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 5.5.1 - Utilization Review Standards › Section 9792.12 - Administrative Penalty Schedule for Utilization Review and Independent Medical Review Violations

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a) Mandatory Utilization Review
					 Administrative Penalties. Notwithstanding Labor Code section
					 129.5(c)(1) through
					 (c)(3), the penalty amount that shall be
					 assessed for each failure to comply with the utilization review process
					 required by Labor Code section
					 4610, and
					 sections 9792.6 through
					 9792.12 of Title 8 of the
					 California Code of Regulations, is:
(1) For
					 failure to establish a Labor Code section
					 4610
					 utilization review plan: $50,000;
(2) For failure to include all of the
					 requirements of section
					 9792.7(a) in the
					 utilization review plan: $5,000;
(3) For failure to file the utilization
					 review plan or a letter in lieu of a utilization review plan with the
					 Administrative Director as required by section
					 9792.7(c):
					 $10,000;
(4) For failure to file a
					 modified utilization review plan with the Administrative Director within 30
					 calendar days after the claims administrator makes a material modification to
					 the plan as required by section
					 9792.7(c):
					 $5,000;
(5) For failure to employ
					 or designate a physician as a medical director, as defined in section
					 9792.6 (
l
), of the
					 utilization review process, as required by section
					 9792.7(b):
					 $50,000;
(6) For issuance of a
					 decision to modify or deny a request for authorization regarding a medical
					 treatment, procedure, service or product where the requested treatment,
					 procedure or service is not within the reviewer's scope of practice (as set
					 forth by the reviewer's licensing board): $25,000;
(7) For failure to comply with the
					 requirement that only a licensed physician may modify, delay, or deny requests
					 for authorization of medical treatment for reasons of medical necessity to cure
					 or relieve, except as provided for in Labor Code section
					 4604.5(c):
					 $25,000;
(8) For failure of a
					 non-physician reviewer (person other than a reviewer, expert reviewer or
					 medical director as defined in section
					 9792.6 of Title 8 of the California
					 Code of Regulations), who approves an amended request without documenting the
					 amended request as provided under section
					 9792.7(b)(3) when
					 a physician has voluntarily withdrawn a request in order to submit an amended
					 request: $1,000;
(9) For failure to
					 communicate the decision in response to a request for an expedited review, as
					 defined in section
					 9792.6(g), in a
					 timely fashion, as required by section
					 9792.9 and section
					 9792.9.1: $15,000;
(10) For failure to approve the request for
					 authorization solely on the basis that the condition for which treatment was
					 requested is not addressed by the medical treatment utilization schedule
					 adopted pursuant to section
					 5307.27 of the
					 Labor Code: $5,000;
(11) For
					 failure to discuss or document attempts to discuss reasonable options for a
					 care plan with the requesting physician as required by Labor Code section
					 4610(g)(3)(B),
					 prior to denying authorization of or discontinuing medical care, in the case of
					 concurrent review: $10,000;
(12)
					 For failure to respond to a complete DWC Form RFA or other request for
					 authorization accepted by a claims administrator under section
					 9792.9.1(c)(2)
					 submitted by the injured employee's requesting treating physician, in the case
					 of a non-expedited concurrent review: $ 2,000;
(13) For failure to respond to a complete DWC
					 Form RFA or other request for authorization accepted by a claims administrator
					 under section
					 9792.9.1(c)(2)
					 submitted for authorization by the injured employee's requesting treating
					 physician, in the case of a non-expedited prospective review: $
					 1,000;
(14) For failure to respond
					 to a complete DWC Form RFA or other request for authorization accepted by a
					 claims administrator under section
					 9792.9.1(c)(2)
					 submitted by the injured employee's requesting treating physician, in the case
					 of a retrospective review: $ 500;
(15) For failure to disclose or otherwise to
					 make available, if requested, the Utilization Review criteria or guidelines to
					 the public, as required by Labor Code section
					 4610,
					 subdivision (f)(5) and section
					 9792.7(d) of Title
					 8 of the California Code of Regulations: $100.
(16) For failure to timely serve the
					 Administrative Director with documentation of compliance pursuant to section
					 9792.11(v)(5):
					 $500.
(17) For failure to timely
					 comply with any compliance requirement listed in the Final Report if no timely
					 answer was filed or any compliance requirement listed in the Determination and
					 Order after any and all appeals have become final: $500.