Current through Register 2024 Notice Reg. No. 38, September 20, 2024
This section applies to any request for authorization of
medical treatment, made under Article 5.5.1 of this Subchapter, for
either:
(1) an occupational injury or
illness occurring on or after January 1, 2013; or
(2) where the decision on the request is
communicated to the requesting physician on or after July 1, 2013, regardless
of the date of injury.
(a) If the request for
authorization of medical treatment is not approved, or if the request for
authorization for medical treatment is approved in part, any dispute shall be
resolved in accordance with Labor Code sections
4610.5 and
4610.6. Neither
the employee nor the claims administrator shall have any liability for medical
treatment furnished without the authorization of the claims administrator if
the treatment is delayed, modified, or denied by a utilization review decision
unless the utilization review decision is overturned by independent medical
review or the Workers' Compensation Appeals Board under this Article.
(b)
(1) A
request for independent medical review must be filed by an eligible party by
mail, facsimile, or electronic transmission with the Administrative Director,
or the Administrative Director's designee, within 30 days of service of the
written utilization review determination issued by the claims administrator
under section
9792.9.1(e)(5).
The request must be made on the Application for Independent Medical Review, DWC
Form IMR, and submitted with a copy of the written decision delaying, denying,
or modifying the request for authorization of medical treatment. At the time of
filing, the employee shall concurrently provide a copy of the signed DWC Form
IMR, without a copy of the written decision delaying, denying, or modifying the
request for authorization of medical treatment, to the claims
administrator.
(2) A party eligible
to file a request for independent medical review includes:
(A) The employee or, if the employee is
represented, the employee's attorney. If the employee's attorney files the DWC
Form IMR, the form must be accompanied by a notice of representation or other
document or written designation confirming representation.
(i) An unrepresented employee may designate a
parent, guardian, conservator, relative, or other designee of the employee as
an agent to act on his or her behalf in filing an application for independent
medical review under this subdivision. A designation of an agent executed prior
to the utilization review decision shall not be valid.
(ii) The physician whose request for
authorization of medical treatment was delayed, denied, or modified may join
with or otherwise assist the employee in seeking an independent medical review.
The physician may submit documents on the employee's behalf pursuant to section
9792.10.5 (b) and
may respond to any inquiry by the independent review
organization.
(B) A
provider of emergency medical treatment when the employee faced 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, may submit an
application for independent medical review under this section on its own behalf
within 30 days after the service of the utilization review decision that either
delays, denies, or modifies the provider's retrospective request for
authorization of the emergency medical treatment.
(3) If expedited review is requested for a
utilization review decision eligible for independent medical review, the
Application for Independent Medical Review, DWC Form IMR, shall include, unless
the initial utilization review decision was made on an expedited basis, written
certification from the employee's treating physician with documentation
confirming that the employee faces an imminent and serious threat to his or her
health as described in section
9792.6.1(j).
(c)
(1) If
at the time of a utilization review decision the claims administrator is also
disputing liability for the treatment for any reason besides medical necessity,
the time for the employee to submit an application for independent medical
review under subdivision (b)(1) is extended to 30 days after service of a
notice to the employee showing that the other dispute of liability has been
resolved.
(2) If the claims
administrator provides the employee with a written utilization review
determination modifying, delaying, or denying a treatment request that does not
contain the required elements set forth in section
9792.9 (l) or
section 9792.9.1(e) at the
time of notification of its utilization review decision, the time limitations
for the employee to submit an application for independent medical review under
subdivision (b)(1) shall not begin to run until the claims administrator
provides the written decision, with all required elements, to the
employee.
(d)
(1) Nothing in this section precludes the
parties from participating in an internal utilization review appeal process on
a voluntary basis provided the employee and, if the employee is represented by
counsel, the employee's attorney, have been notified of the 30-day time limit
to file an objection to the utilization review decision in accordance with
Labor Code sections
4610.5 and
4610.6. Any
request by the injured worker or treating physician for an internal utilization
review appeal process conducted under this subdivision must be submitted to the
claims administrator within ten (10) days after the receipt of the utilization
review decision.
(2) A request for
an internal utilization review appeal must be completed, and a determination
issued, by the claims administrator within thirty (30) days after receipt of
the request under subdivision (d)(1). An internal utilization review appeal
shall be considered complete upon the issuance of a final independent medical
review determination under section
9792.10.6(e) that
determines the medical necessity of the disputed treatment.
(3) Any determination by the claims
administrator following an internal utilization review appeal that results in a
modification of the requested medical treatment shall be communicated to the
requesting physician and the injured worker, the injured worker's
representative, and if the injured worker is represented by counsel, the
injured worker's attorney according to the requirements set forth in section
9792.9.1(e). The
Application for Independent Medical Review, DWC Form IMR, that accompanies the
written decision letter under section
9792.9.1(e)(5)(G)
must indicate that the decision is a modification after
appeal.
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: Sections
133, 4603.5 and 5307.3, Labor Code.
Reference: Sections
4062,
4600, 4600.4, 4604.5, 4610 and
4610.5, Labor Code.
