Medical Provider Networks Approved by DWC

1 Medical Provider network Approved by DWC (Sorted by Name of Applicant). NOTE: The status of the MPNs on this list were produced and processed from information known to DWC as of 04/01/2020. However, changes may have been made since that date. Please contact the DWC Medical Unit to verify the information provided for a specific MPN. *MPN Approval Status Legend BLANK = MPN status has not changed after approval = MPN coverage period should be verified with the DWC Medical Unit P = MPN is on Probation R = MPN was revoked after approval S = MPN is currently Suspended T = MPN was terminated after approval W = MPN was withdrawn after approval Medical Provider Networks Approved by DWC (Sorted by Name of Applicant). NOTE: The status of the MPNs on this list were produced and processed from information known to DWC as of 04/01/2020. However, changes may have been made since that date. Please contact the DWC Medical Unit to verify the information provided for a specific MPN. MPN. MPN Name of Applicant with Type of Date of Internet Website Name of MPN Approval ID # Mailing Address Applicant Approval Address of MPN.

2 Status *. 99 Cents Only Stores LLC. Self-Insured 1564 4000 Union Pacific Avenue Broadspire Signature MPN 08/23/2009 T. Employer Commerce, CA 90023. 99 Only Stores 4000 Union Pacific Avenue WellComp Medical Provider Self-Insured 1302 07/31/2007 T. City of Commerce, CA network Employer 90023. A. Teichert & Son, Inc. WellComp Medical Provider Self-Insured 2301 3500 American River Dr. 06/11/2014 T. network Employer Sacramento, CA 95851. Ag Services, Inc. Zacky Farms Custom CorVel Self-Insured 1751 2020 So. East Ave 01/12/2011 T. MPN Employer Fresno, CA 93721. ABC Unified School District Prime Advantage Medical Self-Insured 0229 16700 Norwalk Boulevard 03/01/2005 T. network Employer Cerritos, CA 90703. ABM Industries Incorporated Self-Insured 0169 1775 The Exchange 6th Flr ABM ESIS MPN 02/02/2005 T. Employer Atlanta, GA 30339. ABM Industries, Incorporated 1775 The Exchange, 6th Self-Insured 1938 ABM MPN 04/20/2012 T. Floor Employer Atlanta, GA 30339. ACE American Insurance Company (Broadspire- 0080 Boeing MPN) Broadspire MPN Insurer 03/07/2005 T.

3 1601 Market Street Philadelphia, PA 19103. Approved MPN Applications: 2450. *MPN Approval Status Legend BLANK = MPN status has not changed after approval; = MPN coverage period should be verified with the DWC Medical Unit; P = MPN is on Probation; R = MPN was revoked after approval; S = MPN is currently Suspended; T = MPN was terminated after approval; W = MPN was withdrawn after approval 1. Medical Provider Networks Approved by DWC (Sorted by Name of Applicant). NOTE: The status of the MPNs on this list were produced and processed from information known to DWC as of 04/01/2020. However, changes may have been made since that date. Please contact the DWC Medical Unit to verify the information provided for a specific MPN. MPN. MPN Name of Applicant with Type of Date of Internet Website Name of MPN Approval ID # Mailing Address Applicant Approval Address of MPN. Status *. ACE American Insurance Company 0716 1 Beaver Valley Road Suite Medex-ACE-GB Insurer 04/19/2005 T. 4E. Wilmington, DE 19803.

4 ACE American Insurance Company 1560 1 Beaver Valley Road Suite Wal-Mart-Medex MPN Insurer 08/12/2009 T. 4E. Wilmington, DE 19803. ACE American Insurance Company 0340 Broadspire MPN Insurer 02/17/2005 T. 1601 Chestnut Street Philadelphia, PA 19103. ACE American Insurance Company 0384 FARA-CVTY Insurer 04/20/2005 T. 1601 Chestnut Street Philadelphia, PA 19103. ACE American Insurance Company ACE American Insurance 0677 Insurer 06/16/2005 T. 1601 Chestnut Street Company - Crawford Select Philadelphia, PA 19103. ACE American Insurance Company Intracorp-Gates McDonald 0960 Insurer 07/28/2005 T. 1601 Chestnut Street MPN. Philadelphia, PA 19103. Approved MPN Applications: 2450. *MPN Approval Status Legend BLANK = MPN status has not changed after approval; = MPN coverage period should be verified with the DWC Medical Unit; P = MPN is on Probation; R = MPN was revoked after approval; S = MPN is currently Suspended; T = MPN was terminated after approval; W = MPN was withdrawn after approval 2.

5 Medical Provider Networks Approved by DWC (Sorted by Name of Applicant). NOTE: The status of the MPNs on this list were produced and processed from information known to DWC as of 04/01/2020. However, changes may have been made since that date. Please contact the DWC Medical Unit to verify the information provided for a specific MPN. MPN. MPN Name of Applicant with Type of Date of Internet Website Name of MPN Approval ID # Mailing Address Applicant Approval Address of MPN. Status *. ACE American Insurance Company 0983 ACE-Medex Select B Insurer 08/05/2005 T. 1601 Chestnut Street Philadelphia, PA 19103. ACE American Insurance Company First Health Comp America 0394 Insurer 03/16/2005 T. 1601 Market Street HCO Select network Philadelphia, PA 19103. ACE American Insurance Company First Health CompAmerica 0125 Insurer 04/12/2005 T. 1601 Market Street Primary network Philadelphia, PA 19103. ACE American Insurance Company First Health Comp America 0506 Insurer 04/20/2005 T. 1601 Market Street HCO Select network Philadelphia, PA 19103.

6 ACE American Insurance Company MedInsights MPN accessing 0748 Insurer 04/28/2005 T. 1601 Market Street Prudent Buyer PPO. Philadelphia, PA 19103. ACE American Insurance ACE/Frank Gates First Company 0427 Health CompAmerica Select Insurer 05/11/2005 W. 1601 Market Street network Philadelphia, PA 19103. ACE American Insurance Company 1826 ACE GBMCS KOJ MPN Insurer 05/02/2011 T. 436 Walnut Street Philadelphia, PA 19106. Approved MPN Applications: 2450. *MPN Approval Status Legend BLANK = MPN status has not changed after approval; = MPN coverage period should be verified with the DWC Medical Unit; P = MPN is on Probation; R = MPN was revoked after approval; S = MPN is currently Suspended; T = MPN was terminated after approval; W = MPN was withdrawn after approval 3. Medical Provider Networks Approved by DWC (Sorted by Name of Applicant). NOTE: The status of the MPNs on this list were produced and processed from information known to DWC as of 04/01/2020. However, changes may have been made since that date.

7 Please contact the DWC Medical Unit to verify the information provided for a specific MPN. MPN. MPN Name of Applicant with Type of Date of Internet Website Name of MPN Approval ID # Mailing Address Applicant Approval Address of MPN. Status *. ACE American Insurance Company 0157 Sedgwick CMS MPN Insurer 02/17/2005 T. 436 Walnut St Philadelphia, PA 19106. ACE American Insurance Company Sedgwick CMS Extended 0159 Insurer 02/17/2005 T. 436 Walnut St MPN. Philadelphia, PA 19106. ACE American Insurance Company Genex Medical Provider 0646 Insurer 06/01/2005 T. 436 Walnut St network (MPN). Philadelphia, PA 19106. ACE American Insurance Company Sedgwick CMS/Harbor Net - 1573 Insurer 12/14/2009 T. 436 Walnut St Ross Stores Philadelphia, PA 19106. ACE American Insurance Company 1581 Coventry network Insurer 01/21/2010 T. 436 Walnut St Philadelphia, PA 19106. ACE American Insurance Company Sedgwick CMS/Harbor MPN. 1623 Insurer 04/19/2010 T. 436 Walnut St - Ace CEC. Philadelphia, PA 19106.

8 ACE American Insurance Company WellComp Medical Provider 1650 Insurer 06/21/2010 T. 436 Walnut St network Philadelphia, PA 19106. Approved MPN Applications: 2450. *MPN Approval Status Legend BLANK = MPN status has not changed after approval; = MPN coverage period should be verified with the DWC Medical Unit; P = MPN is on Probation; R = MPN was revoked after approval; S = MPN is currently Suspended; T = MPN was terminated after approval; W = MPN was withdrawn after approval 4. Medical Provider Networks Approved by DWC (Sorted by Name of Applicant). NOTE: The status of the MPNs on this list were produced and processed from information known to DWC as of 04/01/2020. However, changes may have been made since that date. Please contact the DWC Medical Unit to verify the information provided for a specific MPN. MPN. MPN Name of Applicant with Type of Date of Internet Website Name of MPN Approval ID # Mailing Address Applicant Approval Address of MPN. Status *. ACE American Insurance Company 1673 Broadspire Signature MPN Insurer 08/09/2010 T.

9 436 Walnut St Philadelphia, PA 19106. ACE AMERICAN. INSURANCE COMPANY ACE American Insurance 1764 Insurer 02/01/2011 T. 436 Walnut St Company-GENEX MPN. Philadelphia, PA 19106. Ace American Insurance Company 1961 Sedgwick/Harbor MPN Insurer 05/15/2012 T. 436 Walnut St Philadelphia, PA 19106. ACE American Insurance Company 0103 ACE ESIS MPN Insurer 02/03/2005 T. 436 Walnut St. Philadelphia, PA 19106. ACE American Insurance Company 0768 ACE/BUNCH network Insurer 05/05/2005 T. 436 Walnut St. Philadelphia, PA 19106. ACE American Insurance Company 1605 CorVel MPN Insurer 03/31/2010 T. 436 Walnut St. Philadelphia, PA 19105. ACE American Insurance Company Medtronic CV Santa Rosa 1734 Insurer 12/22/2010 T. 436 Walnut St. MPN. Philadelphia, PA 19106. Approved MPN Applications: 2450. *MPN Approval Status Legend BLANK = MPN status has not changed after approval; = MPN coverage period should be verified with the DWC Medical Unit; P = MPN is on Probation; R = MPN was revoked after approval; S = MPN is currently Suspended; T = MPN was terminated after approval; W = MPN was withdrawn after approval 5.

10 Medical Provider Networks Approved by DWC (Sorted by Name of Applicant). NOTE: The status of the MPNs on this list were produced and processed from information known to DWC as of 04/01/2020. However, changes may have been made since that date. Please contact the DWC Medical Unit to verify the information provided for a specific MPN. MPN. MPN Name of Applicant with Type of Date of Internet Website Name of MPN Approval ID # Mailing Address Applicant Approval Address of MPN. Status *. ACE American Insurance Company 1857 ACE/Bunch/Buffets MPN Insurer 07/14/2011 T. 436 Walnut St. Philadelphia, PA 19106. ACE American Insurance Company CCMSI/ACE First Health 1547 436 Walnut St., Box Comp America Select HCO Insurer 06/24/2009 T. 1000 network Philadelphia, PA 19105. ACE American Insurance Company 0044 Medex MPN Insurer 12/07/2004. 436 Walnut Street m/. Philadelphia, PA 19106. ACE American Insurance Company ACE/Gallagher 0391 Insurer 02/23/2005 T. 436 Walnut Street Bassett/Coventry MPN gbcvtympn Philadelphia, PA 19106.