California Code of Regulations › Title 10 - Investment › Chapter 5 - Insurance Commissioner › Subchapter 3 - Insurers › Article 20 - Standards Applicable to Workers' Compensation Claims Adjusters and Medical Billing Entities and Certification of those Standards by Insurers › Section 2592.01 - Definitions

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
As used in this article:
(a) "Certify" means a written statement made
				  under penalty of perjury.
(b)
				  "Claims adjuster" means a person who, on behalf of an insurer, including an
				  employee or agent of an entity that is not an insurer, is responsible for
				  determining the validity of a workers' compensation claim. The claims adjuster
				  may also establish a case reserve, approve and process all workers'
				  compensation benefits, may hire investigators, attorneys or other professionals
				  and may negotiate settlements of claims. "Claims adjuster" also means a person
				  who is responsible for the immediate supervision of a claims adjuster but does
				  not mean an attorney representing the insurer or a person whose primary
				  function is clerical. "Claims adjuster" also includes an experienced claims
				  adjuster. "Claims adjuster" does not include the medical director or physicians
				  utilized by an insurer for the utilization review process pursuant to Labor
				  Code section
				  4610.
(c) "Classroom" means any space sufficiently
				  designed so that the instructor and students can communicate with a high degree
				  of privacy and relative freedom from outside interference. The instructor or
				  the person or persons assisting the instructor may be physically present or may
				  communicate with students by means of an electronic medium, including, but not
				  limited to, audio, video, computer, or Internet.
(d) "Course" means any program of instruction
				  taken or given to satisfy the requirements of Insurance Code Section
				  11761.
(e) "Curriculum" means a course of study that
				  satisfies the requirements of Insurance Code Section
				  11761. The
				  curriculum must provide sufficient content, including time allocated to each
				  subject area, to enable claims adjusters, medical-only claims adjusters, and
				  medical bill reviewers to meet minimum standards of training, experience, and
				  skill to perform their duties with regard to workers' compensation
				  claims.
(f) "Experienced claims
				  adjuster" means a person who has had at least five (5) years within the past
				  eight (8) years of on-the-job experience adjusting California workers'
				  compensation claims or supervising claims adjusters handling California
				  workers' compensation claims and is designated as an experienced claims
				  adjuster by an insurer. A person who has successfully completed the written
				  examination specified by Title 8, Section
				  15452 of the California Code of
				  Regulations is also considered an experienced claims adjuster, provided that he
				  or she has either (1) worked as a workers' compensation claims adjuster or
				  supervised workers' compensation claims adjusters continuously since passing
				  the examination and is designated as an experienced claims adjuster by an
				  insurer or (2) passed the examination within the previous five (5) years and is
				  designated as an experienced claims adjuster by an insurer. "Experienced claims
				  adjuster" also includes a person who has already been trained and designated a
				  claims adjuster and now meets the requirements of experience or examination
				  completion noted above and is designated an experienced claims adjuster by an
				  insurer.
(g) "Experienced
				  medical-only claims adjuster" means a person who has had at least three (3)
				  years within the past five (5) years of on-the-job experience adjusting
				  California workers' compensation medical-only claims and is designated as an
				  experienced medical-only claims adjuster by an insurer.
(h) "Experienced medical bill reviewer" means
				  a person who has had at least three (3) years within the past five (5) years of
				  on-the-job experience reviewing California workers' compensation medical bills
				  and is designated as an experienced medical bill reviewer by a medical billing
				  entity or by an insurer.
(i)
				  "Instructor" means a person who conveys curriculum content to students on
				  behalf of an insurer, a training entity, or a medical billing entity. An
				  instructor shall have had at least five (5) years within the past eight (8)
				  years of on-the-job experience adjusting California workers' compensation
				  claims and have been designated as a claims adjuster by an insurer or be an
				  individual who has had at least eight (8) years of experience in California
				  workers' compensation within the past twelve (12) years. Persons knowledgeable
				  about specific workers' compensation issues who are not instructors may train
				  students under the direction of an instructor.
(j) "Insurer" means an insurance company
				  admitted to transact workers' compensation insurance in California, the State
				  Compensation Insurance Fund, an employer that has secured a certificate of
				  consent to self-insure from the Department of Industrial Relations pursuant to
				  Labor Code Section
				  3700(b) or
				  (c), or a third party administrator that has
				  secured a certificate of consent pursuant to Labor Code Section
				  3702.1.
(k) "Medical bill reviewer" means a person
				  who is not a claims adjuster or medical-only claims adjuster and who only
				  reviews or adjusts workers' compensation medical bills on behalf of an insurer,
				  including employees or agents of the insurer or employees or agents of a
				  medical billing entity. "Medical bill reviewer" also includes an experienced
				  medical bill reviewer.
(l) "Medical
				  billing entity" means a third party that reviews or adjusts workers'
				  compensation medical bills for insurers.
(m) "Medical-only claims adjuster" means a
				  person who, on behalf of an insurer, including an employee or agent of an
				  entity that is not an insurer, is responsible for determining the validity of
				  workers' compensation claims only involving medical workers' compensation
				  benefits, as defined under Article 2 (commencing with Labor Code section
				  4600) of
				  Chapter 2 of Part 2 of Division 4 of the Labor Code. The medical-only claims
				  adjuster may also establish medical treatment reserves, approve and process
				  medical benefits, and negotiate settlement of medical benefit claims.
				  "Medical-only claims adjuster" also means a person who is responsible for the
				  immediate supervision of a medical-only claims adjuster but does not mean an
				  attorney representing the insurer or a person whose primary function is
				  clerical. "Medical-only claims adjuster" also includes an experienced
				  medical-only claims adjuster. "Medical-only claims adjuster" does not include
				  the medical director or physicians utilized by an insurer for the utilization
				  review process pursuant to Labor Code section
				  4610.
(n) "Post-designation training" means a
				  course of study provided to trained or experienced workers' compensation claims
				  adjusters and medical-only claims adjusters who have been designated by an
				  insurer or provided to trained or experienced medical bill reviewers who have
				  been designated by an insurer or medical billing entity. Post-designation
				  training also includes seminars, workshops, or other informational meetings
				  pertaining to California workers' compensation.
(o) "Student" or "trainee" means an
				  individual taking a course that is required for that person in order to be a
				  workers' compensation claims adjuster, medical-only claims adjuster, or medical
				  bill reviewer.
(p) "Training" means
				  to provide a course of instruction that includes the topics specified in
				  Sections 2592.03 and
				  2592.04.
(q) "Training entity" means any person or
				  organization that provides instructors or curriculum to an insurer or medical
				  billing entity.
1. New
					 section filed 1-23-2006; operative 2-22-2006 (Register 2006, No.
					 4).
Note: Authority cited: Section
						11761,
						Insurance Code. Reference: Section
						11761,
						Insurance Code.