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Data Element Name DN
PAID TO DATE/REDUCED EARNINGS/RECOVERIES AMOUNT 96
PAID TO DATE/REDUCED EARNINGS/RECOVERIES CODE 95
PAYMENT/ADJUSTMENT CODE 85
PAYMENT/ADJUSTMENT END DATE 89
PAYMENT/ADJUSTMENT PAID TO DATE 86
PAYMENT/ADJUSTMENT START DATE 88
(h) Final reports (MTC = FN) are required only for claims where indemnity benefits are paid. For medical-only claims, the final report may be reported under this section or on the annual report (MTC = AN) with claim status = "closed."
(i)(1) A claims administrator's obligation to submit copies of benefit notices to the Administrative Director pursuant to Labor Code Section 138.4 is satisfied upon written determination by the Administrative Director that the claims administrator has demonstrated the capability to submit complete, valid, and accurate data as required under Subsection (d) and continued compliance with that subsection.
(2) Reserved.
(3) On and after September 22, 2006, a claims administrator's obligation to submit an Annual Report of Inventory pursuant to Title 8, California Code of Regulations, section 10104 is satisfied upon determination by the Administrative Director that the claims administrator has demonstrated the capability to submit complete, valid, and accurate data as required under subdivisions (b), (d), (e), and (g), and continued compliance with those subsections.
(j) The data submitted pursuant to this section shall not have any application to, nor be considered in, nor be admissible into, evidence in any personal injury or wrongful death action, except as between an employee and the employee's employer. Nothing in this subdivision shall be construed to expand access to information held in the WCIS beyond that authorized in section 9703 and Labor Code section 138.7.
(k) Each claims administrator required to submit data under this section shall submit to the Administrative Director an EDI Trading Partner Profile at least thirty days prior to its first transmission of EDI data. Each claims administrator shall advise the Administrative Director of any subsequent changes and/or corrections made to the information provided in the EDI Trading Partner Profile by filing a corrected copy of the EDI Trading Partner Profile with the Administrative Director.
Note: Authority cited: Sections 133, 138.4, 138.6 and 138.7, Labor Code. Reference: Sections 138.4, 138.6 and 138.7, Labor Code.
s 9703. Access to Individually Identifiable Information.
(a) No person shall have access to individually identifiable data held in the WCIS except as provided in this section and subdivision (c) of section 138.7 of the Labor Code.
(b) The Division of Workers' Compensation may obtain and use individually identifiable information for the following purposes:
(1) To create and maintain the WCIS, including the selection of claims to survey in order to obtain information not available from the data elements provided by claims administrators.
(2) To help select claims administrators for audits under section 129 of the Labor Code.
(3) To report the promptness with which claims administrators make payments.
(4) To electronically import names, addresses, and other information into Division of Workers' Compensation case files which would otherwise have to be key entered by agency staff.
(5) To conduct research related to the workers' compensation system for the purpose of carrying out the duties of the Division of Workers' Compensation or the Administrative Director.
(c) The following agencies may obtain individually identifiable information from the WCIS, in the manner set forth in a memorandum of understanding between the Administrative Director and the agency, for the purposes specified:
(1) The Division of Occupational Safety and Health may use individually identifiable information to help select employers for health and safety consultations and inspections.
(2) The Division of Labor Statistics and Research may use individually identifiable information to carry out its research and reporting responsibilities under Labor Code sections 150 and 156.
(3) The Department of Health Services may use individually identifiable information to carry out its occupational health and occupational disease prevention responsibilities under section 105175 of the Health and Safety Code.
(d) Upon written request to the Administrative Director, researchers employed by or under contract to the Commission on Health and Safety and Workers' Compensation (CHSWC) may obtain individually identifiable information from the WCIS, in the manner set forth in a memorandum of understanding between the Administrative Director, the commission, and the person or entity conducting research, for the purpose of bona fide statistical research.
(1) Any request from the CHSWC for individually identifiable information under this subdivision shall include the identity of the person or entity conducting the research, the purpose of the research, the research protocol, the need for individually identifiable WCIS data, and an anticipated completion date for the research.
(2) Researchers under contract to the CHSWC seeking individually identifiable WCIS data under this subdivision shall also submit to the Administrative Director written approval of the research protocol by an Institutional Review Board in the same manner as required under subdivision (e). If the researcher under contract to the CHSWC is the University of California or a non profit educational institution, the researcher shall comply with the provisions of Civil Code section 1789.24 subdivision (t).
(3) Individually identifiable information obtained under this subdivision shall not be disclosed to the members of the CHSWC.
(4) No individually identifiable information obtained by researchers under this subdivision may be disclosed to any other person or entity, public or private, for a use other than that research project for which the information was obtained.
(5) Researchers obtaining individually identifiable information under this subdivision shall notify the Administrative Director when the research has been completed. Except as required by researchers subject to subdivision (f), within 30 days thereafter, the CHSWC shall present evidence to the Administrative Director that the data collected has been modified in a manner so that the subjects cannot be identified, directly or through identifiers linked to the subjects.
(e) Individually identifiable information may be provided to other persons or public or private entities for the purpose of bona fide statistical research which does not divulge individually identifiable information concerning any employee, employer, claims administrator, or any other person or entity. Any request for individually identifiable information for this purpose shall include the identity of the requester, the purpose of the research, the methods of research, and the need for individually identifiable WCIS data. The requester shall also submit written approval of the research protocol by an Institutional Review Board, under Title 45, Code of Federal Regulations, Part 46, Subpart A. "Approval" means a determination by the Institutional Review Board that the research protocol was reviewed and provides sufficient safeguards to ensure the confidentiality of individually identifiable information. Any agreement to permit use of the data shall be in writing between the requester and the Administrative Director. Note: The Division shall make available upon request a list of Institutional Review Boards known to the Division that have the authority to grant the required approval and that expressed willingness to review research proposals under this section.
(f) The University of California or any non profit educational institution conducting scientific research must comply with the provisions of Civil Code section 1798.24 subdivision (t).
(g) Each agreement or memorandum of understanding entered concerning the use of individually identifiable information by any agency, entity, or person shall specify the methods to be used to protect the information from unlawful disclosure, and shall include a warning to the receiving party that it is unlawful for any person who has received individually identifiable information from the Division of Workers' Compensation under this section to provide the information to any person who is not entitled to it under this section and Labor Code s 138.7.
(h) Nothing in this section shall be construed to exempt from disclosure any public record contained in an individual's file once an Application for Adjudication has been filed with the Workers' Compensation Appeals Board. This includes any data from an individual's file that are converted to or stored in an electronic format for the purpose of case processing and tracking.
(i) Nothing in this section shall be construed to exempt from disclosure WCIS data in a format that does not contain individually identifiable information.
Note: Authority cited: Sections 127, 133, 138.4, 138.6 and 138.7, Labor Code. Reference: Sections 129, 138.4, 138.6 and 138.7, Labor Code; and Section 1798.24, Civil Code.
s 9704. WCIS Advisory Committee.
(a) The Administrative Director shall maintain a Workers' Compensation Information System Advisory Committee, which shall include, but not be limited to, representatives of claims administrators (including self-insured employers, insurers, and third party administrators), insured employers, organized labor, attorneys, physicians as defined in Labor Code s 3209.3, vocational rehabilitation counselors, academic researchers, the Department of Insurance statistical agent, and appropriate legislative committees and state agencies with jurisdiction over workers' compensation, occupational health, and related areas, including the Commission on Health and Safety and Workers' Compensation and the Employment Development Department.
(b) The advisory committee shall meet at least annually on the call of the Administrative Director, and may provide advice on all aspects of WCIS. The Administrative Director, or his or her designee, shall present to the advisory committee any plan to collect survey data, including any expanded collection of the data elements specified in subdivision (d) of section 9702.
Note: Authority cited: Sections 133 and 138.6, Labor Code. Reference: Sections 138.6 and 138.7, Labor Code.
s 9710. Authority.
The rules and regulations contained in Article 1.5 are adopted pursuant to the authority contained in Sections 123, 123.5(a) and 133 of the California Labor Code.
Note: Authority cited: Sections 123, 123.5(a) and 133, Labor Code. Reference: Sections 123.5(a) and 5313, Labor Code.
s 9711. Operative Date.
The provisions of this Article shall first apply to cases submitted after January 1, 1981, and the affidavit shall first be required for the April 1981 pay period. For the purposes of this Article, all cases submitted prior to January 1, 1981 shall be deemed to have been submitted on January 2, 1981.
Note: Authority cited: Sections 123, 123.5(a) and 133, Labor Code. Reference: Sections 123.5(a) and 5313, Labor Code.
s 9712. Definitions.
For the purposes of this Article and Section 123.5(a) of the Labor Code, the following definitions shall apply:
(a) "Salary" shall include ordinary pay, but shall not include sick leave pay, industrial disability leave or non-industrial disability insurance substantiated by a physician's report.
(b) "Cause" shall mean a cause of action arising out of the substantive rights, liabilities and duties provided for in Sections 132(a) and 139.5, and in Divisions 4 and 4.5 of the Labor Code which is pending before a Workers' Compensation Administrative Law Judge for decision. "Cause" shall not include Compromise and Release agreements, Stipulations with Request for Award, or petitions and motions which have been filed ex parte and are not part of a submission ordered by a Workers' Compensation Administrative Law Judge.
(c) "Pending and Undetermined" means that the Workers' Compensation Administrative Law Judge's decision has not been filed in the record.
(d) "Submitted" means the closing of the record for the receipt of further evidence or argument.
Note: Authority cited: Sections 123, 123.5(a) and 133, Labor Code. Reference: Sections 123.5(a) and 5313, Labor Code.
s 9713. Receipt of Salary.
A Workers' Compensation Administrative Law Judge may not receive his or her salary while any cause before the Workers' Compensation Administrative Law Judge remains pending and undetermined for ninety (90) days after it has been submitted for decision.
Note: Authority cited: Sections 123, 123.5(a) and 133, Labor Code. Reference: Sections 123.5(a) and 5313, Labor Code.
s 9714. Procedures for Compliance with Labor Code Section 123.5(a).
(a) In order to receive his or her salary for each pay period, at some time before 5:00 p.m. on the last working day of each State payroll period, the Workers' Compensation Administrative Law Judge shall submit to the Division of Workers' Compensation an affidavit based upon information and belief in the form prescribed by Section 9714.5, and executed under penalty of perjury, declaring that no cause submitted before him or her remains pending and undetermined for a period of ninety (90) days or more.
(b) When a Workers' Compensation Administrative Law Judge who receives salary by automatic direct deposit does not timely submit the affidavit required by subsection (a), he or she shall, before 5:00 p.m. on the next working day following the direct deposit of salary into his or her account, deliver to the Presiding Workers' Compensation Administrative Law Judge of the district office to which the judge is assigned a money order or cashier's check for the amount of salary automatically deposited.
Note: Authority cited: Section 133, Labor Code. Reference: Sections 123.5(a) and 5313, Labor Code.
s 9714.5. Affidavit.
Department of Industrial Relations Division of Workers' Compensation Workers' Compensation Appeals Board
AFFIDAVIT
(Labor Code Section 123.5(a))
I, __________________, (Name) Workers' Compensation Administrative Law Judge in the ____________________ (City) office of the Division of Workers' Compensation/Workers' Compensation Appeals Board, Department of Industrial Relations, State of California, declare that I have made a reasonable and diligent inquiry concerning those matters submitted to me, and based on information and belief, state that no cause remains pending and undetermined that has been submitted to me for the period of ninety (90) days prior to the first day of ____________________, 20__________. (Date) (Year)
Executed on ---- at, ----
(Date) (City)
California. I declare under penalty of perjury that the foregoing is true and correct.
________________________________________________________
(Signature)
Workers' Compensation Administrative Law Judge
Note: Authority cited: Section 133, Labor Code. Reference: Sections 123.5(a) and 5313, Labor Code.
s 9715. Procedures for Submitting a Cause for Decision.
Minutes of Hearing must be prepared at the conclusion of each hearing and filed in the record. Workers' Compensation Administrative Law Judges are to follow the provisions of Rules of Practice and Procedure Section 10566. Each set of minutes must include a disposition which includes the time and action, if any, required for submissions.
Thereafter, any change in or modification of the disposition must be served on all parties forthwith, together with the statement of the reasons for the change of disposition.
A hearing has not been concluded if the disposition includes an order taking off calendar or an order of continuance for further hearing with or without notice. Continuances and further hearings are governed by Rules of Practice and Procedure Sections 10548 and 10560.
Note: Authority cited: Sections 123, 123.5(a) and 133, Labor Code. Reference: Sections 123.5(a) and 5313, Labor Code.
s 9720.1. Authority.
The rules and regulations contained in Article 1.6 are adopted pursuant to the authority contained in Sections 123.6, 133, and 5307.3 of the Labor Code. This article is designed to enforce the highest ethical standards among workers' compensation referees and to provide all parties with an independent, impartial investigation into allegations of misconduct by referees.
Note: Authority cited: Sections 123.6, 133 and 5307.3, Labor Code. Reference: Sections 111 and 123.6, Labor Code.
s 9720.2. Definitions.
For purposes of this Article and Section 123.6 of the Labor Code, the following definitions shall apply:
(a) "Code" shall mean the Code of Judicial Conduct. When the Supreme Court adopts a Code of Judicial Ethics pursuant to Article VI, section 18(m), of the Constitution, "Code" shall mean the Code of Judicial Ethics and any subsequent revision thereof.
(b) "Committee" shall mean the Workers' Compensation Ethics Advisory Committee as specified in Section 9722 of these regulations.
(c) "Complaint" shall mean a statement alleging facts that, if true, might constitute misconduct.
(d) "Misconduct" shall mean any conduct of a referee that is contrary to the Code or to the other rules of conduct that apply to referees.
(e) "Referee" shall mean a worker's compensation referee employed by the administrative director pursuant to Section 123.5 of the Labor Code. The term includes Presiding Workers' Compensation Referees, Regional Managers (Claims Adjudication), the Assistant Chief, the Administrative Director and any other person, including pro tem referees and state employees, while they are exercising judicial or quasi-judicial powers.
Note: Authority cited: Sections 123.6, 133 and 5307.3, Labor Code. Reference: Sections 111 and 123.6, Labor Code.
s 9721.1. Code of Judicial Conduct or Ethics.
Every referee shall abide by the Code.
Note: Authority cited: Sections 123.6, 133 and 5307.3, Labor Code. Reference: Sections 111 and 123.6, Labor Code.
s 9721.2. Gifts, Honoraria and Travel.
(a) No referee may accept any gift, honorarium or travel that is forbidden to legislators under the Political Reform Act of 1974.
(b) No referee may accept any gift, payment, honorarium, travel, meal or any other thing exceeding five dollars in value, the cost of which is significantly paid for by attorneys who practice before the Workers Compensation Appeals Board or by others whose interests have come or are likely to come before the Board, without first obtaining the written approval of the administrative director. Copies of requests and responses shall be forwarded to the Committee for its annual report. For purposes of this section, "attorneys" includes individual attorneys, law firms, and professional associations that include attorneys as members. For purposes of this section, "others whose interests have come or are likely to come before the Board" includes, but is not limited to, any person or entity which is or has been a party or lien claimant in a workers' compensation proceeding, represents a party or lien claimant, provides educational, consulting or other services relating to workers' compensation, otherwise participates in the workers' compensation adjudicatory process or is an association that includes such persons as members or represents their interests.
(c) This section does not apply to (1) gifts, payments, travel, meals or other things of value given to a referee by a family member who does not appear before the referee in question, (2) ordinary, modest social hospitality in a private home or attendance at a wedding, graduation or religious ceremony, (3) payments, including a division of attorney's fees, made to a referee by the referee's former law firm or other former employer, for services actually rendered prior to the referee's appointment, or (4) union activities of referees.
Note: Authority cited: Sections 123.6, 133 and 5307.3, Labor Code. Reference: Sections 111 and 123.6, Labor Code.
s 9721.31. Financial Interests in Educational Programs.
A referee may not have an ownership interest in, nor may the referee receive a percentage of revenue or any other contingent economic interest relating to, educational programs servicing the workers' compensation community. As used in this section, "percentage of revenues or any other contingent financial interest" does not include usual and customary royalties or residuals paid by commercial publishers in the normal course of business, provided that the publisher does not appear before the referee in question.
Note: Authority cited: Sections 123.6, 133 and 5307.3, Labor Code. Reference: Sections 111 and 123.6, Labor Code.
s 9721.32. Duty to Report Misconduct.
When circumstances warrant, a referee shall take or initiate appropriate disciplinary measures against a referee, lawyer, party, witness, or other person who participates in the workers' compensation process for unprofessional, fraudulent or other improper conduct of which the referee becomes aware.
Note: Authority cited: Sections 123.6, 133 and 5307.3, Labor Code. Reference: Sections 111 and 123.6, Labor Code.
s 9722. The Workers' Compensation Ethics Advisory Committee.
(a) There shall be a Workers' Compensation Ethics Advisory Committee consisting of nine members appointed by the administrative director:
(1) a member of the public representing organized labor,
(2) a member of the public representing insurers,
(3) a member of the public representing self-insured employers,
(4) an attorney who formerly practiced before the Workers' Compensation Appeals Board and who usually represented insurers or employers,
(5) an attorney who formerly practiced before the Workers' Compensation Appeals Board and who usually represented applicants,
(6) a presiding referee,
(7) a referee or retired referee,
(8) and (9) two members of the public outside the workers' compensation community.
Members shall serve for a term of four years. However, to create staggered terms, the first term of members in odd-numbered categories above shall be two years. The administrative director shall designate a chairperson.
(b) The Committee shall meet as necessary to carry out its responsibilities under this article. State employees shall meet on state time and at state expense.
(c) The Committee may do the following:
(1) Receive complaints made against referees,
(2) Forward those complaints to the administrative director with a recommendation to investigate or not to investigate,
(3) Monitor the outcome of complaints, and
(4) Make reports and recommendations to the administrative director, the legislature and the public concerning the integrity of the workers' compensation adjudicatory process. The Committee shall make a public report on or before February 15 or each year, summarizing the activities of the Committee in the previous calendar year. The report shall not contain personally identifiable information concerning complainants or referees, unless the information is already public.
(d) The administrative director shall make staff available to the Committee to assist it in carrying out its functions.
(e) The Committee may receive information that is not available to the public. The Committee shall hold such information strictly confidential from public disclosure. However, this rule of confidentiality shall not prevent the Committee from disclosing information to the referee, if the referee is otherwise entitled to the information.
Note: Authority cited: Sections 123.6, 133 and 5307.3, Labor Code. Reference: Sections 111 and 123.6, Labor Code.
s 9722.1. Commencing an Investigation.
(a) Any person may file a complaint with the Committee. The Committee may require complaints to be filed in a particular form. Nothing in these regulations prohibits any person from complaining directly to a presiding referee or to the administrative director. The presiding referee or the administrative director may, but is not required to, refer such complaints to the Committee.
(b) The Committee shall review the complaint. The Committee may make brief, informal inquiries to obtain information needed to clarify the complaint.
(c) If the Committee determines that the complaint does not allege facts that might constitute misconduct, or if the complaint is merely conjectural or conclusory, obviously unfounded, or stale, or alleges only isolated legal error by the referee, the Committee shall forward the complaint to the administrative director with a recommendation not to proceed with the complaint.
(d) If the Committee determines that the complaint might have merit, the Committee shall refer the complaint to the administrative director. Complaints against the administrative director shall be referred to the Director of Industrial Relations.
(e) Complaints making substantial allegations of criminal conduct, invidious discrimination, sexual harassment, or other serious acts that might require the administrative director's immediate attention, shall be referred forthwith to the administrative director. All other complaints shall be referred to the administrative director within 60 days.
(f) During the course of the investigation, the administrative director shall inform the referee of the nature of the charges. The referee shall have the opportunity to submit a response. A referee who has been informed of the charges shall also be informed of the outcome of the investigation.
Note: Authority cited: Sections 123.6, 133 and 5307.3, Labor Code. Reference: Sections 111 and 123.6, Labor Code.
s 9722.2. Investigation and Action by the Administrative Director.
(a) Upon receiving a complaint from the Committee, the administrative director shall investigate whether a referee has engaged in misconduct.
(b) If the administrative director determines after investigation that the complaint is unfounded or insufficient to justify discipline or other action, the administrative director shall so inform the complainant and the Committee.
(c) If the administrative director determines after investigation that misconduct has occurred, he or she shall take appropriate disciplinary or other action against the referee. The administrative director's action shall be in the form required by Government Code section 19574 or section 19590(b).
(d) The administrative director shall provide the Committee with a copy of his or her decision and shall inform the complaining party of the outcome of the investigation.
Note: Authority cited: Sections 123.6, 133 and 5307.3, Labor Code. Reference: Sections 111 and 123.6, Labor Code.
s 9723. Miscellaneous Provisions.
(a) This article does not replace or diminish the procedural rights of a referee under the State Civil Service Act. Documentation of unfounded or unsustained complaints or complaints which warrant no further investigation shall not be retained in the employee's personnel file.
(b) This article does not replace or diminish the authority of the administrative director to investigate allegations of misconduct, to impose appropriate discipline, or to take any other action authorized by law.
(c) Nothing in this article shall affect the rights and obligations of the administrative director and referees concerning the probationary period under Government Code sections 19170 through 19180.
(d) Pursuant to Government Code section 19574.5, the administrative director may place a referee on leave of absence pending investigation of the accusations listed in that section.
(e) No civil action may be maintained against any person, or adverse employment action taken against a person by any employer, public or private, based on statements presented by the person in proceedings under this section.
(f) A referee or other interested person may request the administrative director to issue an advisory opinion on the application of the Code or other rules to a particular situation. The administrative director may, in his or her sole discretion, issue an advisory opinion. The administrative director may issue an advisory opinion on his or her own initiative.
Note: Authority cited: Sections 123.6, 133 and 5307.3, Labor Code. Reference: Sections 111 and 123.6, Labor Code.
s 9725. Method of Measurement.
The method of measuring physical elements of a disability should follow the Report of the Joint Committee of the California Medical Association and Industrial Accident Commission, as contained in " Evaluation of Industrial Disability" edited by Packard Thurber, Second Edition, Oxford University Press, New York, 1960. This section shall not apply to any permanent disability evaluations performed pursuant to the permanent disability rating schedule adopted on or after January 1, 2005.
Note: Authority cited: Sections 133 and 5307.3, Labor Code. Reference: Sections 4660, 4662, 4663 and 4664, Labor Code.
s 9726. Method of Measurement (Psychiatric).
The method of measuring the psychiatric elements of a disability shall follow the Report of the Subcommittee on Permanent Psychiatric Disability to the Medical Advisory Committee of the California Division of Industrial Accidents, entitled "The Evaluation of Permanent Psychiatric Disability," (hereinafter referred to as the "Psychiatric Protocols") as adopted, forwarded for adoption on July 10, 1987, and subsequent amendments and/or revisions thereto adopted after a public hearing. This section shall not apply to any permanent disability evaluations performed pursuant to the permanent disability rating schedule adopted on or after January 1, 2005. Note:The Report (which contains these Protocols) of the Subcommittee on Permanent Psychiatric Disability, as adopted, does not appear as a printed part of the Administrative Director's Regulations (8 California Code of Regulations, Section 9726); copies will be available through the Medical Director of the Division of Industrial Accidents.
Note: Authority cited: Sections 133 and 5307.3, Labor Code. Reference: Sections 4660, 4662, 4663 and 4664, Labor Code.
s 9727. Subjective Disability.
Subjective Disability should be identified by:
1. A description of the activity which produces the disability.
2. The duration of the disability.
3. The activities which are precluded and those which can be performed with the disability.
4. The means necessary for relief. The terms shown below are presumed to mean the following:
1. A severe pain would preclude the activity precipitating the pain.
2. A moderate pain could be tolerated, but would cause marked handicap in the performance of the activity precipitating the pain.
3. A slight pain could be tolerated, but would cause some handicap in the performance of the activity precipitating the pain.
4. A minimal (mild) pain would constitute an annoyance, but causing no handicap in the performance of the particular activity, would be considered as nonratable permanent disability.
This section shall not apply to any permanent disability evaluations performed pursuant to the permanent disability rating schedule adopted on or after January 1, 2005.
Note: Authority cited: Sections 133 and 5307.3, Labor Code. Reference: Sections 4660, 4662, 4663 and 4664, Labor Code.
s 9732. Authority.
Note: Authority cited: Sections 124, 127, 133, 138.2, 138.3, 138.4, 139, 139.5, 139.6, 4600, 4601, 4602, 4603, 4603.2, 4603.5, 5307.3, 5450, 5451, 5452, 5453, 5454, and 5455, Labor Code. Reference: Chapters 442, 709, and 1172, Statutes of 1977; Chapter 1017, Statutes of 1976.
s 9735. Disability, When Considered Permanent.
s 9738. Permanent Disability Ratings and Evaluations, Kinds.
s 9739. Formal Ratings.
Note: Authority cited: Sections 124, 133 and 5307.3, Labor Code. Reference: Section 124, Labor Code.
s 9742. Informal Ratings.
Note: Authority cited: Sections 124, 5307.3 and 5451, Labor Code. Reference: Sections 124, 5451 and 5453, Labor Code.
s 9743. Form DIA 200, Employee's Request for Informal Permanent Disability Rating.
Note: Authority cited: Sections 124 and 5307.3, Labor Code. Reference: Section 124, Labor Code.
s 9744. Form DIA 201, Insurance Carrier's or Self-Insurer's Request for Informal Permanent Disability Rating.
Note: Authority cited: Sections 124 and 5307.3, Labor Code. Reference: Section 124, Labor Code.
s 9750. Permanent Disability Rating Reports.
Note: Authority cited: Sections 124, 133 and 5307.3, Labor Code. Reference: Section 124, Labor Code.
s 9753. Informal Ratings, Attorney Fee.
s 9756. Permanent Disability Evaluations, Kinds.
s 9757. Pretrial Evaluations.
Note: Authority cited: Sections 124 and 5307.3, Labor Code. Reference: Section 124, Labor Code.
s 9758. Consultative Evaluations.
Note: Authority cited: Sections 124, 5307.3 and 5451, Labor Code. Reference: Sections 123.7, 124 and 5453, Labor Code.
s 9759. Compromise and Release Evaluations.
Note: Authority cited: Sections 124, 133, 5307.3 and 5451, Labor Code. Reference: Sections 123.7, 124 and 5453, Labor Code.
s 9760. Summary Evaluations.
s 9766. Records, Destruction Of.
Note: Authority cited: Sections 124, 127, 133, 138.2, 138.3, 138.4, 139, 139.5, 139.6, 4600, 4601, 4602, 4603, 4603.2, 4603.5, 5307.3, 5450, 5451, 5452, 5453, 5454 and 5455, Labor Code. Reference: Section 124, Labor Code; and Section 14755, Government Code.
s 9767.1. Medical Provider Networks - Definitions.
(a) As used in this article:
(1) "Ancillary services" means any provision of medical services or goods as allowed in Labor Code section 4600 by a non-physician.
(2) "Covered employee" means an employee or former employee whose employer has ongoing workers' compensation obligations and whose employer or employer's insurer has established a Medical Provider Network for the provision of medical treatment to injured employees unless:
(A) the injured employee has properly designated a personal physician pursuant to Labor Code section 4600(d) by notice to the employer prior to the date of injury, or;
(B) the injured employee's employment with the employer is covered by an agreement providing medical treatment for the injured employee and the agreement is validly established under Labor Code section 3201.5, 3201.7 and/or 3201.81.
(3) "Division" means the Division of Workers' Compensation.
(4) "Economic profiling" means any evaluation of a particular physician, provider, medical group, or individual practice association based in whole or in part on the economic costs or utilization of services associated with medical care provided or authorized by the physician, provider, medical group, or individual practice association.
(5) "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.
(6) "Employer" means a self-insured employer, the Self-Insurer's Security Fund, a group of self-insured employers pursuant to Labor Code section 3700(b) and as defined by Title 8, California Code of Regulations, section 15201(s), a joint powers authority, or the state.
(7) "Group Disability Insurance Policy" means an entity designated pursuant to Labor Code section 4616.7(c).
(8) "Health Care Organization" means an entity designated pursuant to Labor Code section 4616.7(a).
(9) "Health Care Service Plan" means an entity designated pursuant to Labor Code section 4616.7(b).
(10) "Insurer" means an insurer admitted to transact workers' compensation insurance in the state of California, California Insurance Guarantee Association, or the State Compensation Insurance Fund.
(11) "Medical Provider Network" ( "MPN") means any entity or group of providers approved as a Medical Provider Network by the Administrative Director pursuant to Labor Code sections 4616 to 4616.7 and this article.
(12) "Medical Provider Network Plan" means an employer's or insurer's detailed description for a medical provider network contained in an application submitted to the Administrative Director by a MPN applicant.
(13) "MPN Applicant" means an insurer or employer as defined in subdivisions (6) and (10) of this section.
(14) "MPN Contact" means an individual(s) designated by the MPN Applicant in the employee notification who is responsible for answering employees' questions about the Medical Provider Network and is responsible for assisting the employee in arranging for an independent medical review.
(15) "Nonoccupational Medicine" means the diagnosis or treatment of any injury or disease not arising out of and in the course of employment.
(16) "Occupational Medicine" means the diagnosis or treatment of any injury or disease arising out of and in the course of employment.
(17) "Physician primarily engaged in treatment of nonoccupational injuries" means a provider who spends more than 50 percent of his/her practice time providing non-occupational medical services.
(18) "Primary treating physician" means a primary treating physician within the medical provider network and as defined by section 9785(a)(1).
(19) "Provider" means a physician as described in Labor Code section 3209.3 or other provider as described in Labor Code section 3209.5.
(20) "Regional area listing" means either:
(A) a listing of all MPN providers within a 15-mile radius of an employee's worksite and/or residence; or
(B) a listing of all MPN providers in the county where the employee resides and/or works if
1. the employer or insurer cannot produce a provider listing based on a mile radius
2. or by choice of the employer or insurer, or upon request of the employee.
(C) If the listing described in either (A) or (B) does not provide a minimum of three physicians of each specialty, then the listing shall be expanded by adjacent counties or by 5-mile increments until the minimum number of physicians per specialty are met.
(21) "Residence" means the covered employee's primary residence.
(22) "Second Opinion" means an opinion rendered by a medical provider network physician after an in person examination to address an employee's dispute over either the diagnosis or the treatment prescribed by the treating physician.
(23) "Taft-Hartley health and welfare fund" means an entity designated pursuant to Labor Code section 4616.7(d).
(24) "Third Opinion" means an opinion rendered by a medical provider network physician after an in person examination to address an employee's dispute over either the diagnosis or the treatment prescribed by either the treating physician or physician rendering the second opinion.
(25) "Treating physician" means any physician within the MPN applicant's medical provider network other than the primary treating physician who examines or provides treatment to the employee, but is not primarily responsible for continuing management of the care of the employee.
(26) "Workplace" means the geographic location where the covered employee is regularly employed.
Note: Authority cited: Sections 133 and 4616(g), Labor Code. Reference: Sections 1063.1, 3208, 3209.3, 3209.5, 3700, 3702, 3743, 4616, 4616.1, 4616.3, 4616.5 and 4616.7, Labor Code; andCalifornia Insurance Guarantee Association v. Division of Workers' Compensation(April 26, 2005) WCAB No. Misc. #249.
s 9767.2. Review of Medical Provider Network Application.
(a) Within 60 days of the Administrative Director's receipt of a complete application, the Administrative Director shall approve or disapprove an application based on the requirements of Labor Code section 4616 et seq. and this article. An application shall be considered complete if it includes information responsive to each applicable subdivision of section 9767.3. Pursuant to Labor Code section 4616(b), if the Administrative Director has not acted on a plan within 60 days of submittal of a complete plan, it shall be deemed approved.
(b) The Administrative Director shall provide notification(s) to the MPN applicant: (1) setting forth the date the MPN application was received by the Division; and (2) informing the MPN applicant if the MPN application is not complete and the item(s) necessary to complete the application.
(c) No additional materials shall be submitted by the MPN applicant or considered by the Administrative Director until the MPN applicant receives the notification described in (b).
(d) The Administrative Director's decision to approve or disapprove an application shall be limited to his/her review of the information provided in the application.
(e) Upon approval of the Medical Provider Network Plan, the MPN applicant shall be assigned a MPN approval number.
Note: Authority cited: Sections 133 and 4616(g), Labor Code. Reference: Section 4616, Labor Code.
s 9767.3. Application for a Medical Provider Network Plan.
(a) As long as the application for a medical provider network plan meets the requirements of Labor Code section 4616 et seq. and this article, nothing in this section precludes an employer or insurer from submitting for approval one or more medical provider network plans in its application.
(b) Nothing in this section precludes an insurer and an insured employer from agreeing to submit for approval a medical provider network plan which meets the specific needs of an insured employer considering the experience of the insured employer, the common injuries experienced by the insured employer, the type of occupation and industry in which the insured employer is engaged and the geographic area where the employees are employed.
(c) All MPN applicants shall submit an original Cover Page for Medical Provider Network Application with original signature, an original application, and a copy of the Cover Page for Medical Provider Network and application to the Division.
(1) A MPN applicant may submit the provider information and/or ancillary service provider information required in section 9767.3(a)(8)(C) and (D) on a computer disk(s) or CD ROM(s). The information shall be submitted as a Microsoft Excel spread sheet or as a Microsoft Access File unless an alternative format is approved by the Administrative Director.
(2) If the network provider information is submitted on a disk(s) or CD ROM(s), the provider file must have at a minimum five columns. These columns shall be: (1) physician name (2) license number (3) the taxpayer identification number (4) specialty and (5) location of each physician.
(3) If the ancillary service provider information is submitted on a disk(s) or CD ROM(s), the file must have at a minimum five columns. The columns shall be (1) the name of the each ancillary provider (2) license number (3) the taxpayer identification number (4) specialty or type of service and (5) location of each ancillary service provider.
(d) If the network is not a Health Care Organization, Health Care Service Plan, Group Disability Insurance Policy, or Taft-Hartley Health and Welfare Fund, a Medical Provider Network application shall include all of the following information:
(1) Type of MPN Applicant: Insurer or Employer.
(2) Name of MPN Applicant.
(3) MPN Applicant's Taxpayer Identification Number.
(4) Name of Medical Provider Network, if applicable.
(5) Division Liaison: Provide the name, title, address, e-mail address, and telephone number of the person designated as the liaison for the Division, who is responsible for receiving compliance and informational communications from the Division and for disseminating the same within the MPN.
(6) The application must be verified by an officer or employee of the MPN applicant authorized to sign on behalf of the MPN applicant. The verification shall state: "I, the undersigned officer or employee of the MPN applicant, have read and signed this application and know the contents thereof, and verify that, to the best of my knowledge and belief, the information included in this application is true and correct."
(7) Nothing in this section precludes a network, entity, administrator, or other third-party, upon agreement with an MPN applicant, from preparing an MPN application on behalf of an insurer or employer.
(8) Description of Medical Provider Network Plan:
(A) State the number of employees expected to be covered by the MPN plan;
(B) Describe the geographic service area or areas within the State of California to be served;
(C) The name, license number, taxpayer identification number, specialty, and location of each physician as described in Labor Code Section 3209.3, or other providers as described in Labor Code Section 3209.5, who will be providing occupational medicine services under the plan. Alternatively, if the physicians are also part of a medical group practice, the name and taxpayer identification number of the medical group practice shall be identified in the application. By submission of the application, the MPN applicant is confirming that a contractual agreement exists with the physicians, providers or medical group practice in the MPN to provide treatment for injured workers in the workers' compensation system and that the contractual agreement is in compliance with Labor Code section 4609, if applicable.
(D) The name, license number (if required by the State of California), taxpayer identification number, specialty or type of service and location of each ancillary service, other than a physician or provider covered under subdivision (d)(8)(C), who will be providing medical services within the medical provider network. By submission of the application, the MPN applicant is confirming that a contractual agreement exists between the MPN and these ancillary services in the MPN or the MPN applicant and these ancillary services in the MPN;
(E) Describe how the MPN complies with the second and third opinion process set forth in section 9767.7;
(F) Describe how the MPN complies with the goal of at least 25% of physicians (not including pediatricians, OB/GYNs, or other specialties not likely to routinely provide care for common injuries and illnesses expected to be encountered in the MPN) primarily engaged in the treatment of nonoccupational injuries;
(G) Describe how the MPN arranges for providing ancillary services to its covered employees. Set forth which ancillary services, if any, will be within the MPN. For ancillary services not within the MPN, affirm that referrals will be made to services outside the MPN;
(H) Describe how the MPN complies with the access standards set forth in section 9767.5 for all covered employees;
(I) Describe the employee notification process, and attach an English and Spanish sample of the employee notification material described in sections 9767.12(a) and (b);
(J) Attach a copy of the written continuity of care policy as described in Labor Code section 4616.2;
(K) Attach a copy of the written transfer of care policy that complies with section 9767.9;
(L) Attach any policy or procedure that is used by the MPN applicant to conduct "economic profiling of MPN providers" pursuant to Labor Code section 4616.1 and affirm that a copy of the policy or procedure has been provided to the MPN providers or attach a statement that the MPN applicant does not conduct economic profiling of MPN providers;
(M) Provide an affirmation that the physician compensation is not structured in order to achieve the goal of reducing, delaying, or denying medical treatment or restricting access to medical treatment; and
(N) Describe how the MPN applicant will ensure that no person other than a licensed physician who is competent to evaluate the specific clinical issues involved in the medical treatment services, when these services are within the scope of the physician's practice, will modify, delay, or deny requests for authorization of medical treatment.
(e) If the entity is a Health Care Organization, a Medical Provider Network application shall set forth the following:
(1) Type of MPN Applicant: Insurer or Employer
(2) Name of MPN Applicant
(3) MPN Applicant's Taxpayer Identification Number
(4) Name of Medical Provider Network, if applicable.
(5) Division Liaison: Provide the name, title, address, e-mail address, and telephone number of the person designated as the liaison for the Division, who is responsible for receiving compliance and informational communications from the Division and for disseminating the same within the MPN.
(6) The application must be verified by an officer or employee of the MPN applicant authorized to sign on behalf of the MPN applicant. The verification shall state: "I, the undersigned officer or employee of the MPN applicant, have read and signed this application and know the contents thereof, and verify that, to the best of my knowledge and belief, the information included in this application is true and correct." (continued)