Cal. Code Regs. Tit. 10, § 2592.01 - Definitions
As used in this article:
(a) "Certify" means a written statement made
under penalty of perjury.
(b)
"Claims adjuster" means a person who, on behalf of an insurer, including an
employee or agent of an entity that is not an insurer, is responsible for
determining the validity of a workers' compensation claim. The claims adjuster
may also establish a case reserve, approve and process all workers'
compensation benefits, may hire investigators, attorneys or other professionals
and may negotiate settlements of claims. "Claims adjuster" also means a person
who is responsible for the immediate supervision of a claims adjuster but does
not mean an attorney representing the insurer or a person whose primary
function is clerical. "Claims adjuster" also includes an experienced claims
adjuster. "Claims adjuster" does not include the medical director or physicians
utilized by an insurer for the utilization review process pursuant to Labor
Code section
4610.
(c) "Classroom" means any space sufficiently
designed so that the instructor and students can communicate with a high degree
of privacy and relative freedom from outside interference. The instructor or
the person or persons assisting the instructor may be physically present or may
communicate with students by means of an electronic medium, including, but not
limited to, audio, video, computer, or Internet.
(d) "Course" means any program of instruction
taken or given to satisfy the requirements of Insurance Code Section
11761.
(e) "Curriculum" means a course of study that
satisfies the requirements of Insurance Code Section
11761. The
curriculum must provide sufficient content, including time allocated to each
subject area, to enable claims adjusters, medical-only claims adjusters, and
medical bill reviewers to meet minimum standards of training, experience, and
skill to perform their duties with regard to workers' compensation
claims.
(f) "Experienced claims
adjuster" means a person who has had at least five (5) years within the past
eight (8) years of on-the-job experience adjusting California workers'
compensation claims or supervising claims adjusters handling California
workers' compensation claims and is designated as an experienced claims
adjuster by an insurer. A person who has successfully completed the written
examination specified by Title 8, Section 15452 of the California Code of
Regulations is also considered an experienced claims adjuster, provided that he
or she has either (1) worked as a workers' compensation claims adjuster or
supervised workers' compensation claims adjusters continuously since passing
the examination and is designated as an experienced claims adjuster by an
insurer or (2) passed the examination within the previous five (5) years and is
designated as an experienced claims adjuster by an insurer. "Experienced claims
adjuster" also includes a person who has already been trained and designated a
claims adjuster and now meets the requirements of experience or examination
completion noted above and is designated an experienced claims adjuster by an
insurer.
(g) "Experienced
medical-only claims adjuster" means a person who has had at least three (3)
years within the past five (5) years of on-the-job experience adjusting
California workers' compensation medical-only claims and is designated as an
experienced medical-only claims adjuster by an insurer.
(h) "Experienced medical bill reviewer" means
a person who has had at least three (3) years within the past five (5) years of
on-the-job experience reviewing California workers' compensation medical bills
and is designated as an experienced medical bill reviewer by a medical billing
entity or by an insurer.
(i)
"Instructor" means a person who conveys curriculum content to students on
behalf of an insurer, a training entity, or a medical billing entity. An
instructor shall have had at least five (5) years within the past eight (8)
years of on-the-job experience adjusting California workers' compensation
claims and have been designated as a claims adjuster by an insurer or be an
individual who has had at least eight (8) years of experience in California
workers' compensation within the past twelve (12) years. Persons knowledgeable
about specific workers' compensation issues who are not instructors may train
students under the direction of an instructor.
(j) "Insurer" means an insurance company
admitted to transact workers' compensation insurance in California, the State
Compensation Insurance Fund, an employer that has secured a certificate of
consent to self-insure from the Department of Industrial Relations pursuant to
Labor Code Section
3700(b) or
(c), or a third party administrator that has
secured a certificate of consent pursuant to Labor Code Section
3702.1.
(k) "Medical bill reviewer" means a person
who is not a claims adjuster or medical-only claims adjuster and who only
reviews or adjusts workers' compensation medical bills on behalf of an insurer,
including employees or agents of the insurer or employees or agents of a
medical billing entity. "Medical bill reviewer" also includes an experienced
medical bill reviewer.
(l) "Medical
billing entity" means a third party that reviews or adjusts workers'
compensation medical bills for insurers.
(m) "Medical-only claims adjuster" means a
person who, on behalf of an insurer, including an employee or agent of an
entity that is not an insurer, is responsible for determining the validity of
workers' compensation claims only involving medical workers' compensation
benefits, as defined under Article 2 (commencing with Labor Code section
4600) of
Chapter 2 of Part 2 of Division 4 of the Labor Code. The medical-only claims
adjuster may also establish medical treatment reserves, approve and process
medical benefits, and negotiate settlement of medical benefit claims.
"Medical-only claims adjuster" also means a person who is responsible for the
immediate supervision of a medical-only claims adjuster but does not mean an
attorney representing the insurer or a person whose primary function is
clerical. "Medical-only claims adjuster" also includes an experienced
medical-only claims adjuster. "Medical-only claims adjuster" does not include
the medical director or physicians utilized by an insurer for the utilization
review process pursuant to Labor Code section
4610.
(n) "Post-designation training" means a
course of study provided to trained or experienced workers' compensation claims
adjusters and medical-only claims adjusters who have been designated by an
insurer or provided to trained or experienced medical bill reviewers who have
been designated by an insurer or medical billing entity. Post-designation
training also includes seminars, workshops, or other informational meetings
pertaining to California workers' compensation.
(o) "Student" or "trainee" means an
individual taking a course that is required for that person in order to be a
workers' compensation claims adjuster, medical-only claims adjuster, or medical
bill reviewer.
(p) "Training" means
to provide a course of instruction that includes the topics specified in
Sections 2592.03 and
2592.04.
(q) "Training entity" means any person or
organization that provides instructors or curriculum to an insurer or medical
billing entity.
Notes
Note: Authority cited: Section 11761, Insurance Code. Reference: Section 11761, Insurance Code.
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