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 5.5.1 - Utilization Review Standards
Section 9792.6.1 - Utilization Review Standards-Definitions - on or After January 1, 2013
Universal Citation: 8 CA Code of Regs 9792.6.1
Current through Register 2024 Notice Reg. No. 38, September 20, 2024
The following definitions apply 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 for authorization of medical treatment is communicated to the requesting physician on or after July 1, 2013, regardless of the date of injury.
(a) "Authorization" means assurance
that appropriate reimbursement will be made for an approved specific course of
proposed medical treatment to cure or relieve the effects of the industrial
injury pursuant to section
4600 of the
Labor Code, subject to the provisions of section
5402 of the
Labor Code, based on either a completed "Request for Authorization," DWC Form
RFA, as contained in California Code of Regulations, title 8, section
9785.5, or a request for
authorization of medical treatment accepted as complete by the claims
administrator under section
9792.9.1(c)(2),
that has been transmitted by the treating physician to the claims
administrator. Authorization shall be given pursuant to the timeframe,
procedure, and notice requirements of California Code of Regulations, title 8,
section 9792.9.1, and may be provided by
utilizing the indicated response section of the "Request for Authorization,"
DWC Form RFA if that form was initially submitted by the treating
physician.
(b) "Claims
Administrator" is a self-administered workers' compensation insurer of an
insured employer, a self-administered self-insured employer, a
self-administered legally uninsured employer, a self-administered joint powers
authority, a third-party claims administrator or other entity subject to Labor
Code section
4610, the
California Insurance Guarantee Association, and the director of the Department
of Industrial Relations as administrator for the Uninsured Employers Benefits
Trust Fund (UEBTF). "Claims Administrator" includes any utilization review
organization under contract to provide or conduct the claims administrator's
utilization review responsibilities.
(c) "Concurrent review" means utilization
review conducted during an inpatient stay.
(d) "Course of treatment" means the course of
medical treatment set forth in the treatment plan contained on the "Doctor's
First Report of Occupational Injury or Illness," Form DLSR 5021, found at
California Code of Regulations, title 8, section
14006, or on the "Primary Treating
Physician's Progress Report," DWC Form PR-2, as contained in section
9785.2 or in narrative form
containing the same information required in the DWC Form PR-2.
(e) "Delay" means a determination, based on
the need for additional evidence as set forth in section
9792.9.1(f), that
the timeframe requirements for the utilization review process provided in
section 9792.9.1(c) cannot
be met.
(f) "Denial" means a
decision by a physician reviewer that the requested treatment or service is is
not authorized.
(g) "Dispute
liability" means an assertion by the claims administrator that a factual,
medical, or legal basis exists, other than medical necessity, that precludes
compensability on the part of the claims administrator for an occupational
injury, a claimed injury to any part or parts of the body, or a requested
medical treatment.
(h) "Disputed
medical treatment" means medical treatment that has been modified, or denied by
a utilization review decision.
(i)
"Emergency health care services" means health care services for a medical
condition manifesting itself by acute symptoms of sufficient severity such that
the absence of immediate medical attention could reasonably be expected to
place the patient's health in serious jeopardy.
(j) "Expedited review" means utilization
review or independent medical review conducted when the injured worker's
condition is such that the injured worker faces 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, or the normal timeframe for the
decision-making process would be detrimental to the injured worker's life or
health or could jeopardize the injured worker's permanent ability to regain
maximum function.
(k) "Expert
reviewer" means a medical doctor, doctor of osteopathy, psychologist,
acupuncturist, optometrist, dentist, podiatrist, or chiropractic practitioner
licensed by any state or the District of Columbia, competent to evaluate the
specific clinical issues involved in the medical treatment services and where
these services are within the individual's scope of practice, who has been
consulted by the reviewer or the utilization review medical director to provide
specialized review of medical information.
(l) "Health care provider" means a provider
of medical services, as well as related services or goods, including but not
limited to an individual provider or facility, a health care service plan, a
health care organization, a member of a preferred provider organization or
medical provider network as provided in Labor Code section
4616.
(m) "Immediately" means within one business
day.
(n) "Material modification" is
when the claims administrator changes utilization review vendor or makes a
change to the utilization review standards as specified in section
9792.7.
(o) "Medical Director" is the physician and
surgeon licensed by the Medical Board of California or the Osteopathic Board of
California who holds an unrestricted license to practice medicine in the State
of California. The Medical Director is responsible for all decisions made in
the utilization review process.
(p)
"Medical services" means those goods and services provided pursuant to Article
2 (commencing with Labor Code section
4600) of
Chapter 2 of Part 2 of Division 4 of the Labor Code.
(q) "Medical Treatment Utilization Schedule"
means the standards of care adopted by the Administrative Director pursuant to
Labor Code section
5307.27 and set
forth in Article 5.5.2 of this Subchapter, beginning with section
9792.20.
(r) "Modification" means a decision by a
physician reviewer that part of the requested treatment or service is not
medically necessary.
(s)
"Prospective review" means any utilization review conducted, except for
utilization review conducted during an inpatient stay, prior to the delivery of
the requested medical services
(t)
"Request for authorization" means a written request for a specific course of
proposed medical treatment.
(1) Unless
accepted by a claims administrator under section
9792.9.1(c)(2), a
request for authorization must be set forth on a "Request for Authorization
(DWC Form RFA)," completed by a treating physician, as contained in California
Code of Regulations, title 8, section
9785.5. Prior to March 1, 2014, any
version of the DWC Form RFA adopted by the Administrative Director under
section 9785.5 may be used by the treating
physician to request medical treatment.
(2) "Completed," for the purpose of this
section and for purposes of investigations and penalties, means that the
request for authorization must identify both the employee and the provider,
identify with specificity a recommended treatment or treatments, and be
accompanied by documentation substantiating the need for the requested
treatment.
(3) The request for
authorization must be signed by the treating physician and may be mailed, faxed
or e-mailed to, if designated, the address, fax number, or e-mail address
designated by the claims administrator for this purpose. By agreement of the
parties, the treating physician may submit the request for authorization with
an electronic signature.
(u) "Retrospective review" means utilization
review conducted after medical services have been provided and for which
approval has not already been given.
(v) "Reviewer" means a medical doctor, doctor
of osteopathy, psychologist, acupuncturist, optometrist, dentist, podiatrist,
or chiropractic practitioner licensed by any state or the District of Columbia,
competent to evaluate the specific clinical issues involved in medical
treatment services, where these services are within the scope of the reviewer's
practice.
(w) "Utilization review
decision" means a decision pursuant to Labor Code section
4610 to
approve, modify, delay, or deny, a treatment recommendation or recommendations
by a physician prior to, retrospectively, or concurrent with the provision of
medical treatment services pursuant to Labor Code sections
4600 or
5402(c).
(x) "Utilization review plan" means the
written plan filed with the Administrative Director pursuant to Labor Code
section
4610, setting
forth the policies and procedures, and a description of the utilization review
process.
(y) "Utilization review
process" means utilization management functions that prospectively,
retrospectively, or concurrently review and approve, modify, delay, or deny,
based in whole or in part on medical necessity to cure or relieve, treatment
recommendations by physicians, as defined in Labor Code section
3209.3, prior
to, retrospectively, or concurrent with the provision of medical treatment
services pursuant to Labor Code section
4600. The
utilization review process begins when the completed DWC Form RFA, or a request
for authorization accepted as complete under section
9792.9.1(c)(2), is
first received by the claims administrator, or in the case of prior
authorization, when the treating physician satisfies the conditions described
in the utilization review plan for prior authorization.
(z) "Written" includes a communication
transmitted by facsimile or in paper form. Electronic mail may be used by
agreement of the parties although an employee's health records shall not be
transmitted via electronic mail.
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 cited: Sections 133, 4603.5 and 5307.3, Labor Code. Reference: Sections 3209.3, 4062, 4600, 4600.4, 4604.5, 4610 and 4610.5, Labor Code.
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