California Code of Regulations › Title 8 - Industrial Relations › Division 1 - Department of Industrial Relations › Chapter 1 - Division of Workers' Compensation - Qualified Medical Evaluator Regulations › Article 3 - Assignment of Qualified Medical Evaluators, Evaluation Procedure › Section 31.5 - QME Replacement Requests

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a) A
				  replacement QME to a panel, or at the discretion of the Medical Director a
				  replacement of an entire panel of QMEs, shall be selected at random by the
				  Medical Director and provided upon request whenever any of the following
				  occurs:
(1) A QME on the panel issued does not
				  practice in the specialty requested by the party holding the legal right to
				  request the panel.
(2) A QME on the
				  panel issued cannot schedule an examination for the employee within ninety (90)
				  days of the initial request for an appointment, or if the 90 day scheduling
				  limit has been waived pursuant to section
				  31.3(e) of Title 8
				  of the California Code of Regulations, the QME cannot schedule the examination
				  within one-hundred and twenty (120) days of the date of the initial request for
				  an appointment.
(3) The injured
				  worker has changed his or her residence address since the QME panel was issued
				  and prior to date of the initial evaluation of the injured worker.
(4) A physician on the QME panel is a member
				  of the same group practice as defined by Labor Code section
				  139.3 as
				  another QME on the panel.
(5) The
				  QME is unavailable pursuant to section
				  33 (Unavailability of the
				  QME).
(6) The evaluator who
				  previously reported in the case is no longer available.
(7) A QME named on the panel is currently, or
				  has been, the employee's primary treating physician or secondary physician as
				  described in section
				  9785 of Title 8 of the California
				  Code of Regulations for the injury currently in dispute.
(8) The claims administrator, or if none the
				  employer, and the employee agree in writing, for the employee's convenience
				  only, that a new panel may be issued in the geographic area of the employee's
				  work place and a copy of the employee's agreement is submitted with the panel
				  replacement request.
(9) The
				  Medical Director, upon written request, finds good cause that a replacement QME
				  or a replacement panel is appropriate for reasons related to the medical nature
				  of the injury. For purposes of this subsection, "good cause" is defined as a
				  documented medical or psychological impairment.
(10) The Medical Director, upon written
				  request, filed with a copy of the Doctor's First Report of Occupational Injury
				  or Illness (Form DLSR 5021 [see 8 Cal. Code Regs. §§
											14006 and
				  14007] ) and the most recent DWC
				  Form PR-2 ("Primary Treating Physician's Progress Report" [See 8 Cal. Code
				  Regs. §
											9785.2] ) or narrative report filed
				  in lieu of the PR-2, determines after a review of all appropriate records that
				  the specialty chosen by the party holding the legal right to designate a
				  specialty is medically or otherwise inappropriate for the disputed medical
				  issue(s). The Medical Director may request either party to provide additional
				  information or records necessary for the determination.
(11) The evaluator has violated section
				  34 (Appointment Notification and
				  Cancellation) of Title 8 of the California Code of Regulations, except that the
				  evaluator will not be replaced for this reason whenever the request for a
				  replacement by a party is made more than fifteen (15) calendar days from either
				  the date the party became aware of the violation of section
				  34 of Title 8 of the California
				  Code of Regulations or the date the report was served by the evaluator,
				  whichever is earlier.
(12) The
				  evaluator failed to meet the deadlines specified in Labor Code section
				  4062.5 and
				  section 38 (Medical Evaluation Time Frames)
				  of Title 8 of the California Code of Regulations and the party requesting the
				  replacement objected to the report on the grounds of lateness prior to the date
				  the evaluator served the report. A party requesting a replacement on this
				  ground shall attach to the request for a replacement a copy of the party's
				  objection to the untimely report.
(13) The QME has a disqualifying conflict of
				  interest as defined in section
				  41.5 of Title 8 of the California
				  Code of Regulations.
(14) The
				  Administrative Director has issued an order pursuant to section
				  10164(c) of Title
				  8 of the California Code of Regulations (order for additional QME
				  evaluation).
(15) The selected
				  medical evaluator, who otherwise appears to be qualified and competent to
				  address all disputed medical issues refuses to provide, when requested by a
				  party or by the Medical Director, either: A) a complete medical evaluation as
				  provided in Labor Code sections
				  4062.3(i)
				  and
				  4062.3(k),
				  or B) a written statement that explains why the evaluator believes he or she is
				  not medically qualified or medically competent to address one or more issues in
				  dispute in the case.
(16) The QME
				  panel list was issued more than twenty four (24) months prior to the date the
				  request for a replacement is received by the Medical Unit, and none of the QMEs
				  on the panel list have examined the injured worker.