California Code of Regulations
Title 10 - Investment
Chapter 5 - Insurance Commissioner
Subchapter 3 - Insurers
Article 20 - Standards Applicable to Workers' Compensation Claims Adjusters and Medical Billing Entities and Certification of those Standards by Insurers
Section 2592.01 - Definitions

(a) "Certify" means a written statement made under penalty of perjury.

(b) "Claims adjuster" means a person who, on behalf of an insurer, including an employee or agent of an entity that is not an insurer, is responsible for determining the validity of a workers' compensation claim. The claims adjuster may also establish a case reserve, approve and process all workers' compensation benefits, may hire investigators, attorneys or other professionals and may negotiate settlements of claims. "Claims adjuster" also means a person who is responsible for the immediate supervision of a claims adjuster but does not mean an attorney representing the insurer or a person whose primary function is clerical. "Claims adjuster" also includes an experienced claims adjuster. "Claims adjuster" does not include the medical director or physicians utilized by an insurer for the utilization review process pursuant to Labor Code section 4610.

(c) "Classroom" means any space sufficiently designed so that the instructor and students can communicate with a high degree of privacy and relative freedom from outside interference. The instructor or the person or persons assisting the instructor may be physically present or may communicate with students by means of an electronic medium, including, but not limited to, audio, video, computer, or Internet.

(d) "Course" means any program of instruction taken or given to satisfy the requirements of Insurance Code Section 11761.

(e) "Curriculum" means a course of study that satisfies the requirements of Insurance Code Section 11761. The curriculum must provide sufficient content, including time allocated to each subject area, to enable claims adjusters, medical-only claims adjusters, and medical bill reviewers to meet minimum standards of training, experience, and skill to perform their duties with regard to workers' compensation claims.

(f) "Experienced claims adjuster" means a person who has had at least five (5) years within the past eight (8) years of on-the-job experience adjusting California workers' compensation claims or supervising claims adjusters handling California workers' compensation claims and is designated as an experienced claims adjuster by an insurer. A person who has successfully completed the written examination specified by Title 8, Section 15452 of the California Code of Regulations is also considered an experienced claims adjuster, provided that he or she has either (1) worked as a workers' compensation claims adjuster or supervised workers' compensation claims adjusters continuously since passing the examination and is designated as an experienced claims adjuster by an insurer or (2) passed the examination within the previous five (5) years and is designated as an experienced claims adjuster by an insurer. "Experienced claims adjuster" also includes a person who has already been trained and designated a claims adjuster and now meets the requirements of experience or examination completion noted above and is designated an experienced claims adjuster by an insurer.

(g) "Experienced medical-only claims adjuster" means a person who has had at least three (3) years within the past five (5) years of on-the-job experience adjusting California workers' compensation medical-only claims and is designated as an experienced medical-only claims adjuster by an insurer.

(h) "Experienced medical bill reviewer" means a person who has had at least three (3) years within the past five (5) years of on-the-job experience reviewing California workers' compensation medical bills and is designated as an experienced medical bill reviewer by a medical billing entity or by an insurer.

(i) "Instructor" means a person who conveys curriculum content to students on behalf of an insurer, a training entity, or a medical billing entity. An instructor shall have had at least five (5) years within the past eight (8) years of on-the-job experience adjusting California workers' compensation claims and have been designated as a claims adjuster by an insurer or be an individual who has had at least eight (8) years of experience in California workers' compensation within the past twelve (12) years. Persons knowledgeable about specific workers' compensation issues who are not instructors may train students under the direction of an instructor.

(j) "Insurer" means an insurance company admitted to transact workers' compensation insurance in California, the State Compensation Insurance Fund, an employer that has secured a certificate of consent to self-insure from the Department of Industrial Relations pursuant to Labor Code Section 3700(b) or (c), or a third party administrator that has secured a certificate of consent pursuant to Labor Code Section 3702.1.

(k) "Medical bill reviewer" means a person who is not a claims adjuster or medical-only claims adjuster and who only reviews or adjusts workers' compensation medical bills on behalf of an insurer, including employees or agents of the insurer or employees or agents of a medical billing entity. "Medical bill reviewer" also includes an experienced medical bill reviewer.

(l) "Medical billing entity" means a third party that reviews or adjusts workers' compensation medical bills for insurers.

(m) "Medical-only claims adjuster" means a person who, on behalf of an insurer, including an employee or agent of an entity that is not an insurer, is responsible for determining the validity of workers' compensation claims only involving medical workers' compensation benefits, as defined under Article 2 (commencing with Labor Code section 4600) of Chapter 2 of Part 2 of Division 4 of the Labor Code. The medical-only claims adjuster may also establish medical treatment reserves, approve and process medical benefits, and negotiate settlement of medical benefit claims. "Medical-only claims adjuster" also means a person who is responsible for the immediate supervision of a medical-only claims adjuster but does not mean an attorney representing the insurer or a person whose primary function is clerical. "Medical-only claims adjuster" also includes an experienced medical-only claims adjuster. "Medical-only claims adjuster" does not include the medical director or physicians utilized by an insurer for the utilization review process pursuant to Labor Code section 4610.

(n) "Post-designation training" means a course of study provided to trained or experienced workers' compensation claims adjusters and medical-only claims adjusters who have been designated by an insurer or provided to trained or experienced medical bill reviewers who have been designated by an insurer or medical billing entity. Post-designation training also includes seminars, workshops, or other informational meetings pertaining to California workers' compensation.

(o) "Student" or "trainee" means an individual taking a course that is required for that person in order to be a workers' compensation claims adjuster, medical-only claims adjuster, or medical bill reviewer.

(p) "Training" means to provide a course of instruction that includes the topics specified in Sections 2592.03 and 2592.04.

(q) "Training entity" means any person or organization that provides instructors or curriculum to an insurer or medical billing entity.