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NBSIA EE Notice as of October 2016
North Bay Schools Insurance Authority
WORKERS’ COMPENSATION
NEW HIRE DOCUMENTS
EE MPN NOTICE/PRE-DESIGNATION
Employee MPN Notice in English and Spanish
School District personnel are required to include the Employee MPN documents for
New Hires.
Fill out employee information on the following page and get employees’ signature as
proof of service. Keep a copy of the proof of service in the employee personnel file.
DO NOT CHANGE THE LANGUAGE IN THESE NOTICES AS THE STATE OF
CALIFORNIA HAS REVIEWED AND APPROVED THESE NOTICES.
CHANGING THE LANGUAGE WILL MAKE THE NOTICE INVALID.
Important Information about Medical Care if You Have a
Work-Related Injury or Illness
Complete Written Employee Notification Re: Medical Provider Network
(Title 8, California Code of Regulations, section 9767.12)
California law requires your employer to provide and pay for medical treatment if you are injured at work.
Your employer has chosen to provide this medical care by using a Workers’ Compensation physician
network called a Medical Provider Network (MPN). This MPN is administered by Networks By Design,
Inc. This notification tells you what you need to know about the MPN program and describes your rights
in choosing medical care for work-related injuries and illnesses.
● What happens if I get injured at work?
In case of an emergency, you should call 911 or go to the closest emergency room.
If you are injured at work, notify your employer as soon as possible. Your employer will provide you with
a claim form. When you notify your employer that you have had a work-related injury, your employer or
insurer will make an initial appointment with a doctor in the MPN.
● What is an MPN?
A Medical Provider Network (MPN) is a group of health care providers (physicians and other medical
providers) used by your employer to treat workers injured on the job. MPNs must allow employees to
have a choice of provider(s). Each MPN must include a mix of doctors specializing in
work
-related
injuries and doctors with expertise in general areas of medicine.
● What MPN is used by my employer?
Your employer is using the NBSIA MPN with the identification number  2505. You must refer to the
MPN name and the MPN identification number whenever you have questions or requests about the MPN.
● Who can I contact if I have questions about my MPN?
The MPN Contact listed in this notification will be able to answer your questions about the use of the MPN
and will address any complaints regarding the MPN.
The contact for your MPN is:
Name: Networks By Design, Inc.
Title: MPN Contact
Address: P.O Box 820 Tracy, California 95376
Telephone Number: (877) 854-3353
Email address: mpninfo@netbyd.com
General information regarding the MPN can also be found at the following website:
www.nbsiampn.org
● What if I need help finding and making an appointment with a doctor?
The MPN Medical Access Assistant will help you find available MPN physicians of your choice and can
assist you with scheduling and confirming physician appointments. The Medical Access Assistant is
available to assist you Monday through Saturday from 7am-8pm (Pacific) and schedule medical
appointments during doctor's’ normal business hours. Assistance is available in English and in Spanish.
The contact information for the Medical Access Assistant is:
Toll Free Telephone Number: (877)854-3353
Fax Number: (209) 879-9387
Email Address: mpninfo@netbyd.com
● How do I find out which doctors are in my MPN?
You can get a regional list of all MPN providers in your area by calling the MPN Contact or by going to our
website at:
www.nbsiampn.org At minimum, the regional list must include a list of all MPN providers within
15 miles of your workplace and/or residence or a list of all MPN providers within the county where
you live and/or work. You may choose which list you wish to receive. You also have the right to obtain a
list of all the MPN providers upon request.
You can access the roster of all treating physicians in the MPN by going to the website at
www.nbsiampn.org
● How do I choose a provider?
Your employer or the insurer for your employer will arrange the initial medical evaluation with a MPN
physician. After the first medical visit, you may continue to be treated by that doctor, or you may choose
another doctor from the MPN. You may continue to choose doctors within the MPN for all of your medical
care for this injury.
If appropriate, you may choose a specialist or ask your treating doctor for a referral to a specialist. Some
specialists will only accept appointments with a referral from the treating doctor. Such specialists might
be listed as “by referral only” in your MPN directory.
If you need help in finding a doctor or scheduling a medical appointment, you may call the Medical
Access Assistant.
● Can I change providers?
Yes. You can change providers within the MPN for any reason, but the providers you choose should be
appropriate to treat your injury. Contact the MPN Contact or your claims adjuster if you want to change
your treating physician.
● What standards does the MPN have to meet?
The MPN has providers for the zip codes in the following counties in California: Napa, Yolo and Solano
and 30 miles surrounding those zip codes.
The MPN must give you access to a regional list of providers that includes at least three physicians in
each specialty commonly used to treat work injuries/illnesses in your industry. The MPN must provide
access to primary treating physicians within 30 minutes or 15 miles and specialists within 60 minutes or
30 miles of where you work or live.
If you live in a rural area or an area where there is a health care shortage, there may be a different
standard.
After you have notified your employer of your injury, the MPN must provide initial treatment within 3
business days. If treatment with a specialist has been authorized, the appointment with the specialist
must be provided to you within 20 business days of your request.
If you have trouble getting an appointment with a provider in the MPN, contact the Medical Access
Assistant.
If there are no MPN providers in the appropriate specialty available to treat your injury within the distance
and time frame requirements, then you will be allowed to seek the necessary treatment outside of the
MPN.
● What if there are no MPN providers where I am located?
If you are a current employee living in a rural area or temporarily working or living outside the MPN
service area, or you are a former employee permanently living outside the MPN service area, the MPN or
your treating doctor will give you a list of at least three physicians who can treat you. The MPN may also
allow you to choose your own doctor outside of the MPN network. Contact your MPN Contact for
assistance in finding a physician or for additional information.
● What if I need a specialist that is not available in the MPN?
If you need to see a type of specialist that is not available in the MPN, you have the right to see a
specialist outside of the MPN.
● What if I disagree with my doctor about medical treatment?
If you disagree with your doctor or wish to change your doctor for any reason, you may choose another
doctor within the MPN.
If you disagree with either the diagnosis or treatment prescribed by your doctor, you may ask for a second
opinion from another doctor within the MPN. If you want a second opinion, you must contact the MPN
Contact or your claims adjuster and tell them you want a second opinion. The MPN should give you at
least a regional or full MPN provider list from which you can choose a second opinion doctor. To get a
second opinion, you must choose a doctor from the MPN list and
make an appointment within 60 days.
You must tell the MPN Contact of your appointment date, and the MPN will send the doctor a copy of
your medical records. You may also request a copy of your medical records that will be sent to the
doctor.
If you do not make an appointment within 60 days of receiving the regional provider list, you will not be
allowed to have a second or third opinion with regard to this disputed diagnosis or treatment of the
treating physician.
If the second-opinion doctor feels that your injury is outside of the type of injury he or she normally treats,
the doctor's office will notify your employer or insurer and you. You will get another list of MPN doctors
or specialists so you can make another selection.
If you disagree with the second opinion, you may ask for a third opinion. If you request a third opinion,
you will go through the same process you went through for the second opinion.
Remember that if you do not make an appointment within 60 days of obtaining another MPN provider list,
then you will
not be allowed to have a third opinion with regard to this disputed diagnosis or treatment of
this treating physician.
If you disagree with the third-opinion doctor, you may ask for an MPN Independent Medical Review
(IMR). Your employer or MPN Contact will give you information and a form for requesting an
Independent Medical Review at the time you select a third-opinion physician.
If either the second or third-opinion doctor or Independent Medical Reviewer agrees with your need for a
treatment or test, you may be allowed to receive that medical service from a provider within the MPN, or
if the MPN does not contain a physician who can provide the recommended treatment, you may choose
a physician outside the MPN within a reasonable geographic area.
● What if I am already being treated for a work-related injury before the MPN begins?
Your employer or insurer has a “Transfer of Care” policy which will determine if you can continue being
temporarily treated for an existing work-related injury by a physician outside of the MPN before your care
is transferred into the MPN.
If your current doctor is not or does not become a member of the MPN, then you may be required to see
a MPN physician. However, if you have properly predesignated a primary treating physician, you cannot
be transferred into the MPN. (If you have questions about predesignation, ask your supervisor.)
If your employer decides to transfer you into the MPN, you and your primary treating physician must
receive a letter notifying you of the transfer.
If you meet certain conditions, you may qualify to continue treating with a non-MPN physician for up to a
year before you are transferred into the MPN. The qualifying conditions to postpone the transfer of your
care into the MPN are set forth in the box below.
Can I Continue Being Treated By My Doctor?
You may qualify for continuing treatment with your non-MPN provider (through transfer of care or
continuity of care) for up to a year if your injury or illness meets any of the following conditions:
● (Acute) The treatment for your injury or illness will be completed in less than 90 days;
● (Serious or Chronic) Your injury or illness is one that is serious and continues for at least 90
days without full cure or worsens and requires ongoing treatment. You may be allowed to be
treated by your current treating doctor for up to one year, until a safe transfer of care can be
made;
● (Terminal) You have an incurable illness or irreversible condition that is likely to cause death
within one year or less;
● (Pending Surgery) You already have a surgery or other procedure that has been authorized
by your employer or insurer that will occur within 180 days of the MPN effective date, or the
termination of contract date between the MPN and your doctor.
You can disagree with your employer’s decision to transfer your care into the MPN. If you don’t want to
be transferred into the MPN, ask your primary treating physician for a medical report on whether you
have one of the four conditions stated above to qualify for a postponement of your transfer into the MPN.
Your primary treating physician has 20 days from the date of your request to give you a copy of his/her
report on your condition. If your primary treating physician does not give you the report within 20 days of
your request, the employer can transfer your care into the MPN and you will be required to use an MPN
physician.
You will need to give a copy of the report to your employer if you wish to postpone the transfer of your
care. If you or your employer disagrees with your doctor’s report on your condition, you or your employer
can dispute it. See the complete Transfer of Care policy for more details on the dispute resolution
process.
For a copy of the Transfer of Care policy, in English or Spanish, ask your MPN Contact.
● What if I am being treated by a MPN doctor who decides to leave the MPN?
Your employer or insurer has a written “Continuity of Care” policy that will determine whether you can
temporarily continue treatment for an existing work injury with your doctor if your doctor is no longer
participating in the MPN.
If your employer decides that you do not qualify to continue your care with the non-MPN provider, you
and your primary treating physician must receive a letter notifying you of this decision.
If you meet certain conditions, you may qualify to continue treating with this doctor for up to a year before
you must choose a MPN physician. These conditions are set forth in the “Can I Continue Being
Treated By My Doctor?” box above.
You can disagree with your employer’s decision to deny you Continuity of Care with the terminated MPN
provider. If you want to continue treating with the terminated doctor, ask your primary treating physician
for a medical report on whether you have one of the four conditions stated in the box above to see if you
qualify to continue treating with your current doctor temporarily.
Your primary treating physician has 20 days from the date of your request to give you a copy of his/her
medical report on your condition. If your primary treating physician does not give you the report within 20
days of your request, your employer’s decision to deny you Continuity of Care with your doctor who is no
longer participating in the MPN will apply, and you will be required to choose a MPN physician.
You will need to give a copy of the report to your employer if you wish to postpone the selection of
another MPN doctor for your continued treatment. If you or your employer disagrees with your doctor’s
report on your condition, you or your employer can dispute it. See the complete Continuity of Care policy
for more details on the dispute resolution process.
For a copy of the Continuity of Care policy, in English or Spanish, ask your MPN Contact.
● What if I have questions or need help?
● MPN Contact: You may always contact the MPN Contact if you have questions about the use
of the MPN and to address any complaints regarding the MPN.
● Medical Access Assistants: You may contact the Medical Access Assistant if you need help
finding MPN physicians and scheduling and confirming appointments.
● Division of Workers’ Compensation (DWC): If you have concerns, complaints or questions
regarding the MPN, the notification process, or your medical treatment after a work-related injury
or illness, you may call the DWC Information and Assistance office at 1-800-736-7401. You may
also go to the DWC website at
www.dir.ca.gov/dwc and under the header “Workers
compensation programs and units” click on “Medical provider networks” for more information
about MPNs.
● Independent Medical Review: If you have questions about the MPN Independent Medical
Review process, contact the Division of Workers’ Compensation’s Medical Unit at:
DWC Medical Unit
P.O. Box 71010
Oakland, CA 94612
(510) 286-3700 or (800) 794-6900
Keep this information in case you have a work-related injury or illness.
Información Importante sobre Cuidado Médico si tiene
una
Lesión o Enfermedad de
Trabajo.
Completa Notificación Inicial Escrita del Empleado sobre la Red de Proveedores Médicos
(Título 8, Código de Regulaciones de California, sección 9767.12)
La ley de California requiere que su empleador le proporcione y pague el tratamiento médico si se lesión
en el trabajo. Su empleador ha elegido proporcionarle este cuidado médico utilizando una red de
médicos de Compensación de Trabajadores llamada Red de Proveedores Médicos o MPN (Medical
Provider Network). Esta MPN está administrada por Networks By Design, Inc. Esta notificación le
informará lo que necesita saber sobre el programa de la MPN y le describirá sus derechos en e
legir
cuidado médico para sus lesiones o enfermedades de trabajo.
● ¿Qué pasa si me lastimo en el trabajo?
En caso de emergencia, debe llamar al 911 o ir a la sala de emergencias más cercana. Si se
lesiona en el trabajo, notifique a su empleador lo más pronto posible. Su empleador le proporcionará
un
formulario de reclamo. Cuando le notifique a su empleador que ha sufrido una lesión de trabajo, su
empleador hará la cita inicial con el médico de la MPN.
● ¿Qué es una MPN?
Una Red de Proveedores Médicos o MPN es un grupo de proveedores de asistencia médica usados por
su empleador (médicos y otros proveedores médicos) utilizados por su empleador para atender a
trabajadores que se lesionan en el trabajo. Cada MPN debe incluir una combinación de médicos que se
especializan en lesiones de trabajo y médicos expertos en áreas de medicina general.
● ¿Que es una MPN usado por mi empleador?
Su empleador está usando NBSIA MPN con número de
identificación
2
 
505
. Usted debe referirse al
nombre y número de identificación de la MPN cuando tenga preguntas o peticiones acerca de la MPN.
● ¿Cómo puedo averiguar cuáles médicos pertenecen a mi MPN?
El Contacto de la MPN enlistado en esta notificación podrá contestar sus preguntas sobre cómo usar el
MPN y resolverá cualquier queja respecto a el MPN.
El contacto para el MPN es:
Nombre: Networks By Design, Inc.
Título: MPN Contact
Dirección: P.O Box 820 Tracy, California 95376
Número telefónico: (877) 854-3353
Correo electrónico: mpninfo@netbyd.com
Información General respecto a la MPN también puede ser encontrada en la siguiente página de la red
www.nbsiampn.org
● ¿Que si necesito ayuda para encontrar un médico?
El Asistente de Acceso Médico de la MPN le ayudará a encontrar un médico de la MPN disponible de su
elección y puede asistirle en hacer y confirmar una cita médica. El Asistente de Acceso Médico está
disponible de Lunes a Sábado de 7am- 8pm (Pacífico) y a programar citas médicas durante las horas de
las oficinas médicas. La asistencia está disponible en Inglés y Español.
La información de contacto para el Asistente de Acceso Médico es:
Número de teléfono gratuito:
(877)854-3353
Número de Fax: (209) 879-9387
Correo Electrónico: mpninfo@netbyd.com
● ¿Cómo averiguo cuáles proveedores médicos son parte de la MPN?
Usted puede obtener una lista regional de los proveedores de la MPN en su área llamando al contacto de
la MPN o visitando nuestro sitio web en:
www.nbsiampn.org Como mínimo, la lista regional debe incluir
una lista de todos los proveedores de la MPN dentro de 15 millas de su lugar de trabajo y / o residencia o
una lista de todos los proveedores de la MPN dentro del condado donde usted vive y / o trabaja. Usted
puede elegir qué lista quiere recibir. Usted también tiene el derecho de obtener una lista de todos los
proveedores de la MPN que lo soliciten.
Puede acceder a la lista de todos los médicos tratantes en el MPN por ir a la página web en:
www.nbsiampn.org
● ¿Cómo escojo un proveedor?
Su empleador o la aseguradora de su empleador arreglara la evaluación médica inicial con un médico de
la MPN. Después de la primera visita médica, puede continuar ser atendido por este médico o puede
elegir otro médico dentro de la MPN. Puede continuar eligiendo médicos de la MPN para todo su
cuidado médico para esta lesión. Si es apropiado, puede escoger un especialista o puede pedirle al
médico que lo está atendiendo que lo refiera a un especialista. Si necesita ayuda en elegir un médico
puede llamar al contacto de la MPN arriba descrito. Algunos especialistas solo aceptarán citas con una
referencia del médico tratante. Dicho especialista puede ser enlistado como “por referencia solamente”
en el directorio de la MPN.
Si necesita ayuda para encontrar un doctor o hacer una cita médica, puede llamar al Asistente de
Acceso Médico.
● ¿Puedo cambiar de proveedor?
Sí. Usted puede cambiar de proveedores dentro de la MPN por cualquier razón, pero los proveedores
que elija deben ser apropiados para tratar su lesión. Contacte al contacto de la MPN o a su ajustador de
reclamos si desea cambiar su médico tratante.
● ¿Qué requisitos debe tener la MPN?
La MPN tiene proveedores en los códigos postales en los siguientes condados de California: Napa, Yolo
y Solano y 30 millas que rodean esos códigos postales.
La MPN tiene que proporcionarle acceso a una lista regional de proveedores que incluya por lo menos
tres médicos en cada especialidad usualmente utilizada para tratar lesiones/enfermedades en su
industria. La MPN debe proporcionarle acceso a médicos primarios, Médicos que tratan dentro de 30
minutos o 15 millas y especialistas dentro de 60 minutos o 30 millas de distancia de donde usted vive o
trabaja. Si usted vive en una área rural o en una área donde hay un cuidado médico escaso, puede ser
un est
ándar diferente.
Después de haber notificado a su empleador sobre su lesión, la MPN debe proporcionar
tratamiento
inicial
dentro de 3 días. Si el tratamiento con un especialista ha sido autorizado, la cita con el especialista
debe de ser proveída dentro de 20 días de negocio desde su pedido.
Si tiene dificultad para conseguir una cita con un proveedor de la MPN, contacte al Asistente de Acceso
Médico.
Si no hay proveedores de la MPN en la especialidad apropiada disponibles a tratar su lesión dentro de la
distancia y tiempos requeridos, entonces se le permitirá buscar el tratamiento necesario fuera de la MPN.
● ¿Qué tal si no hay proveedores de la MPN donde estoy localizado?
Si está temporalmente trabajando o viviendo fuera de la área de servicio de la MPN o en una área rural,
la MPN o el médico que lo está atendiendo le dará una lista de por lo menos tres médicos que lo puedan
atender. La MPN también puede permitirle elegir su propio médico fuera de la red de la MPN. Póngase
en contacto con su contacto de la MPN para asistencia en encontrar un médico o para información
adicional.
● ¿Qué tal si necesito un especialista que no está dentro de la MPN?
Si necesita ver un especialista que no está disponible dentro de la MPN, usted tiene derecho a ver un
especialista fuera de la MPN.
● ¿Qué tal si no estoy de acuerdo con mi médico sobre tratamiento médico?
Si usted no está de acuerdo con su médico o desea cambiar de médico por cualquier razón, usted puede
escoger otro médico dentro de la MPN.
Si usted no está de acuerdo con el diagnosis o tratamiento recetado por su médico, usted puede pedir
una segunda opinión de un médico dentro de la MPN. Si quiere una segunda opinión, debe ponerse en
contacto con la MPN, contacte a su ajustador de reclamos y dígale que quiere una segunda opinión. La
persona de contacto asegurará que por lo menos tenga una lista regional o completa de proveedores de
la MPN para elegirlo. Para obtener una segunda opinión, de
be elegir un médico dentro de la lista de la
MPN y hacer una cita dentro de 60 días. Usted debe decirle al contacto de la MPN la fecha de su cita
y el
contacto de la MPN le mandará al médico una copia de su expediente médico. Usted puede pedir una
copia de su expediente médico que se le enviará al médico.
Si no hace una cita dentro de 60 días a partir de recibir la lista regional de proveedores, no le será
permitido tener una segunda o tercera opinión sobre el disputado diagnóstico o tratamiento recomendado
por el médico que lo está atendiendo.
Si el médico de la segunda opinión siente que su lesión está fuera del tipo de lesión que él o élla
normalmente trata, la oficina del médico le notificará a su empleador o compañía de seguros y usted
obtendrá otra lista de médicos o especialistas de la MPN para que pueda hacer otra selección.
Si usted no está de acuerdo con la segunda opinión, puede pedir por una tercera opinión. Si usted pide
una tercera opinión, usted pasará por el mismo proceso que pasó para la segunda opinión.
Recuerde que si no hace una cita dentro de 60 días a partir de recibir la otra lista de proveedores de la
MPN, entonces no
le será permitido tener una tercera opinión sobre el disputado diagnóstico o
tratamiento recomendado por el médico que lo está atendiendo.
Si usted no está de acuerdo con el médico de la tercera opinión, usted puede pedir una MPN Revisión
Médica Independiente o IMR (Independent Medical Review). Su empleador o el contacto de la MPN le
dará información sobre cómo pedir la Revisión Médica Independiente y un formulario cuando usted
selecciona la tercera opinión médica.
Si el médico o Revisor Médico Independiente de la segunda o tercera opinión está de acuerdo que usted
necesita algún tratamiento o análisis, le será tal vez permitido recibir el servicio médico de un proveedor
dentro de la MPN, o si la MPN no tiene un médico quien puede proveer el tratamiento, puede elegir a un
médico fuera de la MPN dentro de una área geográfica razonable.
● ¿Qué tal si ya estoy siendo atendido por una lesión de trabajo antes de que empiece el MPN?
Su empleador o la compañía de seguros tienen un plan de “Transferencia de Cuidado” que determinará
si usted puede continuar siendo temporalmente atendido por una lesión de trabajo por un médico fuera
de la MPN antes de que su cuidado sea transferido a la MPN.
Si su médico actual no es o no se convierte en un miembro de la MPN, entonces podrá ser obligado a
ver a un médico de la MPN. Sin embargo, si usted apropiadamente ha designado previamente un médico
para atenderlo, usted no puede ser transferido a la MPN. (Si tiene preguntas acerca de la designación
previa, pregúntele a su supervisor.)
Si su empleador decide transferirlo a la MPN, usted y su médico que lo está atendiendo deben recibir
una carta notificándoles de la transferencia.
Si usted llena ciertos requisitos, pueda que califique a continuar ser atendido por un médico fuera de la
MPN hasta por un año antes de que sea transferido a la MPN. Los requisitos para posponer la
transferencia de su cuidado a la MPN están expuestos en la caja debajo.
¿Puedo Continuar Ser Tratado Por Mi Médico?
Usted puede calificar para tratamiento continuo con su proveedor que no está dentro de la MPN (por
transferencia de cuidado o continuidad de cuidado) hasta por un año si su lesión o enfermedad llena
cualquiera de las siguientes condiciones:
• (Agudo) El tratamiento para su lesión o enfermedad será completado en menos de 90 días;
• (Grave o crónico) Su lesión o enfermedad es una que es grave y continúa por lo menos 90
días sin una cura total o empeora y requiere de tratamiento continuo. Se le podrá permitir ser
tratado por su médico actual hasta por un año, hasta que una transferencia de cuidado
segura pueda ser hecha;
• (Terminal) Tiene una enfermedad incurable o condición irreversible que probablemente
cause la muerte dentro de un año o menos;
• (Cirugía pendiente) Ya tiene una cirugía u otro procedimiento que ha sido autorizado por
su empleador o compañía de seguros y que se realizará dentro de 180 días a partir de la
fecha efectiva de la MPN o la fecha de la terminación del contrato entre la MPN y su médico.
Usted puede no estar de acuerdo con la decisión de su empleador sobre transferir su cuidado a la MPN.
Si no quiere ser transferido a la MPN, pídale a su médico que lo está atendiendo por un informe médico
que indique si tiene una de las cuatro condiciones indicadas arriba para poder posponer su transferencia
a la MPN.
El médico que lo está atendiendo tiene 20 días a partir de la fecha de su petición para darle una
copia
del
informe sobre su condición. Si el médico que lo está atendiendo no le da el informe dentro de los 20
días a partir de la fecha de su petición, el empleador podrá transferir su cuidado a la MPN y estará
obligado a utilizar un médico de la MPN.
Tendrá que darle una copia del informe a su empleador si desea posponer la transferencia de su
cuidado. Si usted o su empleador no está de acuerdo con el informe de su médico sobre su condición,
usted o su empleador puede disputarlo. Vea el plan de Transferencia de Cuidado para más detalles
sobre el proceso de resolución de disputa.
Para una copia del plan entero sobre la Transferencia de Cuidado, en inglés o español, pregúntele a su
contacto de la MPN.
● ¿Qué tal si estoy bajo tratamiento con un médico de la MPN que decide dejar la MPN?
Su empleador o compañía de seguros tiene un plan escrito para “La Continuidad de Cuidado” que
determinará si es que podrá continuar temporalmente su tratamiento por su lesión de trabajo actual con
su médico si su médico ya no está participando en la MPN.
Si su empleador decide que usted no califica para continuar su tratamiento con el médico que no es un
proveedor dentro de la MPN, usted y el médico que lo está atendiendo deberán recibir una carta
notificándole de esta decisión.
Si usted llena ciertos requisitos, tal vez podrá calificar para continuar su tratamiento con este médico
hasta por un año antes de que tenga que elegir a un médico de la MPN. Estos requisitos están
expuestos, “¿Puedo Continuar Ser Tratado Por Mi Médico?” en la caja descrita arriba.
Usted puede no estar de acuerdo con la decisión de su empleador sobre negarle la Continuidad de
Cuidado con el proveedor que ya no es parte de la MPN. Si quiere continuar su tratamiento con este
médico, pídale al médico que lo está atendiendo por un informe que indique si tiene una de las cuatro
condiciones descritas en la caja de arriba para ver si califica para seguir recibiendo tratamiento de su
médico actual.
El médico que lo está atendiendo tiene 20 días a partir de la fecha de su petición para darle una
copia
del
informe sobre su condición. Si el médico que lo está atendiendo no le da el informe dentro de los 20
días a partir de la fecha de su petición, la decisión de su empleador de negarle la Continuidad de
Cuidado con su doctor quien ya no participa en la MPN aplicará, y usted será requerido a escoger un
médico de la MPN.
Tendrá que darle una copia del informe a su empleador si desea posponer la selección de un tratamiento
con un médico de la MPN. Si usted o su empleador no está de acuerdo con el informe de su médico
sobre su condición, usted o su empleador puede disputarlo. Vea el plan de transferencia de cuidado
para más detalles sobre el proceso de resolución de disputa.
Para una copia del plan de la Continuidad de Cuidado, en inglés o español, pregúntele a su Contacto de
la MPN.
● ¿Qué tal si tengo preguntas o necesito ayuda?
El Contacto de la MPN: Usted siempre puede ponerse en contacto con el Contacto de la MPN si
tiene preguntas sobre el uso de la MPN y como mandar sus reclamos respecto a la MPN.
● Asistente de Acceso Médico: Puede contactar el Asistente de Acceso Médico si necesita ayuda
para encontrar médicos del MPN y la programación y confirmar citas.
● La División de Compensación de Trabajadores (DWC): Si tiene algún interés queja, pregunta
sobre la MPN, el proceso de notificación, o su tratamiento médico después de una lesión o
enfermedad de trabajo, puede llamar a la Oficina de Información y Asistencia de la DWC al 1-800-
736-7401. También puede consultar con la página web de la DWC en el www.dir.ca.gov/dwc y bajo
el encabezado haga “Workers compensation programs and units” clic en “la red de proveedores
médicos” para más información sobre las MPNs.
● Revisión Médica Independiente: Si usted tiene preguntas sobre el MPN, proceso de la Revisión
Médica Independiente póngase en contacto con la Unidad Médica de la División de Compensación
de Trabajadores en:
DWC Medical Unit
P.O. Box 71010
Oakland, CA 94612
(510) 286-3700 or (800) 794-6900
Mantenga esta información en caso de una lesión o enfermedad
relacionada con el trabajo.
NBSIA EE Notice as of October 2016
EMPLOYEE ACKNOWLEDGEMENT OF THE MEDICAL PROVIDER NETWORK
RECEIPT – PROOF OF SERVICE
In order to provide the most timely and suitable quality medical care in the event of an injury on the job, we have instituted
a Medical Provider Network for Workers’ Compensation.
The following procedures must be followed for all work related injuries and illnesses.
Report promptly any work related injury to the supervisor.
For a referral to the medical provider specialist, contact your employer or Claims Adjuster.
Ensure all medical treatment is handled only through the MPN (Medical Provider Network) unless otherwise
authorized.
Direct all questions about the level of care to the PCP (Primary Care Physician), who is the focal point for all medical
treatment.
A directory of medical care providers is available at my request through my employer.
Please sign below to indicate that you have read and understand the procedures to follow in the event of an injury and your
duties under our Medical Provider Network and have received the following workers’ compensation documents:
Medical Provider Network (MPN) Notice
Employee Name:
SS#:
Address:
City, State, Zip:
Date of Hire:
Date of Birth:
Signature:
Date:
A COPY OF THE MPN DIRECTORY IS AVAILABLE FROM YOUR EMPLOYER OR ADJUSTER UPON YOUR
REQUEST.
Please keep copy in personnel file.
NBSIA EE Notice as of October 2016
Employee Information on the Independent Medical Review (IMR) Process
This notice is to inform you or your rights, responsibilities and process in obtaining an Independent Medical Review (IMR).
If you disagree with your treatment plan or diagnosis that the third opinion physician rendered, you have the right
to request an Independent Medical Review. At the time you request a physician for a third opinion, your MPN contact or
Claims Adjuster will provide you with this form covering the Independent Medical Review process. You will also be provided
with an “Application for Independent Medical Review” form. The MPN Contact or Claims Adjuster will fill out the “MPN
Contact section” for you. You will need to complete the “employee section” of the form, indicate on the form whether you
are requesting an in-person examination or a records review. You may also list an alternative specialty, if any, that is different
from the specialty of the treating physician.
The Administrative Director will select an IMR with an appropriate specialty within ten (10) business days of receiving your
Application for Independent Medical Review form. The Administrative Director’s selection of the IMR will be based on the
specialty of your treating physician, the alternative specialties listed by you and the MPN contact, and the information
submitted with the Application for Independent Medical Review.
If you request an in-person examination, the Administrative Director will randomly select a physician from a list of available
independent medical reviewers, with an appropriate specialty, who has an office located within thirty (30) miles of your
residential address, to be your independent medical reviewer. If there is only one physician with an appropriate specialty
within thirty (30) miles of your residential address, that physician shall be selected to the independent medical reviewer. If
there are no physicians with an appropriate specialty who have offices located within thirty (30) miles of your residential
address, the Administrative Director will search in increasing five (5) mile increments, until one physician is located. If there
are no available physicians with this appropriate specialty, the Administrative Director may choose another specialty based
on the information submitted.
If you request a record review, then the Administrative Director will randomly select a physician with an appropriate specialty
from the list of available independent medical reviewers to be the IMR. If there are no physicians with an appropriate
specialty, the Administrative Director may choose another specialty based on the information submitted.
The Administrative Director will send written notification of the name and contact information of the IMR to you, your attorney,
if any, the MPN Contact and the IMR. The Administrative Director will send a copy of the completed Application for
Independent Medical Review to the IMR.
You, the MPN Contact, or the selected IMR can object within ten (10) calendar days of receipt of the name of the IMR to
the selection if there is a conflict of interest as defined by section 9768.2. If the IMR determines that they do not practice
the appropriate specialty, the IMR shall withdraw within ten (10) calendar days of receipt of the notification of selection. If
the conflict is verified or the IMR withdraws, the Administrative Director will select another IMR from the same specialty. If
there are no available physicians with the same specialty, the Administrative Director may select an IMR with another
specialty based on the information submitted and in accordance with the procedure set forth for an in-person examination
and for a records review.
If you request an in-person examination, within sixty (60) calendar days of receiving the name of the IMR, you must contact
the IMR to arrange an appointment. If you fail to contact the IMR for an appointment within sixty (60) calendar days of
receiving the name of the IMR, then you will be deemed to have waived the IMR process with regard to this disputed
diagnosis or treatment of this treating physician. The IMR shall schedule an appointment with you within thirty (30) calendar
days of the request for an appointment, unless all parties agree to a later date. The IMR shall notify the MPN contact of the
appointment date.
Should you decide to withdraw the request for an Independent Medical Review, you need to provide written notice to the
Administrative Director and the MPN Contact.
During this process, the employee shall remain within the MPN for treatment pursuant to section 9767.6.
The MPN Contact shall send all relevant medical records to the IMR. The MPN Contact shall also send a copy of the
documents to the covered employee. The employee may furnish any relevant medical records or additional materials to the
Independent Medical Reviewer, with a copy to the MPN Contact as set forth in 8 CCR Section 9768.11(a). If you have
requested an in-person examination and a special form of transportation is required because of your medical condition, the
MPN Contact will arrange it for you. The MPN Contact shall furnish transportation and arrange for an interpreter, if
necessary, in advance on the in-person examination. All reasonable expenses of transportation shall be incurred by the
insurer or employer pursuant to Labor Code section 4600. Except for the in-person examination itself, the independent
medical reviewer shall have no ex parte contact with any party. Except for matters dealing with scheduling appointments,
NBSIA EE Notice as of October 2016
scheduling medical tests and obtaining medical records, all communications between the independent medical reviewer
and any party shall be in writing with copies served on all parties.
If the IMR requires further tests, the IMR shall notify the MPN Contact within one (1) working day of the appointment. All
tests shall be consistent with the medical treatment utilization schedule adopted pursuant to Labor Code section 5307.27
or, prior to the adoption of this schedule, the ACOEM guidelines, and for all injuries not covered by the medical treatment
utilization schedule or the ACOEM guidelines, in accordance with other evidence based medical treatment guidelines
generally recognized by the national medical community and that are scientifically based.
PREDESIGNATION OF PERSONAL PHYSICIAN
In the event you sustain an injury or illness related to your employment, you may be treated for such injury or illness
by your personal medical doctor (M.D.), doctor of osteopathic medicine (D.O.) or medical group if:
•
on the date of your work injury you have health care coverage for injuries or illnesses that are not work
related;
• the d
octor is your regular physician, who shall be either a physician who has limited his or her practice of
medicine to general practice or who is a board-certified or board-eligible internist, pediatrician,
obstetrician-gynecologist, or family practitioner, and has previously directed your medical treatment, and
retains your medical records;
• your “personal physician” may be a medical group if it is a single corporation or partnership composed of
licensed doctors of medicine or osteopathy, which operates an integrated multispecialty medical group
providing comprehensive medical services predominantly for nonoccupational illnesses and injuries;
• prior to the injury your doctor agrees to treat you for work injuries or illnesses;
• prior to the injury you provided your employer the following in writing: (1) notice that you want your
personal doctor to treat you for a work-related injury or illness, and (2) your personal doctor's name and
business address.
You ma
y use this form to notify your employer if you wish to have your personal medical doctor or a doctor of
osteopathic medicine treat you for a work-related injury or illness and the above requirements are met.
NOTICE OF
PREDESIGNATION OF PERSONAL PHYSICIAN
Employee: Complete this section.
To: ______
______________________ (name of employer) If I have a work-related injury or illness, I choose to be
treated by:
_________________________________________________________________
(name of doctor)(M.D., D.O., or medical group)
_________________________________________________________________ (street address, city, state, ZIP)
________________
__________________________________ (telephone number)
Employee Name (please print):
_____________________________________________________________________________________________
Emplo
yee's Address:
_____________________________________________________________________________________________
Name of Insurance Company, Plan, or Fund providing health coverage for nonoccupational injuries or illnesses:
Employ
ee's Signature ________________________________Date: __________
Physic
ian: I agree to this Predesignation:
Signature: _______________________________
______________Date: __________
(Physician or Designated Employee of the Physician or Medical Group)
The physi
cian is not required to sign this form, however, if the physician or designated employee of the physician or
medical group does not sign, other documentation of the physician's agreement to be predesignated will be required
pursuant to Title 8, California Code of Regulations, section 9780.1(a)(3).
Title 8, California Code of Regulations, section 9783.
DWC FORM 9783 (7/2014)
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DESIGNACIÓN PREVIA DE MÉDICO PERSONAL
En caso de que usted sufra una lesión o enfermedad relacionada a su empleo, usted puede recibir
tratamiento médico por
esa lesión o enfermedad de su médico personal (M.D.), médico osteópata (D.O.) o grupo médico si:
•
En la fecha de su lesión laboral usted tiene cobertura de atención médica para lesiones o enfermedades no
laborales;
•
el médico es su médico regular, que será o un médico que ha limitado su
práctica médica a
medicina general o un internista certificado o elegible para
serlo, pediatra, gineco-obstetra, o
médico de medicina familiar y que previamente
ha estado a cargo de su tratamiento médico y tiene
su expediente médico;
•
su "médico personal" puede ser un grupo médico si es una corporación o sociedad o
asociación
compuesta de doctores certificados en medicina u osteopatía, que opera un grupo médico
multidisciplinario integrado que predominantemente proporciona amplios
servicios médicos para
lesiones y enfermedades no laborales;
•
antes de la lesión su médico está de acuerdo a proporcionarle tratamiento médico para su
lesión o
enfermedad de trabajo;
•
antes de la lesión usted le proporcionó a su empleador por escrito lo siguiente:
(1)
notificación de que quiere que su médico personal lo trate para una
lesión o enfermedad
laboral y (2) el nombre y dirección comercial de su médico
personal.
Puede usar este formulario para notificarle a su empleador si usted desea que su médico personal o médico
osteópata lo trate para una lesión o enfermedad de trabajo y que los requisitos
mencionados arriba se cumplan.
AVISO DE DESIGNACIÓN PREVIA DE MÉDICOPERSONAL
Empleado: Rellene esta sección.
A: (nombre del empleador) Si sufro una lesión o enfermedad laboral,
yo elijo
recibir tratamiento médico de:
(nombre del médico)(M.D., D.O., o grupo médico)
(dirección, ciudad, estado, código postal)
(número de teléfono)
Nombre del Empleado (en letras de molde, por favor):
Dirección del Empleado:
Nombre de Compañía de Seguros, Plan o Fondo proporcionando cobertura médica para lesiones o enfermedades no
laborales:
_______________________________________________________________________________
Firma del
Empleado Fecha:
Médico: Estoy de acuerdo con esta Designación Previa:
Firma: Fecha:
(Médico o Empleado designado por el Médico o Grupo Médico)
El médico no está obligado a firmar este formulario, sin embargo, si el médico o empleado designado por el
médico o
grupo médico no firma, será necesario presentar documentación sobre el consentimiento del médico
a ser designado
previamente de acuerdo al Código de Reglamentos de California, Título 8, sección
9780.1(a) (3).
Título 8, Código de Reglamentos de California, sección 9783.
FORMULARIO 9783 DE LA DWC (7/2014)
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North Bay Schools Insurance Authority
380A Chadbourne Road
Fairfield, CA 94534-9636
(707) 428-1830
Revised 10/17/16
NBSIA SERVICES
North Bay Schools Insurance Authority was
established in 1979 to provide self-insurance
workers’ compensation coverage for the
school member districts.
NBSIA is here to service our district’s needs and
coordinate for our employees, after an injury
occurs, all workers’ compensation benefits.
Prompt communication between the
employee, their treating physician, district and
NBSIA Claims Team will assist in providing timely
benefits and successful return-to-work efforts if
disabled after an industrial injury.
In our commitment to promoting a safe working
environment, NBSIA has a number of safety
resources available to our district members. For
more information, contact your District’s Safety
Coordinator or call NBSIA Member Services
Department at (707) 428-1830.
FOR FURTHER INFORMATION CONTACT:
State of California, Industrial Relations
Department (800) 564-0771
Information & Assistance Office
Oakland (510) 622-2861
Information & Assistance Office
Santa Rosa (707) 576-2452
Information & Assistance Office
Sacramento (916) 928-3158
www.nbsia.org
Facts
About
Workers’
Compensation
Benefits
For
School
District
Employees
380A Chadbourne Road
Fairfield, CA 94534-9636
www.nbsia.org
What is Workers’ Compensation?
California’s no-fault compensation law was
passed over 90 years ago by the State
Legislature to guarantee prompt, automatic
benefits to employees who sustain an injury or
illness as a result of their employment.
The Joint Powers Authority (JPA) member
districts are self-insured for workers’
compensation benefits. The JPA program is
administrated by North Bay Schools Insurance
Authority, who is responsible for all benefit
coordination for district employees who sustain
an injury or illness arising out of and in the course
and scope of their employment.
If the injury is from repeated exposures, you
have one year from when you realized your
injury was job related to file a claim.
Who is entitled to benefits?
If an injury or illness occurs as a result of your
employment, you are entitled to workers’
compensation benefits. With few exceptions,
all California employers are subject to State
Workers’ Compensation laws.
How are benefits claimed?
The first step is to immediately REPORT your
injury or illness to your supervisor. Your
Supervisor will have you call Company Nurse, a
call center for industrial injuries, at 1-877-778-
2576. Company Nurse will record the
information and guide you to the appropriate
level of care, including medical treatment if
necessary and immediately notify NBSIA of your
incident. At that time a claim form will be
mailed to you within 24 business hours. The
claim form will ask you what, where, when and
how the incident occurred.
Prompt reporting of your injury is the key.
Benefits begin immediately as required by State
regulation, but this cannot occur until you
report your injury. Ensure your rights to benefits
by reporting every work related injury or illness.
Until the date an injury claim is accepted or
rejected, liability for medical treatment shall be
limited to $10,000.00
Are there time limitations for filing a claim for
injury or illness?
To claim benefits for an industrial injury you
should be aware that such a claim is subject to
certain time limitations. An employee has one
(1) year from the date of injury or last date
benefits were provided to institute proceedings
for workers’ compensation benefits. The date
of injury for occupational diseases or
cumulative injuries is defined in the Labor Code
as the date upon which the employee first
suffered disability from and either knew, or in
the exercise of reasonable diligence should
have known, that such disability was caused by
his or her present or prior employment.
Employees who are victims of crime that occur
at the employee’s place of employment may
receive workers’ compensation benefits as a
result of that crime.
Get emergency treatment if needed
If it’s a medical emergency, go to an
emergency room right away. Tell the medical
provider who treats you that your injury is job
related. Your employer may tell you where to
go for follow up treatment.
Where do I go for medical care?
Once you report an injury to your employer you
will be directed to the appropriate medical
provider for care. You will be assigned to a
primary treating physician who is responsible for
managing your care. Your district is part of a
Medical Provider Network (MPN) which is
comprised of selected physicians and medical
facilities in your area. All the physicians in the
MPN are experienced in treating Workers’
Compensation injuries and are familiar with the
reporting requirements for such treatment. You
are required to be treated by a physician within
the MPN for the entire life of your claim unless
you have pre-designated a personal treating
physician prior to your claim. Your employer will
provide you with a form for pre-designating a
personal treating physician at the time of your
being hired or you may request a form from
your Human Resources Department. If you
have additional questions, please contact your
Human Resources Representative or NBSIA.
What are the benefits?
Medical Benefits
Medical benefits are provided to cure and
relieve the effects of an injury to include,
physician’s services, medicines, hospital cost,
lab test, x-rays, crutches, even mileage
expenses for required medical care. There are
no deductibles or co-payments for these
services. The medical provider should send all
bills directly to NBSIA. If you receive a bill,
please immediately send it to NBSIA to ensure
prompt payment.
For injuries occurring on of after 1/1/04
Chiropractic, Physical Therapy and
Occupational Therapy visits shall be limited to
24 visits for each injury.
Temporary Disability (TD) Benefits
Regular school district employees may be
entitled to receive Education Code Benefits in
addition to and/or in conjunction with benefits
afforded by the Labor Code. The Education
Code Benefits include 60 days of Industrial
Leave, to include utilizing sick leave and
vacation benefits. If you are entitled to salary
continuation, through Ed Code benefits,
temporary disability benefits will be included in
your regular paycheck, as NBSIA will
coordinate these benefits afforded by the
Labor Code with your district.
If you are entitled to receive Ed Code benefits,
if your physician releases you to return to work
with restrictions and your district is able to
accommodate the restrictions on a temporary
basis, you will be brought back on a bridge
assignment, which is a temporary work
assignment or modified capacity. Your sick
leave or vacation benefits may be charged for
your absence. You may also no longer be
entitled to industrial leave benefits.
Returning to work as soon as medically possible
affords you the opportunity to maintain your
current accrued benefits.
Most injuries only keep you from working
temporarily. You will be paid temporary
disability benefits while you are unable to work
in a modified or full duty capacity. Temporary
disability may not be paid for the first three days
of disability after the injury, unless you are
hospitalized or off work more than 14 days.
These payments will continue until your doctor
releases you to return to work or determines
that your condition has reached maximum
medical improvement and you are permanent
and stationary (P&S).
Temporary Disability (TD) benefits is two-thirds
(2/3) of your average weekly wage, subject to
minimums and maximums set by the state
legislature.
Aggregate disability payments for a single
injury causing temporary disability shall not
extend for more than 104 compensable weeks
within a period of five years from the date of
commencement of temporary disability
payment, except for certain serious injuries or
conditions.
Permanent Disability (PD) Benefits
Payments may be due if you don’t recover
completely. The amount of payment is based
on:
Your doctor’s medical reports
Your age
Your occupation
How much you can earn in the future.
You will be paid every two weeks if you are
eligible. There are minimum and maximum
weekly payment rates.
Supplemental job displacement: Vouchers
may be due to help pay for retraining or skill
enhancement if you don’t recover completely
and don’t return to work for your employer. The
vouchers range from $4,000 to $10,000
depending on your level of permanent
disability and date of injury. This voucher is for
you to use at a state approved school if:
You have a permanent disability
Your employer does not offer modified
or alternative work and
You don’t return to your employer
within 60 days after your TD ends.
Death Benefits
Death Benefits are provided in the event of a
work related death, to eligible dependents, as
determined by the State of California. Benefits
are paid at the same rate as temporary
disability benefits as set out by State law. This
benefit also covers burial expenses, not to
exceed $5,000.
What if there is a problem
Workers’ compensation is a benefit system,
which provides automatic benefits to an
employee who is injured or has an illness as a
result of their employment. Therefore most
workers’ compensation claims are handled
routinely, but occasionally misunderstandings
may occur. If you believe you have not
received all benefits due to you, please
contact us at NBSIA as most questions can be
cleared up with a phone call.
If you still have concerns, you may contact the
nearest office of the State Division of Workers’
Compensation, www.dwc.ca.gov. The State
employs Information and Assistance Officers to
assist injured employees with problems and
concerns. The Information and Assistance
Officer will review your claim, advise you of
your rights and the procedures for resolving
disputes.
Some concerns may need to be resolved by
the Workers’ Compensation Appeals Board,
the State agency responsible for handling
disputes. The Appeals Board is a court of law
where you may represent yourself or retain an
attorney to represent you. If you are in need of
an attorney, please visit
www.californiaspecialist.com. If you retain an
attorney, their fees will be deducted from any
benefits awarded to you by the Appeals Board.
Attorney fees generally are 9% to 15% of your
final permanent disability award, plus an
additional amount if you receive vocational
rehabilitation benefits.
If it is necessary to go to the Appeals Board,
there is a statute of limitation in which an
application for adjudication of claim must be
filed. You have within one year from the date
of your injury, or last date you were provided
benefits, to file an application with the Appeals
Board.
“Any person who makes or causes to be made any
knowingly false or fraudulent material statement or
material presentation for the purpose of obtaining or
denying workers’ compensation benefits or
payments is guilty of a felony” LC 5401.7
Nondiscrimination Facts
An injured employee may not be
discharged, threatened with discharge, or
discriminated against because they file,
intend to file, testify on behalf of another
employee or settle a workers’ compensation
claim. All injured employees are protected
under the California State Workers’
Compensation Labor Code for such
discrimination. If it is found that an employee
has been discriminated against, the
employee’s compensation shall be
increased by one-half, not to exceed
$10,000. Any such employee shall be entitled
to reinstatement and reimbursement of lost
wages and work benefits caused by the acts
of the employer.
Additional Rights
You may also have other rights under the
Americans with Disabilities Act (ADA) or the
Fair Employment and Housing Act (FEHA). For
additional information, contact FEHA at (800)
884-1684 or the Equal Employment
Opportunity Commission (EEOC) at (800) 669-
4000.
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