Current through Register 2024 Notice Reg. No. 38, September 20, 2024
(a) Effective January 1, 2004, every claims
administrator shall establish and maintain a utilization review process for
treatment rendered on or after January 1, 2004, regardless of date of injury,
in compliance with Labor Code section
4610. Each
utilization review process shall be set forth in a utilization review plan
which shall contain:
(1) The name, address,
phone number, and medical license number of the employed or designated medical
director, who holds an unrestricted license to practice medicine in the state
of California issued pursuant to section
2050
or section
2450
of the Business and Professions Code.
(2) A description of the process whereby
requests for authorization are reviewed, and decisions on such requests are
made, and a description of the process for handling expedited
reviews.
(3) A description of the
specific criteria utilized routinely in the review and throughout the
decision-making process, including treatment protocols or standards used in the
process. The treatment protocols or standards governing the utilization review
process shall be consistent with the Medical Treatment Utilization Schedule
adopted by the Administrative Director pursuant to Labor Code section
5307.27.
(4) A description of the qualifications and
functions of the personnel involved in decision-making and implementation of
the utilization review plan.
(5) A
description of the claims administrator's practice, if applicable, of any prior
authorization process, including but not limited to, where authorization is
provided without the submission of the request for
authorization.
(b)
(1) The medical director shall ensure that
the process by which the claims administrator reviews and approves, modifies,
delays, or denies requests by physicians prior to, retrospectively, or
concurrent with the provision of medical services, complies with Labor Code
section
4610 and these
implementing regulations.
(2) A
reviewer who is competent to evaluate the specific clinical issues involved in
the medical treatment services, and where these services are within the
reviewer's scope of practice, may, except as indicated below, delay, modify or
deny, requests for authorization of medical treatment for reasons of medical
necessity to cure or relieve the effects of the industrial injury.
(3) A non-physician reviewer may be used to
initially apply specified criteria to requests for authorization for medical
services. A non-physician reviewer may approve requests for authorization of
medical services. A non-physician reviewer may discuss applicable criteria with
the requesting physician, should the treatment for which authorization is
sought appear to be inconsistent with the criteria. In such instances, the
requesting physician may voluntarily withdraw a portion or all of the treatment
in question and submit an amended request for treatment authorization, and the
non-physician reviewer may approve the amended request for treatment
authorization. Additionally, a non-physician reviewer may reasonably request
appropriate additional information that is necessary to render a decision but
in no event shall this exceed the time limitations imposed in section
9792.9(c)(1), (c)(2), or
(d), or section
9792.9.1(c) and
(d). Any time beyond the time specified in
these sections is subject to the provisions of section
9792.9(h) or
section 9792.9.1(f).
(c) The complete utilization review plan,
consisting of the policies and procedures, and a description of the utilization
review process, shall be filed by the claims administrator, or by the external
utilization review organization contracted by the claims administrator to
perform the utilization review, with the Administrative Director. In lieu of
filing the utilization review plan, the claims administrator may submit a
letter identifying the external utilization review organization which has been
contracted to perform the utilization review functions, provided that the
utilization review organization has filed a complete utilization review plan
with the Administrative Director. A modified utilization review plan shall be
filed with the Administrative Director within 30 calendar days after the claims
administrator makes a material modification to the plan.
(d) Upon request by the public, the claims
administrator shall make available the complete utilization review plan,
consisting of the policies and procedures, and a description of the utilization
review process.
(1) The claims administrator
may make available the complete utilization review plan, consisting of the
policies and procedures and a description of the utilization review process,
through electronic means. If a member of the public requests a hard copy of the
utilization review plan, the claims administrator may charge reasonable copying
and postage expenses related to disclosing the complete utilization review
plan. Such charge shall not exceed $0.25 per page plus actual postage
costs.
1. New
section filed 12-9-2004 as an emergency; operative 12-13-2004 (Register 2004,
No. 50). A Certificate of Compliance must be transmitted to OAL by 4-12-2005 or
emergency language will be repealed by operation of law on the following
day.
2. New section refiled 4-6-2005 as an emergency; operative
4-12-2005 (Register 2005, No. 14). A Certificate of Compliance must be
transmitted to OAL by 8-10-2005 or emergency language will be repealed by
operation of law on the following day.
3. Certificate of Compliance
as to 4-6-2005 order, including amendment of section, transmitted to OAL
8-10-2005 and filed 9-22-2005 (Register 2005, No. 38).
4. Amendment
filed 2-12-2014; operative 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
4062,
4600, 4600.4, 4604.5 and 4610,
Labor Code.
