§ 10959. 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 (AD) 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 AD's determination. An untimely petition may be summarily dismissed.

(2) Notwithstanding any other provision of these rules or of AD Rules 9767.8(i), 9767.13(f), and 9767.14(f), the petition shall be filed solely in paper (hard copy) form directly with the Office of the Commissioners of the Appeals Board at either its P.O. Box or street address. Up-to-date P.O. Box and street address information may be obtained at the website of the Department of Industrial Relations, Workers' Compensation Appeals Board (currently, at http://www.dir.ca.gov/wcab/WCAB.PetitionforReconsideration.htm) or by telephoning the Office of the Commissioners (currently, [phone]).

(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 AD to the MPN determination.

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

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

(1) The petition may appeal the AD's determination upon one or more of the following grounds and no other: (A) the determination was without or in excess of the AD's powers; (B) the determination was procured by fraud; (C) the evidence does not justify the determination; (D) the petitioner has discovered new evidence material to him or her, which he or she could not, with reasonable diligence, have discovered and presented to the AD prior to the determination; and/or (E) the AD'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 AD 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 AD's determination other than those set forth in the petition appealing.

(3) The petition shall comply with the requirements of sections 10842(a) & (c), 10846, and 10852. It shall also comply with the provisions of section 10845, 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 sections 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 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 appealing unless, within that time, the panel orders that the time be extended so that it may further study the facts and relevant law.

(l) Special Procedures if Timely Request Made to Administrative Director to Re-Evaluate Initial MPN Determination:

Nothing in this section shall preclude a person or entity aggrieved by an MPN determination of the AD from making a timely request to the AD to re-evaluate that initial determination in accordance with sections 9767.8(f), 9767.13(c), and 9767.14(c) or any similar current or future regulation or statute.

(1) If a request for re-evaluation is made to the AD 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 AD files and serves a decision and order regarding the request for re-evaluation.

(2) If a request for re-evaluation is made to the AD after a petition appealing the AD'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.

HISTORY

1. New section filed 9-23-2013; operative 10-23-2013. Submitted as a file and print by the Workers' Compensation Appeals Board pursuant to Government Code section 11351 (Register 2013, No. 39).

Note

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