Logo for Dept of industrial relations California state seal.
Release Number: 2021-67
June 29, 2021

DWC Posts Disclosure of Contract Reimbursement Rate Form

The Division of Workers’ Compensation (DWC) has posted a Disclosure of Contract Reimbursement Rate Form for specific Medical Provider Network (MPN) entities to use when reporting contracted discounted payments made to medical providers. 

Under Labor Code section 5307.12, an MPN entity that provides physician network services or ancillary network services must disclose to payors (a self-insured employer, insurer or third-party claims administrator) contracts that the entity has with a health care provider or health facility which establishes reimbursement rates for services that are more than 20% below the applicable rates in DWC’s Official Medical Fee Schedule, excluding goods and pharmaceuticals. This mandated disclosure is to be made on the form provided by DWC.

Labor Code section 5307.12 becomes operative on July 1, 2021.