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 3.6 - Independent Medical Review › Section 9768.11 - In-Person Examination or Record Review IMR Procedure

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a) The MPN Contact shall send all relevant
					 medical records to the IMR. The MPN Contact shall also send a copy of the
					 documents to the covered employee. The employee may furnish any relevant
					 medical records or additional materials to the Independent Medical Reviewer,
					 with a copy to the MPN Contact. If an in-person examination is requested and if
					 a special form of transportation is required because of the employee's medical
					 condition, it is the obligation of the MPN Contact to arrange for it. The MPN
					 Contact shall furnish transportation and arrange for an interpreter, if
					 necessary, in advance of the in-person examination. All reasonable expenses of
					 transportation shall be incurred by the insurer or employer pursuant to Labor
					 Code section
					 4600. Except
					 for the in-person examination itself, the Independent Medical Reviewer shall
					 have no ex parte contact with any party. Except for matters dealing with
					 scheduling appointments, scheduling medical tests and obtaining medical
					 records, all communications between the Independent Medical Reviewer and any
					 party shall be in writing, with copies served on all parties.
(b) If the IMR requires further tests, the
					 IMR shall notify the MPN Contact within one working day of the appointment. All
					 tests shall be consistent with the medical treatment utilization schedule
					 adopted pursuant to Labor Code section
					 5307.27 or,
					 prior to the adoption of this schedule, the ACOEM guidelines, and for all
					 injuries not covered by the medical treatment utilization schedule or the ACOEM
					 guidelines, in accordance with other evidence based medical treatment
					 guidelines generally recognized by the national medical community and that are
					 scientifically based.
(c) The IMR
					 may order any diagnostic tests necessary to make his or her determination
					 regarding medical treatment or diagnostic services for the injury or illness
					 but shall not request the employee to submit to an unnecessary exam or
					 procedure. If a test duplicates a test already given, the IMR shall provide
					 justification for the duplicative test in his or her report.
(d) If the employee fails to attend an
					 examination with the IMR and fails to reschedule the appointment within five
					 business days of the missed appointment, the IMR shall perform a review of the
					 record and make a determination based on those records.
(e) The IMR shall serve the report on the
					 Administrative Director, the MPN Contact, the employee and the employee's
					 attorney, if any, within 20 days after the in-person examination or completion
					 of the record review.
(f) If the
					 disputed health care service has not been provided and the IMR certifies in
					 writing that an imminent and serious threat to the health of the injured
					 employee exists, including, but not limited to, the potential loss of life,
					 limb, or bodily function, or the immediate and serious deterioration of the
					 injured employee, the report shall be expedited and rendered within three
					 business days of the in-person examination by the IMR.
(g) Subject to approval by the Administrative
					 Director, reviews not covered under subdivision (f) may be extended for up to
					 three business days in extraordinary circumstances or for good cause.
(h) Extensions for good cause shall be
					 granted for:
(1) Medical emergencies of the
					 IMR or the IMR's family;
(2) Death
					 in the IMR's family; or
(3) Natural
					 disasters or other community catastrophes that interrupt the operation of the
					 IMR's office operations.