California Medical Provider Network Implementation Notice (12/2010)

California Medical Provider Network Implementation Notice (12/2010)

Instructions
for
MPN IMPLEMENTATION NOTICE
This notice is to be used by employers who are implementing the Travelers MPN 60 or more
days after their initial Travelers policy (or CSS contract) effective date. Employers who are
implementing the MPN within 60 days of their initial policy effective date are not required to
distribute this notice to all existing employees, but must provide it to new hires.
1. Fill in the following spots on the notice, in both the English and Spanish sections:

Effective date of new MPN = the day after the MPN Notification is posted AND all
required MPN notices have been distributed.

Policy effective date = the date the employer’s initial Travelers policy (or CSS contract)
began. If you are unsure of this date, please check your policy paperwork or contact your
Travelers underwriter.
2. If 60 past initial policy effective date, provide the notice to all employees. The notice must be
given in English to all employees, and ALSO in Spanish to Spanish-speaking employees.
3. Provide the notice to any/all new employees at the time of hire. The notice must be given in
English to all new employees, and ALSO in Spanish to Spanish-speaking employees.
12/2010
MEDICAL PROVIDER NETWORK (MPN)
IMPLEMENTATION NOTICE
Unless you predesignate a physician or medical group, your new work injuries arising on
September 1, 2009
or after ___________________________
will be treated by providers in a new
effective date of new MPN
Medical Provider Network, the Travelers TCT MPN.
April 1, 2012
If you have an existing injury occurring on or after _________________________,
you may be
policy effective date
required to change to a provider in the new MPN. Check with your claims adjuster. You may
obtain more information about the MPN from the workers’ compensation poster or from your
employer.
AVISO DE IMPLEMENTACIÓN DE LA
RED DE PROVEEDORES MÉDICOS (MPN)
A menos que usted designe con anticipación a un médico o grupo médico, las nuevas
1 Septiembre, 2009
lesiones relacionadas con su trabajo que ocurran el ___________________________ o
fecha de vigencia de la nueva MPN
después de esa fecha, serán tratadas por los proveedores que participan en una nueva
Red de Proveedores Médicos, la red Travelers TCT MPN.
1 Abril, 2012
Si usted tiene una lesión actual que ocurrió el _________________________
o después de esa
fecha de vigencia de la póliza
fecha, es posible que deba cambiarse a un proveedor que participe en la nueva MPN. Consulte
con su tasador de reclamaciones. Puede obtener más información sobre la MPN en el póster de
compensación legal por accidentes de trabajo o hablando con su empleador.
12/2010