Covered Notifiction of Rights Mterils Regrding Allied Mnged Cre Incorported Allied Mnged Cre MPN This pmphlet contins importnt informtion bout your medicl cre in cse of workrelted injmy or illness You Are ImportntTo Us Keeping you well nd fully employed is importnt to us. It is your employer's gol to provide you employment in sfe working environment. However, should you become injured or ill, s result of your job, we wnt to ensure you receive prompt qulity medicl tretment. Our gol is to ssist you in mking full recovery nd returning to your job s soon s possible. In complince with Cliforni lw, we provide workers' compenstion benefits, which include the pyment of ll pproprite medicl tretment for workrelted injuries or illnesses. If you hve ny questions regrding the MPN, plese contct Meliss Miller, Mnger, Allied Mnged Cre 9165631911. Allied Mnged Cre "MPN" Allied Mnged Cre, Incorported provides ccess to medicl tretment in the event you sustin workrelted injury or illness through Allied Mnged Cre MPN. Allied Mnged Cre MPN ccesses medicl tretment through selected Anthem Blue Cross Prudent Buyer PPO ("Blue Cross of Cliforni") providers nd the KiserOntheJob Provider Network. Anthem Blue Cross contrcts with doctors, hospitls nd other providers to respond to the specil requirements of onthejob injuries or illnesses. Access to Cre If you should experience workrelted injury or illness, you should: Notify your employer: Immeditely notify your supervisor or employer representtive so you cn secure medicl Employers re required to uthorize medicl tretment within one working dy of your filing of completed clim form (DWC1). To ensure your rights to benefits, report every injury nd request clim form. cre. Initil or Urgent Cre: needed, your employer will direct you to n MPN provider upon initil report of injury. An ppointment for initil medicl cre should be immedite but in If medicl tretment is 1 Notifiction of Rights
no event longer thn MPN Medicl business dys of covered employee's notice to your employer or Access Assistnt tht tretment is needed. 3 For Emergency Cre: In the cse of emergency* go to the nerest helthcre provider. Once your condition is stble, contct your employer, AIMS t (800) 4446157, or Medicl Access Assistnt for ssistnce in locting MPN provider for continued cre. *Emergency cre is defined s need for those helth cre services provided to evlute nd tret medicl conditions of recent onset nd severity tht would led ly person, possessing n verge knowledge of medicine, to believe tht urgent cre is required. Subsequent Cre: All medicl nonemergencies, which require ongoing tretment, indepth medicl testing or rehbilittion progrm, must be uthorized by your clims exminer nd bsed upon mediclly evidenced bsed tretment guidelines (Cliforni Lbor Code 5307.27, nd s set forth in title 8, Cliforni Code of Regultions, section 9792.20 et seq.). Access to subsequent cre, including specilist services, shll be vilble within no more thn twenty (20) business dys of covered employee's resonble requests for n ppointment through n MPN Medicl Access Assistnt. If n MPN Medicl Access Assistnt is unble within ten business dys to schedule n initil medicl ppointment tht will occur within twenty (20) business dys of n employee's request, then Allied Mnged Cre, Incorported shll permit the employee to obtin necessry tretment with n pproprite specilist outside of the MPN. The MPN physicin, who is the primry cre physicin, will continue to direct ll of the covered injured employee's medicl tretment needs. If covered employee is not ble to obtin from n MPN physicin resonble nd necessry medicl tretment within the pplicble ccess stndrds noted bove, the covered employee will be permitted to obtin necessry tretment for tht injury from n pproprite specilist outside the MPN within resonble geogrphic re. When the MPN is ble to provide the necessry tretment through n MPN physicin, covered employee treting outside the MPN my be required to tret with n MPN physicin when trnsfer is pproprite. If ncillry services re not vilble within resonble time or resonble geogrphic re to covered employee, then the employee my obtin necessry ncillry services outside of the MPN within resonble geogrphic re. If you relocte or move outside of Cliforni nd re injured: If you relocte or move outside of Cliforni or outside of Allied Mnged Cre MPN geogrphic service re nd require continued cre for your work relted injury or illness, you my select new physicin to provide ongoing cre or you my contct your clims exminer for ssistnce with locting new primry cre physicin. If your reloction or move is temporry upon your return to Cliforni should you require ongoing medicl cre, immeditely contct your clims exminer or your employer so rrngements cn be mde to return you to your prior MPN provider or, if necessry, for ssistnce in locting new MPN provider for continued cre. 2 Notifiction of Rights
If you re temporrily working outside of Cliforni nd re injured: If you re working outside of Cliforni nd experience work relted injury or notify your employer. For initil, urgent or emergency cre, or follow up nerest helthcre provider for medicl tretment. illness, cre, go to the If you need ssistnce locting physicin or should the physicin you select need uthoriztion to provide cre to you, cll AIMS t (800) 4446147 nd we will ssist you. Upon your return to Cliforni, should you require ongoing medicl cre, immeditely contct your clims exminer or your employer for referrl to MPN provider for continued cre. How to Choose Physicin within the MPN The MPN hs providers for the entire stte of Cliforni. The MPN must give you regionl list of providers tht includes t lest 3 physicins in ech specilty commonly used to tret work relted injuries or illnesses in your industry. The MPN must provide ccess to primry cre physicins within 15 miles or 30 minutes, nd specilists within 30 miles or 60 minutes. To locte prticipting provider or obtin regionl listing: Provider Directories: Online Directories if you hve internet ccess, you my obtin regionl directory prticipting provider ner you by visiting http://www.lliedmngedcre.com/mpn. A copy of the complete provider listing is lso vilble in writing upon request. or locte If you do not hve internet ccess, you my request ssistnce locting n MPN provider or obtining n ppointment by contcting the Medicl Access Assistnt t 844 MPNHELP(8446764357), emil t FDAdmin@lliedmngedcre.com, nd fx 9163623043. Promptly contct your clims exminer with n MPN provider. to notify us of ny ppointment you schedule Choosing Physicin (for ll initil nd subsequent cre): Your employer will direct you to n MPN provider upon initil report of injury. You hve the right to be treted by physicin of your choice within the MPN fter your initil visit. If you wish to chnge your MPN physicin fter your initil visit, you my do so by: Accessing the online provider directories (see bove) Cll the Medicl Access Assistnt or Clims Professionl If you select new physicin, immeditely contct your clims exminer nd provide him or her with the nme, ddress nd phone number of the physicin you hve selected. You should lso provide the dte nd time of your initil evlution. If it mediclly necessry for your tretment to be referred to specilist, your MPN physicin cn mke the pproprite referrl within the network or you my select specilist of your choice within the MPN is 3 Notifiction of Rights
If chiroprctor selected s treting physicin, the chiroprctor my ct s treting physicin only until the 24visit cp is met unless otherwise uthorized by the employer or insurer, fter which the covered employee must select nother treting physicin in the MPN who is not chiroprctor, nd if the employee fils to do so, then the insurer or employer my ssign nother treting physicin who is not chiroprctor. If type of specilist is needed, or recommended by your MPN physicin, but is not vilble to you within the network, you will be llowed to tret with specilist outside of the network. Your clims exminer cn ssist you to identify pproprite specilists if requested. Once you hve identified the pproprite specilist outside of the network, schedule n ppointment nd notify your primry cre physicin nd clims exminer of the ppointment dte nd time. Your MPN physicin, who is your primry cre physicin, will continue to direct ll of your medicl tretment needs. If the MPN cnnot provide is ccess to primry treting physicin within 15 miles or minutes of your workplce or residence, the MPN my llow you to seek tretment outside the MPN. Plese contct your clims exminer for ssistnce. 30 Medicl Access Assistnt(s) MPN Medicl Access Assistnts re vilble, t minimum, from Mondy through Sturdy (excluding Sundys nd holidys) from 7 m to 8 pm, Pcific Time, to provide covered employee ssistnce with ccess to medicl cre under the MPN. The ssistnce includes but is not limited to contcting provider offices during regulr business hours to find vilble MPN physicins of your choice, nd scheduling nd confirming physicin medicl ppointments. Assistnce At is vilble in English nd Spnish. MPN medicl ccess ssistnt is vilble to respond t ll required times, with bility for cllers to leve voice messge. Medicl ccess ssistnts will respond to clls, fxes or messges by the next dy, excluding Sundys nd holidys. MAAs work in coordintionwith the MPN Contct nd the clims djuster(s) to ensure timely nd pproprite medicl tretment is vilble to you. You my contct the Medicl Access Assistnt t 844 MPNHELP(8446764357), emil t FDAdmin@lliedmngedcre.com, lest one the nd fx (916) 3623043. Second nd Third Opinions Second Opinion: If you disgree with the either the dignosis or the tretment prescribed by your MPN physicin, you my obtin second opinion within the MPN. During this process you re required to continue your tretment with n MPN physicin of your choice. In order to obtin second opinion you nd the MPN shre responsibilities: 4 Notifiction of Rights
Inform your clims exminer of your dispute regrding your treting physicin's opinion either orlly or in writing. You re to select physicin or specilist from regionl list of vilble MPN providers, which will be provided to you by your clims exminer upon notifiction of your request for second opinion. You re to mke n ppointment within 60 dys. You re to inform your clims exminer of the ppointment dte nd time. You shll be deemed to hve wived your right to second opinion if you do not mke n ppointment within 60 dys from receipt of the list. You hve the right to request copy of the medicl records sent to the second opinion physicins. If the second opinion doctor feels tht your injury is outside of the type of injury he or she normlly trets, the doctor's office will notify you nd your employer or insurer. You will get nother list of MPN doctors or specilists so you cn mke nother selection. Third Opinion: If you disgree with either the dignosis opinion physicin, you my obtin or the tretment prescribed by the second the MPN. During this third opinion within process you re required to continue your tretment with MPN physicin of your choice. In order to obtin third opinion you nd the MPN shre responsibilities: Inform your clims exminer of your dispute regrding your treting physicin's opinion either orlly or in writing. re to select physicin or specilist from the list of vilble MPN providers previously provided or you my request new regionl re list. You re to mke n ppointment within 60 dys. You re to inform your clims exminer of the ppointment dte nd time. You shll be deemed to hve wived your right to third opinion if you do not mke n ppointment within 60 dys from receipt of the list. You hve the right to request copy of the medicl records sent to the third opinion physicin. If the third opinion doctor feels tht your injury is outside of the type of injury he or she normlly trets, the doctor's office will notify you nd your employer or insurer. You will get nother list of MPN doctors or specilists so you cn mke nother selection. You If the MPN does not contin physicin who cn provide the tretment recommended the Second or Third Opinion physicin, the employee my choose physicin by outside the MPN within resonble geogrphic re. The covered employee my obtin the recommended tretment by chnging physicins to the second opinion physicin, third opinion physicin, or other MPN physicin At the time of selection of the physicin for third opinion, the MPN Contct will notify you bout the Independent Medicl Review process nd provide you with n ppliction for the Independent Medicl Review process (see below). 5 Notifiction of Rights
Independent Medicl Review (IMR) Independent Medicl Review: If you disgree with the dignosis service, dignosis or tretment prescribed by the third opinion physicin, you my request n Independent Medicl Review (IMR). An IMR is performed by physicin selected for you by the Administrtive Director (AD) with the Division of Workers' Compenstion Medicl Unit of the Stte of Cliforni. To request n IMR you will be required to complete nd file Independent Medicl Review Appliction form with the AD. The AD will select n IMR who hs the pproprite specilty necessry to evlute your dispute. The AD will send you written notifiction of the nme, ddress nd phone number of the IMR. You my choose to be seen by the IMR in person or you my request tht the IMR only review your medicl records. Whichever you choose, you will be required to contct the IMR for n ppointment or to rrnge for medicl record review. Your IMR should see you within 30 dys from your request for n ppointment. The IMR will send his/her report to the AD for review nd determintion You my wive your right 60 clendr dys will be to the mde regrding the dispute. IMR process if from receiving the nme of you do not schedule n ppointment the IMR from the AD. within Continuity of Cre Policy Your employer or insurer hs written "Continuity of Cre policy tht will determine whether you cn temporrily continue tretment for n existing work injury with your doctor if your doctor is no longer prticipting in the MPN. " If your employer decides tht you do not qulify to continuing your cre with the nonmpn provider, you nd your primry treting physicin must receive letter of notifiction. If you meet certin conditions, yer before you must switch you my to qulify continue treting with this doctor for up MPN physicins. These conditions re: to (Acute) The tretment for your injury or illness will be completed in less thn 90 dys; (Serious or chronic) Your injury or illness is one tht is serious nd continues for t lest 90 dys without full cure or worsens nd requires ongoing tretment. You my be llowed to be treted by your current treting doctor for up to one yer, until sfe trnsfer of cre cn be mde. (Terminl) You hve n incurble illness or irreversible condition tht is likely to cuse deth within one yer or less. (Pending Surgery) You lredy hve surgery or other procedure tht hs been uthorized by your employer or insurer tht will occur within 180 dys of the termintion of contrct dte between the MPN nd your doctor. You cn disgree with your employer's decision to deny you Continuity of Cre with terminted MPN provider. If you wnt to continue treting with the terminted doctor, 6 Notifiction of Rights to the sk
your primry treting physicin for medicl report on whether you hve one of the four conditions stted bove to see if you qulify to continue treting with your current doctor temporrily. Your primry treting physicin hs 20 dys from the dte of your request to give you copy of his/her medicl report on your condition. If your primry treting physicin does not give you the report within 20 dys of your request, the employer cn trnsfer your cre to nother physicin within the MPN. You will need to give copy of the report to your employer if you wish to postpone the trnsfer of your cre into the MPN. If you or your employer disgrees with your doctor's report on your condition, you or your employer cn dispute it. See the complete Continuity of Cre policy for more detils on the dispute resolution process. For copy of exminer. the entire Continuity of Cre policy, sk your MPN Contct or your clims Trnsfer of Cre Pðlicy Your employer or insurer hs "Trnsfer of Cre policy which will determine if you cn continue being temporrily treted for n existing workrelted injury by physicin outside of the MPN before your cre is trnsferred into the MPN. " If you hve properly predesignted primry treting physicin, you cnnot be trnsferred into the MPN. (If you hve questions bout predesigntion, sk your supervisor.) If your current doctor is not or does not become member of the MPN, then you my be required to see MPN physicin. If your employer decides to trnsfer you into the MPN, you nd your primry treting physicin must receive letter notifying you of the trnsfer. If you meet certin conditions, you my qulify to continue treting with nonmpn physicin for up to yer before you re trnsferred into the MPN. The qulifying conditions to postpone the trnsfer of your cre into the MPN re: (Acute) The tretment for your injury or illness will be completed in less thn 90 dys; (Serious or chronic) Your injury or illness is one tht is serious nd continues for t lest 90 dys without full cure or worsens nd requires ongoing tretment. You my be llowed to be treted by your current treting doctor for up to one yer, until sfe trnsfer of cre cn be mde. (Terminl) You hve n incurble illness or irreversible condition tht is likely to cuse deth within one yer or less. (Pending Surgery) You lredy hve surgery or other procedure tht hs been uthorized by your employer or insurer tht will occur within 180 dys of the MPN effective dte. 7 Notifiction of Rights
You cn disgree with your employer's decision to trnsfer your cre into the MPN. If you don't wnt to be trnsferred into the MPN, sk your primry treting physicin for medicl report on whether you hve one of the four conditions stted bove to qulify for postponement of your trnsfer into the MPN. Your primry treting physicin hs 20 dys from the dte of your request to give you copy of his/her report on your condition. If your primry treting physicin does not give you the report within 20 dys of your request, the employer cn trnsfer your cre into the MPN nd you will be required to use MPN physicin. You will need to give copy of the report to your employer if you wish to postpone the trnsfer of your cre. If you or your employer disgrees with your doctor's report on your condition, you or your employer cn dispute it. See the complete trnsfer of cre policy for more detils on the dispute resolution process. For copy of exminer. the entire trnsfer of cre policy, sk your MPN Contct or your clims For Questions or MPN Inforrntion Wht if I hve questions or need help : MPN Contct: You my lwys contct the MPN Contct to nswer questions bout of MPNs or to submit forml MPN complint by mil t 10360 Old Plcerville Rod, Scrmento CA 95827, phone t (916) 5631911, by fx t 916 the use 3623043, or emil mmiller@lliedmngedcre.com. If you need n explntion bout your medicl tretment for your workrelted injury or illness you cn contct your clims exminer if one hs been ssigned to your cse. Medicl Access Assistnts re vilble Mondy through Sturdy (excluding Sundys nd holidys) from 7 m to 8 pm, Pcific Time, by phone t 844 MPNHELP(8446764357), emil t FDAdmin@lliedmngedcre.com, fx (916) 3623043. Division of Workers' Compenstion (DWC): If you hve concerns, complints or questions regrding the MPN, the notifiction process or your medicl tretment fter workrelted injury or illness, you cn cll DWC's Informtion nd Assistnce Unit t 8007367401. You cn lso go to DWC's website t www.dir.c.gov/dwc nd click on "Medicl provider networks" for more informtion bout MPNs. Independent Medicl Review: If you hve questions bout the Independent Medicl Review process contct the Division of Workers' Compenstion Medicl Unit t: DWC Medicl Unit P.O. Box 71010 Oklnd CA 94612 8 Notifiction of Rights MPN ID
(510)2863700 or (800)7946900 KEEP THIS INFORMATIONIN CASE YOU HAVE A WORK RELATED INJURY OR ITüëšš Notifiction of Rights 9