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 9792.6.1 - Utilization Review Standards-Definitions - on or After January 1, 2013

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
The following definitions apply 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 for authorization of medical treatment is communicated to the
					 requesting physician on or after July 1, 2013, regardless of the date of
					 injury.
(a) "Authorization" means assurance
					 that appropriate reimbursement will be made for an approved specific course of
					 proposed medical treatment to cure or relieve the effects of the industrial
					 injury pursuant to section
					 4600 of the
					 Labor Code, subject to the provisions of section
					 5402 of the
					 Labor Code, based on either a completed "Request for Authorization," DWC Form
					 RFA, as contained in California Code of Regulations, title 8, section
					 9785.5, or a request for
					 authorization of medical treatment accepted as complete by the claims
					 administrator under section
					 9792.9.1(c)(2),
					 that has been transmitted by the treating physician to the claims
					 administrator. Authorization shall be given pursuant to the timeframe,
					 procedure, and notice requirements of California Code of Regulations, title 8,
					 section 9792.9.1, and may be provided by
					 utilizing the indicated response section of the "Request for Authorization,"
					 DWC Form RFA if that form was initially submitted by the treating
					 physician.
(b) "Claims
					 Administrator" is a self-administered workers' compensation insurer of an
					 insured employer, a self-administered self-insured employer, a
					 self-administered legally uninsured employer, a self-administered joint powers
					 authority, a third-party claims administrator or other entity subject to Labor
					 Code section
					 4610, the
					 California Insurance Guarantee Association, and the director of the Department
					 of Industrial Relations as administrator for the Uninsured Employers Benefits
					 Trust Fund (UEBTF). "Claims Administrator" includes any utilization review
					 organization under contract to provide or conduct the claims administrator's
					 utilization review responsibilities.
(c) "Concurrent review" means utilization
					 review conducted during an inpatient stay.
(d) "Course of treatment" means the course of
					 medical treatment set forth in the treatment plan contained on the "Doctor's
					 First Report of Occupational Injury or Illness," Form DLSR 5021, found at
					 California Code of Regulations, title 8, section
					 14006, or on the "Primary Treating
					 Physician's Progress Report," DWC Form PR-2, as contained in section
					 9785.2 or in narrative form
					 containing the same information required in the DWC Form PR-2.
(e) "Delay" means a determination, based on
					 the need for additional evidence as set forth in section
					 9792.9.1(f), that
					 the timeframe requirements for the utilization review process provided in
					 section 9792.9.1(c) cannot
					 be met.
(f) "Denial" means a
					 decision by a physician reviewer that the requested treatment or service is is
					 not authorized.
(g) "Dispute
					 liability" means an assertion by the claims administrator that a factual,
					 medical, or legal basis exists, other than medical necessity, that precludes
					 compensability on the part of the claims administrator for an occupational
					 injury, a claimed injury to any part or parts of the body, or a requested
					 medical treatment.
(h) "Disputed
					 medical treatment" means medical treatment that has been modified, or denied by
					 a utilization review decision.
(i)
					 "Emergency health care services" means health care services for 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.
(j) "Expedited review" means utilization
					 review or independent medical review conducted when the injured worker's
					 condition is such that the injured worker faces 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, or the normal timeframe for the
					 decision-making process would be detrimental to the injured worker's life or
					 health or could jeopardize the injured worker's permanent ability to regain
					 maximum function.
(k) "Expert
					 reviewer" means a medical doctor, doctor of osteopathy, psychologist,
					 acupuncturist, optometrist, dentist, podiatrist, or chiropractic practitioner
					 licensed by any state or the District of Columbia, competent to evaluate the
					 specific clinical issues involved in the medical treatment services and where
					 these services are within the individual's scope of practice, who has been
					 consulted by the reviewer or the utilization review medical director to provide
					 specialized review of medical information.
(l) "Health care provider" means a provider
					 of medical services, as well as related services or goods, including but not
					 limited to an individual provider or facility, a health care service plan, a
					 health care organization, a member of a preferred provider organization or
					 medical provider network as provided in Labor Code section
					 4616.
(m) "Immediately" means within one business
					 day.
(n) "Material modification" is
					 when the claims administrator changes utilization review vendor or makes a
					 change to the utilization review standards as specified in section
					 9792.7.
(o) "Medical Director" is the physician and
					 surgeon licensed by the Medical Board of California or the Osteopathic Board of
					 California who holds an unrestricted license to practice medicine in the State
					 of California. The Medical Director is responsible for all decisions made in
					 the utilization review process.
(p)
					 "Medical services" means those goods and services provided pursuant to Article
					 2 (commencing with Labor Code section
					 4600) of
					 Chapter 2 of Part 2 of Division 4 of the Labor Code.
(q) "Medical Treatment Utilization Schedule"
					 means the standards of care adopted by the Administrative Director pursuant to
					 Labor Code section
					 5307.27 and set
					 forth in Article 5.5.2 of this Subchapter, beginning with section
					 9792.20.
(r) "Modification" means a decision by a
					 physician reviewer that part of the requested treatment or service is not
					 medically necessary.
(s)
					 "Prospective review" means any utilization review conducted, except for
					 utilization review conducted during an inpatient stay, prior to the delivery of
					 the requested medical services
(t)
					 "Request for authorization" means a written request for a specific course of
					 proposed medical treatment.
(1) Unless
					 accepted by a claims administrator under section
					 9792.9.1(c)(2), a
					 request for authorization must be set forth on a "Request for Authorization
					 (DWC Form RFA)," completed by a treating physician, as contained in California
					 Code of Regulations, title 8, section
					 9785.5. Prior to March 1, 2014, any
					 version of the DWC Form RFA adopted by the Administrative Director under
					 section 9785.5 may be used by the treating
					 physician to request medical treatment.
(2) "Completed," for the purpose of this
					 section and for purposes of investigations and penalties, means that the
					 request for authorization must identify both the employee and the provider,
					 identify with specificity a recommended treatment or treatments, and be
					 accompanied by documentation substantiating the need for the requested
					 treatment.
(3) The request for
					 authorization must be signed by the treating physician and may be mailed, faxed
					 or e-mailed to, if designated, the address, fax number, or e-mail address
					 designated by the claims administrator for this purpose. By agreement of the
					 parties, the treating physician may submit the request for authorization with
					 an electronic signature.
(u) "Retrospective review" means utilization
					 review conducted after medical services have been provided and for which
					 approval has not already been given.
(v) "Reviewer" means a medical doctor, doctor
					 of osteopathy, psychologist, acupuncturist, optometrist, dentist, podiatrist,
					 or chiropractic practitioner licensed by any state or the District of Columbia,
					 competent to evaluate the specific clinical issues involved in medical
					 treatment services, where these services are within the scope of the reviewer's
					 practice.
(w) "Utilization review
					 decision" means a decision pursuant to Labor Code section
					 4610 to
					 approve, modify, delay, or deny, a treatment recommendation or recommendations
					 by a physician prior to, retrospectively, or concurrent with the provision of
					 medical treatment services pursuant to Labor Code sections
					 4600 or
					 5402(c).
(x) "Utilization review plan" means the
					 written plan filed with the Administrative Director pursuant to Labor Code
					 section
					 4610, setting
					 forth the policies and procedures, and a description of the utilization review
					 process.
(y) "Utilization review
					 process" means utilization management functions that prospectively,
					 retrospectively, or concurrently review and approve, modify, delay, or deny,
					 based in whole or in part on medical necessity to cure or relieve, treatment
					 recommendations by physicians, as defined in Labor Code section
					 3209.3, prior
					 to, retrospectively, or concurrent with the provision of medical treatment
					 services pursuant to Labor Code section
					 4600. The
					 utilization review process begins when the completed DWC Form RFA, or a request
					 for authorization accepted as complete under section
					 9792.9.1(c)(2), is
					 first received by the claims administrator, or in the case of prior
					 authorization, when the treating physician satisfies the conditions described
					 in the utilization review plan for prior authorization.
(z) "Written" includes a communication
					 transmitted by facsimile or in paper form. Electronic mail may be used by
					 agreement of the parties although an employee's health records shall not be
					 transmitted via electronic mail.