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

(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:

(b) If the request appears eligible for review, the Administrative Director, or his or her designee, shall within fifteen (15) days of the determination, notify the provider and the claims administrator by the most efficient means available that request for independent bill review has been submitted and appears eligible for assignment to an IBRO. The notification shall contain:

(c) Any document filed with the Administrative Director, or his or her designee, under subdivision (b)(3) must be concurrently served on the provider. Any document that was previously provided to the provider or originated from the provider need not be served if a written description of the document and its date is served.

(d) Upon receipt of the documents requested in subdivision (b)(3), or, if no documents have been received, upon the expiration of fifteen (15) days of the date designated on the notification, if the notification was provided by mail, or within twelve (12) days of the date designated on the notification if the notification was provided electronically, the Administrative Director, or his or her designee, shall conduct a further review in order to make a determination as to whether the request is ineligible for independent bill review under subdivision (a).

(e) If the review conducted under either subdivision (a) or subdivision (d) finds that the request is ineligible for independent bill review, the Administrative Director shall, within fifteen (15) days following receipt of the documents requested in subdivision (b)(3) or, if no documents are received, the expiration of the time period indicated above, issue a written determination informing the provider and claims administrator that the request is not eligible for independent bill review and the reasons therefor.

(f) If the Administrative Director or his or her designee determines from the review conducted under subdivision (d), that the request is eligible for independent bill review, the Administrative Director shall assign the request to an IBRO for an independent bill review. Upon assignment of the request, the IBRO shall notify the parties in writing that the request has been assigned to that organization for review. The notification shall contain:

(g) After the assignment to the IBRO, the request shall immediately be assigned to an independent bill reviewer who does not have any material professional, familial, or financial affiliation with any of the individuals, institutions, facilities, services or products as described in Labor Code section 139.5 (c) (2) to review and resolve the dispute.

(h) If in the course of conducting an independent bill review it is determined that the bill reviewer assigned to the dispute has a prohibited interest as described in in Labor Code Section 139.5 (c) (2), the IBRO shall reassign the matter to a different independent bill reviewer.

(i) Upon reassignment under subdivision (h), the IBRO shall immediately notify the Administrative Director, the provider, and claims administrator of the reassignment of the dispute to a different independent bill reviewer.