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 9770 - Definitions

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a) "Administrative
					 Director" means the administrative director of the Division of Workers'
					 Compensation.
(b) "Claims
					 Administrator" means a self-administered insurer providing security for the
					 payment of compensation required by Divisions 4 and 4.5 of the Labor Code, a
					 self-administered self-insured employer, or a third-party claims administrator
					 for a self-insured employer, insurer, legally uninsured employer, or joint
					 powers authority.
(c) "Division"
					 means the Division of Workers' Compensation.
(d) "Employer" means an employer as defined
					 in Section
					 3300 of the
					 Labor Code.
(e) "HCO Enrollee"
					 means a person who is eligible to receive services from an HCO.
(f) "Health care organization" ("HCO") means
					 any entity certified as a health care organization by the administrative
					 director pursuant to Section
					 4600.5 of the
					 Labor Code and this article.
Financing Administration. Washington DC: Superintendent
						of Documents, and updated successor revised manuals.
(g) "Material": A factor is "material" with
					 respect to a matter if it is one to which a reasonable person would attach
					 importance in determining the action to be taken upon the matter.
(h) "Participating provider" means a provider
					 who is employed by or under contract with an HCO for purposes of providing
					 occupational medical or health services or services required by this
					 article.
(i) "Patient" means an HCO
					 enrollee who is currently obtaining treatment or services for a work-related
					 injury or illness.
(j) "Primary
					 treating physician" means the treating physician primarily responsible for
					 managing the care of the injured worker in accordance with Section
					 9785.5.
(k) "Professionally recognized standards of
					 care" means health care practice encompassing the learning, skill and clinical
					 judgment ordinarily possessed and and used by a provider of good standing in
					 similar circumstances.
(l)
					 "Provider" means any professional person, organization, health facility, or
					 other person or institution licensed by the state to deliver or furnish health
					 care services.
(m) "Revocation"
					 means the termination of a health care organization's certification to provide
					 services pursuant to Section
					 4600.5 of the
					 Labor Code and this article.
(n)
					 "Standard Industrial Classification code" means the 4 digit number which
					 identifies the primary type of economic activity which the employer is engaged
					 in that corresponds to the numeric classifications and descriptions listed in
The Standard Industrial Classification Manual 1987
, Office of
					 Management and Budget, Washington DC: Superintendent of Documents, US
					 Government Printing Office, 1989, and updated successor revised
					 manuals.
(o) "Suspension" means the
					 health care organization's authority to enter into new, renewed, or amended
					 contracts with claims administrators has been suspended by the administrative
					 director for a specific period of time.
(p) "Utilization review" or "Utilization
					 Management" is the system used to manage, assess, improve, or review patient
					 care and decision-making through case by case assessments of the medical
					 reasonableness or medical necessity of the frequency, duration, level and
					 appropriateness of medical care and services, based upon professionally
					 recognized standards of care. Utilization review may include, but is not
					 limited to, prospective, concurrent, and retrospective review of a request for
					 authorization of medical treatment.
1. New
						article 4 and section filed 12-31-93; operative 1-1-94. Submitted to OAL for
						printing only pursuant to Government Code section
						11351
						(Register 93, No. 53). For prior history, see Register 84, No.
						35.
2. New subsection (h) and subsection relettering filed 2-14-96;
						operative 2-14-96. Submitted to OAL for printing only pursuant to Government
						Code section
						11351
						(Register 96, No. 7).
3. Repealer of subsection (g) and subsection
						relettering filed 9-21-2015; operative 10-1-2015 pursuant to Government Code
						section
						11343.4(b)(3)
						(Register 2015, No. 39).
Note: Authority cited: Sections
						  133,
						  4600.5,
						  4603.5 and
						  5307.3, Labor
						  Code. Reference: Sections
						  3300,
						  4061.5,
						  4600.5,
						  5400,
						  5401 and
						  5402, Labor
						  Code.