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 9792.9.1 - Utilization Review Standards-Timeframe, Procedures and Notice - on or After January 1, 2013

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
This section applies to any request for authorization of
						medical treatment, submitted under Article 5.5.1 of this Subchapter, for
						either: (1) an occupational injury or illness occurring on or after January 1,
						2013; or (2) where the decision on the request is communicated to the
						requesting physician on or after July 1, 2013, regardless of the date of
						injury.
(a) The request for
					 authorization for a course of treatment as defined in section
					 9792.6.1(d) must
					 be in written form set forth on the "Request for Authorization (DWC Form RFA),"
					 as contained in California Code of Regulations, title 8, section
					 9785.5.
(1) For purposes of this section, the DWC
					 Form RFA shall be deemed to have been received by the claims administrator or
					 its utilization review organization by facsimile or by electronic mail on the
					 date the form was received if the receiving facsimile or electronic mail
					 address electronically date stamps the transmission when received. If there is
					 no electronically stamped date recorded, then the date the form was transmitted
					 shall be deemed to be the date the form was received by the claims
					 administrator or the claims administrator's utilization review organization. A
					 DWC Form RFA transmitted by facsimile after 5:30 PM Pacific Time shall be
					 deemed to have been received by the claims administrator on the following
					 business day, except in the case of an expedited or concurrent review. The copy
					 of the DWC Form RFA or the cover sheet accompanying the form transmitted by a
					 facsimile transmission or by electronic mail shall bear a notation of the date,
					 time and place of transmission and the facsimile telephone number or the
					 electronic mail address to which the form was transmitted or the form shall be
					 accompanied by an unsigned copy of the affidavit or certificate of
					 transmission, or by a fax or electronic mail transmission report, which shall
					 display the facsimile telephone number to which the form was transmitted. The
					 requesting physician must indicate if there is the need for an expedited review
					 on the DWC Form RFA.
(2)
(A) Where the DWC Form RFA is sent by mail,
					 the form, absent documentation of receipt, shall be deemed to have been
					 received by the claims administrator five (5) business days after the deposit
					 in the mail at a facility regularly maintained by the United States Postal
					 Service.
(B) Where the DWC Form RFA
					 is delivered via certified mail, with return receipt mail, the form, absent
					 documentation of receipt, shall be deemed to have been received by the claims
					 administrator on the receipt date entered on the return receipt.
(C) In the absence of documentation of
					 receipt, evidence of mailing, or a dated return receipt, the DWC Form RFA shall
					 be deemed to have been received by the claims administrator five days after the
					 latest date the sender wrote on the document.
(3) Every claims administrator shall maintain
					 telephone access and have a representative personally available by telephone
					 from 9:00 AM to 5:30 PM Pacific Time, on business days for health care
					 providers to request authorization for medical services. Every claims
					 administrator shall have a facsimile number available for physicians to request
					 authorization for medical services. Every claims administrator shall maintain a
					 process to receive communications from health care providers requesting
					 authorization for medical services after business hours. For purposes of this
					 section the requirement that the claims administrator maintain a process to
					 receive communications from requesting physicians after business hours shall be
					 satisfied by maintaining a voice mail system or a facsimile number or a
					 designated email address for after business hours requests.