California Medical Provider Network Employer Implementation Packet

The information and forms in this packet will assist you in implementing and administering the Liberty Mutual Medical Provider Network (”MPN”). The forms contained in this packet are: 1. MPN Employer Packet overview 2. MPN Frequently Asked Questions (“FAQ”) 3. Employee Cover Memo Sample 4. MPN Employee Implementation Letter- To be distributed when implementing MPN or to new employees at time of hire. 5. MPN Employee Notification (English and Spanish)-To be posted at each California employer location. In addition, the MPN Employee Notification must be provided to employees when a Workers’ Compensation injury is reported. 6. Employee Notification Confirmation Form 7. Provider Referral Services Access Information-English 8. Provider Referral Services Access Information-Spanish 9. California Predesignation Forms (English and Spanish)

After reviewing the information in this packet, please let us know if you have questions about implementing or administering the MPN. Thank you,

Golden Eagle InsuranceTM Workers’ Compensation Claims Department

(800) 603-6438

April 2009

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California Medical Provider Network Employer Packet Overview

We are pleased to inform you that Golden Eagle InsuranceTM has a state approved Medical Provider Network (MPN) to assist you in managing your California workers’ compensation claims. In 2005 California’s workers’ compensation statute was changed to allow insurers and self-insured employers to create medical provider networks (MPN) to which they may direct injured employees to for medical treatment. Since Golden Eagle Insurance is a member of the Liberty Mutual Group, we will be able to utilize the Liberty Mutual MPN for new policies written on or after 6/1/2009. The CA MPN consists of a network of medical providers contracted through Blue Cross of California and Kaiser On-the Job (KOJ). We feel this network will provide injured employees with high quality medical care while managing medical costs. Use of the MPN allows employers to exercise greater control of the medical direction of care on workers’ compensation injuries. By referring all industrial injuries to providers within the MPN, you will realize the benefits of keeping medical treatment with MPN medical providers. This will help control medical claims costs and should also work to help injured employees return to work sooner. There are several steps that you, as an employer, need to take to prepare your organization and your employees in order to implement the Liberty Mutual Group MPN. What an Employer Must Do To Implement the CA MPN - Employee Notification: Letter #1 - Implementation of the Liberty Mutual Group Medical Provider Network (MPN) Letter Please note: This is a Mandatory Notice. The MPN Employee Implementation letter is a mandatory letter that must be provided to all CA employees. (If you have Spanish speaking employees, you must also provide them with the Spanish version of the notification.) This letter, approved by the CA Department of Workers’ Compensation, outlines the MPN regulations and includes general information about the MPN process. Distribution:  All current employees – upon receipt of this letter  All future employees – at the time of hire  Any employee transferring into a California location, or otherwise moving into the California Workers’ Compensation jurisdiction Additional Information to Assist with the MPN Implementation: 1. MPN Employee Cover Memo (Optional): This is a one page form and can be used as a cover memo to letter #1 - MPN Initial Employee Notification letter. You should edit the memo to fit your company structure (Human Resources or Management), add contact information, revise the date and add your company logo. 2.

Form B – MPN Employee Notification Confirmation (Optional):

April 2009

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This form is provided in both English and Spanish and may be used to confirm that the employee has received notification on the CA MPN. You may use this or you may have other ways of tracking and verifying the MPN Employee Notification letter was issued and/or received. In the event employee notification is questioned at a later date, when a claim is made, we do recommend this form or other tracking be utilized. 3. Provider Referral Services (PRS) Access Information (Optional): Access to the MPN list of providers is critical and is an essential part of the MPN regulation. This document, provided in both English and Spanish, may be provided to employees and will walk them through accessing the MPN either; (1) internet access by using the URL address: http://www.talispoint.com/liberty/goldeneagle/ext or (2) calling the Provider Referral Service hot line phone number: (800) 944-0443 or (3) calling the employee’s claim handler. 4. California Pre-designation Of Personal Physician DWC Form 9783 (English and Spanish): This is not a MPN mandatory form but there is a reference to this form outlined in the MPN Initial Employee Notification letter. This form may be used, or other similar Pre-designation notification information can be used. All CA employees must receive notification of the right to pre-designate a physician at the time of their employment starts or when they transfer to CA. This CA state form outlines how an employee may pre-designate his/her regular physician to be the primary treating physician for a workers’ compensation claim; the form must be signed by both the employee and his/her treating physician or the physicians designated representative and returned to the employee’s employer. This form, if completed, will be required by the Liberty Mutual claims case manager, when a loss is reported. If the notification of Pre-designation has not previously been provided, we recommend it be done as part of the MPN notification process, as not doing so may allow an injured employee the right to select a provider from outside the MPN. 5. Employer Medical Provider Network Frequently Asked Questions: This document “MPN FAQ” is intended for management and human resources staff only and will help answer the majority of questions that may come from employees when the MPN is being rolled out. If any questions do come up that are not addressed, feel free to contact Golden Eagle Claims at 1-800-603-6438. 6. New Employee Hire Packet: Letter #1 - CA MPN Employee Notification letter must be provided to all new employees as part of their new hire employee packet. Additionally, any employee that transfers to CA must also receive this letter. After All CA Employees are Notified of the CA MPN:  Document in each employee’s personnel file that they have received the required Employee Notification  Send an email to [email protected] with the following information: o Policy Number o Policyholder (Company) Name o Date the MPN notification was completed for all existing employees o Confirmation that all new employees will be notified as part of their new hire employee packet

April 2009

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When the CA MPN takes effect: The MPN will become effective as soon as you notify your California employee per state regulation. The 30 day waiting period has been eliminated as of 8/10/2010. When an employee is injured: A requirement of the MPN is that after an injury is reported an employee must be provided with a copy of the full CALIFORINA MPN EMPLOYEE NOTIFICATION packet. Employers may provide this document. If your company has completed its MPN employee notification and advised us of the implementation date, Golden Eagle InsuranceTM will send this letter at the time a claim is reported to our office. Employer Direction of Medical Care: As a result of the implementation of the MPN, employers will need to validate that their current Work Site Poster contains certified MPN providers. Employers can validate a provider’s inclusion in the MPN via the PRS website: http://www.talispoint.com/liberty/goldeneagle/ext An employer may also call the PRS Hotline at 1-800-944-0443, or call the Golden Eagle InsuranceTM Claims Department at 1-800-603-6438. The PRS Hotline can also be used to locate an MPN provider geographically convenient to an employer’s location and to generate new worksite posting notices. If you need assistance generating updated worksite posters you can contact the Golden Eagle InsuranceTM Claims Department at 1-800-603-6438. If you currently use a provider that has not been certified on the CA MPN, you can contact the Golden Eagle Insurance Claims Department for possible contracting into the MPN. Your claim handler or other representative in the Golden Eagle claims department will forward all nominations to the Liberty Mutual Regional Network Coordinator, to manage the process. Because of the more stringent requirements of the MPN, not all providers will be considered for inclusion. If you choose to continue using the non-MPN provider, you will lose your ability to direct injured employees to the MPN and the injured employees’ medical services may not be covered, under the MPN. As California allows you to direct an injured employee’s initial care, we strongly encourage you to comply with this requirement and post the Work Site Poster in a prominent location. It is important to note that, as of certification of the CA MPN, as an employer you are only able to direct the initial treatment, after which the injured employee may choose any provider from within the MPN for subsequent treatment. Transfer of Care: Employees who were injured before the implementation of the MPN may be moved to an MPN provider for treatment, unless one of the following conditions applies: − − − −

April 2009

An acute condition that is defined as treatment that will resolve within 90 days A serious chronic condition, for which treatment shall be provided for a period of time up to one year A terminal illness, as defined as an incurable or irreversible condition that has a high probability of causing death within one year or less A surgical or other procedure that is authorized by the insurer or employer as a course of treatment that is to occur within 180 days of the MPN effective date

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The Golden Eagle InsuranceTM process for claims handling is to review each injured employees claim, on a case-by-case basis, to determine if the best overall outcome will be to either; 1) allow the employee to continue treatment with their primary treating physician or 2) to move the medical treatment within the MPN. Also, employees that have properly designated a personal physician by notice to the employer prior to the date of injury (see Labor Code 4600(d) for specifications) may treat outside the MPN. Continuity of Care: This process covers employees whose treating physician has either left the MPN or whose contract with the MPN has been terminated. In this circumstance, injured employees may be moved to another provider within the MPN for treatment, unless one of the following conditions applies: − An acute condition resolving within 90 days − A serious chronic condition, for which treatment shall be provided for a period of time up to one year − A terminal illness, as defined as an incurable or irreversible condition that has a high probability of causing death within one year or less − A surgical or other procedure that is authorized by the insurer or employer as a course of treatment that is to occur within 180 days of the MPN effective date. Employer MPN Questions: We are here to help in any way we can. Please contact your California claim handler or call the Golden Eagle InsuranceTM Claims Department at 1-800-603-6438.

April 2009

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California Medical Provider Network Frequently Asked Questions 1.

What is California SB899? SB899 refers to workers’ compensation legislation in California. This legislation changed California’s workers’ compensation regulations to allow insurers and self-insured employers to direct injured employees to a medical provider network (MPN) for medical treatment if they receive state approval for their MPN.

2.

What is a medical provider network (MPN)? Simply put, a medical provider network, or MPN, is a network of physicians that is used to help manage medical costs by directing injured employees to a select group of providers with expertise in treating workers’ compensation injuries. More specifically, the medical provider network relates to wording in SB899 that allows insurers and self-insured employers to direct injured employees to a medical provider network (MPN) for medical treatment if they receive state approval for the network. Insurers or selfinsured employers (as defined in the Labor Code, section 4616.5) must create this network and submit it to the State for approval before injured employees can be directed for care.

3.

What is the Employer’s role in implementing the Liberty Mutual Group MPN plan? The employer must notify all California existing employees, in writing. It is strongly encouraged that the employer carefully and deliberately document when, how, and to whom the “employee implementation” letter was distributed. Employers will also need to provide the MPN implementation letter as part of their new hire packet to all new employees hired after the after the rollout of the MPN.

4.

Is there anything else an employer needs to do to implement the MPN? Yes. Separate from the one page implementation letter initially distributed to all employees (and to new hires), the complete “California MPN Employee Notification” packet must be given to an employee at the time of any injury. This notification packet is enclosed. As with implementation notice, the MPN notification packet should be provided in English and also in Spanish to Spanish speaking employees. The complete implementation packet shall also be posted in both English and Spanish is a conspicuous location frequented by employees during the hours of the workday and in close proximity to the workers’ compensation posting required under section 9881 of the Labor Code.

5.

Must the MPN employee notification (implementation letter) be provided in both English and Spanish? No. The MPN regulations changed on 8/10/2010 and require that the implementation letter be provided in Spanish only where there are Spanish speaking employees.

6.

When all CA employees are notified, is there a 30 day waiting period before the MPN can be implemented? No. The MPN regulations used to have a 30 day waiting period, but part of the 8/10/2010 changes eliminated this waiting period. Customers can begin using the MPN right away after the provide their CA employees with the MPN implementation letter.

7.

How was the Liberty MPN created? In creating the network the following criteria were taken into consideration: • Volume of a provider’s workers’ compensation experience 1

• •

Network quality indicators such as billing and chiropractic and physical therapy treatment or referral Medical cost per service and case

In addition, Liberty Mutual claims and Managed Care professionals reviewed over 17,000 provider locations for inclusion or suppression from the network. Based on their experience with these providers, they identified a significant number of providers for suppression as well as a number of providers with whom Liberty Mutual has had positive results for inclusion. 8.

What does Liberty’s MPN look like? The California MPN network of providers is contracted through Blue Cross of California and Kaiser Onthe-Job (KOJ). Blue Cross of California is a part of WellPoint, Inc., the largest health care company in the United States. Additionally, we have national contracts with vendors for durable medical equipment (DME), pharmacy (retail and home delivery), and transportation that are in the Liberty Mutual Group MPN.

9.

Does the MPN regulation outline physician access standards? Yes and the Liberty Mutual Group MPN includes a minimum of six primary treating physicians, six specialists and two other provider specialties in each zip code. The selection logic ensures that there will be at least two orthopedic surgeons, neurologists, physical medicine specialists and neurosurgeons wherever possible. For all other specialties, at least one of each specialty type occurring within each zip code. In order to meet regulatory requirements, 25% of the providers are engaged in non-occupational medicine. It is possible that a specialty provider an employer is currently using is not in the Liberty MPN. If this is the case, the employee will be able to choose an appropriate provider from within the MPN.

10. Does the MPN apply to employees with claims prior to 1/1/05? Yes, the MPN applies to all dates of loss (see section 9767.9, Transfer of Ongoing Care into the MPN). However, there are certain exceptions that include: − An acute condition resolving within 90 days − A serious chronic condition, for which treatment shall be provided for a period of time up to one year − A terminal illness, as defined as an incurable or irreversible condition that has a high probability of causing death within one year or less − A surgical or other procedure that is authorized by the insurer or employer as a course of treatment that is to occur within 180 days of the MPN effective date. Also, employees that have properly designated a personal physician by notice to the employer prior to the date of injury (see Labor Code 4600(d) for specifications) may treat outside the MPN. 11. Does the insurer have to pay for treatment rendered outside the MPN? If an injured employee treats outside the MPN and self-procures the treatment, the treatment will only be covered if he or she has authorization from his or her Claims handler. Without authorization, treatment outside the MPN may not be covered under the accepted workers’ compensation claim. 12. Can an employee choose any provider from the MPN? Yes, however, the insurer/employer is able to direct the initial treatment to a provider within the MPN. After initial treatment, the injured employee can choose a provider from within the MPN for subsequent treatment. In addition, the regulations indicate that a request for a change of physician within the MPN still takes place under Labor Code 4601.

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13. As employees have the ability to choose providers from within the MPN, does the claims handler lose the ability to “direct” the employee to specialists? Although not specifically stated in the regulations, the publicly held assumption is that the claims case manager can continue to direct the employee to ancillary services such as MRI’s, physical therapy, etc. 14. Is there a geographic mileage requirement in the MPN for access to care? Yes, Section 9767.5, Access Standards states that a covered employee must have a residence or workplace within 30 minutes or 15 miles of an MPN primary care physician or hospital. For all other occupational health services and specialist referrals, the requirement is 60 minutes or 30 miles from the residence or workplace. 15. Are there appointment standards? Yes, for non-emergency services the MPN shall ensure that an appointment for initial treatment is available within 3 business days of the receipt of request for treatment. For non-emergency specialist services to treat common injuries, the MPN shall ensure that an appointment is available within 20 business days of the receipt of referral to a specialist. 16. If the employee pre-designates a treating provider, does it have to be from the employer’s group health plan? Although this was the intent of Labor Code 4600(d), it has never been clarified. However, in order for an employee to be able to pre-designate their treating physician, their employer must provide group health coverage. Additionally, the personal physician must agree to be predesignated and confirmation must be provided to the employer, in writing, prior to the industrial injury. Only predesignations submitted to the employer in compliance with L.C. 4600(d) will be reviewed for validity. 17. Who will monitor the pre-designations to verify that the provider has treated the employee in the past and agrees to treat the employee for WC injuries? Although not addressed in the Labor Code, the employer should do this when they receive the employee’s pre-designation. It is then Liberty’s intent to have its Claims staff, at the time an injury occurs, verify with the pre-designated physician that the injured employee has treated with them previously and the physician agrees to treat the employee for his/her workers’ compensation illness or injury. 18. What happens when a pre-designation is determined to be invalid or the provider does not agree to be pre-designated? The injured employee must receive medical treatment from providers within the MPN. 19. Can a chiropractor or acupuncturist be a pre-designated provider? No, however, they can be a Primary Treating Physician

chosen

from

the

MPN.

20. How does an employer or employees know which providers are part of the Liberty Mutual Group MPN? Access to the MPN is maintained through Liberty’s Provider Referral Service (PRS). You or your employee’s may access PRS using this URL: http://www.talispoint.com/liberty/goldeneagle/ext You may choose either a radius or a specific city to create the directory. We recommend customers review all worksite posters, sometimes referred to as “Posting Notices.” Provider lists and posting notices should be updated to reflect the MPN list of providers. Customer Service Managers can assist employers to identify non-network providers treating injured employees and suggesting alternative providers based on the new MPN.

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21. How can an employer recommend providers for the MPN? Advise your customer service manager or claim service team the name, address, phone number and provider type. FOR ADDITIONAL INFORMATION: The MPN Labor Code is Labor Code section 4616 – 4616.7, and is available at the State’s DWC web site: http://www.leginfo.ca.gov/cgi-bin/displaycode?section=lab&group=04001-05000&file=4616-4616.7 The MPN rulemaking regulations can be viewed at the DWC Forum site: http://www.dir.ca.gov/dwc/DWCPropRegs/MPNReg.htm

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Employee Cover Memo Sample



MEMORANDUM To:

Covered Employees

From:

Human Resources

Date:



Re:

CALIFORNIA WORKERS’ COMPENSATION

California’s workers’ compensation law allows employers and their claim administrators to implement and direct injured employees to a Medical Provider Network (MPN) for medical TM care. Our claim administrator, Golden Eagle Insurance , has implemented the Liberty Mutual Group MPN for workers’ compensation claims. There are over 54,000 MPN providers in the Liberty Group MPN. This is similar to group health networks but specifically designed for work-related injuries. Attached, please find the California MPN Employee Implementation letter. This letter provides a description of how medical treatment for work-related injuries will be handled under the MPN. The description was prepared by Liberty Mutual and contains language required by the State of California. Outlined below are a few key elements of the MPN arrangement and your responsibilities if you experience a work-related injury or illness. Please refer to the attached documents for complete information. 

If you have a new work-related injury or illness and need emergency care, go to the nearest medical facility. For all non-emergency medical care, an MPN provider can be selected from the list that is posted at the job site, provided to you by your supervisor or human resources representative. You must contact your supervisor and/or a human resources representative immediately following your injury, so that a claim can be filed with Liberty Mutual.



Liberty Mutual provides Internet access to the list of providers in their MPN using Provider Referral Services (PRS). You can access PRS at any time to find a medical provider or specialist in your area using the following web address:

http://www.talispoint.com/liberty/goldeneagle/ext or by calling the PRS Hotline at 1-800-944-0443. 

In the event of a claim, if you have any questions about the providers or need a TM specialist referral, you should contact the Golden Eagle Insurance claims handler who is assigned to your claim.

If you have any questions, please be sure to ask your supervisor or human resources representative.

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(Customer Logo may be inserted here) Implementation of the Liberty Mutual Group Medical Provider Network (MPN) MEMORANDUM To:

______________________________________ Covered Employees (employer name here)

From: Human Resources Date: ______________________________(insert date of communication) Re:

California Workers’ Compensation – Medical Provider Network

California’s workers’ compensation law allows employers and their claim administrators to implement and direct injured employees to a Medical Provider Network (MPN) for medical care. Our claim administrator, Golden Eagle Insurance has implemented the Liberty Mutual Group MPN for workers’ compensation claims. This is similar to group health networks but specifically designed for work-related injuries. As required by Division of Workers’ Compensation administrative code section 9767.12, notification must be given to all covered employees prior to implementation of a Medical Provider Network (MPN). Effective _______________, medical treatment for new work injuries will (Enter Date)

be provided through the Liberty Mutual Group MPN. Unless you predesignate a physician or medical group, your new work injuries arising on or after ______________________will be treated by providers (Insert Effective Date of MPN)

in the Liberty Mutual Group MPN. If you have an existing injury, you may be required to change to a provider in the Liberty Mutual Group MPN. The Claims Handler assigned to your claim can provide additional information. Golden Eagle Insurance provides Internet access to the list of providers in their MPN using Provider Referral Services (PRS). You can access PRS at any time to find a medical provider or specialist in your area using the following URL address: http://www.talispoint.com/liberty/ext/?uloc=AGY_GOLDEN_EAGLE or you may contact the PRS at (800) 944-0443. For additional information on the Liberty Mutual Group MPN please refer to the workers’ compensation poster or contact your supervisor or human resources representative.

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(Customer Logo may be inserted here) MEMORÁNDUM A:

______________________________________ Empleados Bajo Cobertura (employer name here)

De:

Recursos Humanos

Fecha: _____________________________ (insert date of communication) Re:

Compensación al Trabajador de California – Red de Prestadores de Servicios Médicos

La ley de compensación al trabajador de California permite que los empleadores y sus compañías administradoras de reclamos implementen y hagan que los empleados que hayan sufrido una lesión, se dirijan a una Red de Prestadores de Servicios Médicos (MPN por sus siglas en inglés) para su atención médica. Nuestra empresa administradora de reclamos, Golden Eagle Insurance ha implementado la MPN de Liberty Mutual Group para los reclamos de compensación al trabajador. Esta red es similar a las redes de salud grupales pero con la diferencia de que la misma está diseñada específicamente para lesiones relacionadas con el trabajo. De acuerdo con lo estipulado por la sección 9767.12 del código administrativo de la División de Compensación al Trabajador, a todos los empleados bajo cobertura se les debe proporcionar una notificación antes de la implementación de la Red de Prestadores de Servicios Médicos (MPN). Con efectividad a partir del _______________, el tratamiento médico de nuevas lesiones (Enter Date)

ocurridas en el trabajo será proporcionado a través de la MPN de Liberty Mutual Group. A menos que usted designe previamente a un médico o grupo médico, sus nuevas lesiones ocurridas en el trabajo a partir del día ____________________ o con posterioridad a esa fecha, (Insert Effective Date of MPN)

serán tratadas por los prestadores de servicios médicos pertenecientes a la MPN de Liberty Mutual Group. Si usted tiene una lesión ya existente, se le puede requerir que cambie a su prestador de servicios médicos por uno que pertenezca a la MPN de Liberty Mutual Group. La persona asignada al Manejo de su Reclamo le puede proporcionar información adicional. Golden Eagle Insurance proporciona el acceso a la lista de prestadores de servicios médicos de su MPN a través de Internet utilizando los Servicios de Referencia a Prestadores (PRS por sus siglas en inglés). Usted puede acceder al servicio de PRS en cualquier momento para encontrar un prestador de servicios médicos o un especialista en su área, utilizando la siguiente dirección URL: http://www.talispoint.com/liberty/ext/?uloc=AGY_GOLDEN_EAGLE o bien se puede poner en contacto con el servicio PRS llamando al (800) 944-0443. Para obtener información adicional referente a la MPN de Liberty Mutual Group, por favor diríjase al anuncio de compensación al trabajador o bien póngase en contacto con su supervisor o con un representante de recursos humanos.

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INITIAL WRITTEN EMPLOYEE NOTIFICATION TITLE 8 CCR SECTION 9767.12

Important Information about Medical Care if you have a Work-Related Injury or Illness Initial 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). Your employer has chosen the Liberty Mutual Group MPN to provide this medical care. This MPN is administered by Liberty Mutual Managed Care LLC. 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 is a MPN? A Medical Provider Network (MPN) is group of health care providers (physicians and other medical providers) used by your employer to treat workers injured on the job. Each MPN must include a mix of doctors specializing in work-related injuries and doctors with expertise in general areas of medicine. MPNs must allow employees to have a choice of provider(s). How do I find out which doctors are in my MPN? MPN physician/provider directory will be available to your employer, physician and you. You may contact your supervisor or Claims Case Manager to request a regional and/or full listing of the MPN provider network. Your employer or Claims Case Manager will provide you the options of receiving (a) electronic access to a regional and/or full listing of the MPN provider network via the Provider Referral Services (PRS) system, at www.libertymutualprs.com; (b) a printed copy of the regional and/or full listing of the MPN provider network; and/or (c) a printed copy of a regional and or full listing of MPN providers by calling either the Liberty Provider Referral Line, 1-800-944-0443. 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. How do I choose a provider? After the first medical visit, you may continue to be treated by this 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. If you need help in choosing a doctor you may call the MPN Contact listed above. 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.

1.

What standards does the MPN have to meet? The MPN has providers for the entire state of California. The MPN must give you 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 physicians within 15 miles and specialists within 30 miles. If you live in a rural area there may be a different standard. The MPN must provide initial treatment within 3 days. You must receive specialist treatment within 20 days of your request. If you have trouble getting an appointment, contact 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 for assistance in finding a physician or for additional information. What if I need a specialist not 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 and tell them you want a second opinion. The MPN should give you at least a regional 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 can 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 this 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 Independent Medical Review (IMR). Your employer or MPN contact person will give you information on requesting an Independent Medical Review and a form at the time you request a third opinion. If either the second or third opinion doctor agrees with your need for a treatment or test, you will be allowed to receive that medical service from a provider inside the MPN, including the second or third opinion physician. If the Independent Medical Reviewer supports your need for a treatment or test you may receive that care from a doctor inside or outside of the MPN.

2.

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 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 current doctor is not or does not become a member of the MPN, then you may be required to see a MPN physician. 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 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 a 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 entire transfer of care policy, 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 continuing your care with the non-MPN provider, you and your primary treating physician must receive a letter of notification.

3.

If you meet certain conditions, you may qualify to continue treating with this doctor for up to a year before you must switch to MPN physicians. These conditions are set forth in the box above, “Can I Continue Being Treated By My Doctor?” 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, the employer can transfer your care into the MPN and you will be required to use a 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 into the MPN. 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 entire Continuity of Care policy, ask your MPN Contact. What if I have questions or need help? For questions and information regarding the MPN program contact your supervisor, the Claims Case Manager, or the Liberty Mutual Group MPN Program Coordinator. The Claims Case Manager and the MPN Program Coordinator may be contacted during normal business hours of 8:00 AM - 5:00 PM, Monday through Friday. The MPN Program Coordinator may be contacted at 800-331-1133 or at [email protected]. MPN website: http://www.libertymutualprs.com 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 can call DWC’s Information and Assistance at 1-800-736-7401. You can also go to DWC’s website at www.dir.ca.gov/dwc and click on “medical provider networks” for more information about MPNs. Independent Medical Review: If you have questions about the 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.

CAMPN Employee Notification - English 8/12

4.

NOTIFICACIÓN INICIAL ESCRITA DEL EMPLEADO SOBRE LA RED DE PROVEEDORES MÉDICOS

Información Importante sobre Cuidado Médico si tiene una Lesión o Enfermedad de Trabajo. 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 lesiona en el trabajo. Su empleador ha elegido a proporcionarle este cuidado médico utilizando una red de médicos de Compensación de Trabajadores llamada Red de Proveedores Médicos (MPN). Su empleador ha elegido el MPN Liberty Mutual Group para proporcionar esta atención médica. Este MPN es administrado por Liberty Mutual Managed Care LLC. Esta notificación le dice lo que usted necesita saber sobre el programa de la MPN y describe sus derechos en la elección de la atención médica para accidentes laborales y enfermedades profesionales. ¿Qué es una MPN? Una Red de Proveedores Médicos o MPN es un grupo de proveedores de asistencia médica (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 areas de médicina general. Las MPNs deben permitir que los empleados tengan una selección de proveedor(es). ¿Cómo puedo encontrar medicos que pertenecen a mi MPN? El Directorio de médicos y profesionales de la MPN de Profesionales Médicos de Liberty Mutual Group (MPN) estará disponible para su empleador, su médico y usted. Usted puede comunicarse con su supervisor o con el Administrador de casos de reclamos para solicitar un listado regional y/o completo de la red de profesionales de la MPN. Su empleador o Administrador de casos de reclamos le brindará la opción de recibir (a) acceso electrónico al listado regional y/o completo de la red de profesionales de la MPN a través del Sistema de Servicios de Referencia a un Profesional (PRS), en www.libertymutualprs.com; (b) una copia impresa del listado regional y/o completo de la red de profesionales de la MPN y/o (c) una copia impresa del listado regional y/o completo de los profesionales de la MPN llamando a la Línea Liberty de Referencia a un Profesional al 1-800-944-0443. ¿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. ¿Cómo escojo un proveedor? 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 eligir un médico puede llamarle al contacto de la MPN arriba descrito. ¿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.

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¿Qué requisitos debe tener la MPN? El MPN tiene proveedores en todo el estado de California. La MPN tiene que proporcionarle 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 dentro de 15 millas y especialistas dentro de 30 millas. Si vive en una area rural puede haber un requisito diferente. La MPN debe proporcionarle tratamiento inicial dentro de 3 días. Debe recibir tratamiento del especialista dentro de 20 días de su petición. Si tiene algun problema en obtener una cita, pongase en contacto con la MPN. ¿Qué tal si no hay proveedores de la MPN donde estoy localizado? Si está temporalmente trabajando o viviendo fuera de la area de servicio de la MPN o en una area 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 MPN para asistencia enencontrar 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 y decirles que quiere una segunda opinión. La persona de contacto asegurará que por lo menos tenga una lista regional de proveedores de la MPN para elegirlo. Para obtener una segunda opinión, debe 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 diagnosis 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 diagnosis 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 Revisión Médica Independiente o IMR (Independent Medical Review). Su empleador o la persona de contacto de la MPN le dará información sobre cómo pedir la Revisión Médica Independiente y un formulario cuando usted pida la tercera opinión. Si el médico de la segunda o tercera opinión está de acuerdo que usted necesita algun tratamiento o análisis, le será permitido recibir el servicio médico de un proveedor dentro de la MPN, incluyendo los médicos de la segunda o tercera opinión. Si el médico que hace la Revisión Médica Independiente corrobora su necesidad para algun tratamiento o análisis, usted podrá recibir ese cuidado de un médico dentro o fuera de la MPN. 2.

¿Qué tal si ya estoy siendo atendido por una lesión de trabajo antes de que empieze la MPN? Su empleador o la compañía de seguros tiene 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 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, preguntele a su supervisor.) Si su médico actual no es o no se convierte en un miembro de la MPN, entonces podrá ser obligado ver a un médico de la MPN. Si su empleador decide tranferirlo a la MPN, usted y su médico que lo está atendiendo deben recibir una carta notificandoles de la tranferencia. 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 tranferencia de su cuidado a la MPN están 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 tranferencia de cuidado o continuidad de cuidado) hasta por un año si su lesión o enfermedad llena cualquiera de las siguentes 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 continua 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 tranferencia 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, pidale 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, preguntele 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 de notificación.

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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 cambiar a un médico de la MPN. Estos requisitos están expuestos en la caja descrita arriba, “¿Puedo Continuar Ser Tratado Por Mi Médico?” 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, pidale 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, 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 de la Continuidad de Cuidado entero, preguntele a su Contacto de la MPN. ¿Qué tal si tengo preguntas o necesito ayuda? Si tiene alguna pregunta o información con respecto al programa de la red MPN comuníquese con su supervisor, con el Administrador de casos de reclamos o con el Coordinador de programas de la Red de Profesionales Médicos de Liberty Mutual Group. Usted puede comunicarse con el Administrador de casos de reclamos y con el Coordinador de programas durante las horas de oficina de 8:00 AM a 5:00 PM, de lunes a viernes. Puede comunicarse con el Coordinador del Programa de la MPN al 800-331-1133, o en [email protected]. sitio web de MPN: http://www.libertymutualprs.com. La División de Compensación de Trabajadores (DWC): Si tiene alguna preocupacion, queja, pregunta sobre la MPN, el proceso de notificación, o su tratamiento médico después de una lesión o enfermedad debido al 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 haga clic en “la red de proveedores médicos” para más información sobre las MPNs. Revisión Médica Independiente: Si usted tiene preguntas sobre el 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

Guarde esta información en caso que tenga una lesión o enfermedad de trabajo

CAMPN Employee Notification - Spanish 8/12

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Liberty Mutual Group MPN Form B - Employee Notification Confirmation

In order to confirm that you have received appropriate notification regarding the Liberty Mutual Group Medical Provider Network (MPN) please complete and sign the attached form. This form must be returned to your employer at the time you first receive employee notification information about the MPN. This may occur at the time of your employer’s MPN presentation, at the time of hire, at the time of your report of injury or at the time you transfer into the MPN. __________________________________________ (Employee Signature)

_____________________ (Date)

_______________________________________________________________________ (Print Employee Full Name)

_________________________________________________________________________________ (Name of Employer)

Any person who makes or causes to be made any knowingly false, or fraudulent material statement or material representation for the purposes of obtaining or denying workers’ compensation benefits or payments is guilty of a felony.

Con el fin de confirmar que usted ha recibido la notificación adecuada acerca de la Red de Profesionales de Servicios Médicos del Grupo Liberty Mutual (MPN) (Liberty Mutual Group Medical Provider Network (MPN)) por favor llene y firme la forma adjunta. Esta forma debe ser entregada a su empleador al momento en que reciba información de la notificación para empleados acerca de la MPN. Esto puede ocurrir al momento de la presentación de la MPN de su empleador, al momento de la contratación, al momento de su reporte de lesión o al momento de su traslado a la MPN. __________________________________________ (Firma del empleado)

_____________________ Fecha

_______________________________________________________________________ (Nombre firma completo) _________________________________________________________________________________ (Nombre del empleador)

Cualquier persona que hace o provoca conscientemente cualquier declaración o representación material falsa o fraudulenta para propósitos de obtener o de negar los beneficios de compensación o pagos de los trabajadores es culpable de un delito grave. 1

California Medical Provider Network Provider Referral Services (PRS) Access Information The information outlined below provides you with instructions on how to select a provider from the Liberty Mutual Group Medical Provider Network (MPN). If you have access to the internet you may access the MPN by following these instructions. If you do not have internet access, you may contact the Liberty Mutual Provider Referral Service hot line phone number: (800) 944-0443 for provider selection or contact your claims case manager for assistance in providing a provider directory for your review.

Internet Access Instructions to the Liberty Mutual Group MPN: 1. Go to Provider Referral Services (PRS) using the following internet URL address: http://www.talispoint.com/liberty/goldeneagle/ext 2. Click on the “Provider Search” tab (top of page) 3. Enter the City and State. State is CA. Click on “Continue.” 4. The screen will change and Plan Type “Medical Provider Network (MPN)” will appear. 5. On the line “Search Distance (miles)” select a mile button. We recommend you start with a “15” mile radius from either your home or work location. You may expand this search for additional providers, if needed. Click on “Continue.” 6. Select a “Provider Type.” We suggest you select all provider types by selecting the first provider and hold down the shift key and select the last provider type. All provider types will now be selected. If you would rather select a specific provider, click on the “Specialty”. You may also select a “SubSpecialty if they are listed.” Select the provider that you feel can provide the treatment you require. Click on “Continue.” If you are unsure which provider type to select, we recommend starting with a “Primary Care Physician (PCP)” 7. You may select any of the providers listed or you may continue to review other providers that are in the MPN. 8. You will see the providers; name, address, miles, phone number and provider specialty listed. 9. To create a map and driving instructions, click on the map that is located to the right side of the provider list. You may also create driving instructions by entering the address and zip code where you are located. 10. You may create a directory of the providers listed. Click on the bottom tab “Select all providers on this page.” Click on “Create Provider Listing.” All providers will be listed. You may print or e-mail the provider list. See the bottom of the provider listing page.

Regional Directory: To create a regional directory, click on the “Directory Region” tab (top of page)

Selecting a Physician and Setting a Medical Appointment: 1. Select a physician that will be able to treat your medical condition 2. Call the physician’s office and advise the following information: I have a Workers’ Compensation claim and you are listed as a approved provider that is contracted with either Blue Cross of California and Kaiser On-the-Job (KOJ). I need to schedule an appointment. Provide your information, the claim number, the claim case managers name and phone number. 3. Call the claim case manager and advise the; name of the physician, address, phone number and date of your appointment.

If you have any questions regarding the above information please contact your claims case manager.

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Red de Proveedores Médicos de California Información de Acceso a Servicios de Remisión a Proveedores (PRS)

La información descrita abajo le ofrece instrucciones sobre cómo seleccionar un proveedor de la Liberty Mutual Group Medical Provider Network (MPN) (Red de Proveedores Médicos del Grupo Liberty Mutual). Si usted tiene acceso a internet puede ingresar a la MPN siguiendo estas instrucciones. Si no tiene acceso a internet, puede ponerse en contacto con el Servicio de Remisión a Proveedores de Liberty Mutual en su línea telefónica de servicio: (800) 944-0443 para selección de un proveedor, o comuníquese con su gerente de casos de reclamación para solicitar asistencia con un directorio de proveedores para que pueda consultarlo.

Instrucciones de Acceso vía Internet a la MPN del Grupo Liberty Mutual: 11. Vaya a Servicios de Remisión a Proveedores (Provider Referral Services - PRS) usando la siguiente dirección URL de internet: http://www.talispoint.com/liberty/goldeneagle/ext 12. Haga clic en la pestaña de “Búsqueda de Proveedor “ (“Provider Search”) (parte superior de la página) 13. Ingrese la Ciudad y el Estado. El estado es CA. Haga clic en “Continuar” (“Continue”). 14. La pantalla cambiará y aparecerá Plan Tipo “Red de Proveedores Médicos (MPN)” (Plan Type “Medical Provider Network (MPN)”). 15. En la línea “Distancia de Búsqueda (millas)” (“Search Distance (miles)”) seleccione un botón de millaje. Le recomendamos iniciar con un radio de “15” millas ya sea desde la ubicación de su casa o de su lugar de trabajo. Puede ampliar la búsqueda para encontrar proveedores adicionales, de ser necesario. Haga clic en “Continuar” (“Continue”). 16. Seleccione un “Tipo de Proveedor” (“Provider Type”). Le sugerimos que seleccione todos los tipos de proveedores eligiendo el primer proveedor y manteniendo oprimida la tecla de mayúsculas hasta seleccionar luego el último tipo de proveedor. Así seleccionará todos los tipos de proveedores. Si prefiere seleccionar un proveedor específico, haga clic sobre la “Especialidad” (“Specialty”). También puede elegir una “Sub-Especialidad” (“Sub-Specialty) si las hay listadas. Seleccione el proveedor que usted considere puede ofrecerle el tratamiento que requiere. Haga clic en “Continuar” (“Continue”). Si no está seguro sobre qué tipo de proveedor elegir, le recomendamos iniciar con un “Médico de Atención Primaria (PCP)” (“Primary Care Physician (PCP))”. 17. Usted puede elegir cualquiera de los proveedores listados o puede continuar repasando otros proveedores que estén dentro de la MPN. 18. En el listado usted podrá ver el nombre, dirección, millas, número de teléfono y especialidad de cada uno de los proveedores. 19. Para crear un mapa y obtener instrucciones sobre cómo llegar en automóvil, haga clic en el mapa ubicado en el lado derecho del listado de proveedores. También puede crear las instrucciones para llegar en automóvil ingresando la dirección y el código postal donde usted está ubicado. 20. Usted puede crear un directorio de los proveedores listados. Haga clic sobre la pestaña inferior “Seleccionar todos los proveedores de esta página” (“Select all providers on this page”). Haga clic en “Crear Listado de Proveedores” (“Create Provider Listing”). Todos los proveedores serán listados. Puede imprimir el listado de proveedores o enviarlo por correo electrónico. Vea la parte inferior de la página del listado de proveedores.

Directorio Regional: Para crear un directorio regional, haga clic en la pestaña “Región del Directorio” (“Directory Region”) (parte superior de la página)

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Cómo Elegir un Médico y Programar una Cita Médica: 4. Seleccione un médico que pueda tratar su afección médica 5. Llame al consultorio del médico y suministre la siguiente información: Tengo una reclamación por Indemnización Laboral y usted está listado como un proveedor aprobado contratado por la Red Blue Cross of California y Kaiser On-theJob (KOJ). Necesito programar una cita. Suministre su información, el número de la reclamación, y el nombre y número de teléfono del gerente de casos de reclamación. 6. Llame al gerente de casos de reclamación y notifíquele el nombre del médico, dirección, número de teléfono y la fecha de su cita.

Si tiene alguna pregunta sobre la anterior información le agradecemos ponerse en contacto con su gerente de casos de reclamación.

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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: • your employer offers group health coverage; • the doctor 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, obstetriciangynecologist, 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 may 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): ________________________________________________________________________ Employee’s Address: ________________________________________________________________________ Employee’s Signature_______________________________________________Date:_____________ Physician: I agree to this Predesignation: Signature:____________________________________________________Date:__________ (Physician or Designated Employee of the Physician or Medical Group) The physician 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. (Optional DWC Form 9783 March 1, 2007)

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DESIGNACIÓN PREVIA DE MÉDICO PARTICULAR En caso de que usted sufra una lesión o enfermedad relacionada con su empleo, usted puede recibir tratamiento médico por esa lesión o enfermedad de su médico particular (M.D.), médico osteópata (D.O.) o grupo médico si: • su empleador le ofrece un plan de salud grupal • el médico es su médico familiar o de cabecera, que será un médico que ha limitado su práctica médica a medicina general o que es un internista certificado o elegible para certificación, pediátra, gineco-obstreta, o médico de medicina familiar y que previamente ha estado a cargo de su tratamiento médico y tiene su expediente médico • su "médico particular" puede ser un grupo médico si es una corporación o sociedad o asociación compuesta de doctores certificados en medicina u osteopatía, que opera un integrado grupo médico multidisciplinario que predominantemente proporciona amplios servicios médicos para lesiones y enfermedades no relacionadas con el trabajo. • 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 siguente: (1) notificación de que quiere que su médico particular le brinde tratamiento para una lesión o enfermedad de trabajo y (2) el nombre y dirección comercial de su médico particular. Puede usar este formulario para notificarle a su empleador que desea que su médico particular o médico osteópata le proporcione tratamiento médico para una lesión o enfermedad de trabajo y que los requisitos mencionados arriba han sido cumplidos. NOTICIA DE DESIGNACIÓN PREVIA DE MÉDICO PARTICULAR Empleado: Rellene esta sección. A: ____________________________ (nombre del empleador) Si sufro una lesión o enfermedad de trabajo, 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): ________________________________________________________________________ Domicilio del Empleado: ________________________________________________________________________ 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 de ser designado previamente de acuerdo al Código de Reglamentos de California, Título 8, sección 9780.1(a)(3). Código de Reglamentos de California, Título 8, sección 9783. (Formulario Opcional 9783 de la DWC 1 de marzo 2007 )

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