This section is applicable to medical treatment services
and goods rendered under Labor Code section
4600, or
medical-legal expenses incurred under Labor Code section
4620, on or
after January 1, 2013.
(a) "Amount of
payment" means the amount of money paid by the claims administrator for either:
(1) Medical treatment services or goods
rendered by a provider or goods supplied in accordance with Labor Code section
4600 that were
authorized by Labor Code section
4610, and for
which there exists an applicable fee schedule adopted by the Administrative
Director for those categories of goods and services, including but not limited
to those found at sections
9789.10 to
9789.111, or for which a contract
for reimbursement rates exists under Labor Code section
5307.11.
(2) Medical-legal expenses, as defined by
Labor Code section
4620, where the
payment is determined in accordance with sections 9793-9795 and
9795.1-9795.4.
(b)
"Billing Code" means those codes adopted by the Administrative Director for use
in the Official Medical Fee Schedule, located at sections
9789.10 to
9789.111, or in the Medical-Legal
Fee Schedule, located at sections
9795(c) and
9795(d).
(c) "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, or a third-party administrator for a self-insured
employer, insurer, legally uninsured employer, or joint powers
authority.
(d) "Contested
liability" means the existence of a good-faith issue which, if resolved against
the injured worker, would defeat the right to any workers' compensation
benefits or the existence of a good-faith issue that would defeat a provider's
right to receive compensation for medical treatment services provided in
accordance with Labor Code section
4600 or for
medical-legal expenses defined in Labor Code section
4620.
(e) "Consolidation" means combining two or
more requests for independent bill review together for the purpose of having
the payment reductions contested in each request resolved in a single
determination.
(f) "Explanation of
review" means the document described in Labor Code section
4603.3 provided
by a claims administrator to a provider upon the payment, adjustment, or denial
of a complete or incomplete itemization of medical services.
(g) "Independent bill review organization" or
"IBRO" means the organization or the organizations designated by the
Administrative Director pursuant to Labor Code section
139.5 to
perform independent bill review under Labor Code section
4603.6.
(h) "Independent bill reviewer" means an
individual retained by the IBRO and subject to the provisions of Labor Code
section
139.5 to review
a request for independent bill review, with supporting documentation, and issue
a determination under the Article.
(i) "Provider" means a provider of medical
treatment services or goods, including a health care facility as defined in
Section One of the California Division of Workers' Compensation Medical Billing
and Payment Guide as incorporated by reference in section
9792.5.1, whose billing processes
are governed by Labor Code section
4603.2 or
4603.4, or a
provider of medical-legal services whose billing processes are governed by
Labor Code sections
4620 and
4622, that has
requested a second bill review and, if applicable, independent bill review to
resolve a dispute over the amount of payment for services according to either a
fee schedule established by the Administrative Director or a contract for
reimbursement rates under Labor Code section
5307.11. A
provider may utilize the services of a billing agent, a person or entity that
has contracted with the provider to process bills under this article for
services or goods rendered by the provider, to request a second bill review or
independent bill review.
Notes
Cal. Code Regs. Tit. 8, §
9792.5.4
1. New
section 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.
2. New section 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.
3. New section refiled
9-30-2013 as an emergency; operative 10-1-2013 (Register 2013, No. 40). A
Certificate of Compliance must be transmitted to OAL by 12-30-2013 or emergency
language will be repealed by operation of law on the following
day.
4. Certificate of Compliance as to 9-30-2013 order, including
amendment of first paragraph and subsections (a)(1)-(2), (d) and (i),
transmitted to OAL 12-30-2013 and filed 2-12-2014; amendments effective
2-12-2014 pursuant to Government Code section
11343.4(b)(3)
(Register 2014, No. 7).
Note: Authority cited: Sections
133,
4603.6,
5307.3 and
5307.6, Labor
Code. Reference: Sections
4060,
4061, 4061.5,
4062,
4600, 4603.2, 4603.3. 4603.4,
4603.6, 4620, 4621, 4622, 4625, 4628 and 5307.6, Labor
Code.
1. New section 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.
2. New section 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.
3. New section refiled
9-30-2013 as an emergency; operative 10-1-2013 (Register 2013, No. 40). A
Certificate of Compliance must be transmitted to OAL by 12-30-2013 or emergency
language will be repealed by operation of law on the following
day.
4. Certificate of Compliance as to 9-30-2013 order, including
amendment of first paragraph and subsections (a)(1)-(2), (d) and (i),
transmitted to OAL 12-30-2013 and filed 2-12-2014; amendments effective
2-12-2014 pursuant to Government Code section
11343.4(b)(3)
(Register 2014, No. 7).