California Code of Regulations › Title 8 - Industrial Relations › Division 1 - Department of Industrial Relations › Chapter 8 - Office of the Director › Subchapter 2 - Administration of Self-Insurance Plans › Article 6 - Estimating Work Injury Claims and Medical Reports › Section 15300 - Estimating and Reporting Work Injury Claims

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a) A list of open indemnity claims shall be
					 submitted with each self insurer's annual report as required by Section
					 15251(b)(5)(A)-(B) and
					 (c)(2)(A)-(B).
(b) The administrator shall set a realistic
					 estimate of future liability for each indemnity claim listed on the self
					 insurer's annual report based on computations which reflect the probable total
					 future cost of compensation and medical benefits due or that can reasonably be
					 expected to be due over the life of the claim. Each estimate listed on the self
					 insurer's annual report shall be based on information in possession of the
					 administrator at the-ending date of the period of time covered by the annual
					 report. Estimated future liabilities listed on the annual report must represent
					 the probable total future cost of compensation for the injury or disease based
					 on information documented as in possession of the administrator at the ending
					 date of the period of time covered by the annual report. In setting estimates
					 of future liability, the administrator shall adhere to the following
					 principles:
(1) Each estimate of future
					 liability shall separately reflect an indemnity component and a medical
					 component. The indemnity component shall include the estimated future cost of
					 all temporary disability, permanent disability, death benefits including burial
					 costs, supplemental job displacement benefit voucher and vocational
					 rehabilitation including vendor costs. The medical component shall include the
					 estimated future cost of all medical treatment, including costs of medical cost
					 containment programs if those costs are allocated to the particular claim, and
					 the estimated future cost of medical evaluations. On or after July 1, 2012 for
					 public self insurers and on or after January 1, 2012 for private self insurers,
					 the medical component shall not include the cost of medical cost containment
					 programs incurred with respect to a particular claim or which can be allocated
					 to a particular claim whether done by an outside vendor or by the self insurer.
					 These costs shall be included as allocated loss adjustment expense amount. Any
					 medical cost containment program costs that cannot be allocated to a particular
					 claim shall be considered unallocated loss adjustment expenses.
NOTE: Medical cost containment program costs include but
						are not limited to:
(A) Bill audit
					 expenses for any medical service rendered, such as hospital bills, nursing home
					 bills, physician bills, chiropractic bills, medical equipment charges, pharmacy
					 charges, physical therapy bills, and medical vendor bills;
(B) Hospital and other treatment utilization
					 reviews including precertification/preadmission, and concurrent or
					 retrospective reviews; and
(C)
					 Access fees and other expenses incurred with respect to managed care
					 organizations, such as, preferred provider networks/organizations (PPOs),
					 medical provider networks (MPNs), pharmacy benefit networks, and Health Care
					 Organizations (HCOs).
Estimates of future liability shall include any increases
						in compensation in either the indemnity or medical component reasonably
						expected to be payable pursuant to Labor Code Sections
						132a,
						4553, and/or
						5814.