Pursuant to CCR 9767.3 (c) (4), - Physicians are NOT authorized to provide treatment at any location other than the location listed in this network listing.
COVID-19 is impacting many practices. Some provider offices are adjusting their hours of operation and some practices are consolidating services and are temporarily closing some of their locations. You should always contact the provider's office to confirm availability. You may also reach out to the Medical Access Assistant when you need help locating and qualifying a provider's practice.
ACCESSING A KASIER PERMANENTE SPECIALIST:
In order to treat with a Kaiser Permanente Specialist, the injured worker must first be evaluated by a Kaiser Permanente On-the-job (KPOJ) Occupational Medicine physician. The KPOJ physician will determine the appropriate Specialist, make the referral and clinic staff will assist to schedule the referral and appointment with the specialist within the MPN. To schedule an initial appointment with a KPOJ physician, call the preferred KPOJ clinic location phone number included in the MPN listing. You may also contact the MPN Medical Access Assistant line listed below for additional assistance.
PRIOR AUTHORIZATION PROGRAM
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On July 1, 2010 the City of Los Angeles implemented a Prior Authorization Program (PAP). All treatment requests must follow the Title 8 CCR § 9792.20-9792.22 MTUS criteria.
The City of Los Angeles' First Care Panel is extended to all MPN providers. The Prior Authorization Program is per claim and not per provider.
General Instructions
- A. No Request for Authorization (RFA) needed for the services or treatments provided to the patient under the PAP program.
- B. A PR-2 or 5021 must be submitted and indicate clearly that the services and procedures rendered supports the medical necessity of the treatment provided. Fax the documents to:
City of Los Angeles UR designated Fax at 213-473-3377
Intercare UR designated Fax at 818-476-4402 - LAPD Sworn Claims
Sedgwick UR designated Fax at 833-784-2352 - LA Fire Claims
Elite UR designated FAX at 951-676-7258 - LAPD Civilian Claims
- C. No RFA's should be sent to the City of LA Contracted Managed Care Providers. A prescription, doctor's medical report or notification form should only be used to inform the providers of the treatment or tests needed.
- D. No Certification Letter will be sent by the City of Los Angeles claims administrators for those procedures which fall under this program.
The Prior Authorization Program will include the following procedures or ancillary services:
PLEASE NOTE: Initial diagnostic tests or procedures can be done to all or any accepted body part(s) and must be provided by the City of Los Angeles' Contracted Managed Care Providers listed below.
- 1. 1. Diagnostic Tests: MIS Phone: 800.894.4674/Fax: 714-736-9494 Email: schedule@mis4wc.com
- MRI
- CT Scan
- X-rays
- EMG/NCS
- 2. Physical Medicine: Med Risk (877) 446-8581, Fax: (855) 806-9754
- Physical Therapy – 12 sessions
- Occupational Therapy – 12 sessions
- Acupuncture – 12 sessions
- Chiropractic – 12 sessions
- Aquatic Therapy – 6 sessions
- 3. Medications: myMatrixx (800) 945-5951
- 90 Days of prescription drugs per Medical Treatment Utilization Formulary.
- Point of Entry Occupational Medicine Clinics may dispense first fill only.
- 4. Durable Medical Equipment:
Optum (888) 880-9656 - Last Names A-L
Century Pacific - (800) 239-4119 - Last Names M-Z
DO NOT ORDER NAME BRANDS FOR ANY DURABLE MEDICAL EQUIPMENT.
Non-surgical basic equipment:
Splints – Off the Shelf
Braces – Off the Shelf
Walkers
Standard wheelchair rental
Slings
Hot and cold packs
Post-Surgical Discharge DME such as:
Cold Packs
Ankle Foot Orthotics, Walking cane, Crutches
Braces, Walker
Standard Wheelchair rental, Tub/Shower, Chair
3-1 commode
- 5. Office Visits & Specialty Referrals
- Routine Office Visits and Follow Ups
- Specialty Consult Referral - Within the MPN
- When diagnosis of hernia is made on initial visit, refer to General Surgeon immediately.
- 6 Psychological Visits for an accepted psych claim
- 7. Corticosteroid Injections (Non-diabetic patients)
- Elbow: Up to 3 injections in cases of severe pain from epicondylitis. Improvement must be shown after initial injection.
- Knee: Up to 3 injections if the patient has osteoarthritis. Improvement must be shown after initial injection.
- Shoulder: Up to 3 injections if the patient has rotator cuff disease. Improvement must be shown after initial injection.
- Fingers: Up to 3 injections for Trigger Finger. Improvement must be shown after initial injection.
- Tetanus Shot if over 10 years from the last injection
- Blood Tests: CBC, BMP, UA, CXR, EKG (only if heart claim)
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| Medical Access Assistant: |
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MPN Contact: |
| Name: Signature Networks PLUS |
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Name: Signature Networks PLUS |
| Toll free number: 844-473-2510 |
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Toll free number: 844-473-2510 |
| Fax number: 866-674-5174 |
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| Email: maacitympn@cityoflampn.com |
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To obtain a copy of any required MPN notifications, please call (866) 222-5378
(BCC) displays in directory to confirm Network/MPN participation in the Anthem Workers' Compensation network.
© 2009 Anthem Workers' Compensation All rights reserved.
(Anthem) is a product of Anthem Workers' CompensationSM, LLC., a Limited Liability Corporation. Anthem accesses independently contracted provider networks through affiliated and other companies, which it makes available by contract to payors of workers' compensation benefits. Anthem has no control or right of control over the professional, medical judgment of independently contracted providers, and is not liable for any acts or failures to act, by independently contracted providers. Anthem is not an insurance company and has no liability for benefits under benefit plans offered or administered by employers or other payors. Anthem Workers' CompensationSM is a service mark of Anthem Workers' Compensation, LLC. Any reference in the material to other organizations or companies, including their Internet sites, is not an endorsement or warranty of the services, information or products provided by those organizations or companies.
