California Code of Regulations › Title 8 - Industrial Relations › Division 1 - Department of Industrial Relations › Chapter 4.5 - Division of Workers' Compensation › Subchapter 2 - Workers' Compensation Appeals Board-Rules and Practice Procedure › Article 13 - Hearings › Section 10786 - Determination of Medical-Legal Expense Dispute

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a) Within 60 days of service of a
					 medical-legal provider objection to a denial of all or a portion of the
					 medical-legal provider's billing pursuant to Labor Code section
					 4622(c),
					 the defendant shall file and serve a petition for determination of
					 medical-legal expenses and a Declaration of Readiness to Proceed. Upon filing
					 of a Declaration of Readiness to Proceed, the medical-legal provider shall be
					 added to the official address record.
(b) If a defendant has failed to file and
					 serve a petition for determination of medical-legal expenses and a Declaration
					 of Readiness in compliance with subdivision (a), a medical-legal provider may
					 file and serve a petition for reimbursement of medical-legal expenses and a
					 Declaration of Readiness to Proceed. Upon filing of a petition for
					 reimbursement of medical-legal expenses and a Declaration of Readiness to
					 Proceed, the medical-legal provider shall be added to the official address
					 record.
(c) Upon receipt of a
					 Declaration of Readiness in accordance with the provisions of subdivisions (a)
					 and (b) of this rule, the matter shall be set for either a status conference or
					 a mandatory settlement conference, in the discretion of the workers'
					 compensation judge.
(d)
					 Notwithstanding any other provision of this rule, if there is a threshold issue
					 relating to the case in chief that would entirely defeat the medical-legal
					 expense claim that must be determined prior to adjudicating the medical-legal
					 expense claim dispute, the Workers' Compensation Appeals Board may defer
					 hearing and determining the medical-legal expense claim dispute until the
					 underlying claim of the employee or dependent has been resolved or
					 abandoned.
(e) A defendant shall be
					 deemed to have waived all objections to a medical-legal provider's billing,
					 other than compliance with Labor Code sections
					 4620 and
					 4621, if:
(1) The provider submitted a properly
					 documented billing to the defendant and, within 60 days thereafter, the
					 defendant failed to serve an explanation of review (EOR) that complies with
					 Labor Code section
					 4603.3 and any
					 applicable regulations adopted by the Administrative Director; or
(2) The defendant failed to make payment
					 consistent with an explanation of review (EOR) that complies with Labor Code
					 section
					 4603.3 and any
					 applicable regulations adopted by the Administrative Director; or
(3) The provider submitted a timely and
					 proper request for a second review to the defendant and, within 14 days
					 thereafter, the defendant failed to serve a final written determination that
					 complies with any applicable regulations adopted by the Administrative
					 Director; or
(4) The defendant
					 failed to make payment consistent with a final written determination that
					 complies with any applicable regulations adopted by the Administrative
					 Director.