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 3.6 - Independent Medical Review › Section 9768.9 - Procedure for Requesting an Independent Medical Review

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a) If a covered employee disputes the
					 diagnostic service, diagnosis, or medical treatment prescribed by the second
					 opinion physician, the injured employee may seek the opinion of a third
					 physician in the MPN. The covered employee and the employer or insurer shall
					 comply with the requirements of section
					 9767.7(d).
					 Additionally, at the time of the selection of the physician for a third
					 opinion, the MPN Contact shall notify the covered employee about the
					 Independent Medical Review process and provide the covered employee with an
					 "Independent Medical Review Application" form set forth in section
					 9768.10. The MPN Contact shall fill
					 out the "MPN Contact Section" of the form and list the specialty of the
					 treating physician and an alternative specialty, if any, that is different from
					 the specialty of the treating physician.
(b) If a covered employee disputes either the
					 diagnostic service, diagnosis or medical treatment prescribed by the third
					 opinion physician, the covered employee may request an Independent Medical
					 Review by filing the completed Independent Medical Review Application form with
					 the Administrative Director. The covered employee shall complete the "employee
					 section" of the form, indicate on the form whether he or she requests an
					 in-person examination or record review, and may list an alternative specialty,
					 if any, that is different from the specialty of the treating
					 physician.
(c) The Administrative
					 Director shall select an IMR with an appropriate specialty within ten business
					 days of receiving the Independent Medical Review Application form. The
					 Administrative Director's selection of the IMR shall be based on the specialty
					 of the treating physician, the alternative specialties listed by the covered
					 employee and the MPN Contact, and the information submitted with the
					 Independent Medical Review Application.
(d) If the covered employee requests an
					 in-person examination, the Administrative Director shall randomly select a
					 physician from the panel of available Independent Medical Reviewers, with an
					 appropriate specialty, who has an office located within thirty miles of the
					 employee's residence address, to be the Independent Medical Reviewer. If there
					 is only one physician with an appropriate specialty within thirty miles of the
					 employee's residence address, that physician shall be selected to be the
					 Independent Medical Reviewer. If there are no physicians with an appropriate
					 specialty who have offices located within thirty miles of the employee's
					 residence address, the Administrative Director shall search in increasing five
					 mile increments, until one physician is located. If there are no available
					 physicians with this appropriate specialty, the Administrative Director may
					 choose another specialty based on the information submitted.
(e) If the covered employee requests a record
					 review, then the Administrative Director shall randomly select a physician with
					 an appropriate specialty from the panel of available Independent Medical
					 Reviewers to be the IMR. If there are no physicians with an appropriate
					 specialty, the Administrative Director may choose another specialty based on
					 the information submitted.
(f) The
					 Administrative Director shall send written notification of the name and contact
					 information of the IMR to the covered employee, the employee's attorney, if
					 any, the MPN Contact and the IMR. The Administrative Director shall send a copy
					 of the completed Independent Medical Review Application to the IMR.
(g) The covered employee, MPN Contact, or the
					 selected IMR can object within 10 calendar days of receipt of the name of the
					 IMR to the selection if there is a conflict of interest as defined by section
					 9768.2. If the IMR determines that
					 he or she does not practice the appropriate specialty, the IMR shall withdraw
					 within 10 calendar days of receipt of the notification of selection. If this
					 conflict is verified or the IMR withdraws, the Administrative Director shall
					 select another IMR from the same specialty. If there are no available
					 physicians with the same specialty, the Administrative Director may select an
					 IMR with another specialty based on the information submitted and in accordance
					 with the procedure set forth in subdivision (d) for an in-person examination
					 and subdivision (e) for a record review.
(h) If the covered employee requests an
					 in-person exam, within 60 calendar days of receiving the name of the IMR, the
					 covered employee shall contact the IMR to arrange an appointment. If the
					 covered employee fails to contact the IMR for an appointment within 60 calendar
					 days of receiving the name of the IMR, then the employee shall be deemed to
					 have waived the IMR process with regard to this disputed diagnosis or treatment
					 of this treating physician. The IMR shall schedule an appointment with the
					 covered employee within 30 calendar days of the request for an appointment,
					 unless all parties agree to a later date. The IMR shall notify the MPN Contact
					 of the appointment date.
(i) The
					 covered employee shall provide written notice to the Administrative Director
					 and the MPN Contact if the covered employee decides to withdraw the request for
					 an Independent Medical Reviewer.
(j) During this process, the employee shall
					 remain within the MPN for treatment pursuant to section
					 9767.6.
1. New
						section filed 12-31-2004 as an emergency; operative 1-1-2005 (Register 2004,
						No. 53). A Certificate of Compliance must be transmitted to OAL by 5-2-2005 or
						emergency language will be repealed by operation of law on the following
						day.
2. Certificate of Compliance as to 12-31-2004 order, including
						amendment of section, transmitted to OAL 4-29-2005 and filed 6-10-2005
						(Register 2005, No. 23).
Note: Authority cited: Sections
						  133 and
						  4616, Labor
						  Code. Reference: Sections
						  4616.3 and
						  4616.4, Labor
						  Code.