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 5.3 - Official Medical Fee Schedule › Section 9789.70 - Ambulance Services

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a)
					 The maximum reasonable fee for ambulance services rendered after January 1,
					 2004 shall not exceed 120% of the applicable fee for the Calendar Year 2004 set
					 forth in CMS's Ambulance Fee Schedule, which is established pursuant to Section
					 1834 of the Social Security Act
					 (42 U.S.C. §
												1395m) and applicable to California. The
					 Ambulance Fee Schedule, which can be found at the CMS Internet Website
http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/AmbulanceFeeSchedule/
)
					 is incorporated by reference and will be made available on the Division of
					 Workers' Compensation's Internet Website (
http://www.dir.ca.gov/DWC/dwc_home_page.htm
)
					 or upon request to the Administrative Director at:
DIVISION OF WORKERS' COMPENSATION (ATTENTION:
						OMFS)
P.O. BOX 420603
SAN FRANCISCO, CA 94142.
(b) This section is not applicable to
					 services provided by any air ambulance provider which at the time of service is
					 an "air carrier" as defined in Title
					 49 U.S.C.A. Section
					 40102, a part of the Airline Deregulation Act
					 of 1978 as amended.
1. New
						section filed 1-2-2004 as an emergency; operative 1-2-2004 (Register 2004, No.
						2). A Certificate of Compliance must be transmitted to OAL by 5-3-2004 or
						emergency language will be repealed by operation of law on the following
						day.
2. Certificate of Compliance as to 1-2-2004 order, including
						designation and amendment of first paragraph as subsection (a) and new
						subsection (b), transmitted to OAL 4-30-2004 and filed 6-15-2004 (Register
						2004, No. 25).
3. New subsection (c) filed 7-13-2010; operative
						7-13-2010. Exempt from the Administrative Procedure Act and OAL review and
						submitted to OAL for printing only pursuant to Government Code section
						11340.9(g)
						(Register 2010, No. 29).
4. Amendment of subsection (a), repealer of
						subsection (b) and subsection relettering filed 2-4-2015; operative 3-5-2015.
						Submitted to OAL for printing only pursuant to Government Code section
						11340.9
						(Register 2015, No. 6).
Note: Authority cited: Sections
						  133,
						  4603.5,
						  5307.1 and
						  5307.3, Labor
						  Code. Reference: Sections
						  4600,
						  4603.2 and
						  5307.1, 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 5.3 - Official Medical Fee Schedule › Section 9789.80 - Skilled Nursing Facility. [Reserved]

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
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 5.3 - Official Medical Fee Schedule › Section 9789.90 - Home Health Care. [Reserved]

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
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 5.3 - Official Medical Fee Schedule › Section 9789.100 - Outpatient Renal Dialysis. [Reserved]

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
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 5.3 - Official Medical Fee Schedule › Section 9789.110 - Update of Rules to Reflect Changes in the Medicare Payment System

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
The OMFS shall be adjusted within 60 days to conform to
						any relevant changes in the Medicare and Medi-Cal payment systems as required
						by law. The Administrative Director shall determine the effective date of the
						change and issue an order informing the public of the change and the effective
						date. Such order shall be posted on the Division's Internet Website:
http://www.dir.ca.gov/DWC/dwc_home_page.htm
.
1. New
						section filed 1-2-2004 as an emergency; operative 1-2-2004 (Register 2004, No.
						2). A Certificate of Compliance must be transmitted to OAL by 5-3-2004 or
						emergency language will be repealed by operation of law on the following
						day.
2. Certificate of Compliance as to 1-2-2004 order, including
						amendment of section, transmitted to OAL 4-30-2004 and filed 6-15-2004
						(Register 2004, No. 25).
Note: Authority cited: Sections
						  133,
						  4603.5,
						  5307.1 and
						  5307.3, Labor
						  Code. Reference: Sections
						  4600,
						  4603.2 and
						  5307.1, 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 5.5 - Application of the Official Medical Fee Schedule (Treatment) › Section 9790 - Authority

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
The rules and regulations contained in this Article are
						adopted pursuant to the authority contained in Sections
						133,
						4603.5,
						307.1 and
						5307.3 of the
						California Labor Code. Sections
						9790.1 -
						9792.1 and Appendices A-C,
						contained in this Article, are not applicable for physician services rendered
						and inpatient hospital facility services for discharges after January 1, 2004,
						unless otherwise specified in this Subchapter 1. Administrative Director --
						Administrative Rules.
1. New
						article 5.5 (sections
						9790-9792) filed 11-9-77; effective
						thirtieth day thereafter (Register 77, No. 46).
2. Amendment of
						section and NOTE filed 10-7-93; operative 1-1-94 (Register 93, No. 41). This
						filing is exempt from much of the APA (including OAL review) pursuant to
						Government Code section
						11351.
3.
						Editorial correction (Register 95, No. 15).
4. Amendment filed
						2-4-2015; operative 3-5-2015. Submitted to OAL for printing only pursuant to
						Government Code section
						11340.9
						(Register 2015, No. 6).
Note: Authority cited: Sections
						  133,
						  4603.5,
						  5307.1 and
						  5307.3, Labor
						  Code. Reference: Sections
						  4600,
						  4603.2 and
						  5307.1, 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 5.5 - Application of the Official Medical Fee Schedule (Treatment) › Section 9791 - Services Covered

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
Except as provided in this article, the Official Medical
						Fee Schedule applies to all covered medical services provided, referred or
						prescribed by physicians (as defined in Section
						3209.3 of the
						Labor Code), regardless of the type of facility in which the medical services
						are performed, including clinic and hospital-based physicians working on a
						contract basis. The Schedule shall not apply to inpatient medical services
						provided by employees of a health facility, medical-legal expenses authorized
						under Section
						4621 of the
						Labor Code, and medical expenses payable pursuant to Section
						9795. Nothing contained in this
						schedule shall preclude any hospital as defined in subdivisions (a), (b), or
						(f) of Section
						1250
						of the Health and Safety Code, or any surgical facility which is licensed under
						subdivision (b) of Section
						1204
						of the Health and Safety Code, or any ambulatory surgical center that is
						certified to participate in the Medicare program under Title XVIII
						(42 U.S.C. Sec.
						1395 et seq.) of the federal Social Security
						Act, or any surgical clinic accredited by the Accreditation Association for
						Ambulatory Health Care (AAAHC), from charging and collecting a facility fee for
						the use of the emergency room or operating room of the
						facility.
1.
						Amendment of section and new NOTE filed 10-7-93; operative 1-1-94 (Register 93,
						No. 41). This filing is exempt from much of the APA (including OAL review)
						pursuant to Government Code section
						11351.
2.
						Amendment filed 10-11-95; operative 10-11-95. Submitted to OAL for printing
						only pursuant to Government Code section
						11351
						(Register 95, No. 41).
Note: Authority cited: Sections
						  133,
						  4603.5,
						  5307.1 and
						  5307.3, Labor
						  Code. Reference: Sections
						  4600,
						  4603.2 and
						  5307.1, 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 5.5 - Application of the Official Medical Fee Schedule (Treatment) › Section 9791.1 - Medical Fee Schedule

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
The Official Medical Fee Schedule shall include the
						procedures, procedure numbers, descriptions, instructions, and unit values
						adopted by the Administrative Director, effective January 1, 1994; as revised
						for services on or after January 1, 1996; and as thereafter revised and
						adopted. The Official California Workers' Compensation Medical Fee Schedule
						(Revised April 1, 1999, and as amended for dates of service on or after
						7/12/02) is hereby incorporated by reference. An order form for purchasing a
						copy of the Schedule can be obtained by contacting the Division of Workers'
						Compensation at the following address:
DIVISION OF WORKERS' COMPENSATION
(ATTENTION: OMFS ORDER)
P.O. BOX 420603
SAN FRANCISCO, CALIFORNIA 94142
The amendments of the OMFS for dates of service on or
						after 7/12/02 may be obtained either by purchasing them from the Division or
						they may be downloaded at no charge from the Division's website at (
http://www.dir.ca.gov/workers'_comp.html
).
1. New
						section filed 8-14-81; effective thirtieth day thereafter (Register 81, No.
						33).
2. Amendment filed 8-29-84; effective thirtieth day thereafter
						(Register 84, No. 35).
3. Change without regulatory effect filed
						7-11-86; effective upon filing (Register 86, No. 28).
4. Amendment
						filed 5-18-87; operative 5-18-87 (Register 87, No. 21).
5. Amendment
						of section and NOTE filed 10-7-93; operative 1-1-94 (Register 93, No. 41). This
						filing is exempt from much of the APA (including OAL review) pursuant to
						Government Code section
						11351.
6.
						Amendment filed 10-11-95; operative 10-11-95. Submitted to OAL for printing
						only pursuant to Government Code section
						11351
						(Register 95, No. 41).
7. Amendment of section incorporating by
						reference "The Official California Workers' Compensation Medical Fee Schedule"
						(revised April 1, 1999) filed 2-19-99; operative 4-1-99 (Register 99, No.
						8).
8. Change without regulatory effect amending section filed
						6-12-2002 pursuant to section
						100, title 1, California Code of
						Regulations (Register 2002, No. 24).
Note: Authority cited: Sections
						  133,
						  4603.5,
						  5307.1 and
						  5307.3, Labor
						  Code. Reference: Sections
						  4600,
						  4603.2 and
						  5307.1, 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 5.5 - Application of the Official Medical Fee Schedule (Treatment) › Appendix C - Ratios Applied to Revise Certain DRG Weights in California

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
Number
DRG
Ratio
004
Spinal Procs
0.6283
008
Peripheral/Cranial Nerve & Orth OR
								Nervous Sys. Procs
0.8082
025
Seizures and Headaches: AD WO
								CC
0.7485
029
Traumatic Stupor and Coma: AD WO
								CC
1.0025
032
Concussion: AD WO
								CC
0.8749
042
Intraocular Proc Exc. Retina, Iris and
								Lens
1.0661
063
Other Ear, Nose, Mouth and Throat OR
								Procs
0.8753
112
Percutaneous Cardiovascular
								Procs
0.8409
140
Angina Pectoris
0.7834
143
Chest Pain
0.8417
160
Hernia Proc: AD Exc. Inguinal or
								Femoral, WO CC
0.9016
162
Hernia Proc: AD Inguinal or Femoral, WO
								CC
0.8672
209
Major Joints and Limb Reattachment,
								Lower Extremity
0.9500
210
Hip and Femur, Exc Major joint Proc: AD
								W CC
1.1800
211
Hip and Femur, Exc Major joint Proc: AD
								WO CC
0.9726
214
Back and Neck Proc W
								CC
0.9674
215
Back and Neck Procs WO
								CC
0.9556
217
Wound Debridement and Skin Graft Exc.
								Hand
0.5717
218
Lower Extr/Humerous Exc. Hip, Foot and
								Femur: AD W CC
1.0298
219
Lower Extr/Humer. Exc. Hip, Foot and
								Femur: AD WO CC
0.9681
221
Knee Proc W CC
0.8177
222
Knee Proc WO CC
1.0382
223
Maj. Shoulder/Elbow Proc/Other Upper
								Extrem. Proc W CC
0.8850
224
Shoulder/Elbow/Forearm Proc exc. Major
								Joint Proc WO CC
1.0122
225
Foot Proc
1.0008
227
Soft Tissue Proc WO
								CC
0.9443
228
Major Thumb/Joint Proc, or Other Hand
								or Wrist Proc W CC
0.9063
229
Hand and Wrist Proc, Exc. Major joint
								Proc WO CC
1.0367
231
Local Excision/Removal Int. Fix.
								Devices Exc. Hip & Femur
0.7341
232
Arthroscopy
0.8166
234
Oth. Musculoskel. Sys/Connective Tissue
								OR Procs WO CC
0.8133
236
Fracture of Hip and
								Pelvis
0.9790
243
Medical Back
0.7609
251
Frac, Sprain, Strain, Disloc Forearm,
								Hand/Foot: AD WO CC
0.9012
254
Frac, Sprain, Strain, Disloc Up Arm/Low
								Leg ex Foot: AD W CC
1.0031
266
Skin Graft/Debridement Exc. Skin Ulcer
								or Cellulitis WO CC
1.1306
277
Cellulitis: AD W CC
0.7910
278
Cellulitis: AD WO
								CC
0.8654
281
Trauma to Skin, Subcutaneous Tiss and
								Breast: AD WO CC
0.9709
415
Infectious and Parasitic Disease OR
								Proc
0.4907
418
Postoperative and Post traumatic
								Infection
0.6801
440
Wound Debridement for
								Injury
0.7738
441
Hand Proc for
								Injury
0.9914
443
Other Proc for Injury WO
								CC
1.0024
445
Traumatic Injury: AD WO
								CC
0.8112
450
Injury/Poison/Drug: AD WO
								CC
0.6657
455
Other Injury/Poisoning and Toxic Effect
								Diagnosis WO CC
0.7483
461
OR Proc with Diagnosis of Other Contact
								with Health Services
0.9207
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 - Application of the Official Medical Fee Schedule (Treatment) › Section 9792.5 - Payment for Medical Treatment

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
This section is applicable to medical treatment rendered
						before October 15, 2011.
(a) As used
					 in this section:
(1) "Claims Administrator"
					 has the same meaning specified in Section
					 9785(a)(3).
(2) "Medical treatment" means the treatment
					 to which an employee is entitled under Labor Code Section
					 4600.
(3) "Physician" has the same meaning
					 specified in Labor Code Section
					 3209.3.
(4) "Required report" means a report which
					 must be submitted pursuant to Section
					 9785.
(5) "Treating physician" means the "primary
					 treating physician" as that term is defined by Section
					 9785(a)(1).
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 5.5.0 - Rules for Medical Treatment Billing and Payment on or After October 15, 2011 › Section 9792.5.1 - Medical Billing and Payment Guide; Electronic Medical Billing and Payment Companion Guide; Various Implementation Guides

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a) The
California Division of
					 Workers' Compensation Medical Billing and Payment Guide
, versions
					 listed below, which set forth billing, payment and coding rules for paper and
					 electronic medical treatment bill submissions, are incorporated by reference.
					 They may be downloaded from the Division of Workers' Compensation through the
					 Department of Industrial Relations' website at
www.dir.ca.gov
or may be obtained by writing to:
DIVISION OF WORKERS' COMPENSATION MEDICAL UNIT
ATTN: MEDICAL BILLING AND PAYMENT GUIDE
P.O. BOX 71010
OAKLAND, CA 94612
(1) California Division of Workers'
					 Compensation Medical Billing and Payment Guide 2011, for bills submitted on or
					 after October 15, 2011.
(2)
					 California Division of Workers' Compensation Medical Billing and Payment Guide,
					 Version 1.1, for bills submitted on or after January 1, 2013.
(3) California Division of Workers'
					 Compensation Medical Billing and Payment Guide, Version 1.2.1, for bills
					 submitted on or after February 12, 2014.
(4) California Division of Workers'
					 Compensation Medical Billing and Payment Guide, Version 1.2.2, for bills
					 submitted on or after October 1, 2015.
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 5.5.0 - Rules for Medical Treatment Billing and Payment on or After October 15, 2011 › Section 9792.5.2 - Standardized Medical Treatment Billing Forms/Formats, Billing Rules, Requirements for Completing and Submitting Form CMS 1500, Form CMS 1450 (or UB-04), American Dental Association Form, Version 2006, Ncpdp Workers' Compensation / Property and Casualty Universal Claim Form, Payment Requirements

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a) On and after
					 October 15, 2011, all paper bills for medical treatment provided by health care
					 providers and health care facilities shall be submitted on billing forms set
					 forth in the
California Division of Workers' Compensation Medical
					 Billing and Payment Guide.
(b) On and after October 15, 2011, all
					 medical bills shall conform to the provisions of the
California
					 Division of Workers' Compensation Medical Billing and Payment Guide
which includes coding, billing standards, timeframes and other rules.
(c) On and after October 18, 2012, all bills
					 for medical treatment provided by health care providers and health care
					 facilities may be electronically submitted to the claims administrator for
					 payment. Electronic bills submitted on or after that date shall conform to the
					 applicable provisions of the
California Division of Workers'
					 Compensation Medical Billing and Payment Guide
and the
California Division of Workers' Compensation Electronic Medical Billing
					 and Payment Companion Guide.
(d) Except as otherwise specifically
					 provided, legally authorized billing agents and assignees shall submit bills in
					 the same manner as the original rendering provider or facility would be
					 required to do had the bills been submitted by the provider or facility
					 directly and shall conform to applicable provisions of the
California
					 Division of Workers' Compensation Medical Billing and Payment Guide
and the
California Division of Workers' Compensation Medical Billing
					 and Payment Companion Guide.
1. New
						section filed 4-18-2011; operative 4-18-2011 pursuant to Government Code
						section
						11343.4
						(Register 2011, No. 16).
Note: Authority cited: Sections
						  133,
						  4603.4,
						  4603.5 and
						  5307.3, Labor
						  Code. Reference: Sections
						  4600,
						  4603.2 and
						  4603.4, 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 5.5.0 - Rules for Medical Treatment Billing and Payment on or After October 15, 2011 › Section 9792.5.3 - Medical Treatment Bill Payment Rules

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a) On and after October 15, 2011, claims
					 administrators shall conform to the payment, communication, penalty, and other
					 provisions contained in the
California Division of Workers'
					 Compensation Medical Billing and Payment Guide,
except that the
					 provisions relating to the payment of electronic medical bills shall become
					 effective on October 18, 2012. This subdivision does not apply to processing or
					 payment of bills submitted before October 15, 2011.
(b) On and after October 18, 2012, claims
					 administrators shall conform to the payment, communication, penalty, and other
					 provisions contained in the
California Division of Workers'
					 Compensation Electronic Medical Billing and Payment Companion
					 Guide.
1. New
						section filed 4-18-2011; operative 4-18-2011 pursuant to Government Code
						section
						11343.4
						(Register 2011, No. 16).
2. Amendment of NOTE filed 12-31-2012 as an
						emergency; operative 1-1-2013 pursuant to Government Code section
						11346.1(d)
						(Register 2013, No. 1). A Certificate of Compliance must be transmitted to OAL
						by 7-1-2013 or emergency language will be repealed by operation of law on the
						following day.
3. Amendment of NOTE refiled 7-1-2013 as an
						emergency; operative 7-1-2013 (Register 2013, No. 27). A Certificate of
						Compliance must be transmitted to OAL by 9-30-2013 or emergency language will
						be repealed by operation of law on the following day.
4. Amendment
						of NOTE refiled 9-30-2013 as an emergency; operative 10-1-2013 (Register 2013,
						No. 40). A Certificate of Compliance must be transmitted to OAL by 12-30-2013
						or emergency language will be repealed by operation of law on the following
						day.
5. Certificate of Compliance as to 9-30-2013 order transmitted
						to OAL 12-30-2013 and filed 2-12-2014 (Register 2014, No.
						7).
Note: Authority cited: Sections
						  133,
						  4603.3,
						  4603.4,
						  4603.5 and
						  5307.3, Labor
						  Code. Reference: Sections
						  4600,
						  4603.2,
						  4603.3 and
						  4603.4, 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 5.5.0 - Rules for Medical Treatment Billing and Payment on or After October 15, 2011 › Section 9792.5.4 - Second Review and Independent Bill Review - Definitions

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
This section is applicable to medical treatment services
						and goods rendered under Labor Code section
						4600, or
						medical-legal expenses incurred under Labor Code section
						4620, on or
						after January 1, 2013.
(a) "Amount of
					 payment" means the amount of money paid by the claims administrator for either:
(1) Medical treatment services or goods
					 rendered by a provider or goods supplied in accordance with Labor Code section
					 4600 that were
					 authorized by Labor Code section
					 4610, and for
					 which there exists an applicable fee schedule adopted by the Administrative
					 Director for those categories of goods and services, including but not limited
					 to those found at sections
					 9789.10 to
					 9789.111, or for which a contract
					 for reimbursement rates exists under Labor Code section
					 5307.11.
(2) Medical-legal expenses, as defined by
					 Labor Code section
					 4620, where the
					 payment is determined in accordance with sections
					 9793-9795 and
					 9795.1-9795.4.
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 5.5.0 - Rules for Medical Treatment Billing and Payment on or After October 15, 2011 › Section 9792.5.5 - Second Review of Medical Treatment Bill or Medical-Legal Bill

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a) If the provider
					 disputes the amount of payment made by the claims administrator on a bill for
					 medical treatment services or goods rendered on or after January 1, 2013,
					 submitted pursuant to Labor Code section
					 4603.2, or
					 Labor Code section
					 4603.4, or bill
					 for medical-legal expenses incurred on or after January 1, 2013, submitted
					 pursuant to Labor Code section
					 4622, the
					 provider may request the claims administrator to conduct a second review of the
					 bill.
(b) The second review must be
					 requested within 90 days of:
(1) The date of
					 service of the explanation of review provided by a claims administrator in
					 conjunction with the payment, adjustment, or denial of the initially submitted
					 bill, if a proof of service accompanies the explanation of review.
(A) The date of receipt of the explanation of
					 review by the provider is deemed the date of service, if a proof of service
					 does not accompany the explanation of review and the claims administrator has
					 documentation of receipt.
(B) If
					 the explanation of review is sent by mail and if in the absence of a proof of
					 service or documentation of receipt, the date of service is deemed to be five
					 (5) calendar days after the date of the United States postmark stamped on the
					 envelope in which the explanation of review was mailed.
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 5.5.0 - Rules for Medical Treatment Billing and Payment on or After October 15, 2011 › Section 9792.5.6 - Provider's Request for Second Bill Review-Form

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
Provider's Request for Second Bill Review. DWC Form
						SBR-1.
Click
						here to view image
Click
						here to view image
1. New
						section filed 12-31-2012 as an emergency; operative 1-1-2013 pursuant to
						Government Code section
						11346.1(d)
						(Register 2013, No. 1). A Certificate of Compliance must be transmitted to OAL
						by 7-1-2013 or emergency language will be repealed by operation of law on the
						following day.
2. New section refiled 7-1-2013 as an emergency;
						operative 7-1-2013 (Register 2013, No. 27). A Certificate of Compliance must be
						transmitted to OAL by 9-30-2013 or emergency language will be repealed by
						operation of law on the following day.
3. New section refiled
						9-30-2013 as an emergency; operative 10-1-2013 (Register 2013, No. 40). A
						Certificate of Compliance must be transmitted to OAL by 12-30-2013 or emergency
						language will be repealed by operation of law on the following
						day.
4. Certificate of Compliance as to 9-30-2013 order, including
						repealer and new DWC Form SBR-1, transmitted to OAL 12-30-2013 and filed
						2-12-2014; amendments effective 2-12-2014 pursuant to Government Code section
						11343.4(b)(3)
						(Register 2014, No. 7).
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 5.5.0 - Rules for Medical Treatment Billing and Payment on or After October 15, 2011 › Section 9792.5.7 - Requesting Independent Bill Review

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a) If the provider further contests the
					 amount of payment made by the claims administrator on a bill for medical
					 treatment services or goods rendered on or after January 1, 2013, submitted
					 pursuant to Labor Code sections
					 4603.2 or
					 4603.4, or bill
					 for medical-legal expenses incurred on or after January 1, 2013, submitted
					 pursuant to Labor Code section
					 4622, following
					 the second review conducted under section
					 9792.5.5, the provider shall
					 request an independent bill review. Unless consolidated under section
					 9792.5.12, a request for
					 independent bill review shall only resolve:
(1) For a bill for medical treatment services
					 or goods, a dispute over the amount of payment for services or goods billed by
					 a single provider involving one injured employee, one claims administrator, and
					 either one date of service and one billing code or one hospital stay, under the
					 applicable fee schedule adopted by the Administrative Director or, if
					 applicable, under a contract for reimbursement rates under Labor Code section
					 5307.11
					 covering one range of effective dates.
(2) For a bill for medical-legal expenses, a
					 dispute over the amount of payment for services billed by a single provider
					 involving one injured employee, one claims administrator, and one
					 comprehensive, follow-up, or supplemental medical legal evaluation report as
					 defined in section
					 9794.
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 5.5.0 - Rules for Medical Treatment Billing and Payment on or After October 15, 2011 › Section 9792.5.8 - Request for Independent Bill Review Form

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
Request for Independent Bill Review. DWC Form
						IBR-1.
Click
						here to view image
Click
						here to view image
Click
						here to view image
Note: Authority cited: Sections
						  133,
						  4603.6 and
						  5307.3, Labor Code. Reference:
						  Sections 4603.2,
						  4603.6 and
						  4622, 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 5.5.0 - Rules for Medical Treatment Billing and Payment on or After October 15, 2011 › Section 9792.5.9 - Initial Review and Assignment of Request for Independent Bill Review to IBRO

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a) Upon
					 receipt of the Request for Independent Bill Review under section
					 9792.5.7, the Administrative
					 Director, or his or her designee, shall conduct a preliminary review to
					 determine whether the request is ineligible for review. In making this
					 determination, the Administrative Director shall consider:
(1) The timeliness and completeness of the
					 request;
(2) The date the medical
					 treatment services or goods were rendered or the medical-legal expenses
					 incurred;
(3) Whether the second
					 request for review of the bill under section
					 9792.5.5 was timely requested by
					 the provider;
(4) Whether the
					 second review of the bill under section
					 9792.5.5 was timely completed by
					 the claims administrator;
(5)
					 Whether, for a bill for medical treatment services or goods, the medical
					 treatment was authorized by the claims administrator under Labor Code section
					 4610.
(6) If the required fee for the review was
					 paid pursuant to section
					 9792.5.7(d)(1)(A) or
					 (B);
(7) Any previous or duplicate requests for
					 independent bill review of the same bill for medical treatment services or bill
					 for medical-legal expenses.
(8) If
					 the dispute between the provider and the claims administrator is ineligible
					 under section
					 9792.5.7(b) or
					 contains any other issue than the amount of payment of the
					 bill.
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 5.5.0 - Rules for Medical Treatment Billing and Payment on or After October 15, 2011 › Section 9792.5.10 - Independent Bill Review - Document Filing

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a) The independent bill reviewer assigned
					 the request shall review all information provided by the parties to determine
					 if any additional information is necessary to resolve the dispute. If the
					 independent bill reviewer determines that additional information is necessary,
					 the independent bill reviewer shall contact the claims administrator and the
					 provider in writing to request the information.
(b) If the independent bill reviewer requests
					 information from either the claims administrator or the provider, or both, the
					 party shall file the documents with the independent bill reviewer at the
					 address listed in the correspondence in Section
					 9792.5.9(f). The
					 requested documents must be received within 35 days of the request, if the
					 request is made by mail, or 32 days of the request, if the request is made
					 electronically. The filing party shall concurrently serve the non-filing party
					 with the documents requested by the independent bill reviewer.
(c) Except for the documents submitted under
					 this section, and those requested under section
					 9792.5.12, neither the provider nor
					 the claims administrator shall file any additional documents with the
					 independent bill reviewer.
1. New
						section filed 12-31-2012 as an emergency; operative 1-1-2013 pursuant to
						Government Code section
						11346.1(d)
						(Register 2013, No. 1). A Certificate of Compliance must be transmitted to OAL
						by 7-1-2013 or emergency language will be repealed by operation of law on the
						following day.
2. New section refiled 7-1-2013 as an emergency;
						operative 7-1-2013 (Register 2013, No. 27). A Certificate of Compliance must be
						transmitted to OAL by 9-30-2013 or emergency language will be repealed by
						operation of law on the following day.
3. New section refiled
						9-30-2013 as an emergency; operative 10-1-2013 (Register 2013, No. 40). A
						Certificate of Compliance must be transmitted to OAL by 12-30-2013 or emergency
						language will be repealed by operation of law on the following
						day.
4. Certificate of Compliance as to 9-30-2013 order, including
						amendment of subsection (b), transmitted to OAL 12-30-2013 and filed 2-12-2014;
						amendments effective 2-12-2014 pursuant to Government Code section
						11343.4(b)(3)
						(Register 2014, No. 7).
Note: Authority cited: Sections
						  133,
						  4603.6,
						  5307.3 and
						  5307.6, Labor
						  Code. Reference: Sections
						  4060,
						  4061,
						  4061.5,
						  4062,
						  4600,
						  4603.2,
						  4603.3. 4603.4, 4603.6, 4620, 4621,
						  4622, 4625, 4628 and 5307.6, 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 5.5.0 - Rules for Medical Treatment Billing and Payment on or After October 15, 2011 › Section 9792.5.11 - Withdrawal of Independent Bill Review

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
The provider may, concurrent with written notice to the
						claims administrator, withdraw a request for independent bill review at any
						time prior to the issuance of a final determination on the amount of payment
						owed under section
						9792.5.14.
(a) If the request is withdrawn prior to its
					 assignment to an IBRO for an independent bill review under section
					 9792.5.9(f), the
					 provider shall be reimbursed the amount of $270.00 from the fee provided with
					 the request under section
					 9792.5.7(d).
(b) If the request is withdrawn subsequent to
					 its assignment to an IBRO for an independent bill review under section
					 9792.5.9(f), the
					 provider shall not be reimbursed the fee provided with the request under
					 section 9792.5.7(d).
1. New
						section filed 12-31-2012 as an emergency; operative 1-1-2013 pursuant to
						Government Code section
						11346.1(d)
						(Register 2013, No. 1). A Certificate of Compliance must be transmitted to OAL
						by 7-1-2013 or emergency language will be repealed by operation of law on the
						following day.
2. New section refiled 7-1-2013 as an emergency;
						operative 7-1-2013 (Register 2013, No. 27). A Certificate of Compliance must be
						transmitted to OAL by 9-30-2013 or emergency language will be repealed by
						operation of law on the following day.
3. New section refiled
						9-30-2013 as an emergency; operative 10-1-2013 (Register 2013, No. 40). A
						Certificate of Compliance must be transmitted to OAL by 12-30-2013 or emergency
						language will be repealed by operation of law on the following
						day.
4. Certificate of Compliance as to 9-30-2013 order, including
						amendment of section, transmitted to OAL 12-30-2013 and filed 2-12-2014;
						amendments effective 2-12-2014 pursuant to Government Code section
						11343.4(b)(3)
						(Register 2014, No. 7).
Note: Authority cited: Sections
						  133,
						  4603.6,
						  5307.3 and
						  5307.6, Labor
						  Code. Reference: Sections
						  4060,
						  4061,
						  4061.5,
						  4062,
						  4600,
						  4603.2,
						  4603.3. 4603.4, 4603.6, 4620, 4621,
						  4622, 4625, 4628 and 5307.6, 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 5.5.0 - Rules for Medical Treatment Billing and Payment on or After October 15, 2011 › Section 9792.5.12 - Independent Bill Review - Consolidation or Separation of Requests

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a) With a request
					 for independent bill review submitted under section
					 9792.5.7, a provider may request
					 combining two or more requests, with a maximum of twenty (20), for independent
					 bill review for the purpose of having the payment reductions contested in each
					 request resolved in a single determination issued under section
					 9792.5.14.
(b) In applying this section, the following
					 definitions shall be used:
(1) "Common issues
					 of law and fact" means the denial or reduction of the amount of payment in each
					 request was made for similar reasons and arose from a similar fact pattern
					 material to the reason for the denial or reduction.
(2) "Delivery of similar or related services"
					 means like or coordinated medical treatment services or goods, or medical-legal
					 services, provided to one or more injured employees.
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 5.5.0 - Rules for Medical Treatment Billing and Payment on or After October 15, 2011 › Section 9792.5.14 - Independent Bill Review - Determination

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a) Within sixty (60) days of the assignment
					 of a dispute to an independent bill reviewer under section
					 9792.5.9(g), the
					 reviewer shall issue a written determination, in plain language, if any
					 additional amount of money is owed the provider under the request for
					 independent bill review. The determination shall state the reasons for the
					 determination and the information received and relied upon by the independent
					 bill reviewer in rendering the determination.
(b) If the independent bill reviewer finds
					 any additional amount of money is owed to the provider, the determination shall
					 also order the claims administrator to reimburse the provider the amount of the
					 filing fee in addition to any additional payments for services found
					 owing.
(c) The independent bill
					 reviewer shall serve the determination on the provider, the claims
					 administrator and the Administrative Director.
(d) The determination issued by the
					 independent bill reviewer shall be deemed to be the determination of the
					 Administrative Director and shall be binding on all parties.
1. New
						section filed 12-31-2012 as an emergency; operative 1-1-2013 pursuant to
						Government Code section
						11346.1(d)
						(Register 2013, No. 1). A Certificate of Compliance must be transmitted to OAL
						by 7-1-2013 or emergency language will be repealed by operation of law on the
						following day.
2. New section refiled 7-1-2013 as an emergency;
						operative 7-1-2013 (Register 2013, No. 27). A Certificate of Compliance must be
						transmitted to OAL by 9-30-2013 or emergency language will be repealed by
						operation of law on the following day.
3. New section refiled
						9-30-2013 as an emergency; operative 10-1-2013 (Register 2013, No. 40). A
						Certificate of Compliance must be transmitted to OAL by 12-30-2013 or emergency
						language will be repealed by operation of law on the following
						day.
4. Certificate of Compliance as to 9-30-2013 order transmitted
						to OAL 12-30-2013 and filed 2-12-2014 (Register 2014, No.
						7).
Note: Authority cited: Sections
						  133,
						  4603.6,
						  5307.3 and
						  5307.6, Labor
						  Code. Reference: Sections
						  4060,
						  4061,
						  4061.5,
						  4062,
						  4600,
						  4603.2,
						  4603.3. 4603.4, 4603.6, 4620, 4621,
						  4622, 4625, 4628 and 5307.6, 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 5.5.0 - Rules for Medical Treatment Billing and Payment on or After October 15, 2011 › Section 9792.5.15 - Independent Bill Review - Implementation of Determination and Appeal

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a) Upon receiving
					 the determination of the Administrative Director that an additional amount of
					 money is owed to the provider on a bill for medical treatment services
					 submitted pursuant to Labor Code sections
					 4603.2 or
					 4603.4, or bill
					 for medical-legal expenses submitted pursuant to Labor Code section
					 4622, the
					 claims administrator shall, unless appealed under subdivision (b), pay the
					 additional amounts set forth in the determination per the timely payment
					 requirements set forth in Labor Code sections
					 4603.2 and
					 4603.4.
(b) Pursuant to Labor Code section
					 4603.6(f),
					 the provider or the claims administrator may appeal a determination of the
					 Administrative Director under section
					 9792.5.14 by filing a petition with
					 the Workers' Compensation Appeals Board.
(c) If the final determination of the
					 Administrative Director is reversed by the Workers' Compensation Appeals Board,
					 the dispute shall be remanded to the Administrative Director. The
					 Administrative Director shall:
(1) Submit the
					 dispute to independent bill review by a different IBRO, if available;
(2) If a different IBRO is not available
					 after remand, the Administrative Director shall submit the dispute to the
					 original IBRO for review by a different reviewer in the
					 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 5.5.1 - Utilization Review Standards › Section 9792.7 - Utilization Review Standards-Applicability

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a) Effective January 1, 2004, every claims
					 administrator shall establish and maintain a utilization review process for
					 treatment rendered on or after January 1, 2004, regardless of date of injury,
					 in compliance with Labor Code section
					 4610. Each
					 utilization review process shall be set forth in a utilization review plan
					 which shall contain:
(1) The name, address,
					 phone number, and medical license number of the employed or designated medical
					 director, who holds an unrestricted license to practice medicine in the state
					 of California issued pursuant to section
					 2050 or section
					 2450
					 of the Business and Professions Code.
(2) A description of the process whereby
					 requests for authorization are reviewed, and decisions on such requests are
					 made, and a description of the process for handling expedited
					 reviews.
(3) A description of the
					 specific criteria utilized routinely in the review and throughout the
					 decision-making process, including treatment protocols or standards used in the
					 process. The treatment protocols or standards governing the utilization review
					 process shall be consistent with the Medical Treatment Utilization Schedule
					 adopted by the Administrative Director pursuant to Labor Code section
					 5307.27.
(4) A description of the qualifications and
					 functions of the personnel involved in decision-making and implementation of
					 the utilization review plan.
(5) A
					 description of the claims administrator's practice, if applicable, of any prior
					 authorization process, including but not limited to, where authorization is
					 provided without the submission of the request for
					 authorization.