Cal. Code Regs. Tit. 8, § 10580 - Petition Appealing Medical Provider Network Determination of the Administrative Director

(a) Any aggrieved person or entity may file a petition appealing a determination of the Administrative Director to:

(1) Deny a medical provider network (MPN) application;

(2) Revoke or suspend an MPN plan;

(3) Place an MPN plan on probation;

(4) Deny a petition to revoke or suspend an MPN plan; or

(5) Impose administrative penalties relating to an MPN.

(b) The petition shall be filed only as follows:

(1) The petition shall be filed no later than 20 days after the date of service of the Administrative Director's determination. An untimely petition may be summarily dismissed.

(2) Notwithstanding any other provision of these rules or of Administrative Director rules 9767.8(i), 9767.13(f) and 9767.14(f), the petition shall be filed solely in paper form directly with the Office of the Commissioners of the Workers' Compensation Appeals Board.

(3) The petition shall not be submitted to any district office of the Workers' Compensation Appeals Board, including the San Francisco District Office, and it shall not be submitted electronically.

(4) A petition submitted in violation of this subdivision shall neither be accepted for filing nor deemed filed and shall not be acknowledged or returned to the submitting party.

(c) The caption of the petition shall identify it as a "Petition Appealing Administrative Director's Medical Provider Network Determination."

(d) The caption of the petition shall include:

(1) The name of the MPN or MPN applicant;

(2) The identity of the petitioner; and

(3) The case number assigned by the Administrative Director to the MPN determination.

(e) The petition shall include a copy of the Administrative Director's determination and proof of service of that determination.

(f) The petition shall comply with each of the following provisions:

(1) The petition may appeal the Administrative Director's determination upon one or more of the following grounds and no other:

(A) The determination was without or in excess of the Administrative Director's powers;

(B) The determination was procured by fraud;

(C) The evidence does not justify the determination;

(D) The petitioner has discovered new material evidence, which the petitioner could not, with reasonable diligence, have discovered and presented to the Administrative Director prior to the determination; and/or

(E) The Administrative Director's findings of fact do not support the determination.

(2) The petition shall set forth specifically and in full detail the factual and/or legal grounds upon which the petitioner considers the determination of the Administrative Director to be unjust or unlawful, and every issue to be considered by the Workers' Compensation Appeals Board. The petitioner shall be deemed to have finally waived all objections, irregularities and illegalities concerning the Administrative Director's determination other than those set forth in the petition appealing.

(3) The petition shall comply with the requirements of rules 10945(a) and (c), and 10972. It shall also comply with the provisions of rule 10940, including but not limited to the 25-page restriction.

(4) Any failure to comply with the provisions of this subdivision shall constitute valid ground for summarily dismissing or denying the petition.

(g) A copy of the petition shall be concurrently served on the Division of Workers' Compensation, Medical Provider Network Unit (MPN Unit).

(h) The petition shall be assigned to a panel of the Appeals Board in accordance with Labor Code section 115.

(i) Within 30 days after the filing of an answer or the lapse of the time allowed for filing one, the Appeals Board shall issue a notice for an evidentiary hearing regarding the petition. The evidentiary hearing shall be set for the purposes of specifying the issue(s) in dispute and any stipulations, taking testimony, and listing and identifying any documentary evidence offered. The proceedings shall be transcribed by a court reporter, which the Appeals Board in its discretion may order the petitioner to provide. The Appeals Board also may order the petitioner to pay the costs of the transcript(s) of the evidentiary hearing.

(j) In its discretion, the Appeals Board may provide that the evidentiary hearing shall be conducted by:

(1) One or more commissioners of the Appeals Board; or

(2) A workers' compensation judge appointed under Labor Code section 5309(b) for the sole purpose of holding hearings and ascertaining facts necessary to enable the Appeals Board to render a decision on the petition; a workers' compensation judge appointed for this purpose shall not render any factual determinations, but may make a recommendation regarding the credibility of any witness(es) presented.

The time, date, length and place of the evidentiary hearing shall be determined by the Appeals Board in its discretion.

(k) The assigned panel of the Appeals Board shall determine when the petition is submitted for decision. Within 60 days after submission, the panel shall render a decision on the petition unless, within that time, the panel orders that the time be extended so that it may further study the facts and relevant law.

(l) Where a timely request to the Administrative Director for a re-evaluation of an initial determination is filed in accordance with rules 9767.8(f), 9767.13(c), and 9767.14(c), the following procedures shall apply:

(1) If a request for re-evaluation is made to the Administrative Director prior to filing a petition with the Office of the Commissioners of the Appeals Board, the time for filing such a petition shall be tolled until the Administrative Director files and serves a decision and order regarding the request for re-evaluation.

(2) If a request for re-evaluation is made to the Administrative Director after a petition appealing the Administrative Director's initial determination is filed with the Office of the Commissioners of the Appeals Board, the petitioner shall file a copy of the re-evaluation request with the Office of the Commissioners in accordance with subdivisions (b)(2) and (b)(3), together with a cover letter requesting that its petition be dismissed without prejudice. A copy of the cover letter and request for re-evaluation shall be concurrently served on the Division of Workers' Compensation MPN Unit.

Notes

Cal. Code Regs. Tit. 8, § 10580

1. Amendment filed 12-19-2002; operative 1-1-2003. Submitted to OAL for printing only pursuant to Government Code section 11351 (Register 2002, No. 51).
2. Renumbering of former section 10580 to section 10672 and renumbering and amendment of former section 10959 to section 10580 filed 12-17-2019; operative 1-1-2020. Submitted to OAL for printing only pursuant to Government Code section 11351 (Register 2019, No. 51).

Note: Authority cited: Sections 133, 5307, 5309 and 5708, Labor Code. Reference: Sections 4616 et seq., 5300(f), 5309 and 5900 et seq., Labor Code.

1. Amendment filed 12-19-2002; operative 1-1-2003. Submitted to OAL for printing only pursuant to Government Code section 11351 (Register 2002, No. 51).
2. Renumbering of former section 10580 to section 10672 and renumbering and amendment of former section 10959 to section 10580 filed 12-17-2019; operative 1-1-2020. Submitted to OAL for printing only pursuant to Government Code section 11351 (Register 2019, No. 51).