California Code of Regulations › Title 8 - Industrial Relations › Division 1 - Department of Industrial Relations › Chapter 4.5 - Division of Workers' Compensation › Subchapter 1.5 - Injuries on or After January 1, 1990 › Article 5.5 - Administrative Penalties Pursuant to Labor Code Section 5814.6 › Section 10112.1 - Definitions

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
As used in this article:
(a) "Adjusting location" means the office
					 where claims are administered. Separate underwriting companies, employers that
					 are both self-administered and self-insured, and/or third-party administrators
					 operating at one location shall be combined as one adjusting location only if
					 claims are administered under the same management at that location. Where
					 claims are administered from an office that includes a satellite office at
					 another location, claims administered at the satellite office(s) will be
					 considered as part of the single adjusting location for investigation and
					 auditing purposes under this article when it is demonstrated that the claims
					 are under the same immediate management.
(b) "Administrative Director" means the
					 Administrative Director of the Division of Workers Compensation, including his
					 or her designee.
(c) "Claim" means
					 a request for compensation, or record of an occurrence in which compensation
					 reasonably would be expected to be payable for an injury arising out of and in
					 the course of employment.
(d)
					 "Claim file" means a record in paper or electronic form, or any combination,
					 containing all of the information specified in section
					 10101.1 of Title 8 of the
					 California Code of Regulations and all documents or entries related to the
					 provision, payment, delay, or denial of benefits or compensation under
					 Divisions 1, 4 or 4.5 of the Labor Code.
(e) "Claims administrator" means a
					 self-administered workers' compensation insurer; a self-administered
					 self-insured employer; a self-administered legally uninsured employer; a
					 self-administered joint powers authority; or a third-party claims administrator
					 for an insurer, a self-insured employer, a legally uninsured employer or a
					 joint powers authority.
(f)
					 "Compensation" means every benefit or payment, including vocational
					 rehabilitation, supplemental job displacement benefits, medical treatment,
					 medical and medical-legal expenses, conferred by Divisions 1 and 4 of the Labor
					 Code on an injured employee or the employee's dependents.
(g) "Compensation order" means any award,
					 order or decision issued by the Workers' Compensation Appeals Board or the
					 Division of Workers' Compensation vocational rehabilitation unit by which a
					 party is entitled to payment of compensation.
(h) "Concurrent medical treatment
					 authorization" means authorization requested or provided during an inpatient
					 stay.
(i) " Determination and
					 Order" means Determination and Order in re Labor Code §
											5814.6
					 Administrative Penalties.
(j)
					 "Employee" means every person in the service of another, as defined under
					 Article 2 of Chapter 2 of Part 1 of Division 4 of the Labor Code (Sections
					 3350 et seq.), or in the case of
					 the employee's death, his or her dependent, as each is defined in Division 4 of
					 the Labor Code, or the employee's or dependent's agent or attorney.
(k) "Employer" shall have the same meaning as
					 the word 'employer' as defined in Division 4 of the Labor Code (sections
					 3300 et seq.).
(l) "General business practice" means a
					 pattern of violations of Labor Code section
					 5814 at a
					 single adjusting location that can be distinguished by a reasonable person from
					 an isolated event. The pattern of violations must occur in the handling of more
					 than one claim. The pattern of violations may consist of one type of act or
					 omission, or separate, discrete acts or omissions in the handling of more than
					 one claim. However, where a claim file with a violation of Labor Code section
					 5814 has been
					 adjusted at multiple adjusting locations, that claim file may be considered
					 when determining the general business practice of any of the adjusting
					 locations where the conduct that caused the violation occurred even if the file
					 has been transferred to a different adjusting location.
(m) "Indemnity" means payments made directly
					 to an eligible person as a result of a work injury and as required under
					 Division 4 of the Labor Code, including but not limited to temporary disability
					 indemnity, salary continuation in lieu of temporary disability indemnity,
					 permanent disability indemnity, vocational rehabilitation temporary disability
					 indemnity, vocational rehabilitation maintenance allowance, life pension and
					 death benefits.
(n) "Insurer" means
					 any company, group, or entity in, or which has been in, the business of
					 transacting workers' compensation insurance for one or more employers subject
					 to the workers' compensation laws of this state. The term insurer includes the
					 State Compensation Insurance Fund.
(o) "Investigation" means the process used by
					 the Administrative Director, or his or her designee, pursuant to Section
					 10112.2 and/or Government Code
					 sections
					 11180
					 through
					 11191, to
					 determine whether a violation of Labor Code section
					 5814.6 has
					 occurred, including but not limited to reviewing, evaluating, copying and
					 preserving electronic and paper records, files, accounts and other things, and
					 interviewing potential witnesses.
(p) "Joint powers authority" means any
					 county, city, city and county, municipal corporation, public district, public
					 agency, or political subdivision of the state, but not the state itself,
					 included in a pooling arrangement under a joint exercise of powers agreement
					 for the purpose of securing a certificate of consent to self-insure workers'
					 compensation claims under Labor Code Section
					 3700(c).
(q) "Knowingly" means acting with knowledge
					 of the facts of the conduct at issue. For the purposes of this article, a
					 corporation has knowledge of the facts an employee receives while acting within
					 the scope of his or her authority. A corporation has knowledge of information
					 contained in its records and of the actions of its employees performed in the
					 scope and course of employment. An employer or insurer has knowledge of
					 information contained in the records of its third-party administrator and of
					 the actions of the employees of the third-party administrator performed in the
					 scope and course of employment.
(r)
					 "Notice of Assessment" means Notice of Labor Code §
											5814.6
					 Administrative Penalty Assessment.
(s) "Penalty award" means a final order or
					 final award by the Workers' Compensation Appeals Board to pay penalties due to
					 a violation of section
					 5814 of the
					 Labor Code.
(t) "Petition Appealing
					 Determination and Order" means Petition Appealing Determination and Order of
					 the Administrative Director in re Labor Code §
											5814.6
					 Administrative Penalties.
(u)
					 "Proof of service" means an affidavit or declaration made under penalty of
					 perjury and filed with one or more documents required to be filed, setting out
					 a description of the document(s) being served, the names and addresses of all
					 persons served, whether service was made personally or by mail, the date of
					 service, and the place of service or the address to which mailing was
					 made.
(v) "Prospective medical
					 treatment authorization" means authorization requested or provided prior to the
					 delivery of the medical services.
(w) "Recommended Determination and Order"
					 means Recommended Determination and Order in re Labor Code §
											5814.6
					 Administrative Penalties.
(x)
					 "Retrospective medical treatment authorization" means authorization requested
					 or provided after medical services have been provided and for which services
					 approval has not already been given.
(y) "Salary continuation" means payment made
					 to an injured employee as provided under Division 4 of the Labor
					 Code.
(z) "Serve" means to file or
					 deliver a document or to cause it to be delivered to the Administrative
					 Director or his or her designee, or to such other person as is required under
					 this article.
(aa) "Stipulated
					 Order" means a Notice of Assessment that was timely paid.
(bb) "Supplemental job displacement benefits"
					 means benefits as described under Labor Code section
					 4658.5 and
					 sections 10133.50-10133.59 of Title 8 of the
					 California Code of Regulations.
(cc) "Third-party administrator" means an
					 agent under contract to administer the workers' compensation claims of an
					 insurer, a self-insured employer, a legally uninsured employer, a self-insured
					 joint powers authority or on behalf of the California Insurance Guarantee
					 Association. The term third-party administrator includes the State Compensation
					 Insurance Fund for locations that administer claims for legally uninsured and
					 self-insured employers, and also includes managing general agents.
(dd) "Utilization review files" means those
					 files, documents or records, whether paper or electronic, containing
					 information that documents an employer or insurer utilization review process
					 required under Division 4 of the Labor Code.
(ee) "Workers' Compensation Appeals Board"
					 means the Appeals Board, commissioners, deputy commissioners, presiding
					 workers' compensation judges and workers' compensation administrative law
					 judges.
1. Change
						without regulatory effect renumbering former subchapter 1.8, article 1
						(sections 10225-10225.2) to subchapter 1.5,
						article 5.5 (sections
						10112.1-10112.3) and renumbering
						former section
						10225 to section
						10112.1 filed 4-7-2008 pursuant to
						section 100, title 1, California Code of
						Regulations (Register 2008, No. 15).
Note: Authority cited: Sections
						  133,
						  5307.3 and
						  5814.6, Labor
						  Code. Reference: Sections
						  129.5,
						  139.48,
						  5814 and
						  5814.6, Labor
						  Code.