San Francisco, CA – The Division of Workers’ Compensation (DWC) has posted a 15-day notice of modification to the proposed utilization review (UR) and independent medical review (IMR) regulations to the DWC website. Members of the public are invited to present written comments regarding the proposed modifications to firstname.lastname@example.org until 5 p.m. on October 11. The proposed modifications include:
- A revised Request for Authorization form (DWC Form RFA), emphasizing that it must be signed by the employee’s treating physician.
- A statement on the DWC Form RFA that it is not a separately reimbursable report under the Official Medical Fee Schedule.
- Section 9792.6.1(t): The definition of “request for authorization” is amended to allow, by agreement of the parties, an electronic signature.
- Section 9792.9.1(c)(2): A non-conforming request for authorization (i.e., an incomplete Form RFA or request that does not use the form) must be returned to the requesting physician within three business days or else be considered as complete and subject to all applicable timeframes and requirements.
- Section 9792.9.1(e)(5)(G): The envelope for the IMR application shall only be provided to the injured worker. Also, prior to March 1, 2014, any version of the DWC Form IMR adopted by the Administrative Director under section 9792.10.2 may be used by the claims administrator in a written decision modifying, delaying or denying treatment authorization.
- Section 9792.9.1(f): The requirements for a UR reviewer to request additional information, an additional test, or consultation by an expert reviewer have been revised to clarify the deadlines for issuing adverse UR decisions.
- Section 9792.10.1(b)(1): At the time of filing for IMR, the employee must provide a copy of the signed DWC Form IMR, without a copy of the adverse utilization review decision, to the claims administrator.
- Section 9792.10.1(d)(1): Any request by the employee or treating physician for an internal utilization review appeal process must be submitted to the claims administrator within ten (10) days after the receipt of the utilization review decision.
- Section 9792.10.1(d)(2): Any determination following an internal utilization review appeal that results in a modification of the requested medical treatment must include the IMR form that indicates the decision is a modification after appeal.
- A revised Application for Independent Medical Review (DWC Form IMR), that expressly provides that a copy of the underlying UR determination must accompany the application and that a copy of the application be mailed or faxed to the claims administrator.
- Section 9792.10.3: The Administrative Director, for determining the eligibility of an IMR application, may consider the failure by the requesting physician to respond to a request by the claims administrator for information reasonably necessary to make a utilization review determination, for additional required examinations or tests, or for a specialized consultation.
- Section 9792.10.4: The independent review organization delegated the responsibility by the Administrative Director to conduct independent medical review pursuant to Labor Code section 139.5 (IMRO) may consolidate two or more eligible applications for independent medical review by a single employee for resolution in a single determination if the applications involve the same requesting physician and the same date of injury.
- Section 9792.10.5: Copies of documents to be provided to the employee by the claims administrator shall not include mental health records withheld from the employee pursuant to Health and Safety Code section 123115(b).
- Section 9792.10.6(j): Upon receipt of credible information that the claims administrator has failed to has failed to comply with its obligations under the independent medical review requirements the Administrative Director shall, concurrent or subsequent to the issuance of the final determination issued by the independent review organization, issue an order to show cause for the assessment of administrative penalties against the claims administrator under new section 9792.12(c).
- Section 9792.10.7: Upon receipt of credible information that the claims administrator has failed to implement the final determination, the Administrative Director shall issue an order to show cause for the assessment of administrative penalties against the claims administrator under new section 9792.12(c).
Source: CA DWC