reglab/statecodes huggingface dataset:
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 3.5 - Medical Provider Network › Section 9767.5.1 - Physician Acknowledgments

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a) An MPN applicant shall obtain from each
					 physician participating in the MPN a written acknowledgment in which the
					 physician affirmatively elects to be a member of the MPN as provided in this
					 section. This section does not apply to a physician who is a shareholder,
					 partner, or employee of a medical group that elects to participate in the MPN,
					 however this section applies to the medical group that elects to participate in
					 the MPN.
(b) The following persons
					 may execute the acknowledgment:
(1) If the
					 acknowledgment is for one or more physicians, it shall be executed by:
(A) The physician(s); or
(B) An employee of the physician or an
					 employee of the physician's office; or
(C) If authorized by the physician(s), an
					 agent or representative of a medical group.
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 3.5 - Medical Provider Network › Section 9767.7 - Second and Third Opinions

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a) If the covered employee disputes either
					 the diagnosis or the treatment prescribed by the primary treating physician or
					 the treating physician, the employee may obtain a second and third opinion from
					 physicians within the MPN. During this process, the employee is required to
					 continue his or her treatment with the treating physician or a physician of his
					 or her choice within the MPN.
(b)
					 If the covered employee disputes either the diagnosis or the treatment
					 prescribed by primary treating physician or the treating physician, it is the
					 employee's responsibility to:
(1) inform the
					 person designated by the employer or insurer that he or she disputes the
					 treating physician's opinion and requests a second opinion (the employee may
					 notify the person designated by the employer or insurer either in writing or
					 orally);
(2) select a physician or
					 specialist from a list of available MPN providers;
(3) make an appointment with the second
					 opinion physician within 60 days; and
(4) inform the person designated by the
					 employer or insurer of the appointment date. It is the employer's or insurer's
					 responsibility to (1) provide at least a regional area listing of MPN providers
					 and/or specialists to the employee for his/her selection based on the specialty
					 or recognized expertise in treating the particular injury or condition in
					 question and inform the employee of his or her right to request a copy of the
					 medical records that will be sent to the second opinion physician; (2) contact
					 the treating physician, provide a copy of the medical records or send the
					 necessary medical records to the second opinion physician prior to the
					 appointment date, and provide a copy of the records to the covered employee
					 upon request; and (3) notify the second opinion physician in writing that he or
					 she has been selected to provide a second opinion and the nature of the dispute
					 with a copy to the employee. If the appointment is not made within 60 days of
					 receipt of the list of the available MPN providers, then the employee shall be
					 deemed to have waived the second opinion process with regard to this disputed
					 diagnosis or treatment of this treating physician.
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 3.5 - Medical Provider Network › Section 9767.8 - Modification of Medical Provider Network Plan

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a) The MPN applicant shall serve the
					 Administrative Director with two copies of the completed, signed Notice of MPN
					 Plan Modification and any necessary documentation in compact discs or flash
					 drives in word-searchable PDF format. The hard copy of the original signed
					 Notice of Medical Provider Network Plan Modification form and any necessary
					 documentation shall be maintained by the MPN applicant and made available for
					 review by the Administrative Director upon request. Electronic signatures in
					 compliance with California Government Code section
					 16.5 are
					 accepted. The MPN applicant shall serve these documents with the Administrative
					 Director within the stated time frames or if no time frame is stated, then
					 before any of the following changes occur:
(1) Change in the name of the MPN or the name
					 of the MPN applicant. Filing required within (15) fifteen business days of the
					 change. Provide written documentation reflecting date of change.
(2) Change in the eligibility status of the
					 MPN applicant. Filing required within fifteen (15) business days of written
					 knowledge of a change in eligibility. Provide written documentation reflecting
					 date of change.
(3) Change of MPN
					 Liaison or Authorized Individual: Filing required within fifteen (15) business
					 days of change. Provide written documentation reflecting date of
					 change.
(4) Change in MPN
					 geographic service area within the State of California.
(5) A material change in the continuity of
					 care policy.
(6) A material change
					 in the transfer of care policy.
(7)
					 Change in policy or procedure that is used by the MPN or an entity contracted
					 with the MPN or MPN applicant to conduct "economic profiling of MPN providers"
					 pursuant to Labor Code section
					 4616.1.
(8) Change in how the MPN complies with the
					 access standards.
(9) A material
					 change in any of the employee notification materials, including a change in MPN
					 contact, a change in the Medical Access Assistants contact information, or a
					 change in provider listing access or MPN website information, required by
					 section 9767.12.
(10) Change in use of one of the following
					 deemed entities: Health Care Organization (HCO), Health Care Service Plan,
					 Group Disability Insurer, or Taft-Hartley Health and Welfare Trust
					 Fund.
(11) Revision of any plan
					 section(s) required by section
					 9767.3(d) due to a
					 change of any MPN administrator(s) listed in the MPN Plan.
(12) Replacement of entire MPN plan
					 application.
(13) Updating to the
					 current regulations pursuant to section
					 9767.15.
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 3.5 - Medical Provider Network › Section 9767.11 - Economic Profiling Policy

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a) An MPN applicant's filing of its economic
					 profiling policies and procedures shall include:
(1) An overall description of the profiling
					 methodology, data used to create the profile and risk adjustment;
(2) A description of how economic profiling
					 is used in utilization review;
(3)
					 A description of how economic profiling is used in peer review; and
(4) A description of any incentives and
					 penalties used in the program and in provider retention and termination
					 decisions.
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 3.5 - Medical Provider Network › Section 9767.13 - Denial of Approval of Application or Reapproval; RE-Evaluation

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a) The
					 Administrative Director shall deny approval or reapproval of a plan if the MPN
					 applicant does not satisfy the requirements of this article and Labor Code
					 section
					 4616 et seq.
					 and shall state the reasons for disapproval in writing in a Notice of
					 Disapproval, and shall transmit the Notice to the MPN applicant by U.S.
					 Mail.
(b) An MPN applicant denied
					 approval may either:
(1) Submit a corrected
					 application or plan for reapproval addressing the deficiencies; or
(2) Request a re-evaluation by the
					 Administrative Director.
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 3.5 - Medical Provider Network › Section 9767.14 - Probation, Suspension or Revocation of Medical Provider Network Plan; Hearing

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a)
					 The Administrative Director may place on probation, suspend or revoke a Medical
					 Provider Network if:
(1) Service under the MPN
					 is not being provided according to the terms of the approved MPN
					 plan.
(2) The MPN fails to meet the
					 requirements of Labor Code section
					 4616 et seq.
					 and this article.
(3) The MPN fails
					 to meet the requirements for reapproval under Labor Code section
					 4616 et seq. or
					 this article.
(4) False or
					 misleading information is knowingly or repeatedly submitted by the MPN or a
					 participating provider or the MPN knowingly or repeatedly fails to report
					 information required by this article.
(5) The MPN knowingly continues to use the
					 services of a provider or medical reviewer whose license, registration, or
					 certification has been suspended or revoked or who is otherwise ineligible to
					 provide treatment to an injured worker under California law.
(6) The MPN applicant no longer meets the
					 eligibility requirements to have an MPN, including but not limited to the
					 following situations: the MPN applicant is no longer recognized as a
					 self-insured entity with the Office of Self-Insurance Plans for any period of
					 time during which the MPN applicant has an MPN or if the MPN applicant is no
					 longer properly licensed to provide workers' compensation insurance by the
					 Department of Insurance for any period of time during which the MPN applicant
					 has an MPN or is no longer an entity that provides physician network services.
(A) Once an MPN applicant is no longer
					 eligible to have an MPN, by operation of law, the MPN is automatically
					 suspended and MPN coverage will not be deemed valid for new claims during the
					 period of suspension, pending revocation by the Administrative Director. During
					 the effective dates of suspension, any injured worker with a new claim shall be
					 informed of the employee's right to be treated by a physician of his or her own
					 choice or at a facility of his or her own choice within a reasonable geographic
					 area 30 days after reporting the injury, pursuant to Labor Code section
					 4600(c).
					 After a suspension has ended, any transfer of the employee's care back into the
					 MPN shall be subject to the MPN transfer of care
					 requirements.
(7) The MPN
					 fails to respond to at least two or more repeated requests or inquiries by the
					 Administrative Director to comply with the requirements of this article or
					 Labor Code sections
					 4616 et
					 seq.
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 3.5 - Medical Provider Network › Section 9767.16 - Medical Provider Network Complaints

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a) Any person contending a Medical Provider
					 Network is in violation of the requirements of this article or Labor Code
					 sections
					 4616 through
					 4616.7 shall
					 submit a written complaint directly with the MPN Contact.
(1) The written complaint shall provide an
					 explanation to the MPN with sufficient detail of the MPN's alleged violation
					 under this article or any of Labor Code sections
					 4616 through
					 4616.7. The
					 written complaint shall include, but not be limited to, the following
					 information:
(A) Citation of the specific
					 statutory or regulatory provision(s) violated;
(B) When the alleged violation
					 occurred;
(C) If the alleged
					 violation is still occurring;
(D)
					 What attempts the complainant has made with the MPN to address the
					 violation;
(E) What, if any, impact
					 there has been on an injured worker; and
(F) What remedy is sought for the alleged
					 violation.
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 3.5 - Medical Provider Network › Section 9767.16.5 - DWC Medical Provider Network Complaint Form 9767.16.5

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
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1. New
						section filed 8-27-2014; operative 8-27-2014 pursuant to Government Code
						section
						11343.4(b)(3)
						(Register 2014, No. 35).
Note: Authority cited: Sections
						  133 and
						  4616, Labor
						  Code. Reference: Sections
						  4616(b)
						  and
						  4616, Labor
						  Code.
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 3.5 - Medical Provider Network › Section 9767.17 - Petition for Suspension or Revocation of a Medical Provider Network

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a) The DWC
					 Petition for Suspension or Revocation of a Medical Provider Network Form
					 9767.17.5, as contained in title 8, California Code of Regulations, section
					 9767.17.5, may be filed with the
					 Division of Workers' Compensation by any person who can show:
(1) The employer, insurer or entity that
					 provides physician network services failed to maintain its qualifying status to
					 have an MPN, or
(2) That an MPN has
					 systematically failed to meet access standards under 9767.5, at minimum, on
					 more than one occasion in at least two specific access locations within the MPN
					 geographic service area. Additionally, the MPN failed to ensure in each
					 instance that a worker received necessary medical treatment within the MPN or
					 failed to authorize treatment outside of the MPN within the required time
					 frames and access standards.
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 3.5 - Medical Provider Network › Section 9767.17.5 - DWC Petition for Suspension or Revocation of a Medical Provider Network Form 9767.17.5 [New]

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
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1. New
						section filed 8-27-2014; operative 8-27-2014 pursuant to Government Code
						section
						11343.4(b)(3)
						(Register 2014, No. 35).
Note: Authority cited: Sections
						  133 and
						  4616, Labor
						  Code. Reference: Section
						  4616(b)(5),
						  Labor Code.
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 3.5 - Medical Provider Network › Section 9767.19 - Administrative Penalty Schedule; Hearing, Mitigation and Appeal

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a) A penalty may
					 be assessed against an MPN applicant for each failure of an MPN to comply with
					 the Medical Provider Network requirements in Labor Code sections
					 4616 through
					 4616.7 and
					 Title 8, California Code of Regulations, sections
					 9767.1 et seq. For MPN applicants
					 who have multiple MPNs and for multiple MPNs using the same network, if a
					 specific violation affects more than one MPN, multiple penalties will not be
					 assessed against the MPN applicant(s) provided that the violation is remedied
					 for all affected MPNs within a reasonable time period, as determined by the
					 Administrative Director based on the nature and extent of the violation.
					 Penalties may be assessed against an MPN applicant for the following
					 violations:
(1) MPN filing requirements with
					 DWC:
(A) Failure to file a Notice of MPN Plan
					 Modification within fifteen (15) business days of a change in the name of the
					 MPN or the MPN applicant, $500 initially and for each seven calendar days
					 thereafter if the failure continues, up to $5,000.
(B) Failure to file a Notice of MPN Plan
					 Modification within fifteen (15) business days of a change in the MPN
					 applicant's eligibility status, $2,500.
(C) Failure to file a Notice of MPN Plan
					 Modification within fifteen (15) business days of a change in DWC liaison or
					 authorized individual, $500 initially and for each seven calendar days
					 thereafter if the failure continues, up to $5,000.
(D) Failure to file a Notice of MPN Plan
					 Modification for a material change in any of the employee notification
					 materials, including but not limited to a change in MPN contact or MPN medical
					 access assistant information or a change in provider listing access or website
					 information required by section
					 9767.12, $2,500.
(E) Failure to file a Notice of MPN Plan
					 Modification for all other material changes that require the filing of a
					 Modification of MPN plan as set forth in section
					 9767.8, $1,000.
(F) Failure to file a complete plan for MPN
					 reapproval within the time frames set forth in section
					 9767.15, $2,500.
(G) Failure to include geocoding of its
					 current provider listing with the MPN reapproval application, $500 for each 30
					 days or part thereof that the failure continues after the date of submission of
					 the reapproval plan.
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 9768.2 - Conflicts of Interest

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a)
					 The IMR shall not have any material, professional, familial, or financial
					 affiliation with any of the following:
(1) The
					 injured employee's employer or employer's workers' compensation
					 insurer;
(2) Any officer, director,
					 management employee, or attorney of the injured employee's medical provider
					 network, employer or employer's workers' compensation insurer;
(3) Any treating health care provider
					 proposing the service or treatment;
(4) The institution at which the service or
					 treatment would be provided, if known;
(5) The development or manufacture of the
					 principal drug, device, procedure, or other therapy proposed for the injured
					 employee whose treatment is under review; or
(6) The injured employee, the injured
					 employee's immediate family, or the injured employee's
					 attorney.
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 9768.3 - Qualifications of Independent Medical Reviewers

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a) To qualify to be on the Administrative
					 Director's list of Independent Medical Reviewers, a physician shall file a
					 Physician Contract Application pursuant to section
					 9768.5 that demonstrates to the
					 satisfaction of the Administrative Director that the physician:
(1) Is board certified. For physicians, the
					 Administrative Director shall recognize only specialty boards recognized by the
					 appropriate California licensing board.
(2) Has an unrestricted license as a
					 physician in California under the appropriate licensing Board;
(3) Is not currently under accusation by any
					 governmental licensing agency for a quality of care violation, fraud related to
					 medical practice, or felony conviction or conviction of a crime related to the
					 conduct of his or her practice of medicine;
(4) Has not been terminated or had discipline
					 imposed by the Industrial Medical Council or Administrative Director in
					 relation to the physician's role as a Qualified Medical Evaluator; is not
					 currently under accusation by the Industrial Medical Council or Administrative
					 Director; has not been denied renewal of Qualified Medical Evaluator status,
					 except for non-completion of continuing education or for non-payment of fees;
					 has neither resigned nor failed to renew Qualified Medical Evaluator status
					 while under accusation or probation by the Industrial Medical Council or
					 Administrative Director or after notification that reappointment as a Qualified
					 Medical Evaluator may or would be denied for reasons other than non-completion
					 of continuing education or non-payment of fees; and has not filed any
					 applications or forms with the Industrial Medical Council or Administrative
					 Director which contained any untrue material statements;
(5) Has not been convicted of a felony crime
					 or a crime related to the conduct of his or her practice of medicine;
					 and
(6) Has no history of
					 disciplinary action or sanction, including but not limited to, loss of staff
					 privileges or participation restrictions taken or pending by any hospital,
					 government or regulatory body.
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 9768.4 - IMR Contract Application Procedures

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a) A physician seeking to serve as an
					 Independent Medical Reviewer shall:
(1) Apply
					 to the Administrative Director on the Physician Contract Application set forth
					 in section 9768.5.
(2) Furnish a certified copy of his or her
					 board certification, a copy of his or her current license to practice medicine,
					 and submit other documentation of his or her qualifications as the
					 Administrative Director may require.
(3) Designate specialties based on each of
					 his or her board certifications.
(4) Designate the address(es) of the
					 physician's office with necessary medical equipment where in-person
					 examinations will be held.
(5)
					 Agree to see any injured worker assigned to him or her within 30 days unless
					 there is a conflict of interest as defined in section
					 9768.2.
(6) During the application process and after
					 being notified by the Administrative Director that the contract application has
					 been accepted, the physician shall keep the Administrative Director informed of
					 any change of address, telephone, email address or fax number, and of any
					 disciplinary action taken by a licensing board.
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 9768.5 - Physician Contract Application Form

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
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1. New
						section filed 12-31-2004 as an emergency; operative 1-1-2005 (Register 2004,
						No. 53). A Certificate of Compliance must be transmitted to OAL by 5-2-2005 or
						emergency language will be repealed by operation of law on the following
						day.
2. Certificate of Compliance as to 12-31-2004 order, including
						amendment of section, transmitted to OAL 4-29-2005 and filed 6-10-2005
						(Register 2005, No. 23).
3. Change without regulatory effect
						amending form filed 10-18-2006 pursuant to section
						100, title 1, California Code of
						Regulations (Register 2006, No. 42).
4. Change without regulatory
						effect amending form filed 5-21-2007 pursuant to section
						100, title 1, California Code of
						Regulations (Register 2007, No. 21).
Note: Authority cited: Sections
						  133 and
						  4616, Labor
						  Code. Reference: Section
						  4616.4, Labor
						  Code.
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 9768.6 - Administrative Director's Action on Contract Application Submitted by Physician

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a) After reviewing a completed contract
					 application submitted by a physician, if the Administrative Director finds that
					 the physician meets the qualifications, he/she shall accept the contract
					 application made by the physician to be an Independent Medical Reviewer by
					 executing the IMR contract, notify the physician by mail, and add the
					 physician's name to the list of Independent Medical Reviewers. The contract
					 term shall be for a two-year term beginning with the date of acceptance by the
					 Administrative Director.
(b) If the
					 Administrative Director determines that a physician does not meet the
					 qualifications, he/she shall notify the physician by mail that the physician's
					 contract application is not accepted and the reason for the
					 rejection.
(c) A physician whose
					 contract application has not been accepted may reapply.
(d) If the Administrative Director denies a
					 physician's contract application following at least two subsequent submissions,
					 the physician may seek further review of the Administrative Director's decision
					 by filing an appeal with the Workers' Compensation Appeals Board, and serving a
					 copy on the Administrative Director, within twenty days after receipt of the
					 denial.
1. New
						section filed 12-31-2004 as an emergency; operative 1-1-2005 (Register 2004,
						No. 53). A Certificate of Compliance must be transmitted to OAL by 5-2-2005 or
						emergency language will be repealed by operation of law on the following
						day.
2. Certificate of Compliance as to 12-31-2004 order, including
						amendment of subsection (a), transmitted to OAL 4-29-2005 and filed 6-10-2005
						(Register 2005, No. 23).
Note: Authority cited: Sections
						  133 and
						  4616, Labor
						  Code. Reference: Sections
						  4616.4 and
						  5300(f),
						  Labor Code.
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 9768.7 - IMR Request to be Placed on Voluntary Inactive Status

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
A physician may request to be placed on the inactive list
						during the IMR contract term. The physician shall submit the request to the
						Administrative Director and specify the time period that he or she is
						requesting to be on voluntary inactive status. The two-year contract term is
						not extended due to a physician's request to be placed on voluntary inactive
						status.
1. New
						section filed 12-31-2004 as an emergency; operative 1-1-2005 (Register 2004,
						No. 53). A Certificate of Compliance must be transmitted to OAL by 5-2-2005 or
						emergency language will be repealed by operation of law on the following
						day.
2. Certificate of Compliance as to 12-31-2004 order transmitted
						to OAL 4-29-2005 and filed 6-10-2005 (Register 2005, No.
						23).
Note: Authority cited: Sections
						  133 and
						  4616, Labor
						  Code. Reference: Section
						  4616.4, Labor
						  Code.
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 9768.8 - Removal of Physicians from Independent Medical Reviewer List

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a) The
					 Administrative Director may cancel the IMR contract and remove a physician from
					 the Independent Medical Reviewer list if the Administrative Director determines
					 based upon the Administrative Director's monitoring of reports:
(1) That the physician, having been notified
					 by the Administrative Director of the physician's selection to render an
					 Independent Medical Review, has not issued the Independent Medical Review
					 report in a case within the time limits prescribed in these regulations on more
					 than one occasion; or
(2) That the
					 physician has not met the reporting requirements on more than one occasion;
					 or
(3) That the physician has at
					 any time failed to disclose to the Administrative Director that the physician
					 had a conflict of interest pursuant to section
					 9768.2; or
(4) That the physician has failed to schedule
					 appointments within the time frame required by these regulations on more than
					 one occasion; or
(5) That the
					 physician has failed to maintain the confidentiality of medical records and the
					 review materials consistent with the applicable state and federal
					 law.
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 9768.12 - Contents of Independent Medical Review Reports

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a) Reports of Independent Medical Reviewers
					 shall include:
(1) The date of the in-person
					 examination or record review;
(2)
					 The patient's complaint(s);
(3) A
					 listing of all information received from the parties reviewed in preparation of
					 the report or relied upon for the formulation of the physician's
					 opinion;
(4) The patient's medical
					 history relevant to the diagnostic services, diagnosis or medical
					 treatment;
(5) Findings on record
					 review or in-person examination;
(6) The IMR's diagnosis;
(7) The physician's opinion whether or not
					 the proposed treatment or diagnostic services are appropriate and indicated. If
					 the proposed treatment or diagnostic services are not appropriate or indicated,
					 any alternative diagnosis or treatment recommendation consistent with the
					 medical treatment utilization schedule shall be included;
(8) An analysis and determination whether the
					 disputed health care service is consistent with the medical treatment
					 utilization schedule established pursuant to Labor Code section
					 5307.27 or,
					 prior to the adoption of this schedule, the ACOEM guidelines. For injuries not
					 covered by the medical treatment utilization schedule or by the ACOEM
					 guidelines, an analysis and determination whether the treatment rendered is in
					 accordance with other evidence-based medical treatment guidelines which are
					 generally recognized by the national medical community and scientifically
					 based; and
(9) The signature of the
					 physician.
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 9768.13 - Destruction of Records by the Administrative Director

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
The Administrative Director may destroy any forms or
						documents submitted to the Administrative Director as part of the IMR process
						two years after the date of receipt.
1. New
						section filed 12-31-2004 as an emergency; operative 1-1-2005 (Register 2004,
						No. 53). A Certificate of Compliance must be transmitted to OAL by 5-2-2005 or
						emergency language will be repealed by operation of law on the following
						day.
2. Certificate of Compliance as to 12-31-2004 order transmitted
						to OAL 4-29-2005 and filed 6-10-2005 (Register 2005, No.
						23).
Note: Authority cited: Sections
						  133 and
						  4616, Labor
						  Code. Reference: Section
						  4616.4, Labor
						  Code.
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 9768.14 - Retention of Records by Independent Medical Reviewer

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
Each Independent Medical Reviewer shall retain all
						comprehensive medical reports completed by the Independent Medical Reviewer for
						a period of five years from the date of the IMR report.
1. New
						section filed 12-31-2004 as an emergency; operative 1-1-2005 (Register 2004,
						No. 53). A Certificate of Compliance must be transmitted to OAL by 5-2-2005 or
						emergency language will be repealed by operation of law on the following
						day.
2. Certificate of Compliance as to 12-31-2004 order, including
						amendment of section, transmitted to OAL 4-29-2005 and filed 6-10-2005
						(Register 2005, No. 23).
Note: Authority cited: Sections
						  133 and
						  4616, Labor
						  Code. Reference: Section
						  4616.4, Labor
						  Code.
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 9768.15 - Charges for Independent Medical Reviewers

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a) Payment for the services of the
					 Independent Medical Reviewers shall be made by the employer or
					 insurer.
(b) The fee shall be based
					 on the Official Medical Fee Schedule using confirmatory consultation codes
					 (99271 through 99275 for in-person examinations or 99271 through 99273 for
					 evaluations not requiring an in-person examination), 99080 for reports, and
					 99358 for record reviews, and any other appropriate codes or
					 modifiers.
(c) An IMR shall not
					 accept any additional compensation from any source for his or her services as
					 an IMR except for services provided to treat a medical emergency that arose
					 during an in-person examination pursuant to section
					 9768.11(j).
1. New
						section filed 12-31-2004 as an emergency; operative 1-1-2005 (Register 2004,
						No. 53). A Certificate of Compliance must be transmitted to OAL by 5-2-2005 or
						emergency language will be repealed by operation of law on the following
						day.
2. Certificate of Compliance as to 12-31-2004 order, including
						amendment of subsections (a) and (b), transmitted to OAL 4-29-2005 and filed
						6-10-2005 (Register 2005, No. 23).
Note: Authority cited: Sections
						  133 and
						  4616, Labor
						  Code. Reference: Section
						  4616.4, Labor
						  Code.
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 9768.16 - Adoption of Decision

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a)
					 The Administrative Director shall immediately adopt the determination of the
					 Independent Medical Reviewer and issue a written decision within 5 business
					 days of receipt of the report.
(b)
					 The parties may appeal the Administrative Director's written decision by filing
					 a petition with the Workers' Compensation Appeals Board and serving a copy on
					 the Administrative Director, within twenty days after receipt of the
					 decision.
1. New
						section filed 12-31-2004 as an emergency; operative 1-1-2005 (Register 2004,
						No. 53). A Certificate of Compliance must be transmitted to OAL by 5-2-2005 or
						emergency language will be repealed by operation of law on the following
						day.
2. Certificate of Compliance as to 12-31-2004 order, including
						amendment of subsection (a), transmitted to OAL 4-29-2005 and filed 6-10-2005
						(Register 2005, No. 23).
Note: Authority cited: Sections
						  133 and
						  4616, Labor
						  Code. Reference: Sections
						  4616.4 and
						  5300(f),
						  Labor Code.
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 9768.17 - Treatment Outside the Medical Provider Network

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a) If the IMR agrees with the diagnosis,
					 diagnostic service or medical treatment prescribed by the treating physician,
					 the covered employee shall continue to receive medical treatment from
					 physicians within the MPN.
(b) If
					 the IMR does not agree with the disputed diagnosis, diagnostic service or
					 medical treatment prescribed by the treating physician, the covered employee
					 shall seek medical treatment with a physician of his or her choice either
					 within or outside the MPN. If the employee chooses to receive medical treatment
					 with a physician outside the MPN, the treatment is limited to the treatment
					 recommended by the IMR or the diagnostic service recommended by the
					 IMR.
(c) The medical treatment
					 shall be consistent with the medical treatment utilization schedule established
					 pursuant to Labor Code section
					 5307.27 or,
					 prior to the adoption of this schedule, the ACOEM guidelines. For injuries not
					 covered by the medical treatment utilization schedule or by the ACOEM
					 guidelines, the treatment rendered shall be in accordance with other
					 evidence-based medical treatment guidelines which are generally recognized by
					 the national medical community and scientifically based.
(d) The employer or insurer shall be liable
					 for the cost of any approved medical treatment in accordance with Labor Code
					 section
					 5307.1 or
					 5307.11.
1. New
						section filed 12-31-2004 as an emergency; operative 1-1-2005 (Register 2004,
						No. 53). A Certificate of Compliance must be transmitted to OAL by 5-2-2005 or
						emergency language will be repealed by operation of law on the following
						day.
2. Certificate of Compliance as to 12-31-2004 order, including
						amendment of NOTE, transmitted to OAL 4-29-2005 and filed 6-10-2005 (Register
						2005, No. 23).
Note: Authority cited: Sections
						  133 and
						  4616, Labor
						  Code. Reference: Sections
						  4616.4,
						  5307.1,
						  5307.11 and
						  5307.27, Labor
						  Code.
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 4 - Certification Standards for Health Care Organizations › Section 9771 - Applications for Certification

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a) Any of the following entities may apply
					 for certification as a health care organization:
(1) A disability insurer licensed by the
					 Department of Insurance to transact health insurance or disability income
					 insurance pursuant to Part 2 of Division 2 of the Insurance Code.
(2) Any workers compensation health care
					 provider organization.
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 4 - Certification Standards for Health Care Organizations › Section 9771.1 - Updating Applications

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a) Every application submitted under Section
					 9771(e) shall be
					 kept current to reflect accurately the actual operation of the HCO. An
					 applicant or a certified HCO shall file an amendment to its application to show
					 any change in any information contained in the application. Amendments include
					 changes, deletions, additions and variations to the original application and
					 its exhibits, including sample contracts. Amendments shall be filed as set
					 forth in this section. However, the administrative director may approve an
					 alternative form of submitting an amendment if it substantially accomplishes
					 the purposes of this section.
(b)
					 An original and one copy of an amendment shall be submitted to the
					 administrative director as follows:
(1) Submit
					 an Execution Page of the application, indicating it is an "Amendment to Pending
					 Application" or "Amendment to Application of a Certified
					 Organization";
(2) Furnish only
					 those pages of the application and/or those exhibits which are changed by the
					 amendment.
(3) If a page of the
					 application is amended, complete all items on that page and "redline" or
					 otherwise clearly designated the changed item. At the lower left-hand corner of
					 each page, type "Rev. [date]", giving the effective date of the
					 amendment.
(4) If an exhibit is
					 being amended:
(A) Furnish the complete
					 exhibit as amended, bearing the same number as the original exhibit, with the
					 changed portions of the exhibit "redlined" or otherwise clearly designated,
					 or
(B) Furnish the pages of the
					 exhibit which are amended, each page to be marked with the exhibit number and
					 the page number of the exhibit, and with the changed portions "redlined" or
					 otherwise clearly designated. At the lower left-hand corner of each page, type
					 "Rev. [date]", giving the effective date of the amendment. If this method of
					 amendment is employed, the applicant shall refile the entire exhibit as amended
					 whenever more than 10 percent if its pages have been
					 amended.
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 4 - Certification Standards for Health Care Organizations › Section 9771.2 - Information to Be Furnished as it Becomes Available

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a) If an HCO, or any person listed in
					 section 9771(e)(8), is
					 named as a defendant in a lawsuit that is materially related to the provision
					 of medical treatment under Labor Code section
					 4600, the HCO
					 shall inform the administrative director within 5 days of the day it becomes
					 aware the suit is filed and shall provide a copy of the complaint.
(b)
(1) If
					 a certified HCO is a health care services plan and if the Director of the
					 Department of Managed Health Care begins proceedings against the plan under
					 Articles 7 or 8 of the Knox-Keene Health Care Service Plan Act of 1975, the
					 certified HCO shall inform the administrative director within 5 days of the day
					 it becomes aware of the proceedings. The requirements of this subdivision shall
					 also apply to an HMO deemed an HCO pursuant to Labor Code Section
					 4600.5(c)
					 while the administrative director is reviewing the documentation required by
					 Section 9771 subdivisions (g)(1) and (2)
					 prior to issuing the HMO its certification.
(2) If an applicant or a certified HCO is a
					 disability insurer and if the Commissioner of Insurance begins proceedings
					 against the insurer under Insurance Code section
					 704 or an
					 examination under section
					 730, the applicant or certified HCO
					 shall inform the administrative director within 5 days of the day it becomes
					 aware of the proceedings or examination.
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 4 - Certification Standards for Health Care Organizations › Section 9771.6 - Application of Regulations Concerning Workers' Compensation Health Care Provider Organizations

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
Sections
						9771.6 through
						9771.83 apply only to workers'
						compensation health care organizations as defined by Section
						9771.60(m).
1. New
						section filed 4-15-98; operative 4-15-98. Submitted to OAL for printing only
						pursuant to Stats. 1997, Ch. 346, Section
						5 (Register 98, No.
						16).
Note: Authority cited: Stats. 1997, Ch. 346, Section
						  5. Reference: Sections
						  4600.3,
						  4500.5 and
						  4600.6, Labor
						  Code.
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 4 - Certification Standards for Health Care Organizations › Section 9771.60 - Further Definitions

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
The following definitions apply to the interpretation of
						these rules and the Act:
(a) "Act"
					 means Sections
					 4600.3,
					 4600.5 and
					 4600.6 of the Code
(b) "Advertisement" includes the disclosure
					 form required pursuant to Section
					 4600.6(e) of the
					 Code.
(c)
(1) An "affiliate" of a person is a person
					 controlled by, under common control with, or controlling such person.
(2) A person's relationship with another
					 person is that of an "affiliated person" if such person is, as to such other
					 person, a director, trustee or a member of its executive committee or other
					 governing board or committee, or that of an officer or general partner, or
					 holds any other position involving responsibility and authority similar to that
					 of a principal officer or general partner; or who is the holder of 5 percent or
					 more of its outstanding equity securities; or who has any such relationship
					 with an affiliate of such person. An affiliate is also an affiliated
					 person.