Current through Register 2024 Notice Reg. No. 38, September 20, 2024
(a) The costs of independent medical review
and the administration of the independent medical review system shall be borne
by claims administrators. For each Application for Independent Medical Review,
DWC Form IMR, assigned to an independent review organization for an independent
medical review of a disputed medical treatment, the fee for the claims
administrator shall be:
(1) For calendar year
2013:
(A) For regular review:
(i) $560.00 for each application where a
determination is issued under section
9792.10.6(b) by a
medical reviewer who:
(1) is a physician as
defined by Labor Code section
3209.3;
and
(2) holds an M.D. or D.O.
degree. If the review is conducted and a determination, or determinations if
applicable, is issued by two medical reviewers as defined in this provision,
the cost is $760.00
(ii)
$495.00 for each application where a determination is issued under section
9792.10.6(b) by a
medical reviewer who:
(1) is a physician as
defined by Labor Code section
3209.3;
and
(2) holds a degree other than an
M.D. or D.O. degree. If the review is conducted and a determination, or
determinations if applicable, is issued by two medical reviewers as defined in
this provision, the cost is $655.00
(B) For expedited review:
(i) $685.00 for each application where a
determination is issued under section
9792.10.6(b) by a
medical reviewer who:
(1) is a physician as
defined by Labor Code section
3209.3;
and
(2) holds an M.D. or D.O.
degree. If the review is conducted and a determination, or determinations if
applicable, is issued by two medical reviewers as defined in this provision,
the cost is $850.00.
(ii)
$595.00 for each application where a determination is issued under section
9792.10.6(b) by a
medical reviewer who:
(1) is a physician as
defined by Labor Code section
3209.3;
and
(2) holds a degree other than an
M.D. or D.O. degree. If the review is conducted and a determination, or
determinations if applicable, is issued by two medical reviewers as defined in
this provision, the cost is $760.00.
(C) For withdrawn reviews:
(i) $215.00 for each application where review
is terminated by the independent review organization prior to the receipt of
the documentation and information provided under section
9792.10.5 by a medical
reviewer.
(ii) If the review of an
application and documentation and information provided under section
9792.10.5 is terminated by the
independent review organization during or subsequent to the review of by a
medical reviewer, the cost will be the same as if a determination under section
9792.10.6(b) had
been issued by the medical reviewer.
(2) For calendar year 2014:
(A) For regular review:
(i) $550.00 for each application where a
determination is issued under section
9792.10.6(b) by a
medical reviewer who:
(1) is a physician as
defined by Labor Code section
3209.3;
and
(2) holds a M.D. or D.O. degree.
If the review is conducted and a determination, or determinations if
applicable, is issued by two medical reviewers as defined in this provision,
the cost is $740.00.
(ii)
$475.00 for each application where a determination is issued under section
9792.10.6(b) by a
medical reviewer who:
(1) is a physician as
defined by Labor Code section
3209.3;
and
(2) holds a degree other than an
M.D. or D.O. degree. If the review is conducted and a determination, or
determinations if applicable, is issued by two medical reviewers as defined in
this provision, the cost is $635.00.
(B) For expedited review:
(i) $645.00 for each application where a
determination is issued under section
9792.10.6(b) by a
medical reviewer who:
(1) is a physician as
defined by Labor Code section
3209.3;
and
(2) holds a M.D. or D.O. degree.
If the review is conducted and a determination, or determinations if
applicable, is issued by two medical reviewers as defined in this provision,
the cost is $830.00.
(ii)
$575.00 for each application where a determination is issued under section
9792.10.6(b) by a
medical reviewer who:
(1) is a physician as
defined by Labor Code section
3209.3;
and
(2) holds a degree other than an
M.D. or D.O. degree. If the review is conducted and a determination, or
determinations if applicable, is issued by two medical reviewers as defined in
this provision, the cost is $740.00.
(C) For withdrawn reviews:
(i) $215.00 for each application where review
is terminated by the independent review organization prior to the receipt of
the documentation and information provided under section
9792.10.5 by a medical
reviewer.
(ii) If the review of an
application and documentation and information provided under section
9792.10.5 is terminated by the
independent review organization subsequent to the receipt of the documentation
and information provided under section
9792.10.5 by a medical reviewer,
the cost will be the same as if a determination under section
9792.10.6(b) had
been issued by the medical reviewer.
(b) The independent medical review
organization shall bill each claims administrator for payment in arrears for
every independent medical review initiated under this Article that was
completed or terminated prior to completion. Invoices shall identify each
independent medical review, the fees assessed for each review, and the
aggregate total fee owed by the claims administrator.
(c) The aggregate total fee owed by the
claims administrator for the prior calendar month shall be paid to the
independent medical review organization within thirty (30) days of the billing.
If the aggregate total fee is not paid within ten (10) days after it becomes
due, there shall be added an additional amount equal to 10 percent, plus
interest at the legal rate, which shall be paid at the same time but in
addition to the total aggregate fee.
(d) The fees paid by claims administrators
for independent medical review under this section are non-refundable and not
subject to discount or rebate. Any questions or disputes over the aggregate
total fee and additional payments owed by the claims administrator under
subdivision (c), late payments, and untimely determinations shall be submitted
to the Administrative Director for informal resolution. Any request to resolve
a dispute must be accompanied by a written statement setting forth the amount
in dispute and the nature of the dispute.
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 transmitted to OAL 12-30-2013 and filed 2-12-2014
(Register 2014, No. 7).
Note: Authority: Sections
133, 4603.5, 5307.3 and 4610.6,
Labor Code. Reference: Sections 4610, 4610.5 and 4610.6, Labor
Code.
