Current through Register 2024 Notice Reg. No. 38, September 20, 2024
(a)
(1)
Within fifteen (15) days following the mailing of the notification from the
independent review organization that the disputed medical treatment has been
assigned for independent medical review, or within twelve (12) days if the
notification was sent electronically, or for expedited review within
twenty-four (24) hours following receipt of the notification, the independent
medical review organization shall receive from the claims administrator all of
the following documents:
(A) A copy of all
reports of the physician relevant to the employee's current medical condition
produced within six months prior to the date of the request for authorization,
including those that are specifically identified in the request for
authorization or in the utilization review determination. If the requesting
physician has treated the employee for less than six months prior to the date
of the request for authorization, the claims administrator shall provide a copy
of all reports relevant to the employee's current medical condition produced
within the described six month period by any prior treating physician or
referring physician.
(B) A copy of
the written Application for Independent Medical Review, DWC Form IMR, that was
included with the written determination, issued under section
9792.9.1(e)(5),
which notified the employee that the disputed medical treatment was denied,
delayed or modified. Neither the written determination nor the application's
instructions should be included.
(C) Other than the written determination by
the claims administrator issued under section
9792.9.1(e)(5), a
copy of all information, including correspondence, provided to the employee by
the claims administrator concerning the utilization review decision regarding
the disputed treatment.
(D) A copy
of any materials the employee or the employee's provider submitted to the
claims administrator in support of the request for the disputed medical
treatment.
(E) A copy of any other
relevant documents or information used by the claims administrator in
determining whether the disputed treatment should have been provided, and any
statements by the claims administrator explaining the reasons for the decision
to deny, modify, or delay the recommended treatment on the basis of medical
necessity.
(F) The claims
administrator's response to any additional issues raised in the employee's
application for independent medical review.
(2) The claims administrator shall,
concurrent with the provision of documents under subdivision (a), forward to
the employee or the employee's representative a notification that lists all of
the documents submitted to the independent review organization under
subdivision (a). The claims administrator shall provide with the notification a
copy of all documents that were not previously provided to the employee or the
employee's representative excluding mental health records withheld from the
employee pursuant to Health and Safety Code section
123115(b).
(3) Any newly developed or discovered
relevant medical records in the possession of the claims administrator after
the documents identified in subdivision (a) are provided to the independent
review organization shall be forwarded immediately to the independent review
organization. The claims administrator shall concurrently provide a copy of
medical records required by this subdivision to the employee, or the employee's
representative, or the employee's treating physician, unless the offer of
medical records is declined or otherwise prohibited by law.
(b)
(1)
Within fifteen (15) days following the mailing of the notification from the
independent review organization that the disputed medical treatment has been
assigned for independent medical review, or within twelve (12) days if the
notification was sent electronically, or for expedited review, within
twenty-four (24) hours following receipt of the notification, independent
medical review organization shall receive from the employee, if represented the
employee's attorney, or any party identified in section
9792.10.1(b)(2),
any of the following documents:
(i) The
treating physician's recommendation indicating that the disputed medical
treatment is medically necessary for the employee's medical
condition.
(ii) Medical information
or justification that a disputed medical treatment, on an urgent care or
emergency basis, was medically necessary for the employee's medical
condition.
(iii) Reasonable
information supporting the position that the disputed medical treatment is or
was medically necessary, including all information provided by the employee's
treating physician, or any additional material that the employee believes is
relevant.
(2) The
employee, if represented the employee's attorney or any party identified in
section 9792.10.1(b)(2)
shall, concurrent with the provision of documents under subdivision (b),
forward the documents provided under subdivision (b) on the claims
administrator, except that documents previously provided to the claims
administrator need not be provided again if a list of those documents is
served.
(3) Any newly developed or
discovered relevant medical records in the possession of the employee, if
represented the employee's attorney, or any party identified in section
9792.10.1(b)(2),
after the documents identified in subdivision (b) are provided to the
independent review organization shall be forwarded immediately to the
independent review organization. The employee, if represented the employee's
attorney, or any party identified in section
9792.10.1(b)(2),
shall concurrently provide a copy of medical records required by this
subdivision to the claims administrator, unless the offer of medical records is
declined or otherwise prohibited by law.
(c) At any time following the submission of
documents under subdivision (a) and (b), the independent review organization
may reasonably request appropriate additional documentation or information
necessary to make a determination that the disputed medical treatment is
medically necessary. Additional documentation or other information requested
under this section shall be sent by the party to whom the request was made,
with a copy forwarded to all other parties, within five (5) business days after
the request is received in routine cases or one (1) calendar day after the
request is received in expedited cases.
(d) The confidentiality of medical records
shall be maintained pursuant to applicable state and federal laws.
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.
