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 - Utilization Review Standards-Definitions - for Utilization Review Decisions Issued Prior to July 1, 2013 for Injuries Occurring Prior to 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 an occupational injury or illness occurring prior to January 1,
						2013 if the decision on the request is communicated to the requesting physician
						prior to July 1, 2013.
(a) "ACOEM
					 Practice Guidelines" means the American College of Occupational and
					 Environmental Medicine's Occupational Medicine Practice Guidelines, Second
					 Edition.
(b) "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 the Doctor's First Report of Occupational Injury or
					 Illness," Form DLSR 5021, 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.
(c) "Claims Administrator" is a
					 self-administered workers' compensation insurer, 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
					 claims administrator may utilize an entity contracted to conduct its
					 utilization review responsibilities.
(d) "Concurrent review" means utilization
					 review conducted during an inpatient stay.
(e) "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, 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.
(f) "Dispute liability" means an assertion by
					 the claims administrator that a factual, medical, or legal basis exists 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.
(g)
					 "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.
(h) "Expedited review" means utilization
					 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.
(i) "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.
(j) "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.
(k) "Immediately" means within 24 hours after
					 learning the circumstances that would require an extension of the timeframe for
					 decisions specified in subdivisions (b)(1), (b)(2) or (c) and (g)(1) of section
					 9792.9.
(l) "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.
(m) "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.
(n)
					 "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.
(o) "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.
(p) "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.
(q) "Request for
					 authorization" means a written confirmation of an oral request for a specific
					 course of proposed medical treatment pursuant to Labor Code section
					 4610(h)
					 or a written request for a specific course of proposed medical treatment. An
					 oral request for authorization must be followed by a written confirmation of
					 the request within seventy-two (72) hours. Both the written confirmation of an
					 oral request and the written request must be set forth on the "Doctor's First
					 Report of Occupational Injury or Illness," Form DLSR 5021, section
					 14006, or on the Primary Treating
					 Physician Progress Report, DWC Form PR-2, as contained in section
					 9785.2, or in narrative form
					 containing the same information required in the PR-2 form. If a narrative
					 format is used, the document shall be clearly marked at the top that it is a
					 request for authorization.
(r)
					 "Retrospective review" means utilization review conducted after medical
					 services have been provided and for which approval has not already been
					 given.
(s) "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.
(t) "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.
(u) "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.
					 Utilization review does not include determinations of the work-relatedness of
					 injury or disease, or bill review for the purpose of determining whether the
					 medical services were accurately billed.
(v) "Written" includes a facsimile as well as
					 communications in paper form.
1. New
						section filed 7-20-95; operative 7-20-95. Submitted to OAL for printing only
						pursuant to Government Code section
						11351
						(Register 95, No. 29).
2. Amendment of subsections (a)(4), (c)(1),
						(c)(3)(iii)-(iv) and (c)(4)(i)-(iii) filed 11-9-98; operative 1-1-99 (Register
						98, No. 46).
3. New article 5.5.1 (sections
						9792.6-9792.11) and repealer and
						new section filed 12-9-2004 as an emergency; operative 12-13-2004 (Register
						2004, No. 50). A Certificate of Compliance must be transmitted to OAL by
						4-12-2005 or emergency language will be repealed by operation of law on the
						following day.
4. New article 5.5.1 (sections
						9792.6-9792.11) and repealer and
						new section refiled 4-6-2005 as an emergency; operative 4-12-2005 (Register
						2005, No. 14). A Certificate of Compliance must be transmitted to OAL by
						8-10-2005 or emergency language will be repealed by operation of law on the
						following day.
5. Certificate of Compliance as to 4-6-2005 order,
						including amendment of section and NOTE, transmitted to OAL 8-10-2005 and filed
						9-22-2005 (Register 2005, No. 38).
6. Amendment of section heading,
						repealer and new first paragraph and 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.
7. Amendment of section heading, repealer and new
						first paragraph and 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.
8. Amendment of section
						heading, repealer and new first paragraph and 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.
9. Certificate of Compliance as to 9-30-2013 order, including
						new subsections (f) and (o), subsection relettering and amendment of NOTE,
						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,
						  4603.5 and
						  5307.3, Labor
						  Code. Reference: Sections
						  3209.3,
						  4062,
						  4600,
						  4600.4,
						  4604.5,
						  4610 and
						  4610.5, Labor
						  Code.