORK (MPN) SITE COORDINATOR INSTRUCTIONS IMPORTANT: Implementatin and administratin f the MPN requires that yu understand and cmply with many laws, plicies, and prcedures, as explained in this Site Crdinatr s Guide. Failure t carry ut yur respnsibilities culd jepardize medical cntrl f the claim, and culd result in significantly higher disability and medical csts paid fr treatment t prviders nt in the MPN. If yu have any questins abut the MPN, please d nt hesitate t cntact the MPN Call Center. What t d if an Emplyee is Injured at Wrk 1. Arrange fr medical care In the event f an emergency, call 911. The injured emplyee is t be sent immediately t the nearest apprpriate MPN prvider r hspital (if this can be quickly lcated), r sent t the nearest emergency rm. After the injured emplyee is stabilized, he r she may be re-directed int the MPN. Emergency Health Care Services r Urgent Care is defined as health care services fr a medical cnditin manifesting itself by acute symptms f sufficient severity such that the absence f immediate medical attentin culd reasnably be expected t place the patient s health in serius jepardy. In a nn-emergency situatin, direct the injured emplyee withut delay (within 24 hurs) t the MPN designated prvider fr an initial medical evaluatin. Ntify the injured emplyee f his r her right t chse anther MPN prvider after this initial visit. Nte: The emplyee has the right t see a dctr clse t their hme r wrk place. Travel must be limited t n mre than 15 miles r 30 minutes t see a treating dctr r emergency care prvider r 30 miles r 60 minutes t see a specialist. If the emplyee lives in a rural area where a netwrk prvider cannt be fund within these distances, he r she is entitled t seek treatment utside the netwrk with nn-cntracted prviders. 2. Reprt Once yu have learned f an emplyee s injury, immediately reprt the injury t American All Risk Lss Administratrs tll free at (800) Cmmunicate 4. Fllw-up Give the injured emplyee a DWC-1, a cpy f the MPN Emplyee Handbk and infrmatin n hw t access the MPN list f prviders in their gegraphic area. T identify Dels Insurance Cmpany/TMC MPN prviders in yur area, please visit r call the MPN Call Center tll free at (866) If the emplyee receives initial treatment at a Hspital Emergency Rm, cntact the emplyee and ensure that the emplyee is receiving fllw-up care frm an MPN Medical Prvider. Fr questins abut the Dels Insurance Cmpany/TMC MPN, please cntact the MPN call center at , r send an t mpnhelp@aartpa.cm Dels/TMC MPN Site Crdinatr Guide Page 3 f 15

4 Additinal Infrmatin that may be Helpful Secnd and Third Opinin Prcess The fllwing infrmatin is prvided t the injured wrker in the MPN Emplyee Handbk: If yu dispute either the diagnsis r treatment prescribed by yur treating physician, yu may btain a secnd and third pinin frm anther physician within the MPN. During this prcess, yu must cntinue yur treatment within the MPN. Fr btaining a secnd pinin, it is YOUR respnsibility t: Infrm the AARLA claims examiner that yu dispute the treating physician s pinin and yu are requesting a secnd pinin. Select a physician r specialist frm a list f available MPN prviders. Make an appintment with the secnd physician within 60 days. Infrm the AARLA claims examiner f the appintment date. Fr btaining a secnd pinin, it is AARLA s respnsibility t: Prvide a list f MPN prviders and/r specialists fr yu t select a secnd pinin physician based n the specialty r recgnized expertise in treating yur injury r cnditin in questin. Cntact yur treating physician. Prvide a cpy f the medical recrds r send the necessary medical recrds t the secnd pinin physician prir t the appintment. Prvide a cpy f the recrds t yu upn request. Ntify the secnd pinin physician in writing that he r she has been selected t prvide a secnd pinin and the nature f the dispute. A cpy f this letter will be sent t yu. If yu d nt make the appintment with a secnd pinin physician within 60 days f receiving the list f available MPN prviders, then yu will nt be able t btain a secnd pinin regarding the diagnsis r treatment in dispute. If, after yur secnd pinin physician reviews yur medical recrds, he r she determines that yur injury is utside the scpe f his/her practice, the secnd pinin physician will ntify yu and AARLA s that the AARLA claims examiner can prvide a new list f MPN prviders. The secnd and third pinin physicians must prvide his/her pinin f the disputed diagnsis r treatment in writing and ffer alternative diagnsis r treatment recmmendatins, if applicable. These physicians may rder diagnstic testing if medically necessary. A cpy f the written reprt will be given t yu, the persn designated by yur emplyer r insurer, and the treating physician within 20 days f the date f yur appintment r receipt f the results f the diagnstic tests, whichever is later. Yu will be allwed t btain the recmmended treatment within the MPN netwrk. Yu may btain this recmmended treatment by changing physicians t the secnd pinin physician, t a third pinin physician (if yu seek the pinin f a third physician within the MPN), r anther physician within the MPN. If yu disagree with either the diagnsis r treatment prescribed by the secnd pinin physician, yu may seek the pinin f a third physician within the MPN, fllwing the same prcedure as abve fr requesting a secnd pinin. If yu disagree with either the diagnsis r treatment prescribed by the third pinin physician, yu may file with the Administrative Directr a request fr an Independent Medical Review. Fr questins abut the Dels Insurance Cmpany/TMC MPN, please cntact the MPN call center at , r send an t mpnhelp@aartpa.cm Dels/TMC MPN Site Crdinatr Guide Page 4 f 15

5 Independent Medical Review The injured emplyee must btain a secnd and a third pinin befre requesting an Independent Medical Review. If the emplyee disagrees with either the diagnsis r treatment prescribed by the third pinin physician, he r she may file with the Administrative Directr a request fr an Independent Medical Review. The emplyee may btain an Independent Medical Review by submitting an applicatin t the Administrative Directr f the State f Califrnia Divisin f Wrkers Cmpensatin. Upn request f a third pinin, he r she will be prvided with the IMR applicatin and instructins frm by the AARLA Claims Examiner. The Administrative Directr, r an independent medical review rganizatin, will assign the independent medical review dctr, wh may, at the request f the emplyee, cnduct a medical examinatin during the review. The AARLA claims examiner will prvide the independent medical reviewer with all relevant medical reprts. The independent medical reviewer must issue a reprt t the Administrative Directr, in writing, that includes his r her analysis and determinatin whether the disputed health care services met the State s treatment guidelines. The reprt must be issued within 20 days f the examinatin r recrd review, r within less time upn request f the Administrative Directr. Hwever, if the reviewer certifies the disputed health care service is a serius threat t the emplyee s health, the reprt must be prvided within three days f the examinatin. If the independent medical reviewer des nt agree with the disputed diagnsis, diagnstic service r medical treatment prescribed by the treating physician, the emplyee has the right t receive this treatment frm any dctr f his r her chice, inside r utside the MPN and AARLA will pay fr apprved treatment. If the emplyee chses t receive medical treatment with a physician utside the MPN, the treatment is limited t the treatment recmmended by the IMR r the diagnstic service recmmended by the IMR. Access Standards The MPN is designed t ensure cmpliance with state regulatins cncerning standards f access t medical care fr injured emplyees with bth primary care physicians and fr specialists utilized in the treatment f ccupatinal injuries. Access is facilitated as fllws: 1. A primary treating physician is available within 30 minutes r 15 miles f the residence r wrkplace f emplyees. 2. A hspital fr emergency health care services, r if separate frm such hspital, a prvider f all emergency health care services, is available within 30 minutes r 15 miles f the residence r wrkplace f emplyees. 3. Occupatinal health services prviders and specialists are available within 60 minutes r 30 miles f an emplyee s residence r wrkplace. 4. Cvered emplyees with a residence r wrk place beynd 30 miles f a prvider within the MPN netwrk may receive care frm an ut-f-netwrk, nn-cntracted prvider. All services will be available and accessible at reasnable emplyees t all cvered emplyees. The fllwing is the AARLA s written plicy fr arranging r apprving nn-emergency medical care fr: (1) a cvered emplyee authrized by the emplyer t temprarily wrk r travel fr wrk utside the MPN gegraphic service area when the need fr medical care arises; (2) a frmer emplyee whse emplyer has nging wrkers cmpensatin bligatins and wh permanently resides utside the MPN gegraphic service area; and (3) an injured emplyee wh decides t temprarily reside utside the MPN gegraphic service area during recvery. 1. When an emplyee as described abve has a need fr nn-emergency medical care in cnnectin with the industrial injury r illness utside f the service area, the emplyee will be prvided the chice f at least three physicians utside the MPN gegraphical service area wh either have been referred by the emplyee s primary treating physician within the MPN r wh have been selected by AARLA. Fr questins abut the Dels Insurance Cmpany/TMC MPN, please cntact the MPN call center at , r send an t mpnhelp@aartpa.cm Dels/TMC MPN Site Crdinatr Guide Page 5 f 15

6 2. In additin t physicians within the MPN, the emplyee may change physicians amng the referred physicians and may btain a secnd and third pinin frm the referred physicians. 3. The referred physicians will be lcated within the access standards described in paragraphs 3 and Fr nn-emergency services, AARLA will have an appintment fr initial treatment available within 3 business days f the AARLA s receipt f a request fr treatment within the MPN. 5. Fr nn-emergency specialist services t treat cmmn injuries experienced by the cvered emplyees based n the type f ccupatin r industry in which the emplyee is engaged, AARLA will have an appintment available within 20 business days f AARLA s receipt f a referral t a specialist within the MPN. 6. If the primary treating physician refers the emplyee t a type f specialist nt included in the MPN, the emplyee may select a specialist frm utside the MPN. 7. Once the injured/ill emplyee returns t the service area, medical care will be transferred t a prvider within the MPN. This infrmatin will be cmmunicated thrugh the MPN Emplyee Handbk. The fllwing is AARLA/TMC s written plicy t allw an injured emplyee t receive emergency medical treatment frm a medical service r hspital prvider wh is nt a member f the MPN: If an emplyee requires emergency medical health care services fr a wrk-related injury r illness frm a prvider wh is utside the MPN, the initial treatment will be cvered and the emplyee, nce stabilized, will have medical treatment transferred t a prvider within the MPN. Emergency health care services means health care services fr a medical cnditin manifesting itself by acute symptms f sufficient severity such that the absence f immediate medical attentin culd reasnably be expected t place the patient s health in serius jepardy. The fllwing is AARLA/TMC s written plicy describing the emplyee ntificatin prcess: AARLA/TMC is prviding a cpy f the MPN Emplyee Handbk t each emplyer, whereupn the emplyer will prvide an MPN Emplyee Handbk t each cvered emplyee prir t implementatin. The MPN Emplyee Handbk will als be prvided t new cvered emplyees at the time f hire r when an existing emplyee transfers int the MPN. This MPN Emplyee Handbk is als available fr review n the internet. Each emplyer lcatin will have a Site Crdinatr designated t serve as the lcal MPN resurce. AARLA/TMC is prviding cpies f the Emplyers Respnsibilities Ntice, MPN Emplyee Handbk and Site Crdinatr Guide t each Site Crdinatr. This guide utlines varius duties and requirements fr the successful peratin and crdinatin f the MPN. Access fr Ancillary services is prvided by AARLA/TMC thrugh the MPN. In such cases where an ancillary service is nt gegraphically accessible, the injured emplyee is permitted t btain ancillary service utside f the MPN. A listing f available MPN Ancillary Services is as fllws: Acute Care Hspitals Alchl and Chemical Dependency Ambulance Services Ambulatry Emergency Center Ambulatry Surgery Center Anesthesilgy Audilgy Services Cardiac Mnitring Center Chemical Dependency Hspital Dialysis Center Durable Medical Equipment (DME) EMG Services Extended Care Facility Functinal Capacity Exams Hme Health Care Hspice Care Services Imaging/Radilgy Services Infusin Therapy Services Interpreting Services Labratry Services Mammgraphy Services Mental Health Facility MRI Services Outpatient Diagnstic Services Outpatient Medical Services Fr questins abut the Dels Insurance Cmpany/TMC MPN, please cntact the MPN call center at , r send an t mpnhelp@aartpa.cm Dels/TMC MPN Site Crdinatr Guide Page 6 f 15

7 Pediatric Hspital Pharmacy Services Physical Therapy & Rehabilitatin Services Prsthetic & Orthtics Psychiatric Hspital Radiatin Onclgy Centers Radilgy Rehab Case Management Rehabilitatin Hspital Skilled Nursing Facilities Sleep Disrder Clinics Specialty Ancillary Services Specialty Hspital Transprt Vcatinal Rehabilitatin Services Wrk Hardening Services Fr nn-emergency services, an appintment fr initial treatment will be made available within three business days f AARLA/TMC s receipt f a request fr treatment within the MPN. AARLA/TMC will ensure that an appintment is available within 20 business days f receipt f a referral t an MPN specialist, fr nn-emergency service t treat cmmn injuries experienced by the emplyee in the ccupatin r industry in which he r she is engaged. Fr questins abut the Dels Insurance Cmpany/TMC MPN, please cntact the MPN call center at , r send an t mpnhelp@aartpa.cm Dels/TMC MPN Site Crdinatr Guide Page 7 f 15

8 Cntinuity f Care Plicy Cmpletin f Treatment by a Terminated Prvider AARLA/TMC will cmply with the prvisins set frth in Califrnia Labr Cde Sectins (d) and (e) when the cvered emplyee requests cmpletin f treatment by a terminated prvider. AARLA will prvide t all emplyees entering the wrkers cmpensatin system ntice f its written Cntinuity f Care plicy and infrmatin regarding the prcess fr an emplyee t request a review under the plicy and will prvide, upn request, a cpy f the written plicy t the emplyee. AARLA/TMC will cmply with the requirements f LC (d) and (e) as fllws: AARLA/TMC will prvide either verbal r written ntice t the injured emplyee f the terminatin frm the MPN f his r her treating prvider. AARLA/TMC will arrange fr transfer f care t anther MPN prvider r will prvide fr the cmpletin f treatment with the terminated prvider accrding t LC (d). If the injured emplyee requests cmpletin f treatment with the terminated prvider, the AARLA claim adjuster will review the claim fr cmpliance t LC (d). If the injured emplyee meets the criteria as defined by LC (d), AARLA will prvide: Cmpletin f care fr up t 90 days f treatment fr an acute cnditin as defined in LC (d)(3)(A) as a medical cnditin that invlves a sudden nset f symptms due t an illness, injury r ther medical prblem that requires prmpt medical attentin and that has a limited duratin. Cmpletin f treatment shall be prvided fr the duratin f the acute cnditin. Cmpletin f care fr the perid f time necessary t cmplete a curse f treatment fr a serius chrnic cnditin up t ne year frm the date f determinatin that the injured emplyee has a serius chrnic cnditin defined in LC (d)(3)(B) as a medical cnditin due t a disease, illness, r ther medical prblem r medical disrder that is serius in nature and that persists withut full cure r wrsens ver an extended perid f time r requires nging treatment t maintain remissin r prevent deteriratin. Cmpletin f care shall be prvided fr a perid f time necessary t cmplete a curse f treatment and t arrange fr a safe transfer t anther prvider, as determined in cnsultatin with the emplyee and the terminated prvider and cnsistent with gd prfessinal practice. Cmpletin f treatment shall nt exceed 12 mnths frm the cntract terminatin date. Cmpletin f care fr the duratin f a terminal illness as defined in LC (d)(3)(C) as an incurable r irreversible cnditin that has a high prbability f causing death within ne year r less. Perfrmance f surgery r ther prcedure that has been authrized as part f a dcumented curse f treatment and will ccur within 180 days frm the MPN cverage effective date as discussed in LC (d)(3)(D). AARLA/TMC will ntify terminated prviders whse services are cntinued beynd the cntract terminatin date pursuant t LC (d)(4)(A) that they must agree in writing t be subject t the same cntractual terms and cnditins that were impsed upn the prvider prir t terminatin. The AARLA claim adjuster may direct the injured emplyee t an MPN prvider if the terminated prvider des nt agree t cmply with the prir cntractual terms and cnditins. Unless therwise agreed by the terminated prvider and AARLA/TMC, the services rendered pursuant t this sectin shall be cmpensated at rates and methds f payment similar t thse used by AARLA/TMC fr currently cntracting prviders prviding similar services wh are practicing in the same r a similar gegraphic area as the terminated prvider. The AARLA claims adjuster may direct the injured emplyee t an MPN prvider if the terminated prvider des nt accept the payment rates prvided fr in this paragraph. If the terminated prvider was terminated fr cause, fraud, r ther criminal activity, the injured emplyee shall be transferred t an MPN prvider. Nthing stated abve prhibits AARLA frm agreeing t prvide cntinuity f care with a terminated prvider shuld AARLA determine that it is in the best interest f the injured emplyee t cntinue treatment with the terminated prvider. Fr questins abut the Dels Insurance Cmpany/TMC MPN, please cntact the MPN call center at , r send an t mpnhelp@aartpa.cm Dels/TMC MPN Site Crdinatr Guide Page 8 f 15

9 Dispute Reslutins: After AARLA makes a determinatin f the emplyee s medical cnditin, AARLA will ntify the emplyee (with a letter written in English and in Spanish sent t the emplyee s residence, using laypersn s terms t the maximum extent pssible), advising whether r nt he r she will be required t select a new prvider frm within the MPN. If the terminated prvider wishes t cntinue t treat and if the injured emplyee disputes the medical determinatin, he r she will be required t request a reprt frm the treating physician that addresses whether his r her medical determinatin falls int any f the fur cnditins referenced abve (as set frth in Labr Cde (d)(3). The treating physician will be required t prvide this reprt within 20 calendar days frm the request. If the treating physician fails t issue the reprt, then AARLA s determinatin shall apply. If AARLA disputes the medical determinatin by the treating physician, the dispute will be reslved using the QME prcess pursuant t Labr Cde sectin If the treating physician agrees with AARLA s determinatin that the injured emplyee s medical cnditin des nt meet the cnditins set frth in Labr Cde sectin (d)(3), the emplyee will be required t select a new prvider frm within the MPN during the dispute reslutin prcess. If the treating physician des nt agree with AARLA s determinatin that the injured emplyee s medical cnditin des nt meet the cnditins set frth in Labr Cde sectin (d)(3), the injured emplyee shall cntinue t treat with the terminated prvider until the dispute is reslved. Fr questins abut the Dels Insurance Cmpany/TMC MPN, please cntact the MPN call center at , r send an t mpnhelp@aartpa.cm Dels/TMC MPN Site Crdinatr Guide Page 9 f 15

10 Cntinuity f Care Plicy (Spanish) Terminación del tratamient pr un prveedr quien es desincrprad de la RPM. AARLA/TMC acatará cn ls prvisines establecid en el Artícul (d) y (e) del Códig de Labral, cuand el emplead cubiert slicita la terminación del tratamient pr un prveedr quien es desincrprad de la RPM. AARLA prveerá a tds ls empleads que entren al sistema de cmpensación a ls trabajadres una ntificación de su plítica pr escrit de Cntinuidad de Cuidad Médic y la infrmación sbre el prces para que un emplead puede slicitar una revisión baj esta plítica y deberá entregarle al emplead, en el mment en el que se l slicite, una cpia pr escrit de la misma. AARLA/TMC acatará cn ls siguiente requisits del Códig de Labral (d) y (e): AARLA/TMC prveerá avis verbal escrit al emplead lesinad acerca de la terminación de la RPM de su prveedr de servicis médics. AARLA/TMC se encargará de transferencia de cuidad médic a un tr prveedr dentr la RPM prveerá pr la terminación del tratamient cn el prveedr quien es desincrprad de la RPM según del Artícul (d) de la Códig Labral. Si el emplead lesinad demanda terminación del tratamient cn un prveedr quien es desincrprad de la RPM, el examinadr de reclams de AARLA repasará el reclam para cnfrmidad al Códig de Labral (d). Si el emplead lesinad satisfacerla ls criteris cm se definid pr el Códig de Labral (d), AARLA prveerá: Terminación del cuidad pr hasta 90 días del tratamient para una "cndición aguda" según l definid en LC (d)(3)(A) cm "cndición médica que implica un inici repentin de ls síntmas debid a la enfermedad, a la lesión al tr prblema médic que requiere la atención médica prnt y que tiene una duración limitada". La terminación del cuidad para el períd del tiemp necesari para terminar un curs del tratamient para una "cndición crónica seria" hasta un añ a partir de la fecha de la determinación que el emplead dañad tiene una "cndición crónica seria" definió en LC (d)(3)(B) cm "cndición médica debid a la enfermedad, la enfermedad, el tr prblema médic desrden médic que es seri en naturaleza y que persiste sin la curación cmpleta se empera sbre un períd del tiemp extendid requiere el tratamient en curs mantener la remisión prevenir la deteriración". La terminación del cuidad será prprcinada pr un períd del tiemp necesari para terminar un curs del tratamient y para arreglar para una transferencia segura a tr abastecedr, según l determinad en la cnsulta cn el emplead y el prveedr terminad y cnstante cn buena práctica prfesinal. La terminación del tratamient n excederá 12 meses a partir de la fecha de la terminación del cntrat. Terminación del cuidad para la duración de una "enfermedad terminal" según l definid en LC (d)(3)(C) cm "cndición incurable irreversible que tiene una alta prbabilidad de causar muerte dentr de un añ de mens. Funcinamient de la cirugía del tr prcedimient que se ha autrizad cm parte de un curs del tratamient dcumentad y currirá en el plaz de 180 días a partir de la fecha eficaz de la cbertura del MPN según l discutid en LC (d)(3)(D). AARLA/TMC pdrá pedirle al prveedr de servicis quien es desincrprad de la RPM cuys servicis cntinúen después de la fecha de la terminación del cntrat según del Artícul (d)(4)(A) de la Códig Labral que acuerde pr escrit sujetarse a ls misms términs y cndicines cntractuales, que se impusiern al prveedr antes de la terminación del cntrat. El examinadr de reclams de AARLA pdrá guiar el emplead lesinad a un tr prveedr de servicis dentr la RPM si el prveedr quien es desincrprad de la RPM n está de acuerd cn cumplir n cumple cn ests términs y cndicines cntractuales. A mens que AARLA/TMC y el prveedr desincrprad acuerden l cntrari, ls servicis prestads de acuerd cn l dispuest en esta sección se cmpensarán baj las tarifas y ls métds de pag similares a ls que actualmente utiliza AARLA/TMC para pagarles a ls prveedres baj cntrat que prveen servicis similares y que ejercen dentr de la misma área gegráfica un área similar a ésta que la del prveedr desincrprad. El examinadr de reclams de AARLA pdrá guiar el emplead lesinad a un tr prveedr de servicis dentr la RPM si el prveedr desincrprad n acepta ls hnraris a ls que se hace mención en este párraf. Fr questins abut the Dels Insurance Cmpany/TMC MPN, please cntact the MPN call center at , r send an t mpnhelp@aartpa.cm Dels/TMC MPN Site Crdinatr Guide Page 10 f 15

11 Si el cntract cn el prveedr desincrprad fue rescindid pr mtivs de disciplina médica, pr raznes de fraude de tr delit, el emplead lesinad debe se transfería a un prveedr dentr la RPM. Nada afirmad más arriba prhíbe AARLA/TMC de estar de acuerd cn prviend cntinuidad de tratamient cn un prveedr desincrprad, si AARLA/TMC determina que es mejr para el emplead lesinad que cntinuar el tratamient cn el prveedr desincrprad. Una cpia de AARLA s determinación de las cndicines medicas del emplead serán enviadas al su medical primari de acuerd cn d.1. Una cpia de esta póliza será dispnible para cualquier emplead sbre su pedir de acuerd cn a.12. Reslucines Del Cnflict: Después de que AARLA haga una determinación de la cndición médica del emplead, AARLA ntificará a emplead (cn una letra escrita en inglés y en españl enviada a la residencia del emplead, usand ls términs de ls persnas rdinarias al grad máxim psible), acnsejand si n l la requerirán seleccinar un abastecedr nuev dentr del MPN. Si el abastecedr terminad desea cntinuar tratand y si el emplead dañad disputa la determinación médica, l la requerirán slicitar un infrme del médic que trata que trata si su su determinación médica baja en cualesquiera de las cuatr cndicines referidas arriba (según l dispuest en el códig de labral (d)(3). Requerirán al médic que trata prprcinar este infrme dentr de 20 días de calendari de la petición. Si el médic que trata n puede publicar el infrme, entnces la determinación de AARLA se aplicará. Si AARLA disputa la determinación médica pr el médic que trata, el cnflict será resuelt usand el prces de QME cnfrme a la sección de trabaj 4062 del códig de labral. Si el médic que trata cnviene cn la determinación de AARLA que la cndición médica del emplead dañad n resuelve las cndicines dispuestas en la sección de trabaj del códig (d)(3), requerirán al emplead seleccinar un abastecedr nuev dentr del MPN durante el prces de la reslución del cnflict. Si el médic que trata n cnviene cn la determinación de AARLA que la cndición médica del emplead dañad n resuelve las cndicines dispuestas en la sección de trabaj del códig (d)(3), el emplead dañad cntinuará tratand cn el abastecedr terminad hasta que se resuelve el cnflict. Una cpia de esta póliza será dispnible para cualquier emplead sbre su pedir de acuerd cn a.12. Fr questins abut the Dels Insurance Cmpany/TMC MPN, please cntact the MPN call center at , r send an t mpnhelp@aartpa.cm Dels/TMC MPN Site Crdinatr Guide Page 11 f 15

12 Transfer f Onging Care Plicy AARLA/TMC will cmply with the prvisins set frth in Califrnia Cde f Regulatins, Title 8, regarding Transfer f Onging Care int the MPN. If a prvider delivering nging care fr a cvered injured emplyee is already participating in the newly implemented MPN, AARLA will ntify the injured emplyee if his r her treatment is being prvided under the MPN prvisins. If a prvider delivering nging care fr a cvered injured emplyee prir t the inceptin f the MPN is nt a prvider under the Dels Insurance Cmpany/TMC MPN, AARLA as the claims administratr will prvide: Cmpletin f care fr up t 90 days f treatment fr an acute cnditin as defined in 8 CCR (e)(1) as a medical cnditin that invlves a sudden nset f symptms due t an illness, injury r ther medical prblem that requires prmpt medical attentin and that has a duratin f less than 90 days. Cmpletin f treatment shall be prvided fr the duratin f the acute cnditin. Cmpletin f care fr the perid f time necessary t cmplete a curse f treatment fr a serius chrnic cnditin up t ne year frm the date f determinatin that the injured emplyee has a serius chrnic cnditin as defined in 8 CCR (e)(2) as a medical cnditin due t a disease, illness, catastrphic injury, r ther medical prblem r medical disrder that is serius in nature and that persists withut full cure r wrsens ver 90 days and requires nging treatment t maintain remissin r prevent deteriratin. Cmpletin f care shall be prvided fr a perid f time necessary, up t ne year: (A) t cmplete a curse f treatment apprved by AARLA; and (B) t arrange fr transfer t anther prvider within the MPN, as determined by AARLA. The ne year perid f cmpletin f treatment starts frm the date f the injured emplyee s receipt f the ntificatin f the determinatin that the emplyee has a serius chrnic cnditin. Cmpletin f care fr the duratin f a terminal illness as defined in 8 CCR (e)(3) as an incurable r irreversible cnditin that has a high prbability f causing death within ne year r less. Perfrmance f surgery r ther prcedure that has been authrized as part f a dcumented curse f treatment and will ccur within 180 days frm the MPN cverage effective date as discussed in 8 CCR (e)(4). Until the injured cvered emplyee is transferred int the MPN, the emplyee s physician may make referrals t prviders within r utside the MPN. AARLA will cnduct an assessment f the injured emplyee s medical cnditin prir t any determinatin that the nging care des nt meet any f the abve criteria and therefre culd be eligible fr a transfer int the MPN. This assessment may invlve the guidance f a TMC nurse case manager. AARLA will send ntificatin f the determinatin f the transfer f care t the injured emplyee s residence and t the injured emplyee s primary treating physician. The ntificatin will be prvided in English and Spanish and will use laypersn s terms t the maximum extent pssible. If the injured emplyee disputes the medical determinatin that transfer f care int the MPN is apprpriate, he r she must request a reprt frm the primary treating physician addressing whether the nging care falls within any f the cnditins identified abve. The treating physician must prvide the Fr questins abut the Dels Insurance Cmpany/TMC MPN, please cntact the MPN call center at , r send an t mpnhelp@aartpa.cm Dels/TMC MPN Site Crdinatr Guide Page 12 f 15

13 reprt t the emplyee within 20 calendar days f the request. If the treating physician fails t issue the reprt, then AARLA s determinatin regarding cmpletin f treatment shall apply. If the primary treating physician agrees with AARLA s determinatin that the injured emplyee s medical cnditin des nt meet the cnditins identified abve (as set frth in 8 CCR (e)(1) thrugh (4), the transfer f care shall prceed during the dispute reslutin prcess. If the primary treating physician disagrees with AARLA s determinatin that the injured emplyee s medical cnditin des nt meet the cnditins identified abve (as set frth in 8 CCR (e)(1) thrugh (4), the transfer f care shall nt prceed until the dispute is reslved. Any dispute cncerning the medical determinatin made by the primary treating physician cncerning transfer f care will be reslved by the QME prcess pursuant t LC Referrals made t prviders subsequent t the implementatin f the MPN are t be made t a prvider within the MPN. Nthing stated abve prhibits AARLA frm agreeing t prvide care utside the MPN shuld AARLA determine that it is within the best interest f the injured emplyee t cntinue treatment with the nn- MPN prvider. Fr questins abut the Dels Insurance Cmpany/TMC MPN, please cntact the MPN call center at , r send an t mpnhelp@aartpa.cm Dels/TMC MPN Site Crdinatr Guide Page 13 f 15

14 Transfer f Onging Care Plicy (Spanish) Plítica de Transferencia de Cuidad Médic AARLA/TMC acatará cn ls prvisines establecid en el Títul 8 Artícul del Códig de ls Regulacines de Califrnia, acerca del Transferencia de Tratamient Cntinuad dentr la RPM. Si un prveedr entregand tratamient cntinuad para un emplead lesinad cubiert ya participa en el RPM recientemente cmenzada, AARLA avisará el emplead lesinad que su tratamient está siend prestad según l dispuest pr la RPM. Si un prveedr entregand tratamient cntinuad para un emplead lesinad cubiert antes del cmienz de la RPM n está un prveedr según ls prvisines de la RPM, AARLA/TMC prveerá: Terminación del cuidad pr hasta 90 días del tratamient para una "cndición aguda" según l definid en 8 CCR (e)(1) cm "cndición médica que implica un inici repentin de ls síntmas debid a la enfermedad, a la lesión al tr prblema médic que requiere la atención médica prnt y que tiene una duración de mens de 90 días". La terminación del tratamient será prprcinada para la duración de la cndición aguda. Terminación del cuidad para el períd del tiemp necesari para terminar un curs del tratamient para una "cndición crónica seria" hasta un añ a partir de la fecha de la determinación que el emplead dañad tiene una "cndición crónica seria" cm definid en 8 CCR (e)(2) cm "cndición médica debid a la enfermedad, a la enfermedad, a la lesión catastrófica, al tr desrden médic del prblema médic que es seri en naturaleza y que persiste sin la curación cmpleta se empera sbre 90 días y requiere el tratamient en curs mantener la remisión prevenir la deteriración". La terminación del cuidad será prprcinada pr un períd del tiemp necesari, hasta un añ: (a) para terminar un curs del tratamient aprbó pr AARLA; y (b) arreglar para la transferencia a tr abastecedr dentr del MPN, según l determinad pr AARLA. El un períd del añ de la terminación del tratamient empieza cn la fecha del recib del emplead dañad de la ntificación de la determinación que el emplead tiene una cndición crónica seria. Terminación del cuidad para la duración de una "enfermedad terminal" según l definid en 8 CCR (e)(3) cm "cndición incurable irreversible que tiene una alta prbabilidad de causar muerte dentr de un añ de mens". Funcinamient de la cirugía del tr prcedimient que se ha autrizad cm parte de un curs del tratamient dcumentad y currirá en el plaz de 180 días a partir de la fecha eficaz de la cbertura del MPN según l discutid en 8 CCR (e)(4). Hasta que el emplead cubiert herid sea transferid en el MPN, el médic del emplead puede hacer remisines a prveedres dentr de fuera del MPN. AARLA llevará a cab un evaluación de la cndición médica del emplead antes de cualquier determinación que el tratamient cntinuad n satisface cualquier de ls criteris más arriba y pr es puede ser elegible para una transferencia dentr la RPM. Esta evaluación puede incluir la dirección de un enfermer de TMC. AARLA enviará la ntificación de la determinación de la transferencia del cuidad a la residencia del emplead dañad y al médic que trata primari del emplead dañad. La ntificación será prprcinada en inglés y españl y utilizará ls términs de la persna rdinaria al grad máxim psible. Si el emplead lesinad disputa la determinación médic que un transferencia de cuidad médic dentr la RPM esta aprpiad, él ella debe demandar un infrme del médic primari que trata declarand si el cuidad médic cntinuad esta dentr de cualquier de ls cndicines identificadas más arriba. El médic que trata debe prprcinar el infrme al emplead dentr de 20 días de calendari de la petición. Si el médic que trata n puede publicar el infrme, entnces la determinación de AARLA cn respect a la terminación del tratamient se aplicará. Si el médic primari que trata está de acuerd cn la determinación de AARLA que la cndición médic del emplead lesinad n satisface las cndicines identificadas más arriba (cm establecid en el Títul 8 Artícul (e)(1) pr (4) del Códig de ls Regulacines de Califrnia), la transferencia del cuidad médic prcederá durante el prces de la reslución de la disputa. Si el médic primari que trata n está de acuerd cn la determinación de AARLA que la cndición médic del emplead lesinad n satisface las cndicines identificadas más arriba (cm establecid en el Títul 8 Artícul (e)(1) pr (4) del Códig de ls Regulacines de Califrnia), la transferencia del cuidad médic n prcederá durante el prces de la reslución de la disputa. Fr questins abut the Dels Insurance Cmpany/TMC MPN, please cntact the MPN call center at , r send an t mpnhelp@aartpa.cm Dels/TMC MPN Site Crdinatr Guide Page 14 f 15

15 Cualquier disputa acerca de la determinación médic hech pr el médic primari que trata acerca de la transferencia de cuidad médic será reslvió según el Artícul 4062 del Códig de Labral. Referencias hechas a ls prveedres siguiente de la puesta en práctica de la RPM deben ser hechs a un prveedr dentr la RPM. Nada afirmad más arriba prhíbe AARLA/TMC de estar de acuerd cn prviend cntinuidad de tratamient cn un prveedr afuera la RPM, si AARLA/TMC determina que es mejr para el emplead lesinad que cntinuar el tratamient cn el prveedr quien es afuera la RPM. Fr questins abut the Dels Insurance Cmpany/TMC MPN, please cntact the MPN call center at , r send an t mpnhelp@aartpa.cm Dels/TMC MPN Site Crdinatr Guide Page 15 f 15