Medical Provider Network
How is the Medical Provider Network different than how medical treatment was provided prior to July 1, 2007?
The difference is that everyone will first go to a designated medical facility regardless of pre-designating a personal physician. You can continue treatment at the designated medical facility or select a doctor or facility from the Medical Provider Network.
In the case of emergency and after hour injuries or illnesses, that will remain the same in that the employee can seek medical treatment at the nearest emergency facility or hospital. With the implementation of the MPN, follow-up treatment is then with a designated medical facility.
What is the difference in the treatment process if I select my own pre-designated physician?
The City and County of San Francisco is still required to be in accordance with Utilization Protocols and will still require pre-designated physicians to have pre-approved treatment protocols. If treatment is utilized through the MPN, much of the pre-approval process is eliminated so treatment can be obtained more quickly.
Can I pre-designate my medical group as opposed to my individual doctor?
Yes you can. You can select your personal physician or the medical group that physician belongs to given they will handle your workers' compensation claim and have your medical records on file.
Why can't I pre-designate my personal chiropractor or acupuncturist?
The State of California parameters do not allow this. Predesignated physicians must be doctors of medicine or osteopathy.
Where do I send my Pre-Designation Form?
To the City and County of San Francisco c/o Intercare:
PO BOX 579
Roseville, CA 95661
Attn: Danielle Buri
Also, send a copy to your departmental human resources division and keep a copy for your own records.
Do I need to use a special form to pre-designate my personal physician?
No, but you do need to include your name, address, social security number, your physician's name, address and phone number,date the form and sign it. Send this to the above mentioned address.
Do I have to use my pre-designated physician if I complete a pre-designation form?
No, and you may find that you already have experience with an existing physician within the MPN which you want to have treat you. You simply select that physician.
Utilization review (UR) is the process used by employers or claims administrators to review treatment to determine if it is medically necessary.
All employers or claims administrators handling their workers’ compensation claims are required by law to have a UR program. This program uses medical treatment guidelines set by the state to decide whether or not to approve medical treatment recommended by your doctor. Learn more about the CCSF’s Utilization Review program .
What are the medical treatment guidelines set by the state?
California’s medical treatment utilization schedule (MTUS) details treatments scientifically proven to cure or relieve work-related injuries and illnesses. The MTUS lays out treatments that are effective for certain injuries, how often the treatment should be given, the extent of the treatment and other details.
Where can I look at the MTUS?
Go to www.dir.ca.gov/dwc. In the right navigation pane, under “Quick Links” click on “Publications”. Scroll down to schedules and click on medical treatment utilization schedule (MTUS).
What if the treatment my doctor recommends isn’t in the MTUS?
Your doctor needs to use other scientifically-based medical treatment guidelines generally accepted by the national medical community to support the recommended treatment.
I was awarded future medical treatment for my work injury. I have a copy of the award. Does UR apply to me?
Yes. The law requiring UR went into effect Jan. 1, 2004. It applies to all medical treatment being given, even if you received your award before Jan. 1, 2004.
Who can evaluate the medical treatment my doctor has recommended?
Anyone handling claims can approve the treatment recommended by your doctor. However, a decision to deny or change your treatment can only be made by a doctor who understands the type of injury or illness you have and the treatment being recommended.
What happens when my doctor recommends treatment and the claims administrator does a UR?
The claims administrator must do the review and make a decision within five days of the date your doctor requested the treatment. If additional information is needed to make a decision, the claims administrator can have up to 14 days.
What if my doctor has already provided the treatment and the claims administrator does a UR?
The review must be done and the decision given to your doctor within 30 days.
What happens if I got treated and the claims administrator says they won’t pay for it? Do I have to pay?
Most likely, no. This is a problem your doctor and the claims administrator need to work out.
What if my doctor requests treatment while I am in the hospital?
Your doctor may request a regular or “expedited review” while you’re receiving treatment in the hospital.
What is an expedited review?
This happens when your doctor recommends treatment and says you face a serious threat to your health if you don’t receive it. That could mean possible loss of life, limb or other major bodily function. It could also mean the normal time frame for a decision could harm your life or health, or could permanently risk your ability to recover to the fullest.
How long does an expedited review take?
The claims administrator has 72 hours from when they get the information they need to make the decision. If your condition is so serious that 72 hours is too long, they have to make the decision sooner.
Can the claims administrator stop my treatment if I’m in the hospital?
The claims administrator can’t stop treatment recommended by your doctor until they talk to your doctor and figure out another plan your doctor agrees to.
Will the claims administrator tell me if they decide to change, delay or deny my doctor’s request to treat me?
Yes. The claims administrator has to tell you, your attorney if you are represented, and your doctor in writing and state why they are changing, delaying, or denying your treatment.
What if I disagree with the claims administrator’s decision?
There are specific timelines you must meet or you will lose important rights. As of July 1, 2013, medical treatment disputes for all dates of injury will be resolved by physicians through the process of independent medical review (IMR). If UR denies or modifies a treating physician's request for medical treatment because the treatment is not medically necessary, you can ask for a review of that decision through IMR.
Along with the written determination letter that denied or modified your requested treatment, you will receive an unsigned but completed IMR form and addressed envelope. If you disagree with the decision, you must sign and send this form in the envelope to start the IMR process.
Please visit the IMR FAQ at http://www.dir.ca.gov/dwc/IMR/IMR_FAQs.htm for detailed information about the process itself, eligibility and deadlines, as well as a link to the IMR request form.
Is there any way to help make UR go smoothly?
UR works best when your doctor stays in contact with the claims administrator’s doctor throughout the process. Your doctor must state the reasons for the treatment being requested when making the request. And if the claims administrator’s doctor asks for more information, your doctor should respond.
What if more than 14 days have gone by since my doctor requested treatment and we haven’t heard or received anything from the claims administrator?
If your doctor has not been able to get a response from the claims administrator, you should file a declaration of readiness to proceed to expedited hearing. A claims administrator who fails to meet the appropriate deadline for a utilization review cannot object to the doctor providing the requested treatment.
Temporary Disability Benefit
Temporary disability (TD) benefits are payments you get if you lose wages because your injury prevents you from doing your usual job while recovering.
Do I need to fill out the claim form (DWC 1) my employer gave me?
Yes, if you want to make sure you qualify for all benefits. If you do not file the claim form within a year of your injury you may not be able get benefits. Your employer must give you a DWC 1 Claim Form within one day of knowing you were injured. Filling out the claim form opens your workers’ comp case. State law also lays out benefits beyond the basics you may qualify for once you file the claim form with your employer. Those benefits include, but are not limited to:
• A presumption that your injury or illness was caused by work if your claim is not accepted or denied within 90 days of giving the completed claim form to your employer
• Up to $10,000 in treatment under medical treatment guidelines while the claims administrator considers your claim • An increase in your disability payments if they’re late
• A way to resolve any disagreements that might come up between you and the claims administrator over whether your injury or illness happened on the job, the medical treatment you receive and whether you will receive permanent disability benefits.
What if my employer didn’t give me the DWC 1 Claim Form?
Ask your employer for the form or call the claims administrator to get it. The claims administrator is the person or entity handling your employer’s claims. The name and phone number of this entity should be posted at your workplace in the same area where other workplace information, like the minimum wage, is posted. You may be able to confirm who your claims administrator is by going to http://www.caworkcompcoverage.com/. You can also get the form from the Division of Workers’ Compensation (DWC) website at www.dwc.ca.gov. In the right navigation pane, under “Quick Links,” click on “forms”.
What are TD benefits?
TD benefits are payments you get from the claims administrator if you can’t do your usual job while recovering from your injury or illness. TD benefits are not taxable. If you can do some work while recovering but earn less than before the injury, you will receive temporary partial disability benefits. If you can’t work at all while recovering you will receive temporary total disability benefits. Some employers have plans that pay all your wages for all or part of the time you are temporarily disabled. These plans are called salary continuation. There are different types of salary continuation plans. Some use your vacation and/or sick leave to supplement the TD payments required by state law. Check with your employer to find out if you are covered by one of these plans.
How is TD calculated?
As a general rule, you are paid two-thirds of your gross (pre-tax) wages at the time of injury, with minimum and maximum rates set by law. Your wages are figured out by using all forms of income you receive from work: wages, food, lodging, tips, commissions, overtime and bonuses. Wages can also include earnings from work you did at other jobs at the time you were injured. Give proof of these earnings to the claims administrator. The claims administrator will consider all forms of income when calculating your TD benefits.
When does TD start and stop?
TD payments begin when your doctor says you can’t do your usual work for more than three days or you get hospitalized overnight. Payments must be made every two weeks. Generally, TD stops when you return to work, or when the doctor releases you for work, or says your injury has improved as much as it’s going to. If you were injured between April 19, 2004 and Jan. 1, 2008, your TD payments won’t last more than 104 weeks from the first payment for most injuries. Those injured on or after Jan. 1, 2008 are eligible to receive 104 weeks of disability payments within a five-year period.
The five-year period is counted from the date of injury. Payments for a few long-term injuries, such as severe burns or chronic lung disease, can go longer than 104 weeks. TD payments for these injuries can continue for up to 240 weeks of payment within a five-year period.
You can also file a state disability insurance (SDI) claim with the Employment Development Department. You should file this claim even if your workers’ comp case is accepted. This will allow you to get SDI payments after the 104 weeks of TD payments if you are still too sick or hurt to go back to work. To learn more call 1- 800-480-3287 or visit their website at www.edd.ca.gov/disability.
Do I get other benefits while receiving TD?
You have the right to receive medical treatment right away. The claims administrator may investigate your claim before deciding whether or not to accept it. Even if it investigates, the claims administrator must approve medical treatment for your injury within one working day after you submit a DWC 1 Claim Form. The treatment you get must be within medical treatment guidelines set by the state. The total cost of the treatment you get during the investigation cannot be more than $10,000.
You should also be reimbursed for transportation costs including mileage, parking and tolls for trips to and from the doctor's office. The claims administrator also pays for prescriptions, physical therapy visits and other medical costs.
What if there is a problem with my benefits?
If you have a concern, speak up. Talk to your employer or the claims administrator handling your claim and try to resolve the problem. Misunderstandings and mistakes sometimes occur, but you can resolve most of them by calling the claims administrator. If this doesn’t work, get help by trying the following:
Contact a state Division of Workers’ Compensation (DWC) Information and Assistance (I&A) officer: State I&A officers answer questions to help injured workers. They provide information and forms and help resolve problems with your claim. They hold free workshops to teach injured workers about their rights and responsibilities under the law. Go to www.dwc.ca.gov to find a local office.
Consult an attorney: Lawyers who specialize in helping injured workers with their workers’ compensation claims are called applicant’s attorneys. Their job is to plan a strategy for your case, gather information to support your claim, keep track of deadlines and represent you in hearings before a workers’ compensation judge at your local Workers’ Compensation Appeals Board office. If you hire an attorney, the attorney’s fees will be taken out of benefits you receive. A judge must approve the fees.
If you have a serious problem with your claim you may need to go before a workers’ compensation judge. In that case, you must fill out an application for adjudication of claim. That form normally must be filed within one year from the date of your injury or the last date you were paid benefits. Use I&A Guide 4 to help you file this form.
Permanent Disability Benefit
Permanent disability (PD) is any lasting disability from your work injury or illness that affects your ability to earn a living. If your injury or illness results in PD you are entitled to PD benefits, even if you are able to go back to work.
Do I need to fill out the claim form (DWC 1) my employer gave me?
Yes, if you want to make sure you qualify for all benefits. If you do not file the claim form within a year you may not be able to get benefits. Your employer must give you a DWC 1 Claim Form within one day of knowing you were injured. Filling out the claim form opens your workers’ comp case. State law also lays out benefits beyond the basics you may qualify for once you file the claim form with your employer. Those benefits include, but are not limited to:
• A presumption that your injury or illness was caused by work if your claim is not accepted or denied within 90 days of giving a claim form to your employer • Up to $10,000 in treatment under medical treatment guidelines while the claims administrator considers your claim
• An increase in your disability payments if they’re late
• A way to resolve any disagreements that might come up between you and the claims administrator over whether your injury or illness happened on the job, the medical treatment you receive and whether you will receive PD benefits.
What if my employer didn’t give me the DWC 1 Claim Form?
Ask your employer for the form or call the claims administrator to get it. The claims administrator is the person or entity handling your employer’s claims. The name and phone number of this entity should be posted at your workplace in the same area where other workplace information, like the minimum wage, is posted. You may be able to confirm who your claims administrator is by going to www.caworkcompcoverage.com. You can also get the form from the Division of Workers’ Compensation (DWC) Web site at www.dwc.ca.gov. In the right navigation pane, under “Quick Links,” click on “forms”.
Who decides if I should get PD benefits? How is that done?
A doctor decides if your injury or illness caused PD. The doctor’s report is then turned into a PD rating. The process used to turn the doctor’s report into a rating can vary depending on your date of injury and other factors. The PD rating determines the benefits you’ll receive.
After your doctor decides your injury or illness has stabilized and no change is likely, PD is evaluated. At that time, your condition has become permanent and stationary (P&S). Your doctor might use the term maximal medical improvement (MMI) instead of P&S.
Once you are P&S or have reached MMI, your doctor will send a report to the claims administrator telling them whether you have any PD. The doctor also decides if any of your disability was caused by something other than your work injury, such as a previous injury or another condition. This is called apportionment.
The claims administrator may ask you to fill out a form describing your disability.
What if I don’t agree with the doctor?
If you or the claims administrator disagrees with your doctor's findings you can be seen by a doctor called a qualified medical evaluator (QME). You request a QME list (called a panel) from the DWC Medical Unit. The claims administrator will send you the forms to request a QME. Your employer will pay for the cost of the QME exam. You have 10 days from the date the claims administrator tells you to begin the QME process to submit your request form to the DWC Medical Unit . If you do not submit the form within 10 days, the claims administrator will do it for you and will get to choose the kind of doctor you’ll see.
There are other specific and strict timelines you must meet in filing your QME forms or you will lose important rights. Read the DWC Information and Assistance (I&A) Unit Guide 2 and refer to fact sheet E for more information.
What is a PD rating and how is it calculated?
First, after your exam, the doctor will write a medical report about your impairment. Impairment means how your injury affects your ability to do normal life activities. The report includes whether any portion of your impairment was caused by something other than your work injury. The doctor’s report ends with an impairment number. Next, the impairment number is put into a formula to calculate your percentage of disability. Disability means how the impairment affects your ability to work. Your occupation and age at the time of your injury affect your PD calculation. If you were hurt before Jan. 1, 2013 your diminished future earning capacity shall also be a factor in your rating. Then, any portion of your disability caused by something other than your work injury is taken out of the calculation. Your disability will then be stated as a percentage.
Your percentage of disability equals a specific dollar amount, depending on the date of your injury and your average weekly wages at the time of injury. A rating specialist from the DWC Disability Evaluation Unit may help calculate your rating.
If your employer has 50 or more employees, and you were injured before 2013, the amount also may be affected by whether or not your employer makes a suitable return to work offer. For injuries occurring on or after Jan. 1, 2013 all permanent disability ratings will be increased by a Whole Person Impairment factor of 1.4.
How is PD paid?
Once your doctor says you have PD, the claims administrator will estimate how much you should receive and begin making payments to you, even if the final percentage of disability has not been calculated. PD benefits are paid in addition to temporary disability (TD) benefits you received. The claims administrator must begin paying your PD within 14 days after TD ends and continue the payments until a reasonable estimate of your disability amount has been paid. If you have not missed any work, PD payments are due from the date the doctor says you are P&S. PD benefits continue to be paid every two weeks on a day picked by the claims administrator until a reasonable estimate of your disability amount has been paid. When the actual amount of PD due has been determined, the amount over the estimate must be paid.
If you were injured and have ratable permanent disability, as of Jan. 1, 2013 PD payments are not due if you return to modified, alternative or regular work with your employer at 85 percent of your wages or return to work for any employer at 100 percent of your wages. When you receive your PD award, you will then receive an adjusted payment beginning with the last date TD was paid or when you made a maximum medical recovery, whichever is earlier.
How is my claim finally resolved?
After the amount of PD in a claim is determined, there is usually a settlement or award for benefits. This award must be approved by a workers' compensation judge. If you have an attorney, your attorney should help you obtain this award. If you don’t have an attorney, the claims administrator should help you obtain the award. You can also get help from the I&A officer at the local Workers’ Compensation Appeals Board office. If your doctor said further medical treatment for your injury or illness might be necessary, the award may provide future medical care.
There are two types of settlements. A settlement is agreed on by you and the claims administrator.
You can resolve your whole claim through one lump sum settlement called a compromise and release (C&R). A C&R may be best when you want to control your own medical care and/or you want a lump sum payment for your PD. A C&R usually means that after you get the lump sum payment approved by the workers’ compensation judge, the claims administrator will not be liable for any further payments or medical care.
You can also agree to a settlement called a stipulation with request for award (stip). A stip usually includes a sum of money and future medical treatment. Payments take place over time. A judge will review the agreement.
If you cannot agree to a settlement with the claims administrator, you can go before a workers compensation judge, who will decide your PD award. A judge’s finding is called a findings and award (F&A). The F&A generally consists of an amount of money and a provision for the claims administrator to pay for approved future medical treatment.
If your injury results in a permanent disability and the state determines that your PD benefit is disproportionately low compared to your earning loss, you may qualify for additional money from the Department of Industrial Relations’ Special Earnings Loss Supplemental program which is also known as the Return to Work Program. If you have questions or think you qualify, contact your local I & A office or visit the DIR website at www.dir.ca.gov.