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 9792.10.1 - Utilization Review Standards-Dispute Resolution - on or After January 1, 2013

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
This section applies to any request for authorization of
						medical treatment, made under Article 5.5.1 of this Subchapter, for
						either:
(1) an occupational injury or
					 illness occurring on or after January 1, 2013; or
(2) where the decision on the request is
					 communicated to the requesting physician on or after July 1, 2013, regardless
					 of the date of injury.
(a) If the request for
					 authorization of medical treatment is not approved, or if the request for
					 authorization for medical treatment is approved in part, any dispute shall be
					 resolved in accordance with Labor Code sections
					 4610.5 and
					 4610.6. Neither
					 the employee nor the claims administrator shall have any liability for medical
					 treatment furnished without the authorization of the claims administrator if
					 the treatment is delayed, modified, or denied by a utilization review decision
					 unless the utilization review decision is overturned by independent medical
					 review or the Workers' Compensation Appeals Board under this Article.
(b)
(1) A
					 request for independent medical review must be filed by an eligible party by
					 mail, facsimile, or electronic transmission with the Administrative Director,
					 or the Administrative Director's designee, within 30 days of service of the
					 written utilization review determination issued by the claims administrator
					 under section
					 9792.9.1(e)(5).
					 The request must be made on the Application for Independent Medical Review, DWC
					 Form IMR, and submitted with a copy of the written decision delaying, denying,
					 or modifying the request for authorization of medical treatment. At the time of
					 filing, the employee shall concurrently provide a copy of the signed DWC Form
					 IMR, without a copy of the written decision delaying, denying, or modifying the
					 request for authorization of medical treatment, to the claims
					 administrator.
(2) A party eligible
					 to file a request for independent medical review includes:
(A) The employee or, if the employee is
					 represented, the employee's attorney. If the employee's attorney files the DWC
					 Form IMR, the form must be accompanied by a notice of representation or other
					 document or written designation confirming representation.
(i) An unrepresented employee may designate a
					 parent, guardian, conservator, relative, or other designee of the employee as
					 an agent to act on his or her behalf in filing an application for independent
					 medical review under this subdivision. A designation of an agent executed prior
					 to the utilization review decision shall not be valid.
(ii) The physician whose request for
					 authorization of medical treatment was delayed, denied, or modified may join
					 with or otherwise assist the employee in seeking an independent medical review.
					 The physician may submit documents on the employee's behalf pursuant to section
					 9792.10.5 (b) and
					 may respond to any inquiry by the independent review
					 organization.
(B) A
					 provider of emergency medical treatment when the employee faced an imminent and
					 serious threat to his or her health, including, but not limited to, the
					 potential loss of life, limb, or other major bodily function, may submit an
					 application for independent medical review under this section on its own behalf
					 within 30 days after the service of the utilization review decision that either
					 delays, denies, or modifies the provider's retrospective request for
					 authorization of the emergency medical treatment.
(3) If expedited review is requested for a
					 utilization review decision eligible for independent medical review, the
					 Application for Independent Medical Review, DWC Form IMR, shall include, unless
					 the initial utilization review decision was made on an expedited basis, written
					 certification from the employee's treating physician with documentation
					 confirming that the employee faces an imminent and serious threat to his or her
					 health as described in section
					 9792.6.1(j).
(c)
(1) If
					 at the time of a utilization review decision the claims administrator is also
					 disputing liability for the treatment for any reason besides medical necessity,
					 the time for the employee to submit an application for independent medical
					 review under subdivision (b)(1) is extended to 30 days after service of a
					 notice to the employee showing that the other dispute of liability has been
					 resolved.
(2) If the claims
					 administrator provides the employee with a written utilization review
					 determination modifying, delaying, or denying a treatment request that does not
					 contain the required elements set forth in section
					 9792.9 (
l
) or
					 section 9792.9.1(e) at the
					 time of notification of its utilization review decision, the time limitations
					 for the employee to submit an application for independent medical review under
					 subdivision (b)(1) shall not begin to run until the claims administrator
					 provides the written decision, with all required elements, to the
					 employee.
(d)
(1) Nothing in this section precludes the
					 parties from participating in an internal utilization review appeal process on
					 a voluntary basis provided the employee and, if the employee is represented by
					 counsel, the employee's attorney, have been notified of the 30-day time limit
					 to file an objection to the utilization review decision in accordance with
					 Labor Code sections
					 4610.5 and
					 4610.6. Any
					 request by the injured worker or treating physician for an internal utilization
					 review appeal process conducted under this subdivision must be submitted to the
					 claims administrator within ten (10) days after the receipt of the utilization
					 review decision.
(2) A request for
					 an internal utilization review appeal must be completed, and a determination
					 issued, by the claims administrator within thirty (30) days after receipt of
					 the request under subdivision (d)(1). An internal utilization review appeal
					 shall be considered complete upon the issuance of a final independent medical
					 review determination under section
					 9792.10.6(e) that
					 determines the medical necessity of the disputed treatment.
(3) Any determination by the claims
					 administrator following an internal utilization review appeal that results in a
					 modification of the requested medical treatment shall be communicated to the
					 requesting physician and the injured worker, the injured worker's
					 representative, and if the injured worker is represented by counsel, the
					 injured worker's attorney according to the requirements set forth in section
					 9792.9.1(e). The
					 Application for Independent Medical Review, DWC Form IMR, that accompanies the
					 written decision letter under section
					 9792.9.1(e)(5)(G)
					 must indicate that the decision is a modification after
					 appeal.