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 9768.1 - Definitions

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a) As used in this
					 article, the following definitions apply:
(1)
					 "American College of Occupational and Environmental Medicine's Occupational
					 Medicine Practice Guidelines" ("ACOEM") means the American College of
					 Occupational and Environmental Medicine's Occupational Medicine Practice
					 Guidelines, 2nd Edition (2004), published by OEM Press. The Administrative
					 Director incorporates ACOEM by reference. A copy may be obtained from OEM
					 Press, 8 West Street, Beverly Farms, Massachusetts 01915 (
www.oempress.com
).
(2) "Appropriate specialty" means a medical
					 specialty in an area or areas appropriate to the condition or treatment under
					 review.
(3) "Independent Medical
					 Reviewer" ("IMR") means the physician who is randomly selected pursuant to
					 subdivision (b) of Labor Code section
					 4616.4.
(4) "In-person examination" means an
					 examination of an injured employee by a physician which involves more than a
					 review of records, and may include a physical examination, discussing the
					 employee's medical condition with the employee, taking a history and performing
					 an examination.
(5) "Material
					 familial affiliation" means a relationship in which one of the persons or
					 entities listed in section
					 9768.2 is the parent, child,
					 grandparent, grandchild, sibling, uncle, aunt, nephew, niece, spouse, or
					 cohabitant of the Independent Medical Reviewer.
(6) "Material financial affiliation" means a
					 financial interest (owns a legal or equitable interest of more than 1% interest
					 in the party, or a fair market value in excess of $2000, or relationship of
					 director, advisor, or active participant) in any person or entity listed in
					 section 9768.2. It also means any gift or
					 income of more than $300 in the preceding year except for income for services
					 as a second opinion physician, third opinion physician, treating physician,
					 Agreed Medical Evaluator, Qualified Medical Evaluator, or Independent Medical
					 Reviewer.
(7) "Material
					 professional affiliation" means any relationship in which the Independent
					 Medical Reviewer shares office space with, or works in the same office of, any
					 person or entity listed in section
					 9768.2.
(8) "Medical emergency" means a medical
					 condition manifesting itself by acute symptoms of sufficient severity such that
					 the absence of immediate medical attention could reasonably be expected to
					 place the patient's health in serious jeopardy.
(9) "Medical Provider Network Contact" ("MPN
					 Contact") means the individual(s) designated by the MPN Applicant in the
					 employee notification who is responsible for answering employees' questions
					 about the Medical Provider Network and is responsible for assisting the
					 employee in arranging for an Independent Medical Review.
(10) "Panel" means the contracted providers
					 in a specific specialty.
(11)
					 "Relevant medical records" means all information that was considered in
					 relation to the disputed treatment or diagnostic service, including:
(A) a copy of all correspondence from, and
					 received by, any treating physician who provided a treatment or diagnostic
					 service to the injured employee in connection with the injury;
(B) a complete and legible copy of all
					 medical records and other information used by the physicians in making a
					 decision regarding the disputed treatment or diagnostic service;
(C) the treating physician's report with the
					 disputed treatment or diagnosis; and
(D) the second and third opinion physicians'
					 reports.
(12) "Residence"
					 means the covered employee's primary residence.