California Code of Regulations › Title 8 - Industrial Relations › Division 1 - Department of Industrial Relations › Chapter 4.5 - Division of Workers' Compensation › Subchapter 1 - Administrative Director-Administrative Rules › Article 5.5.1 - Utilization Review Standards › Section 9792.11 - Investigation Procedures: Labor Code Section 4610 Utilization Review Violations

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a) To carry out the responsibilities
					 mandated by Labor Code Section
					 4610(i),
					 the Administrative Director, or his or her designee, shall investigate the
					 utilization review process of any employer, insurer or other entity subject to
					 the provisions of section
					 4610. The
					 investigation shall include, but not be limited to, review of the practices,
					 files, documents and other records, whether electronic or paper, of the claims
					 administrator, and any other person responsible for utilization review
					 processes for an employer. As used in sections
					 9792.11 through
					 9792.15, the phrase 'utilization
					 review organization' includes any person or entity with which the employer, or
					 an insurer, or third party administrator, contracts to fulfill part or all of
					 the employer's utilization review responsibilities under Labor Code section
					 4610 and Title 8 of the California
					 Code of Regulations, sections
					 9792.6 through
					 9792.15.
(b) Notwithstanding Labor Code section
					 129(a) through
					 (d) and section
					 129.5 subdivisions (a) through (d),
					 the Administrative Director, or his or her designee, may conduct a utilization
					 review investigation pursuant to Labor Code section
					 4610, which may
					 include, but is not limited to, an audit of files and other records.
(c) The Administrative Director, or his or
					 her designee, may conduct a utilization review investigation at any location
					 where Labor Code Section
					 4610
					 utilization review processes occur, as follows:
(1) For utilization review organizations:
(A) A Routine Investigation shall be
					 initiated at each known utilization review organization at least once every
					 five (5) years. The investigation shall include a review of a random sample of
					 requests for authorization, as defined by section
					 9792.6(q) or
					 section 9792.6.1(t),
					 received by the utilization review organization during the three most recent
					 full calendar months preceding the date of the issuance of the Notice of
					 Utilization Review Investigation. The investigation may also include a review
					 of any credible complaints received by the Administrative Director since the
					 time of the previous investigation. If there has not been a previous
					 investigation, the investigation may include a review of any credible
					 complaints received by the Administrative Director since the effective date of
					 sections 9792.11 through
					 9792.15.
(B) Target Investigations:
1. A Return Target Investigation of the same
					 investigation subject shall be conducted within 18 months of the date of the
					 previous investigation if the performance rating was less than eighty-five
					 percent.
2. A Special Target
					 Investigation may be conducted at any time based on credible information
					 indicating the possible existence of a violation of Labor Code section
					 4610 or
					 sections 9792.6 through
					 9792.12.
3. The Return Target Investigation and the
					 Special Target Investigation may include:
(i)
					 a review of the requests for authorization previously investigated which
					 contained violations;
(ii) a review
					 of the file or files pertaining to the complaint or possible
					 violation;
(iii) a random sample of
					 requests for authorization received by the utilization review organization
					 during the three most recent full calendar months preceding the date of the
					 issuance of the Notice of Utilization Review Investigation;
(iv) a sample of a specific type of request
					 for authorization; and
(v) any
					 credible complaints received by the Administrative Director since the time of
					 any prior investigation. If there has not been a previous investigation, the
					 investigation may include a review of any credible complaints received by the
					 Administrative Director since the effective date of sections
					 9792.11 through
					 9792.15.