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(a) Provide continuing information concerning the rights, benefits and obligations under the workers' compensation laws of the State of California to employees, employers, medical providers, claims administrators and other interested parties.
(b) Assist in the prompt resolution of misunderstandings, disputes, and controversies arising out of claims for compensation, without formal proceedings, to the end that full and timely compensation benefits are furnished.
(c) Distribute such information pamphlets in English, Spanish and other languages as needed that have been prepared and approved by the Administrative Director to all inquiring employees and to such other parties that may request copies of the same.
(d) Establish and maintain liaison with the persons located in the geographic area served by the district office, with other affected State agencies, with organizations representing employees, employers, claims administrators and the medical community.
(e) Discharge such other duties consistent with the purposes of this Article as from time to time may be delegated by the Administrative Director.
Note: Authority cited: Sections 133, 139.6, 5307.3 and 5451, Labor Code. Reference: Sections 5450-5455, Labor Code.
s 9925. Use of Other Division Facilities.
In undertaking his or her duties, the Information and Assistance Officer may use the services of the Industrial Medical Council, the Disability Evaluation Unit, the Rehabilitation Unit, the Audit Unit and any other unit or units of the Division of Workers' Compensation available to aid in the resolution of disputes.
Copies of medical reports, permanent disability rating evaluations, earnings data and other pertinent information obtained by the Information and Assistance Officer shall be furnished to all parties involved in a dispute.
Note: Authority cited: Sections 133, 136.6, 5307.3 and 5451, Labor Code. Reference: Sections 5450-5455, Labor Code.
s 9926. Referrals to a Qualified Medical Evaluator.
Upon the submission of a matter to an Information and Assistance Officer, the Officer, with the agreement of a party to pay the cost and with the consent of an unrepresented employee, may request that the Administrative Director direct the injured employee to be examined by a Qualified Medical Evaluator selected by the Medical Director, within the scope of the qualified medical evaluator's professional training, for the purpose of addressing any pertinent clinical question other than those issues specified in Labor Code Section 4061.
Note: Authority cited: Sections 133, 139.6, 5307.3, 5451 and 5703.5(b), Labor Code. Reference: Sections 5450-5455, Labor Code.
s 9927. Jurisdiction.
(a) Any party to a claim may consult with an Information and Assistance Officer at any time to seek advice and assistance in the resolution of any misunderstanding, dispute, or controversy. The request for assistance need not be in writing, or be in any particular form, but it shall apprise the Information and Assistance Officer of the nature of the dispute and any other pertinent information to facilitate an appropriate inquiry by the Information and Assistance Officer. The Information and Assistance Officer shall communicate with the parties and provide information and assistance in resolving disputes.
(b) If an Application for Adjudication of Claim has been filed with the Workers' Compensation Appeals Board, any party may consult with an Information and Assistance Officer to seek assistance in resolving controverted issues or misunderstandings at any time prior to the filing of a Declaration of Readiness to Proceed. If the employee is not represented or by consent of the parties, the Information and Assistance Officer may continue to provide assistance after a filing of a Declaration of Readiness to Proceed.
(c) The Information and Assistance Officer shall provide assistance to asbestos workers in obtaining benefits from the Asbestos Workers' Account and/or the responsible employer pursuant to Section 4410 of the Labor Code.
(d) When the injured worker is not represented by an attorney or other representative, and either a Compromise and Release agreement or Stipulations with Request for Award, other than those presented at or subsequent to a regularly scheduled hearing, has been filed with the Workers' Compensation Appeals Board, the information and assistance officer shall: review the documents; contact the parties when indicated; coordinate with other units within the Division of Workers' Compensation; seek to determine that the employee is aware of the significance of the agreement; and make recommendations to the parties and the workers' compensation judge. The Manager of the Information and Assistance Unit shall notify the Presiding Workers' Compensation Judge when this service cannot be provided timely.
Note: Authority cited: Sections 133, 139.6, 5307.3 and 5451, Labor Code. Reference: Sections 5450-5455, Labor Code.
s 9928. Procedures for Mediation and Recommendations.
(a) The Information and Assistance Officer is not bound by technical or formal rules of procedure but may make inquiries into any matter referred to him or her in a manner best suited to protect the rights of all parties and to achieve substantial justice.
(b) When there is a dispute regarding the provision of workers' compensation benefits, the employee, claims administrator or any party may request the Information and Assistance Officer to mediate the dispute. The Information and Assistance Officer will attempt to resolve the dispute by mediation, which may include a conference. The officer shall make appropriate inquiries to determine the contentions of the parties, identify the matters which may prevent amicable resolution, and afford all parties an opportunity to present their positions.
(c) In the event a dispute is not resolved through mediation, the Information and Assistance Officer shall issue a recommendation as soon as possible.
(d) In order to toll the statutes of limitations pursuant to Section 5454 of the Labor Code, the Information and Assistance Officer must notify in writing all parties to any misunderstanding, dispute or controversy of the fact that said Information and Assistance Officer has taken under consideration the misunderstanding, dispute or controversy submitted to him or her for a recommendation.
(e) Upon issuing a recommendation, the Officer shall advise the parties of his or her recommendation in a written communication which describes in non-technical terms the nature of the differences, the proposed resolution and the rationale used in arriving at that resolution. The communication shall also advise the parties that the tolling of any applicable statute of limitations will cease 60 days after the issuance of the recommendation, and shall further advise the parties of their right to obtain a decision from the appeals board if the recommendation is not accepted by the parties. In the event a party does not accept the recommendation of the Information and Assistance Officer, the party must notify all other parties in writing within 30 days of receipt of the recommendation. Where the Information and Assistance Officer feels that further mediation may resolve the dispute, he or she will notify the parties of the availability of the Information and Assistance Officer to provide such further mediation.
Note: Authority cited: Sections 133, 139.6, 5307.3, 5451 and 5453, Labor Code. Reference: Sections 5450-5455, Labor Code.
s 9928.1. Procedures for Asbestos Workers.
When consulted by an asbestos worker or his/her representative, the Information and Assistance Officer shall aid the worker in procuring those records, reports and other information which are necessary for the identification to responsible employers and insurance carriers, and in obtaining information required by the Asbestos Workers' Account before payments may be made pursuant to Section 4406.
Note: Authority cited: Sections 5307.3 and 5451, Labor Code. Reference: Sections 139.6, 4410 and 5451, Labor Code.
s 9929. Costs.
(a) Except as otherwise provided by this Section or by Section 5452 of the Labor Code, no fees or costs shall be charged to any party for services provided by the Division of Industrial Accidents under this Article.
(b) If the employee is represented, such representative may request that the Information and Assistance Officer refer the matter to a Workers' Compensation Judge for the determination of the value of the services of such representative. The Information and Assistance Officer shall, thereafter, refer such request to the Presiding Judge of the office which has jurisdiction over the claim.
s 9990. Fees for Transcripts; Copies of Documents; Certifications; Case File Inspection; Electronic Transactions
The Division will charge and collect fees for copies of records or documents. For the purposes of this section, "records" includes any writing containing information relating to the conduct of the public's business which is prepared, owned, or used by the Division, regardless of the physical form or characteristics. "Writing" means handwriting, typewriting, printing, photostatting, photographing and every other means of recording any form of communication thereof, and all papers, maps, magnetic tapes, photographic films and prints, electronic facsimiles, any form of stored computer data, magnetic cards or disks, drums, and other documents.
Fees will be charged and collected by the Division as follows:
(a) For copies of papers, records or documents, not certified or otherwise authenticated, one dollar ($1.00) for the first copy and twenty cents ($0.20) for each additional copy of the same page, except to the injured worker to whom the fee will be ten cents ($.10) per page.
(1) State sales tax and postage will be added to this fee.
(b) For certification of copies of official records or documents and orders of evidence taken or proceedings had, ten dollars ($10.00) for each certification.
(1) Where the Division is requested to both copy and certify a document, the fee is the sum of the fees prescribed in (a) and (b) above.
(c) For paper transcripts of any testimony, three dollars ($3.00) for each page of the first copy of transcripts; thereafter, one dollar and fifty cents ($1.50) for each page of additional copies of the transcript.
(1) Sales tax and postage will be added to this fee.
(2) Transcripts delivered on a medium other than paper shall be compensated at the same rate set for paper transcripts, except an additional fee shall be charged to cover the cost of the medium and any copies thereof.
(d) For inspection of a case file not stored in the place where the inspection is requested, ten dollars ($10.00) plus any postage or other delivery costs, except when requested by an injured employee or his or her attorney or his or her representative of record.
(e) For electronic records maintained by the Division:
(1) Listing of WCAB new case filings:
(A) $305.00 per transmission for WCAB new case opening records transmitted to the requester on tape.
(B) $85.00 per download for WCAB new case opening records transmitted to the requester by direct electronic download.
Paper copies of the WCAB new case opening records provided in addition to the electronic data will be subject to a separate charge of $0.10 per page, plus postage.
(2) Electronic response to an electronic inquiry concerning a case's status, a lien's status, or other case specific information available in electronic form, through EDEX (the Division's Electronic Data Exchange program), twenty cents ($0.20) per transaction.
(3) The Division will provide electronic copies of WCAB new case opening records or EDEX access only pursuant to a written agreement with the administrative director.
(4) Copies of existing electronic records, other than those electronic records set forth in subsections (e)(1) or (e)(2), that constitute disclosable public records, will be provided as required by law, for the Division's actual costs of retrieving and transmitting the data, including programming and processing time, storage media, postage or shipping costs and sales tax. All programming and processing time required to create new data sorts of existing electronically maintained records will be charged at the Division's standard rate of $40.00 per hour, billed in fifteen (15) minute increments.
(f) Copies of Division records containing information that is privileged or otherwise non-disclosable will be redacted before release.
Note: Authority cited: Sections 127, 133, 138.7 and 5307.3, Labor Code. Reference: Sections 127 and 138.7, Labor Code.
s 9992. Payment of Fees in Advance.
Payment of fees in Section 9990 must accompany the request, either in cash or by check or money order made payable to the Division of Workers' Compensation, except as otherwise provided in the establishment of payment accounts.
Note: Authority cited: Sections 127, 133 and 5307.3, Labor Code. Reference: Section 127, Labor Code.
s 9994. Payment for Transcripts.
For transcripts of testimony or other proceeding of record, a deposit fee based on the number of paper pages, as estimated by the division, shall be paid by the requesting party in advance. If the actual fee exceeds the deposit, the purchaser will be notified of the balance to be paid prior to release of the transcripts or any copies. Any excess deposit will be returned to the purchaser.
Note: Authority cited: Sections 127, 133 and 5307.3, Labor Code. Reference: Section 127, Labor Code.
s 10001. Definitions.
As used in this Article:
(a) "Alternative work" means work (1) offered either by the employer who employed the injured worker at the time of injury, or by another employer where the previous employment was seasonal work, (2) that the employee has the ability to perform, (3) that offers wages and compensation that are at least 85 percent of those paid to the employee at the time of injury, and (4) that is located within a reasonable commuting distance of the employee's residence at the time of injury.
(b) "Claims Administrator" means a self-administered insurer providing security for the payment of compensation required by Divisions 4 and 4.5 of the Labor Code, a self-administered self-insured employer, a self-administered joint powers authority, a self-administered legally uninsured, or a third-party claims administrator for a self-insured employer, insurer, legally uninsured employer, or joint powers authority.
(c) "Modified Work" means regular work modified so that the employee has the ability to perform all the functions of the job and that offers wages and compensation that are at least 85 percent of those paid to the employee at the time of injury, and located within a reasonable commuting distance of the employee's residence at the time of injury.
(d) "Permanent and stationary" means the point in time when the employee has reached maximal medical improvement, meaning his or her condition is well stabilized, and unlikely to change substantially in the next year with or without medical treatment, based on (1) an opinion from a treating physician, AME, or QME; (2) a judicial finding by a Workers' Compensation Administrative Law Judge, the Workers' Compensation Appeals Board, or a court; or (3) a stipulation that is approved by a Workers' Compensation Administrative Law Judge or the Workers' Compensation Appeals Board.
(e) "Regular Work" means the employee's usual occupation or the position in which the employee was engaged at the time of injury and that offers wages and compensation equivalent to those paid to the employee at the time of injury, and located within a reasonable commuting distance of the employee's residence at the time of injury.
(f) "Seasonal Work" means employment as a daily hire, a project hire, or an annual season hire.
Note: Authority cited: Sections 133, 139.48 and 5307.3, Labor Code. Reference: Sections 139.48 and 4658.1, Labor Code;Henry v. WCAB(1998) 68 Cal.App.4th 981.
s 10002. Offer of Work; Adjustment of Permanent Disability Payments.
(a) This section shall apply to all injuries occurring on or after January 1, 2005, and to the following employers:
(1) Insured employers who employed 50 or more employees at the time of the most recent policy inception or renewal date for the insurance policy that was in effect at the time of the employee's injury;
(2) Self-insured employers who employed 50 or more employees at the time of the most recent filing by the employer of the Self-Insurer's Annual Report that was in effect at the time of the employee's injury; and
(3) Legally uninsured employers who employed 50 or more employees at the time of injury.
(b) Within 60 calendar days from the date that the condition of an injured employee with permanent partial disability becomes permanent and stationary:
(1) If an employer does not serve the employee with a notice of offer of regular work, modified work or alternative work for a period of at least 12 months, each payment of permanent partial disability remaining to be paid to the employee from the date of the end of the 60 day period shall be paid in accordance with Labor Code section 4658(d)(1) and increased by 15 percent.
(2) If an employer serves the employee with a notice of offer of regular work, modified work or alternative work for a period of at least 12 months, and in accordance with the requirements set forth in paragraphs (3) and (4), each payment of permanent partial disability remaining to be paid from the date the offer was served on the employee shall be paid in accordance with Labor Code section 4658(d)(1) and decreased by 15 percent, regardless of whether the employee accepts or rejects the offer.
(3) The employer shall use Form DWC-AD 10133.53 (Section 10133.53) to offer modified or alternative work, or Form DWC-AD 10003 (Section 10003) to offer regular work. The claims administrator may serve the offer of work on behalf of the employer.
(4) The regular, alternative, or modified work that is offered by the employer pursuant to paragraph (2) shall be located within a reasonable commuting distance of the employee's residence at the time of the injury, unless the employee waives this condition. This condition shall be deemed to be waived if the employee accepts the regular, modified, or alternative work, and does not object to the location within 20 calendar days of being informed of the right to object. The condition shall be conclusively deemed to be satisfied if the offered work is at the same location and the same shift as the employment at the time of injury.
(c) If the claims administrator relies upon a permanent and stationary date contained in a medical report prepared by the employee's treating physician, QME, or AME, but there is subsequently a dispute as to an employee's permanent and stationary status, and there has been a notice of offer of work served on the employee in accordance with subdivision (b), the claims administrator may withhold 15% from each payment of permanent partial disability remaining to be paid from the date the notice of offer was served on the employee until there has been a final judicial determination of the date that the employee is permanent and stationary pursuant to Labor Code section 4062.
(1) Where there is a final judicial determination that the employee is permanent and stationary on a date later than the date relied on by the employer in making its offer of work, the employee shall be reimbursed any amount withheld up to the date a new notice of offer of work is served on the employee pursuant to subdivision (b).
(2) Where there is a final judicial determination that the employee is not permanent and stationary, the employee shall be reimbursed any amount withheld up to the date of the determination.
(3) The claims administrator is not required to reimburse permanent partial disability benefit payments that have been withheld pursuant to this subdivision during any period for which the employee is entitled to temporary disability benefit payments.
(d) If the employee's regular work, modified work, or alternative work that has been offered by the employer pursuant to paragraph (1) of subdivision (b) and has been accepted by the employee, is terminated prior to the end of the period for which permanent partial disability benefits are due, the amount of each remaining permanent partial disability payment from the date of the termination shall be paid in accordance with Labor Code section 4658 (d) (1), as though no decrease in payments had been imposed, and increased by 15 percent. An employee who voluntarily terminates his or her regular work, modified work, or alternative work shall not be eligible for the 15 percent increase in permanent partial disability payments pursuant to this subdivision.
(e) Nothing in this section shall prevent the parties from settling or agreeing to commute the permanent disability benefits to which an employee may be entitled. However, if the permanent disability benefits are commuted by a Workers' Compensation Administrative Law Judge or the Workers' Compensation Appeals Board pursuant to Labor Code section 5100, the commuted sum shall account for any adjustment that would have been required by this section if payment had been made pursuant to Labor Code section 4658.
(f) When the employer offers regular, modified or alternative work to the employee that meets the conditions of this section and subsequently learns that the employee cannot lawfully perform regular, modified or alternative work, the employer is not required to provide the regular, modified or alternative work.
(g) If the employer offers regular, modified, or alternative seasonal work to the employee, the offer shall meet the following requirements:
(1) the employee was hired for seasonal work prior to injury;
(2) the offer of regular, modified or alternative seasonal work is of reasonably similar hours and working conditions to the employee's previous employment, and the one year requirement may be satisfied by cumulative periods of seasonal work;
(3) the work must commence within 12 months of the date of the offer; and
(4) The offer meets the conditions set forth in this section.
Note: Authority cited: Sections 133, 139.48 and 5307.3, Labor Code. Reference: Sections 139.48 and 4658, Labor Code;Del Taco v. WCAB(2000) 79 Cal.App.4th 1437;Anzelde v. WCAB(1996) 61 Cal. Comp. Cases 1458 (Writ denied); andHenry v. WCAB(1998) 68 Cal.App.4th 981.
s 10003. Form [DWC AD 10003 Notice of Offer of Work].
Note: Authority cited: Sections 133, 139.48 and 5307.3, Labor Code. Reference: Sections 139.48 and 4658, Labor Code.
s 10004. Return to Work Program.
(a) This section shall apply to injuries occurring on or after July 1, 2004;
(b) An "Eligible Employer" means any employer, except the state or an employer eligible to secure the payment of compensation pursuant to subdivision (c) of Section 3700, who, based on the employer's payroll records or other equivalent documentation or evidence, employed 50 or fewer full-time employees on the date of injury.
(c) "Full-time employee" means an employee who, during the period of his or her employment within the year preceding the injury, worked an average of 32 or more hours per week.
(d) The Return to Work Program is administered by the Administrative Director for the purpose of promoting the employee's early and sustained return to work following a work-related injury or illness.
(e) This program shall be funded by the Return to Work Fund, which shall consist of all penalties collected pursuant to Labor Code section 5814.6 and transfers made to this fund by the Administrative Director from the Workers' Compensation Administrative Revolving Fund established pursuant to Labor Code section 62.5. The reimbursement offered to eligible employees as set forth in this section shall be available only to the extent funds are available.
(f) An eligible employer shall be entitled to reimbursement through this program for expenses incurred to make workplace modifications to accommodate an employee's return to modified or alternative work, up to the following maximum amounts:
(1) $1,250 to accommodate each temporarily disabled employee, for expenses incurred in allowing such employee to perform modified or alternative work within physician-imposed temporary work restrictions; and
(2) $2,500 to accommodate each permanently disabled employee, for expenses incurred in returning such employee to sustained modified or alternative work within physician-imposed permanent work restrictions; however, if an employer who has received reimbursement for a temporarily disabled employee under paragraph (1) is also requesting reimbursement for the same employee for accommodation of permanent disability, the maximum available reimbursement is $2,500. For the purpose of this subdivision, "sustained modified or alternative work" is work anticipated to last at least 12 months.
(g) Reimbursement shall be provided for any of the following expenses, provided they are specifically prescribed by a physician or are reasonably required by restrictions set forth in a medical report:
(1) modification to worksite;
(2) equipment;
(3) furniture;
(4) tools; or
(5) any other necessary costs reasonably required to accommodate the employee's restrictions.
(h) An eligible employer seeking reimbursement pursuant to subdivision (d) shall submit a "Request for Reimbursement of Accommodation Expenses" (Form DWC AD 10005, section 10005) to the Division of Workers' Compensation Return to Work Program within ninety (90) calendar days from the date of the expenditure for which the employer is seeking reimbursement. As a condition to reimbursement, the expenditure shall not have been paid or covered by the employer's insurer or any source of funding other than the employer. The filing date may be extended upon a showing of good cause for such extension. The employer shall attach to its request copies of all pertinent medical reports that contain the work restrictions being accommodated, any other documentation supporting the request, and all receipts for accommodation expenses. Requests should be sent to the mailing address for the Division of Workers' Compensation Return to Work Program that is listed in the web site of the Division of Workers' Compensation, at: http://www.dir.ca.gov/dwc/dwc_home_page.htm
(i) The Administrative Director or his or her designee shall review each "Request for Reimbursement of Accommodation Expenses," and within sixty (60) business days of receipt shall provide the employer with notice of one of the following:
(1) that the request has been approved, together with a check for the reimbursement allowed, and an explanation of the allowance, if less than the maximum amounts set forth in subdivision (d); or
(2) that the request has been denied, with an explanation of the basis for denial; or
(3) that the request is deficient or incomplete and indicating what clarification or additional information is necessary.
(j) In the event there are insufficient funds in the Return to Work Fund to fully reimburse an employer or employers for workplace modification expenses as required by this section, the Administrative Director shall utilize the following priority list in establishing the amount of reimbursement or whether reimbursement is allowed, in order of decreasing priority as follows:
(1) Employers who have not previously received any reimbursement under this program;
(2) Employers who have not previously received any reimbursement under this program for the employee who is the subject of the request;
(3) Employers who are seeking reimbursement for accommodation required in returning a permanently disabled employee to sustained modified or alternative work; and,
(4) Employers who are requesting reimbursement for accommodation required by a temporarily disabled employee.
(k) An eligible employer may appeal the Administrative Director's notice under subdivision (i) by filing a Declaration of Readiness to Proceed with the local district office of the Workers' Compensation Appeals Board within twenty calendar days of the issuance of the notice, together with a petition entitled "Appeal of Administrative Director's Reimbursement Allowance," setting forth the basis of the appeal. A copy of the Declaration of Readiness to Proceed and the petition shall be concurrently served on the Administrative Director.
Note: Authority cited: Sections 133, 139.48 and 5307.3, Labor Code. Reference: Sections 62.5, 139.48 and 5814.6, Labor Code.
s 10005. Form [DWC AD 10005 Request for Reimbursement of Accommodation Expenses].
Request for Reimbursement of Accommodation Expenses
For injuries on or after July 1, 2004
Form DWC AD 10005
Note: Authority cited: Sections 133, 139.48 and 5307.3, Labor Code. Reference: Sections 62.5, 139.48 and 5814.6, Labor Code.
s 10006. Notice to Employee.
Note: Authority cited: Sections 133, 138.4, 139.5 and 5307.3, Labor Code. Reference: Chapter 1435, 1974 Stats.
s 10007. Reports to Bureau.
Note: Authority cited: Sections 133, 138.4, 139.5 and 5307.3, Labor Code. Reference: Chapter 1435, 1974 Stats.
s 10007.1. Entitlement Issues.
Note: Authority cited: Section 139.5, Labor Code. Reference: Section 133, Labor Code.
s 10008. Identification of Need for Vocational Rehabilitation Services.
Note: Authority cited: Sections 133, 138.4, 139.5 and 5307.3, Labor Code. Reference: Chapter 1435, 1974 Stats.
s 10009. Initiation of Vocational Rehabilitation Services.
Note: Authority cited: Sections 133, 138.4, 139.5 and 5307.3, Labor Code. Reference: Chapter 1435, 1974 Stats.
s 10010. Independent Vocational Evaluators.
Note: Authority cited: Sections 133, 138.4, 139.5 and 5307.3, Labor Code. Reference: Chapter 1435, 1974 Stats.
s 10011. Vocational Rehabilitation Plans.
Note: Authority cited: Sections 133, 138.4, 139.5 and 5307.3, Labor Code. Reference: Chapter 1435, 1974 Stats.
s 10012. Plan Approval.
Note: Authority cited: Sections 133, 138.4, 139.5 and 5307.3, Labor Code. Reference: Chapter 1435, 1974 Stats.
s 10013. Entitlement Issues.
Note: Authority cited: Sections 133, 138.4, 139.5 and 5307.3, Labor Code. Reference: Chapter 1435, 1974 Stats.
s 10014. Bureau Resolution of Disputes.
Note: Authority cited: Sections 133, 138.4, 139.5 and 5307.3, Labor Code. Reference: Chapter 1435, 1974 Stats.
s 10015. Interruption of Services.
Note: Authority cited: Sections 133, 138.4, 139.5 and 5307.3, Labor Code. Reference: Chapter 1435, 1974 Stats.
s 10016. Conclusion of Vocational Rehabilitation Services.
Note: Authority cited: Sections 133, 138.4, 139.5 and 5307.3, Labor Code. Reference: Chapter 1435, 1974 Stats.
s 10017. Reinstatement of Vocational Rehabilitation Benefits.
Note: Authority cited: Sections 133, 138.4, 139.5 and 5307.3, Labor Code. Reference: Chapter 1435, 1974 Stats.
s 10018. Vocational Rehabilitation Temporary Disability Indemnity.
Note: Authority cited Sections 133, 138.4, 139.5 and 5307.3, Labor Code. Reference: Chapter 1435, 1974 Stats.
s 10019. Bureau File Retention.
Note: Authority cited: Sections 133, 138.4, 139.5 and 5307.3, Labor Code. Reference: Chapter 1435, 1974 Stats.
s 10020. Enforcement of Notice and Reporting Requirements.
Note: Authority cited: Sections 133, 138.4, 139.5 and 5307.3, Labor Code. Reference: Chapter 1435, 1974 Stats.
s 10021. Rehabilitation of Industrially Injured Inmates.
Note: Authority cited: Sections 133, 138.4, 139.5 and 5307.3, Labor Code. Reference: Chapter 1435, 1974 Stats.
s 10100. Definitions -Prior to January 1, 1994.
The following definitions apply in Articles 1 through 7 of this Subchapter for injuries occurring on or after January 1, 1990 and before January 1, 1994.
(a) Adjusting Location. The office where claims are administered.
(b) Administrative Director. The Administrative Director of the Division of Workers' Compensation or his/her duly authorized representative.
(c) Audit. Any audit performed by the Audit Unit of the Division of Workers' Compensation pursuant to Labor Code Sections 129 and 129.5.
(d) Claims Administrator. A self-administered insurer providing security for the payment of compensation required by Divisions 4 and 4.5 of the Labor Code, a self-administered self-insured employer, or a third-party claims administrator for a self-insured employer, insurer, legally uninsured employer, or joint powers authority.
(e) Claim File. A record, either in legible paper or electronic form which can be produced into legible paper, containing all of the information specified in Section 10101 and related documents pertaining to a given work-injury claim.
(f) Claim Log. A handwritten or printed ledger maintained by the claims administrator listing each work injury case by the date the injury was reported to the claims administrator and listing the date of injury. The claim log contents are specified in Section 10103.
(g) Compensation. Compensation as defined in Labor Code Section 3207.
(h) Duly Authorized Representative. A designated employee or unit of the Department of Industrial Relations.
(i) DWC. The Division of Workers' Compensation of the Department of Industrial Relations.
(j) Employee. An employee, his or her dependents or his agent.
(k) Indemnity Case. A work-injury claim which has or may result in any of the following benefits:
(1) Temporary Disability
(2) Permanent Disability
(3) Life Pension
(4) Death Benefits
(5) Vocational Rehabilitation
( l) Insurer. Any company, group or entity in, or which has been in, the business of transacting workers' compensation insurance for employers subject to the workers' compensation laws of this state. The term insurer includes the State Compensation Insurance Fund.
(m) Investigation. The process of examining and evaluating a claim to determine the nature and extent of all legally required benefits, if any, which are due under the claim. Investigation may include formal or informal methods of gathering information relevant to evaluating the claim such as: obtaining employment records, obtaining earnings records, informal or formal interviews of the employee, employer, or witnesses, deposition of parties or witnesses, obtaining expert opinion where an issue requires an expert opinion for its resolution, such as obtaining a medical-legal evaluation.
(n) Issue Date. The date upon which a notice of penalty assessment or an order of the Administrative Director is served.
(o) Joint Powers Authority. Any county, city, city and county, municipal corporation, public district, public agency, or political subdivision of the state, but not the state itself, including in a pooling arrangement under a joint exercise of powers agreement for the purpose of securing a certificate of consent to self-insure workers' compensation claims under Labor Code Section 3700(c).
(p) Medical-Only Claim. A work-injury case which requires compensation only for medical treatment by a physician.
(q) Medical Fee Schedule. Official schedule promulgated by the Administrative Director pursuant to Labor Code Section 5307.1. Refer to Title 8 of existing CCR Section 9791.1 through Section 9792.
(r) Non-Random. Any method of selecting an audit subject which is specific to that audit subject, based on any or all of the factors provided in Labor Code Section 129(b).
(s) Notice of Compensation Due. The Notice of Assessment issued pursuant to Labor Code Section 129(c).
(t) Open Claim. A work-injury claim in which future payment of compensation may be due or for which reserves for the future payment of compensation are maintained.
(u) Payment Schedule. The two-week cycle of indemnity payments due on the day designated with the first payment as required by Labor Code Section 4650(c) or 4702(b).
(v) Random. Any method of selecting an audit subject which is not based on factors specific to that audit subject, but instead which chooses subjects from a broad cross-section of possible subjects. Random selection methods may stratify by general groups and need not be statistically precise.
(w) Self-insured Employer. An employer that has been issued a certificate of consent to self-insure as provided by Labor Code Section 3700(b) or (c), including a joint powers authority or the State of California as a legally uninsured employer.
(x) Third-Party Administrator. An agent under contract to administer the workers' compensation claims of an insurer, self-insured employer, or joint powers authority.
(y) VRMA. Vocational rehabilitation maintenance allowance.
(z) Work-Injury Claim. A claim for an injury that is reported or reportable to the Division of Labor Statistics and Research pursuant to Sections 6409, 6409.1 and 6413 of the Labor Code.
Note: Authority cited: Sections 59, 133, 129.5, 138.4 and 5307.3, Labor Code. Reference: Sections 7, 124, 129, 129.5, 3700, 3702.1, 4636, 4650(c), 5307.1 and 5402, Labor Code.
s 10100.1. Definitions -On or After January 1, 1994.
The following definitions apply in Articles 1 through 7 of this Subchapter for injuries occurring on or after January 1, 1994.
(a) Adjusting Location. The office where claims are administered.
(b) Administrative Director. The Administrative Director of the Division of Workers' Compensation or the Director's duly authorized representative, designee, or delegee.
(c) Audit. An audit performed under Labor Code Sections 129 and 129.5.
(d) Audit Subject. A single adjusting location of a claims administrator which has been selected for audit. If a claims administrator has more than one adjusting location, other locations may be selected as separate audit subjects. In its discretion, the Audit Unit may combine more than one adjusting location of a claims administrator as a single non-random audit subject.
(e) Audit Unit. The organizational unit within the Division of Workers' Compensation which audits insurers, self-insured employers and third-party administrators pursuant to Labor Code Sections 129 and 129.5.
(f) Claim. A request for compensation for an injury arising out of and in the course of employment, whether disputed or not, or notice or knowledge that such an injury has occurred or is alleged to have occurred.
(g) Claim File. A record in paper or electronic form, or a combination, containing all of the information specified in Section 10101.1 of these Regulations and all documents or entries related to the provision or denial of benefits.
(h) Claim Log. A handwritten or printed ledger maintained by the claims administrator listing each work-injury claim as specified in Section 10103.1 of these Regulations.
(i) Claims Administrator or Administrator. A self-administered workers' compensation insurer, a self-administered self-insured employer, a self-administered legally uninsured employer, a self-administered joint powers authority, or a third-party claims administrator for an insurer, a self-insured employer, a legally-uninsured employer or a joint powers authority.
(j) Closed Claim. A work-injury claim in which future payment of compensation cannot be reasonably expected to be due.
(k) Compensation. Every benefit or payment, including vocational rehabilitation, medical, and medical-legal expenses, conferred by Divisions 1 and 4 of the Labor Code on an injured employee or the employee's dependents.
( l ) Date of Knowledge of Injury and Disability. The date the employer had knowledge or reasonably can be expected to have had knowledge of (1) a worker's injury or claim for injury, and (2) the worker's inability or claimed inability to work because of the injury.
(m) Denied Claim. A claim for which all liability has been denied at any time, even if the claim was accepted before or after the denial. A claim which otherwise meets this definition is a denied claim even if medical-legal expenses were paid.
(n) Employee. An employee, or in the case of the employee's death, his or her dependent, as each is defined in Division 4 of the Labor Code, or the employee's or dependent's agent.
(o) First Payment of Temporary Disability Indemnity. (1) The first payment of temporary disability indemnity made to an injured worker for a work injury; or (2) the first resumed payment of temporary disability indemnity following any period of one or more days for which no temporary disability indemnity was payable for that work injury; or (3) the first resumed payment of temporary disability indemnity following issuance of a lawful notice that temporary disability benefits were ending.
(p) Indemnity Claim. A work-injury claim which has resulted or may result in entitlement to any of the following benefits: temporary disability indemnity or salary continuation in lieu of temporary disability indemnity, permanent disability indemnity, death benefits, or vocational rehabilitation.
(q) Insurer. Any company, group, or entity in, or which has been in, the business of transacting workers' compensation insurance for employers subject to the workers' compensation laws of this state. The term insurer includes the State Compensation Insurance Fund.
(r) Investigation. The process of examining and evaluating a claim to determine the nature and extent of all legally required benefits, if any, which are due under the claim. Investigation may include formal or informal methods of gathering information relevant to evaluating the claim such as: obtaining employment records; obtaining earnings records; informal or formal interviews of the employee, employer, or witnesses; deposition of parties or witnesses; obtaining expert opinion where an issue requires an expert opinion for its resolution, such as obtaining a medical-legal evaluation.
(s) Joint Powers Authority. Any county, city, city and county, municipal corporation, public district, public agency, or political subdivision of the state, but not the state itself, included in a pooling arrangement under a joint exercise of powers agreement for the purpose of securing a certificate of consent to self-insure workers' compensation claims under Labor Code Section 3700(c).
(t) Medical-Only Claim. A work-injury claim in which no indemnity benefits are payable.
(u) Non-Random. Any method of selecting an audit subject which is specific to that audit subject, based on any or all of the factors provided in Labor Code Section 129(b).
(v) Notice of Compensation Due. The Notice of Assessment issued pursuant to Labor Code Section 129(c).
(w) Open Claim. A work-injury claim in which future payment of compensation may be due or for which reserves for the future payment of compensation are maintained.
(x) Payment Schedule. Either:
(1) The two-week cycle of indemnity payments due on the day designated with the first payment as required by Labor Code Section 4650(c) or 4702(b), including any lawfully changed payment schedule; or
(2) The two-week cycle of payments of vocational rehabilitation maintenance allowance (VRMA) required by Title 8, California Code of Regulations, Division 1, Chapter 4.5, Subchapter 1.5, Article 7, Section 10125.1.
(y) Random. Any method of selecting an audit subject which is not based on factors specific to that audit subject, but instead which chooses subjects from a broad cross-section of possible subjects. Random selection methods may stratify by general groups and need not be statistically precise.
(z) Record of Payment. An accurate written or electronic record of all compensation payments in a claim file, including but not limited to:
(1) The check number, date the check was issued, name of the payee, amount, and for indemnity payments the time period(s) covered by the payment;
(2) All dates for which salary continuation as defined by Labor Code Section 4650(g) was provided instead of direct indemnity payments; the dates for which salary continuation was authorized; and documentation when applicable that sick leave or other leave credits were restored for any periods for which salary continuation was payable;
(3) A copy of each bill received which included a medical progress or work status report; and either a copy of each other bill received or documentation of the contents of that bill showing the date and description of the service provided, provider's name, amount billed, date the claims administrator received the bill, and date and amount paid.
(aa) Self-insured Employer. An employer, either as an individual employer or as a group of employers, that has been issued a certificate of consent to self-insure as provided by Labor Code Section 3700(b) or (c), including a joint powers authority or the State of California as a legally uninsured employer.
(bb) Third-Party Administrator. An agent under contract to administer the workers' compensation claims of an insurer, self-insured employer, or joint powers authority.
(cc) VRMA. Vocational rehabilitation maintenance allowance.
Note: Authority cited: Sections 59, 133, 129.5, 138.4, 5307.3, Labor Code. Reference: Sections 7, 124(a), 129(a), (b), (c), 129.5(a), (b), 3700, 3702.1, 4636, 4650(c), 5307.1, 5402, Labor Code.
s 10100.2. Definitions.
The following definitions apply in Articles 1 through 7 of this Subchapter for audits conducted on or after January 1, 2003.
(a) Adjusting Location. The office where claims are administered. Separate underwriting companies, self-administered, self-insured employers, and/or third-party administrators operating at one location shall be combined as one audit subject for the purposes of audits conducted pursuant to Labor Code Section 129(b) only if claims are administered under the same management at that location.
Where claims are administered from an office that includes a satellite office at another location, claims administered at the satellite office(s) will be considered as part of the single adjusting location for auditing purposes when demonstrated that the claims are under the same immediate management.
(b) Administrative Director. The Administrative Director of the Division of Workers' Compensation or the Director's duly authorized representative, designee, or delegee.
(c) Audit. An audit performed under Labor Code Sections 129 and 129.5.
(d) Audit Subject. A single adjusting location of a claims administrator which has been selected for audit. If a claims administrator has more than one adjusting location, other locations shall be considered as separate audit subjects for the purposes of implementing Labor Code Sections 129(a) and 129(b). However, the Audit Unit at its discretion may combine more than one adjusting location of a claims administrator as a single targeted audit subject, or may designate one insurer, insurer group, or self-insured employer at one or more third-party administrator adjusting locations as a single targeted audit subject.
(e) Audit Unit. The organizational unit within the Division of Workers' Compensation which audits and/or investigates insurers, self-insured employers and third-party administrators pursuant to Labor Code Sections 129 and 129.5.
(f) Claim. A request for compensation, or record of an occurrence in which compensation reasonably would be expected to be payable for an injury arising out of and in the course of employment.
(g) Claim File. A record in paper or electronic form, or a combination, containing all of the information specified in Section 10101.1 of these Regulations and all documents or entries related to the provision, delay, or denial of benefits.
(h) Claim Log. A handwritten, printed, or electronically maintained listing maintained by the claims administrator listing each work-injury claim as specified in Section 10103.2 of these Regulations.
(i) Claims Administrator or Administrator. A self-administered workers' compensation insurer, a self-administered self-insured employer, a self-administered legally uninsured employer, a self-administered joint powers authority, or a third-party claims administrator for an insurer, a self-insured employer, a legally-uninsured employer or a joint powers authority.
(j) Closed Claim. A work-injury claim in which future payment of compensation cannot be reasonably expected to be due.
(k) Compensation. Every benefit or payment, including vocational rehabilitation, medical, and medical-legal expenses, conferred by Divisions 1 and 4 of the Labor Code on an injured employee or the employee's dependents.
(l) Date of Knowledge of Injury and Disability. The date the employer had knowledge or reasonably can be expected to have had knowledge, pursuant to Labor Code Section 5402, of (1) a worker's injury or claim for injury, and (2) the worker's inability or claimed inability to work because of the injury.
(m) Denied Claim. A claim for which all liability has been denied at any time, even if the claim was accepted before or after the denial. A claim which otherwise meets this definition is a denied claim even if medical-legal expenses were paid.
(n) Employee. An employee, or in the case of the employee's death, his or her dependent, aseach is defined in Division 4 of the Labor Code, or the employee's or dependent's agent. (continued)