As used in the regulations in Chapter 1:
(a) "Accreditation" means the conferring of
recognized status as a provider of physician education by the Administrative
Director.
(b) "Administrative
Director" means the administrative director of the Division of Workers'
Compensation of the State of California Department of Industrial Relations, and
includes his, her or their designee.
(c) "Agreed Panel QME" means the Qualified
Medical Evaluator described in Labor Code section
4062.2(c),
that the claims administrator, or if none the employer, and a represented
employee agree upon and select from a QME panel list issued by the Medical
Director prior to January 1, 2013, without using the striking process. An
Agreed Panel QME shall be entitled to be paid at the same rate as an Agreed
Medical Evaluator under section
of Title
89795 of
Title 8 of the California Code of
Regulations for medical/legal evaluation procedures and medical testimony. The
provisions of this subdivision related to "Agreed Panel QME" do not apply to
panel lists issued after January 1, 2013.
(d) "AMA Guides" means American Medical
Association, Guides to the Evaluation of Permanent Impairment [Fifth
Edition].
(e) "AME" means Agreed
Medical Evaluator, a physician selected by agreement between the claims
administrator, or if none the employer, and a represented employee to resolve
disputed medical issues referred by the parties in a workers' compensation
proceeding.
(f) "Appeals Board"
means the Workers' Compensation Appeals Board within the State of California
Department of Industrial Relations.
(g) "Audit" means a formal evaluation of a
continuing education program, disability evaluation report writing course, or
an accredited education provider which is conducted at the request of the
Medical Director.
(h)
"Comprehensive Medical-Legal Evaluation" means a medical evaluation performed
pursuant to Labor Code Sections
4060,
4061,
4062,
4062.1,
4062.2 or
4067 and
meeting the requirements of section
of Title
89793(c) of
Title 8 of the
California Code of Regulations.
(i)
"Claims Administrator" means the person or entity responsible for the payment
of compensation for any of the following: 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 group self-insurer, an
insured employer, the director of the Department of Industrial Relations as
administrator for the Uninsured Employers Benefits Trust Fund (UEBTF) and for
the Subsequent Injuries Benefit Trust Fund (SIBTF), a third-party claims
administrator for a self-insured employer, insurer, legally uninsured employer,
group self-insurer, or joint powers authority, and the California Insurance
Guarantee Association (CIGA). The UEBTF shall only be subject to these
regulations after proper service has been made on the uninsured employer and
the Appeals Board has obtained jurisdiction over the UEBTF by joinder as a
party.
(j) "Continuing Education
Program" means a systematic learning experience (such as a course, seminar, or
audiovisual or computer learning program) which serves to develop, maintain, or
increase the knowledge, skills and professional performance of physicians who
serve as Qualified Medical Evaluators in the California workers' compensation
system.
(k) "Course" means the 16
hours of instruction in disability evaluation report writing which is required
of a Qualified Medical Evaluator prior to appointment. A course must be
approved by the Administrative Director.
(l) "Credit Hour" means a sixty minute hour.
A credit hour may include time for questions and answers related to the
presentation.
(m) "Direct medical
treatment" means that special phase of the physician-patient relationship
during which the physician:
(1) attempts to
clinically diagnose and to alter or modify the expression of a non-industrial
illness, injury or pathological condition; or
(2) attempts to cure or relieve the effects
of an industrial injury.
(n) "Distance Learning" means an education
program in which the instructor and student are in different locations, as in
programs based on audio or video tapes, computer programs, or printed
educational material.
(o) "DEU" is
the Disability Evaluation Unit under the Administrative Director which is
responsible for issuing disability ratings pursuant to §
of Title
810150 of
Title 8 of the California Code of
Regulations.
(p) "Education
Provider" means the individual or organization which has been accredited by the
Administrative Director to offer physician education programs. There are two
categories of providers:
(1) the
Administrative Director; and
(2)
individuals, partnerships, or corporations, hospitals, clinics or other patient
care facilities, educational institutions, medical or health-related
organizations whose membership includes physicians as defined in Labor Code
section
3209.3,
organizations of non-medical participants in the California workers'
compensation system, and governmental agencies. In the case of a national
organization seeking accreditation, the California Chapter or organization
affiliated with the national organization shall be accredited by the
Administrative Director in lieu of the national organization.
(q) "Employer" means any employer
within the meaning of Labor Code section
3300, including
but not limited to, any of the following:
(1)
an uninsured employer and the Uninsured Employers Benefits Trust Fund (UEBTF)
pursuant to Labor Code Section
3716,
(2) an insured employer,
(3) a self-insured employer and
(4) a lawfully uninsured employer. The UEBTF
shall only be subject to these regulations after proper service has been made
on the uninsured employer and the Appeals Board has obtained jurisdiction over
the UEBTF by joinder as a party.
(r) "Evaluator" means any of the following:
"Qualified Medical Evaluator", "Agreed Medical Evaluator", "Agreed Panel QME"
or "Panel QME", as appropriate in a specific case.
(s) "Follow-up comprehensive medical-legal
evaluation" means a medical evaluation performed pursuant to Labor Code
sections
4060,
4061,
4062,
4062.1,
4062.2 or
4067 and
meeting the requirements of Section
of Title
89793(g) of
Title 8 of the
California Code of Regulations.
(t)
"Future medical care" means medical treatment as defined in Labor Code section
4600 that is
reasonably required to cure or relieve an injured worker of the effects of the
industrial injury after an injured worker has reached maximum medical
improvement or permanent and stationary status including a description of the
type of the medical treatment that might be necessary in the future.
(u) "Medical Treatment Utilization Schedule"
or "MTUS" means the treatment utilization scheduled adopted by the
Administrative Director of the Division of Workers' Compensation as required by
Labor Code section
5307.27 and
sections
9792.20
et seq of
Title 8 of the California Code of Regulations.
(v) "Medical Director" means the Medical
Director appointed by the Administrative Director pursuant to Labor Code
section
122 and
includes any Associate Medical Directors when acting as his, her or their
designee.
(w) "Mental health
record" means a medical treatment or evaluation record created or reviewed by a
licensed physician as defined in Labor Code section
3209.3 in the
course of treating or evaluating a mental disorder.
(x) "Panel QME" means the physician, from a
QME panel list provided by the Medical Director, who is selected under Labor
Code section
4062.1(c)
when the injured worker is not represented by an attorney, and when the injured
worker is represented by an attorney, the physician whose name remains after
completion of the striking process or who is otherwise selected as provided in
Labor Code section
4062.2(c)
when the parties are unable to agree on an Agreed Panel QME.
(y) "Physician's office" means a bona fide
office facility which is identified by a street address and any other more
specific designation such as a suite or room number and which contains the
usual and customary equipment for the evaluation and treatment appropriate to
the physician's medical specialty or practice.
(z) "Qualified Medical Evaluator (QME)" means
a physician licensed by the appropriate licensing body for the state of
California and appointed by the Administrative Director pursuant to Labor Code
section
139.2,
provided, however, that acupuncturist QMEs shall not perform comprehensive
medical-legal evaluations to determine disability.
(aa) "QME competency examination" means an
examination administered by the Administrative Director for the purpose of
demonstrating competence in evaluating medical-legal issues in the workers'
compensation system. This examination shall be given at least as often as twice
annually.
(bb) "QME competency
examination for acupuncturists" means an examination administered by the
Administrative Director for the purpose of demonstrating competence in
evaluating medical-legal issues in the workers' compensation system which are
not pertinent to the determination of disability, but should be understood by
acupuncturist QMEs. This examination shall be given at least as often as twice
annually.
(cc) "Request for factual
correction" means a request by an unrepresented injured worker or a claims
administrator, or their representative, to a panel QME to change an incorrect
statement or assertion of fact contained in a comprehensive medical-legal
evaluation to a statement or assertion of fact that is capable of verification
from written records submitted to a panel QME pursuant to section
of title
835 of
title 8 of the California Code of
Regulations.
(dd) "Significant
Financial Interest or Affiliation Held by Faculty", as used in sections
11.5,
14,
55,
118 and
119 pertaining to faculty of
approved disability report writing or continuing education courses under these
regulations, means grant or research support; status as a consultant, member of
a speakers' bureau, or major stock shareholder; or other financial or material
interest for the program faculty member or his, her or their family.
(ee) "Specified Financial Interests" means
having a shared financial interest that must be reported or disclosed pursuant
to sections
11,
17,
29,
50 or on the "SFI Form 124"
attached to QME Form 100, 103 or 104 as required by these
regulations.
(ff) "Supplemental
medical-legal evaluation" means a medical evaluation performed pursuant to
Labor Code sections
4060,
4061,
4062,
4062.1,
4062.2 or
4067 and
meeting the requirements of section
of Title
89793(m) of
Title 8 of the
California Code of Regulations.
(gg) "Treating physician" means a physician
who has provided direct medical treatment to an employee which is reasonably
required to cure or relieve the effects of an industrial injury pursuant to
section
4600 of the
Labor Code.
(hh) "Unrepresented
employee" means an employee not represented by an attorney.
(ii) "Electronic address" or "Electronic
Service Address" means an email address, document download address or service,
or other electronic or physical repository capable of receiving electronic
transmissions that must be encrypted to protect the integrity of the
transmission.
Notes
Cal. Code
Regs. Tit. 8, §
1
Note: Authority cited: Sections 53, 133, 139.2, 4060,
4061, 4062, 4062.1, 4062.2 and 5307.3, Labor Code. Reference: Sections 139.2,
139.3, 139.31, 139.4, 139.43, 3716, 4060, 4061, 4061.5, 4062, 4062.1, 4062.2,
4062.3, 4062.5, 4067, 4600, 4604.5 and 4660-4664, Labor Code.
Note: Authority cited: Sections
53,
133,
139.2,
4060,
4061,
4062,
4062.1,
4062.2 and
5307.3, Labor
Code. Reference: Sections
139.2,
139.3,
139.31,
139.4,
139.43,
3716,
4060,
4061,
4061.5,
4062,
4062.1,
4062.2,
4062.3,
4062.5,
4067,
4600,
4604.5 and
4660-
4664, Labor
Code.
1. Repealer and new
section filed 8-1-94; operative 8-31-94 (Register 94, No. 31). For prior
history, see Register 93, No. 38.
2. Change without regulatory
effect amending subsections (c), (g), (h), (k) and (p) filed 9-19-94 pursuant
to section 100, title 1, California Code of Regulations (Register 94, No.
38).
3. Amendment of subsections (d) and (f), repealer and new
subsection (m), amendment of subsections (n) and (o), new subsections (p) and
(q) and subsection relettering, and amendment of newly designated subsection
(r) filed 8-23-96; operative 9-22-96 (Register 96, No. 34).
4. New
subsection (s) and subsection relettering filed 6-3-97; operative 7-3-97
(Register 97, No. 23).
5. Amendment of subsections (f) and (r) filed
4-14-2000; operative 5-14-2000 (Register 2000, No. 15).
6. New
subsections (a) and (e), repealer of former subsection (f), new subsections
(h), (j), (k), (m), (r) and (x) and subsection relettering filed 10-16-2000 as
an emergency; operative 1-1-2001 (Register 2000, No. 42). A Certificate of
Compliance must be transmitted to OAL by 5-1-2001 or emergency language will be
repealed by operation of law on the following day.
7. New
subsections (a) and (e), repealer of former subsection (f), new subsections
(h), (j), (k), (r) and (x) and subsection relettering refiled 5-2-2001 as an
emergency; operative 5-2-2001 (Register 2001, No. 18). A Certificate of
Compliance must be transmitted to OAL by 8-30-2001 or emergency language will
be repealed by operation of law on the following day.
8. Certificate
of Compliance as to 5-2-2001 order, including further amendment of section,
transmitted to OAL 7-12-2001 and filed 8-23-2001 (Register 2001, No.
34).
9. Amendment of chapter heading, section and Note filed
1-13-2009; operative 2-17-2009 (Register 2009, No. 3).
10. Repealer
of subsection (b), new subsections (t) and (cc) and subsection relettering
filed 12-31-2012 as an emergency; operative 1-1-2013 pursuant to Government
Code section
11346.1(d)
(Register 2013, No. 1). A Certificate of Compliance must be transmitted to OAL
by 7-1-2013 or emergency language will be repealed by operation of law on the
following day.
11. Repealer of subsection (b), new subsections (t)
and (cc) and subsection relettering refiled 7-1-2013 as an emergency; operative
7-1-2013 (Register 2013, No. 27). A Certificate of Compliance must be
transmitted to OAL by 9-30-2013 or emergency language will be repealed by
operation of law on the following day.
12. Certificate of Compliance
as to 7-1-2013 order, including amendment of subsections (t) and (cc),
transmitted to OAL 8-2-2013 and filed 9-16-2013; amendments operative 9-16-2013
pursuant to Government Code section
11343.4(b)(3)(Register
2013, No. 38).
13. Amendment of subsections (b)-(c), (k), (o), (s),
(v), (dd) and (ff) and new subsection (ii) filed 2-26-2024; operative
2/26/2024
pursuant to Government Code section 11343.4(b)(3) (Register
2024, No. 9).