reglab/statecodes huggingface dataset:
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 4 - Certification Standards for Health Care Organizations › Section 9771.61 - Prohibition of Bonuses or Gratuities in Solicitations

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
No person subject to the provisions of the Act shall
						offer or otherwise distribute any bonus or gratuity to a potential self-insured
						employer, group of self-insured employers, or insurer of an employer for the
						purpose of inducing enrollment or to an existing self-insured employer, group
						of self-insured employers, or insurer of an employer for the purpose of
						inducing the continuation of enrollment.
1. New
						section filed 4-15-98; operative 4-15-98. Submitted to OAL for printing only
						pursuant to Stats. 1997, Ch. 346, Section
						5 (Register 98, No.
						16).
Note: Authority cited: Stats. 1997, Ch. 346, Section
						  5. Reference: Sections
						  4600.3,
						  4500.5 and
						  4600.6, Labor
						  Code.
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 4 - Certification Standards for Health Care Organizations › Section 9771.64 - Organization Assurances Prior to Solicitation

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
Prior to allowing any person to engage in acts of
						solicitation on its behalf, each organization shall reasonably assure itself
						that such person has sufficient knowledge of its organization, procedures,
						workers' compensation health care contracts, and the provisions of the Act and
						these rules to do so lawfully.
1. New
						section filed 4-15-98; operative 4-15-98. Submitted to OAL for printing only
						pursuant to Stats. 1997, Ch. 346, Section
						5 (Register 98, No.
						16).
Note: Authority cited: Stats. 1997, Ch. 346, Section
						  5. Reference: Sections
						  4600.3,
						  4500.5 and
						  4600.6, Labor
						  Code.
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 4 - Certification Standards for Health Care Organizations › Section 9771.65 - Filing of Advertising and Disclosure Forms

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a) Two copies of a proposed advertisement
					 shall be filed. To minimize the expense of changes in advertising copy, it may
					 be submitted in draft form for preliminary review subject to the later filing
					 of a proof or final copy, and the later filing of a proof or final copy may be
					 waived when the draft copy is presented in a manner reasonably representing the
					 final appearance of the advertisement. The text of audio or audio/visual
					 advertising should indicate any directions for presentation, including voice
					 qualities and the juxtaposition of the visual materials with the
					 text.
(b) The Administrative
					 Director will not issue letters of nondisapproval of advertising. If the person
					 submitting the advertisement requests an order shortening the 30-day waiting
					 period under Section
					 4600.6(d) of the
					 Code, such order will be issued when an appropriate showing of the need
					 therefor is made.
1. New
						section filed 4-15-98; operative 4-15-98. Submitted to OAL for printing only
						pursuant to Stats. 1997, Ch. 346, Section
						5 (Register 98, No.
						16).
Note: Authority cited: Stats. 1997, Ch. 346, Section
						  5. Reference: Sections
						  4600.3,
						  4500.5 and
						  4600.6, Labor
						  Code.
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 4 - Certification Standards for Health Care Organizations › Section 9771.66 - Deceptive Advertising

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
Without limitation upon the meaning of Section
						4600.6 of the Code, an
						advertisement or other consumer information is untrue, misleading or deceptive
						if:
(a) It represents that payment is
					 provided in full for the charge for workers' compensation health care other
					 than in accordance with what is required under the Labor Code.
(b) It represents that payment is provided
					 for the customary charges for workers' compensation health care other than in
					 accordance with what is required under the Labor Code.
(c) It represents that the organization, firm
					 or solicitor or any provider or other person associated therewith is licensed
					 or regulated by the Department of Managed Health Care or Administrative
					 Director or other governmental agency, unless such statement is required by law
					 or regulation or unless such statement is accompanied by a satisfactory
					 statement which counters any inference that such licensing or regulation is an
					 assurance of financial soundness or the quality or extent of workers'
					 compensation health care.
1. New
						section filed 4-15-98; operative 4-15-98. Submitted to OAL for printing only
						pursuant to Stats. 1997, Ch. 346, Section
						5 (Register 98, No.
						16).
2. Amendment of subsection (c) filed 1-9-2003; operative
						1-9-2003 pursuant to Government Code section
						11343.4
						(Register 2003, No. 2).
Note: Authority cited: Stats. 1997, Ch. 346, Section
						  5. Reference: Sections
						  4600.3,
						  4500.5 and
						  4600.6, Labor
						  Code.
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 4 - Certification Standards for Health Care Organizations › Section 9771.67 - Disclosure Form

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a) The
					 disclosure form required under subdivision (a) of Section
					 4600.6(e) of the
					 Code and made available to employers and employees shall conform to the
					 requirements established by the Administrative Director of the Division of
					 Workers' Compensation of the Department of Industrial Relations (Cal. Code
					 Regs., Tit. 8, Sec.
					 9770 et seq. ).
1. New
						section filed 4-15-98; operative 4-15-98. Submitted to OAL for printing only
						pursuant to Stats. 1997, Ch. 346, Section
						5 (Register 98, No.
						16).
Note: Authority cited: Stats. 1997, Ch. 346, Section
						  5. Reference: Sections
						  4600.3,
						  4500.5 and
						  4600.6, Labor
						  Code.
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 4 - Certification Standards for Health Care Organizations › Section 9771.68 - Deceptive Workers' Compensation Health Care Provider Organization Names

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a) A change of
					 organization name is a "material modification".
(b) An organization name will be considered
					 deceptive if it suggests the quality of care furnished by the organization or
					 if it suggests that the cost of workers' compensation health care provided to
					 employees is lower than the cost of similar health care purchased elsewhere,
					 and in any such case the express or implied representation contained in the
					 organization name is demonstrably untrue or is not supported by substantial
					 evidence at all times while such name is used by the organization. Nothing in
					 this subsection limits or restricts the Administrative Director from a
					 determination that an organization or solicitor firm name is deceptive for
					 reasons other than those stated herein.
1. New
						section filed 4-15-98; operative 4-15-98. Submitted to OAL for printing only
						pursuant to Stats. 1997, Ch. 346, Section
						5 (Register 98, No.
						16).
Note: Authority cited: Stats. 1997, Ch. 346, Section
						  5. Reference: Sections
						  4600.3,
						  4500.5 and
						  4600.6, Labor
						  Code.
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 4 - Certification Standards for Health Care Organizations › Section 9771.69 - Workers' Compensation Health Care Contracts

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a) All workers' compensation health care
					 contracts and endorsements and amendments shall be printed legibly and shall
					 include at least the following:
(1) The
					 information required to be included on disclosure forms by Section
					 4600.6(e) of the
					 Code and the information required to be included on disclosure forms by Rule
					 9771.67.
(2) Definitions of all
					 terms contained in the contract which:
(A) Are
					 defined by the Act, relevant Labor Code provisions, and the Regulations of the
					 Administrative Director.
(B)
					 Require definition in order to be understood by a reasonable person not
					 possessing special knowledge of law, medicine, or organizations;
(C) Specifically describes the eligibility of
					 employees.
(3)
					 Appropriate captions, in boldface type, regarding the provision of workers'
					 compensation health care, consistent with the requirements of the certification
					 standards for health care organizations promulgated by the Administrative
					 Director of the Division of Workers' Compensation of the Department of
					 Industrial Relations (Cal. Code Regs., Tit. 8, Sec.
					 9770, et seq. ).
(A) A benefit afforded by the contract shall
					 not be subject to any limitation, exclusion, exception, reduction, deductible,
					 or copayment, if any, which renders the benefit illusory.
(4) Provisions relating to cancellation under
					 appropriate caption, in boldface type, which provisions shall include a
					 statement of the time when a notice of cancellation becomes
					 effective.
(5) A provision
					 requiring the organization to provide written notice within a reasonable time
					 to the other party of any termination or breach of contract by, or inability to
					 perform of, any contracting provider if the other party may be materially and
					 adversely affected thereby.
(6) A
					 provision requiring a self-insured employer, group of self-insured employers,
					 or insurer of an employer to mail promptly to each employee a legible, true
					 copy of any notice of cancellation of the organization contract which may be
					 received from the organization and to provide promptly to the organization
					 proof of such mailing and the date thereof.
(7) A provision that (i) the organization is
					 subject to the requirements of the Labor Code, the Regulations of the
					 Administrative Director, and (ii) any provision required to be in the contract
					 by the above shall bind the organization whether or not provided in the
					 contract.
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 4 - Certification Standards for Health Care Organizations › Section 9771.71 - Disclosure of Conflicts of Interest

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a) An organization shall not enter into any
					 transaction with a person currently named in Item D of its application under
					 Rule 9771.62 unless, prior thereto, each of the following conditions is met:
(1) The material facts concerning the
					 transaction and the person's interest therein are disclosed to the governing
					 body of the organization.
(2) The
					 transaction is approved by a disinterested majority of the governing
					 body.
(3) Such facts and such
					 approval are made a part of the minutes of such governing body or, if no
					 minutes are required of such governing body, otherwise retained as a record of
					 the organization.
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 4 - Certification Standards for Health Care Organizations › Section 9771.72 - Contracts with Solicitor Firms

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
An organization shall not permit a solicitor firm to
						solicit self-insured employers, groups of self-insured employers, or insurers
						of an employer on its behalf except pursuant to a written contract which meets
						all of the following minimum requirements:
(a) The solicitor firm shall comply, and
					 shall cause its principal persons and employees to comply, with all applicable
					 provisions of the Act and the rules thereunder.
(b) The solicitor firm shall promptly notify
					 the organization of the institution of any disciplinary proceedings against it
					 or against any of its principal persons or employees relating to any license
					 issued to any such person by the California Insurance Commissioner.
1. New
						section filed 4-15-98; operative 4-15-98. Submitted to OAL for printing only
						pursuant to Stats. 1997, Ch. 346, Section
						5 (Register 98, No.
						16).
Note: Authority cited: Stats. 1997, Ch. 346, Section
						  5. Reference: Sections
						  4600.3,
						  4500.5 and
						  4600.6, Labor
						  Code.
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 4 - Certification Standards for Health Care Organizations › Section 9771.73 - Fiscal Soundness, Insurance, and Other Arrangements

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a) An organization shall demonstrate fiscal
					 soundness as follows:
Demonstrate an approach to the risk of insolvency which
						allows for the continuation of health care services for the duration of the
						contract period, the continuation of health care services to employees who are
						under treatment or confined on the date of insolvency in an in-patient facility
						until their discharge, and payments to unaffiliated providers for health care
						services rendered.
(b) In
					 passing upon an organization's showing pursuant to this section, the
					 Administrative Director will consider all relevant factors, including but not
					 limited to:
(1) The method of compensating
					 providers and the terms of provider contracts, especially as to the obligations
					 of providers to employees in the event of the organization's
					 insolvency.
(2) The methods by
					 which the organization controls and monitors the utilization of health care
					 services.
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 4 - Certification Standards for Health Care Organizations › Section 9771.74 - Fidelity Bond

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a) Each
					 organization shall at all times maintain a fidelity bond covering each officer,
					 director, trustee, partner and employee of the organization, whether or not
					 they are compensated. The fidelity bond may be either a primary commercial
					 blanket bond or a blanket position bond written by an insurer licensed by the
					 California Insurance Commissioner, and it shall provide for 30 days' notice to
					 the Administrative Director prior to cancellation. The fidelity bond shall
					 provide at least the minimum coverage for the organization determined by the
					 following schedule:
Annual Gross
								  Income
Minimum
								  Coverage
Up to
$
								100,000..........................
$
10,000
100,000
								to
300,000..........................
20,000
300,000
								to
500,000..........................
30,000
500,000
								to
750,000..........................
50,000
750,000
								to
1,000,000..........................
75,000
1,000,000
								to
2,000,000..........................
100,000
2,000,000
								to
4,000,000..........................
200,000
4,000,000
								to
6,000,000..........................
400,000
6,000,000 to
10,000,000..........................
600,000
10,000,000
								to
20,000,000..........................
1,000,000
20,000,000 and
								over..........................
2,000,000
(b) The fidelity bond required pursuant to
					 subsection (a) may contain a provision for a deductible amount from any loss
					 which, except for such deductible provision, would be recoverable from the
					 insurer. A deductible provision shall not be in excess of 10 percent of the
					 required minimum bond coverage, but in no event shall the deductible amount be
					 in excess of $100,000.
1. New
						section filed 4-15-98; operative 4-15-98. Submitted to OAL for printing only
						pursuant to Stats. 1997, Ch. 346, Section
						5 (Register 98, No.
						16).
Note: Authority cited: Stats. 1997, Ch. 346, Section
						  5. Reference: Sections
						  4600.3,
						  4500.5 and
						  4600.6, Labor
						  Code.
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 4 - Certification Standards for Health Care Organizations › Section 9771.75 - Reimbursements on a Fee-for-Services Basis: Determination of Status of Claims

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
Every organization shall institute procedures whereby all
						claim forms received by the organization from providers of workers'
						compensation health care for reimbursement on a fee-for-service basis are
						maintained and accounted for in a manner which permits the determination of the
						date of receipt of any claim, the status of any claim, the dollar amount of
						unpaid claims at any time, and rapid retrieval of any claim. Although any
						categories for status-determination held unobjectionable by the Administrative
						Director may be used, for the purposes of this section, the following
						status-determination categories, as a group, shall be presumptively
						reasonable:
(1) to be
					 processed,
(2) processed, waiting
					 for payment,
(3) pending, waiting
					 for approval for payment or denial,
(4) pending, waiting for additional
					 information,
(5) denied,
(6) paid, and, if appropriate,
(7) other.
These procedures shall involve the use of either a claims
						log, claims numbering system, electronic data processing records, and/or any
						other method held unobjectionable by the Administrative Director.
1. New
						section filed 4-15-98; operative 4-15-98. Submitted to OAL for printing only
						pursuant to Stats. 1997, Ch. 346, Section
						5 (Register 98, No.
						16).
Note: Authority cited: Stats. 1997, Ch. 346, Section
						  5. Reference: Sections
						  4600.3,
						  4500.5 and
						  4600.6, Labor
						  Code.
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 4 - Certification Standards for Health Care Organizations › Section 9771.76 - Medical Survey Procedure

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a) Unless the Administrative Director in his
					 discretion determines that advance notice will render the survey less useful,
					 an organization will be notified approximately four weeks in advance of the
					 date for commencement of an onsite medical survey. The Administrative Director
					 may, without prior notice, conduct inspections of organization facilities or
					 other elements of a medical survey, either in conjunction with the medical
					 survey or as part of an unannounced inspection program.
(b) The onsite medical survey of an
					 organization shall include, but not be limited to, the following procedures to
					 the extent considered necessary based upon prior experience with the
					 organization and in accordance with the procedures and standards developed by
					 the Administrative Director.
(1) Review of
					 the procedures for obtaining workers' compensation health care including, but
					 not limited to, the scope of health care.
(A)
					 The availability and adequacy of facilities for telephone communication with
					 health personnel, emergency health care facilities, out-of-the-area coverage,
					 referral procedures, and medical encounters.
(B) The means of advising employees of the
					 procedures to obtain health care, including the hours of operation, location
					 and nature of facilities, types of health care, telephone and other
					 arrangements for appointment setting.
(C) The availability of qualified personnel
					 at each facility referred to in Section
					 4600.6(j) of the
					 Code to receive and handle inquiries concerning health care and
					 grievances.
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 4 - Certification Standards for Health Care Organizations › Section 9771.77 - Medical Survey: Report of Correction of Deficiencies

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
Prior to or immediately upon the expiration of the 30-day
						period following notice to an organization of a deficiency as provided in
						subdivision (8) of Section
						4600.6(o) of the
						Code, the organization shall file a written statement with the Administrative
						Director identifying the deficiency and describing the action taken to correct
						the deficiency and the results of such action. The report shall be signed by a
						principal officer of the organization.
Where such deficiencies reasonably may be adjudged to
						require long-term corrective action or to be of a nature which reasonably may
						be expected to require a period longer than 30 days to remedy, evidence that
						the organization has initiated remedial action and is on the way to achieving
						acceptable levels of compliance may be submitted for review by the
						Administrative Director.
1. New
						section filed 4-15-98; operative 4-15-98. Submitted to OAL for printing only
						pursuant to Stats. 1997, Ch. 346, Section
						5 (Register 98, No.
						16).
Note: Authority cited: Stats. 1997, Ch. 346, Section
						  5. Reference: Sections
						  4600.3,
						  4500.5 and
						  4600.6, Labor
						  Code.
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 4 - Certification Standards for Health Care Organizations › Section 9771.78 - Removal of Books and Records from State

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
The books and records of an organization, management
						company, solicitor firm, and any provider or subcontractor providing workers'
						compensation health care or other services to an organization, management
						company, or solicitor firm shall not be removed from this state without the
						prior written consent of the Administrative Director.
1. New
						section filed 4-15-98; operative 4-15-98. Submitted to OAL for printing only
						pursuant to Stats. 1997, Ch. 346, Section
						5 (Register 98, No.
						16).
Note: Authority cited: Stats. 1997, Ch. 346, Section
						  5. Reference: Sections
						  4600.3,
						  4500.5 and
						  4600.6, Labor
						  Code.
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 4 - Certification Standards for Health Care Organizations › Section 9771.79 - Examination Procedure

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
Regular and additional or nonroutine examinations
						conducted by the Administrative Director pursuant to Section
						4600.6(q) of the
						Code will ordinarily be commenced on an unannounced basis. To the extent
						feasible, deficiencies noted will be called to the attention of the responsible
						officers of the company under examination during the course of the examination,
						and in that event the company should take the corrective action indicated. When
						deemed appropriate, the company will be advised by letter of the deficiencies
						noted upon the examination. If the deficiency letter requires a report from the
						organization, such report must be furnished within 15 days or such additional
						time as may be allowed.
1. New
						section filed 4-15-98; operative 4-15-98. Submitted to OAL for printing only
						pursuant to Stats. 1997, Ch. 346, Section
						5 (Register 98, No.
						16).
Note: Authority cited: Stats. 1997, Ch. 346, Section
						  5. Reference: Sections
						  4600.3,
						  4500.5 and
						  4600.6, Labor
						  Code.
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 4 - Certification Standards for Health Care Organizations › Section 9771.80 - Additional or Nonroutine Examinations and Surveys

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a) An examination or survey is additional or
					 nonroutine for good cause for the purposes of Section
					 4600.6(q) of the
					 Code when the reason for such examination or survey is any of the following:
(1) The organization's noncompliance with
					 written instructions from the Administrative Director;
(2) The organization has violated, or the
					 Administrative Director has reason to believe that the organization has
					 violated, any of the provisions of Sections
					 4600.3,
					 4600.5, or
					 4600.6 of the Code or regulations
					 referring to those sections.
(3)
					 The organization has committed, or the Administrative Director has reason to
					 believe that the organization has committed, any of the acts or omissions
					 enumerated in Section
					 4600.5(k) of the
					 Code.
(4) The Administrative
					 Director deems such additional or nonroutine examination or survey necessary to
					 verify representations made to the Administrative Director by an organization
					 in response to a deficiency letter.
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 4 - Certification Standards for Health Care Organizations › Section 9771.81 - Financial Statements

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a) Whenever pursuant to these rules or
					 pursuant to an order or request of the Administrative Director under the Code a
					 financial statement or other report is required to be audited or be accompanied
					 by the opinion of a certified public accountant, such accountant shall be
					 independent of the licensee, determined in accordance with Section
					 602.02 of Financial Reporting
					 Release No. 1 issued by the Securities and Exchange Commission (Securities Act
					 Release 6395, April 15, 1982).
(b)
					 The financial statements shall be audited by an independent accountant in
					 accordance with Rule 9771.60(e).
(c) Except as provided in subsection (d),
					 financial statements of an organization required pursuant to these rules must
					 be on a combining basis with an affiliate, if the organization or such
					 affiliate is substantially dependent upon the other for the provision of
					 workers' compensation health care, management or other services. An affiliate
					 will normally be required to be combined, regardless of its form of
					 organization, if the following conditions exist:
(1) The affiliate controls, is controlled by,
					 or is under common control with, the organization, either directly or
					 indirectly (see subsections (c) and (d) of Rule 9771.60), and
(2) The organization or the affiliate is
					 substantially dependent, either directly or indirectly, upon the other for
					 services or revenue.
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 4 - Certification Standards for Health Care Organizations › Section 9771.82 - Books and Records

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a)
					 Each organization, solicitor firm, and solicitor shall keep and maintain their
					 books of account and other records on a current basis.
(b) Each organization shall make or cause to
					 be made and retain books and records which accurately reflect:
(1) The names and last known addresses of all
					 employees eligible to receive workers' compensation health care, and all
					 contracting self-insured employers, groups of self-insured employers and
					 insurers of employers.
(2) All
					 contracts required to be submitted to the Administrative Director and all other
					 contracts entered into by the organization.
(3) All requests made to the organization for
					 payment of moneys for workers' compensation health care, the date of such
					 requests, and the dispositions thereof.
(4) A current list of the names and addresses
					 of all individuals employed by the organization as solicitors.
(5) A current list of the names and addresses
					 of all solicitor firms with which the organization contracts.
(6) A current list of the names and addresses
					 of all of the organization's officers, directors, principal shareholders,
					 general managers, and other principals.
(7) The amount of any commissions paid to
					 persons who obtain self-insured employers, groups of self-insured employers,
					 and insurers of employers for workers' compensation health care provider
					 organizations, and the manner in which said commissions are
					 determined.
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 4 - Certification Standards for Health Care Organizations › Section 9771.83 - Retention of Books and Records

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
Every organization and solicitor firm shall preserve for
						a period of not less than five years, the last two years of which shall be in
						an easily accessible place at the offices of the organization or solicitor
						firm, the books of account and other records required under the provisions, and
						for the purposes, of the Act. After such books and records have been preserved
						for two years, they may be warehoused or stored, or microfilmed, subject to
						their availability to the Administrative Director within not more than 5 days
						after request therefore.
1. New
						section filed 4-15-98; operative 4-15-98. Submitted to OAL for printing only
						pursuant to Stats. 1997, Ch. 346, Section
						5 (Register 98, No.
						16).
Note: Authority cited: Stats. 1997, Ch. 346, Section
						  5. Reference: Sections
						  4600.3,
						  4500.5 and
						  4600.6, Labor
						  Code.
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 4 - Certification Standards for Health Care Organizations › Section 9773.1 - Referrals to Chiropractors

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
HCOs shall maintain guidelines for chiropractor care in
						accordance with paragraph (2) of subdivision (1) of Section
						4600.5 of the
						Labor Code. The HCO must include a description of the HCO's guidelines and
						utilization review process for chiropractic care, including the HCO's
						definition of "neuromusculoskeletal condition", and the procedure whereby
						enrollees may be referred to chiropractors in accordance with the HCO's
						guidelines.
1. New
						section filed 12-31-93; operative 1-1-94. Submitted to OAL for printing only
						pursuant to Government Code section
						11351
						(Register 93, No. 53).
Note: Authority cited: Sections
						  133,
						  4600.5,
						  4603.5 and
						  5307.3, Labor
						  Code. Reference: Section
						  3209.3,
						  4600 and
						  4600.5, Labor
						  Code.
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 4 - Certification Standards for Health Care Organizations › Section 9774 - Quality of Care

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a) An HCO
					 must include a written program designed to ensure a level of care for
					 occupational injuries and illnesses which meets professionally recognized
					 standards of care. The program must be designed and directed by providers to
					 document that the quality of care provided is reviewed, that problems are
					 identified, that effective action is taken to improve care where deficiencies
					 are identified, that follow-up measures are planned where indicated, and that
					 all of the requirements of this division are met. The plans must describe the
					 goals and objectives of the program and organizational arrangements, including
					 staffing, the methodology for on-going monitoring and evaluation of health
					 services, the scope of the program, and required levels of activity. Quality of
					 care problems must be identified and corrected. The program must demonstrate
					 that the HCO's utilization review activities are designed to improve the
					 quality of care provided.
The HCO shall describe and implement a program, including
						the following:
(1) A description of
					 the process whereby the medical reasonableness or medical necessity of requests
					 for authorization are reviewed and decisions on such requests are made by the
					 HCO. The description shall include the specific criteria utilized in the review
					 and throughout the decision-making process, including treatment protocols or
					 standards in any software, database, or other resource used in the process.
					 Treatment protocols must be consistent with any guidelines adopted pursuant to
					 paragraph (8) of subdivision (e) of Section
					 139 of the
					 Labor Code.
(2) A description of
					 the qualifications of the personnel involved in reviewing and making decisions
					 concerning requests for authorization, including the professional
					 qualifications of the personnel, and the manner in which such personnel are
					 involved in the review process. Medical decisions must be rendered by
					 physicians with licenses unrestricted by their licensing board.
(3) A description of manual and automated
					 data storage and retrieval systems for medical and utilization review; and the
					 types of data analyses, reports, and manner in which results are communicated
					 to providers.
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 4 - Certification Standards for Health Care Organizations › Section 9776 - Workplace Safety and Health

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a) The HCO must maintain the capability to
					 work cooperatively and in conjunction with claims administrators, employers,
					 and employees to promote workplace health and safety and to detect workplace
					 exposures and hazards, including:
(1)
					 education of employees and employers on health and medical aspects of workplace
					 health and safety issues;
(2)
					 consultation on employee medical screening for early detection of occupational
					 disease, and assessment of workplace risk factors.
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 4 - Certification Standards for Health Care Organizations › Section 9776.1 - Return to Work Coordination

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
An HCO shall maintain a return to work program in
						conjunction with the employer and claims administrator to facilitate and
						coordinate returning injured workers to the workplace, to assess the
						feasibility and availability of modified work or modified duty, and to minimize
						risk of employee exposure after return to work to risk factors which may
						aggravate or cause recurrence of injury. The duties of the HCO shall be
						specified in the contract between the HCO and the claims
						administrator.
1. New
						section filed 12-31-93; operative 1-1-94. Submitted to OAL for printing only
						pursuant to Government Code section
						11351
						(Register 93, No. 53).
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 4 - Certification Standards for Health Care Organizations › Section 9777 - Patient Assistance and Notification

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a) The HCO shall inform HCO enrollees upon
					 enrollment in the plan and annually thereafter of the details of their
					 coverage, and their rights and options under the HCO including:
(1) how HCO enrollees are informed of the
					 procedure for processing and resolving grievances, including the location(s)
					 and telephone number where grievances may be submitted; and
(2) how HCO enrollees are informed of their
					 right to file a complaint with the administrative director in accordance with
					 subdivision (d) of Section
					 9775.
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 4 - Certification Standards for Health Care Organizations › Section 9778 - Evaluation

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a) The HCO must
					 include a timely and accurate method to report to the administrative director
					 the following information, in a standardized format to be prescribed by the
					 administrative director:
(1) Aggregated
					 information on the number of HCO enrollees and their age, sex, geographical
					 distribution, occupation, and SIC, by federal employer identification
					 number.
(2) Information required to
					 be provided pursuant to this section shall be made available by the HCO to the
					 administrative director, in a form and manner to be prescribed by the
					 administrative director, annually, on March 1.
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 4 - Certification Standards for Health Care Organizations › Section 9779 - Certification

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a) Once an
					 applicant has completed an application and submitted a fee in accordance with
					 Section 9771 and has demonstrated to the
					 administrative director that its organization has met all of the criteria for
					 certification, the administrative director will certify the organization as an
					 HCO for a period of three years, unless earlier revoked or suspended.
(b) Once the Administrative Director has
					 determined that an entity licensed as a full service health care service plan
					 under Section
					 1353
					 of the Health and Safety Code (a Knox-Keene Health Care Service Plan Act) and
					 deemed to be an HCO pursuant to Labor Code Section
					 4600.5(c)
					 has complied with the requirements of Section
					 9771 subsections (g)(1) and (2) the
					 administrative director shall certify the organization as an HCO, pursuant to
					 Section 4600.5(c), for a
					 period of three years unless earlier revoked or suspended.
(c) A certification shall state that a
					 particular entity is certified as a health care organization to provide health
					 care to injured employees for injuries and diseases and other services in
					 accordance with the terms of the entity's application. The certification shall
					 also state:
(1) the geographic service area
					 in which the health care organization is permitted to provide health
					 care,
(2) the maximum number of
					 enrollees,
(3) the name or names
					 under which the health care organization is permitted to provide health
					 care,
(4) the date of expiration of
					 the certification, and
(5) any other
					 conditions or limitations.
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 4 - Certification Standards for Health Care Organizations › Section 9779.1 - On-Site Surveys

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a)
					 The HCO must ensure that it will be available for and cooperate with on-site
					 surveys as the administrative director deems necessary to insure compliance
					 with this article, including during the initial certification process. The
					 administrative director will coordinate on-site surveys with the Department of
					 Managed Health Care to the extent feasible.
(b) The administrative director will notify
					 the HCO of deficiencies found by the survey team. The administrative director
					 will provide the HCO a reasonable time to correct the deficiencies. Failure on
					 the part of the HCO to timely correct noted deficiencies may result in
					 suspension or revocation of an HCO's certification in accordance with Section
					 9779.2.
(c) Reports of all surveys shall be open to
					 public inspection, except that no survey shall be made public unless the HCO
					 has had an opportunity to review the survey and file a statement in response
					 within 30 days, to be attached to the report. Deficiencies shall not be made
					 public if they are corrected within 30 days of the date that the HCO was
					 notified.
(d) Non-routine audits
					 will be charged based on the actual cost for performing the audit. The amount
					 shall include the actual salaries or compensation paid to the persons making
					 the audit, the expenses incurred in the course thereof, and overhead costs in
					 connection therewith as fixed by the Administrative Director. Overhead costs
					 shall be based on the total expenditure for operating expenses and equipment,
					 except travel, of the managed care unit of the Division of Workers'
					 Compensation for the previous fiscal year. The invoice will be sent upon the
					 completion of the audit and shall be paid within 30 calendar days.
1. New
						section filed 12-31-93; operative 1-1-94. Submitted to OAL for printing only
						pursuant to Government Code section
						11351
						(Register 93, No. 53).
2. Editorial correction of section heading
						(Register 96, No. 7).
3. New subsection (d) and amendment of NOTE
						filed 2-14-96; operative 2-14-96. Submitted to OAL for printing only pursuant
						to Government Code section
						11351
						(Register 96, No. 7).
4. Amendment of subsection (a) filed 1-9-2003;
						operative 1-9-2003 pursuant to Government Code section
						11343.4
						(Register 2003, No. 2).
Note: Authority cited: Sections
						  133,
						  4600.5,
						  4600.7,
						  4603.5 and
						  5307.3, Labor
						  Code. Reference: Sections
						  4600,
						  4600.5 and
						  4600.7, Labor
						  Code.
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 4 - Certification Standards for Health Care Organizations › Section 9779.2 - Suspension; Revocation; Hearing

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a) Complaints pertaining to an HCO's
					 violations of this article may be directed in writing to the administrative
					 director. Upon receipt of a complaint, or in the course of monitoring the HCO's
					 operations, the administrative director may investigate an alleged violation.
					 The investigation may include, but not be limited to, a request for and review
					 of pertinent HCO records, interviewing medical and administrative personnel, or
					 an on-site medical survey. If the investigation reveals reasonable cause to
					 belive that the HCO has violated a requirement of this article, the
					 administrative director may initiate proceedings to suspend or revoke an HCO's
					 certification.
(b) Certification of
					 an HCO may be suspended or revoked if:
(1)
					 Service under the HCO is not being provided according to the terms of the
					 certified HCO.
(2) The HCO fails to
					 meet the requirements of this article, the Labor Code, or other applicable
					 law.
(3) False or misleading
					 information is knowingly or repeatedly submitted by the HCO or a participating
					 provider or the HCO knowingly or repeatedly fails to report information
					 required by this article.
(4) The
					 HCO knowingly continues to use the services of a provider or medical reviewer
					 whose license, registration, or certification has been suspended or revoked or
					 who is otherwise ineligible to provide treatment to an inured worker under
					 California law.
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 4 - Certification Standards for Health Care Organizations › Section 9779.4 - DWC Form 1194

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
Click
						here to view image
Click
						here to view image
1. New
						section filed 3-27-95; operative 3-27-95. Submitted to OAL for printing only
						pursuant to Government Code section
						11351
						(Register 95, No. 13).
2. Amendment filed 1-9-2003; operative
						1-9-2003 pursuant to Government Code section
						11343.4
						(Register 2003, No. 2).
Note: Authority cited: Sections
						  133,
						  4600.5,
						  4603.5 and
						  5307.3, Labor
						  Code. Reference: Sections
						  4600 and
						  4600.5, Labor
						  Code.