Cal. Code Regs. Tit. 8, § 9793 - Definitions
As used in this article:
(a) "Claim" means a claim for compensation as
evidenced by either the filing of a claim form pursuant to Section
5401 of the
Labor Code or notice or knowledge of an injury under Section
5400 or
5402 of the
Labor Code.
(b) "Contested claim"
means any of the following:
(1) Where the
claims administrator has rejected liability for a claimed benefit.
(2) Where the claims administrator has failed
to accept liability for a claim and the claim has become presumptively
compensable under Section
5402 of the
Labor Code.
(3) Where the claims
administrator has failed to respond to a demand for the payment of compensation
after the expiration of any time period fixed by statute for the payment of
indemnity benefits, including where the claims administrator has failed to
either commence the payment of temporary disability indemnity or issue a notice
of delay within 14 days after knowledge of an employee's injury and disability
as provided in Section
4650 of the
Labor Code.
(4) Where the claims
administrator has accepted liability for a claim and a disputed medical fact
exists.
(c)
"Comprehensive medical-legal evaluation" means an evaluation, which includes an
examination of an employee, and which (A) results in the preparation of a
narrative medical report prepared and attested to in accordance with Section
4628 of the
Labor Code, any applicable procedures promulgated under Section
139.2 of the
Labor Code, and the requirements of Section
10682 and (B) is either:
(1) performed by a Qualified Medical
Evaluator pursuant to subdivision (h) of Section
139.2 of the
Labor Code, or
(2) performed by a
Qualified Medical Evaluator, Agreed Medical Evaluator, or the primary treating
physician for the purpose of proving or disproving a contested claim, and which
meets the requirements of paragraphs (1) through (5), inclusive, of subdivision
(h).
(d) "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 group self-insurer, or a third-party
claims administrator for a self-insured employer, insurer, legally uninsured
employer, group self-insurer, or joint powers authority.
(e) "Disputed medical fact" means an issue in
dispute, including an objection under Section
4062 of the
Labor Code to a medical determination made by a treating physician concerning:
(1) the employee's medical
condition,
(2) the cause of the
employee's medical condition,
(3)
For injuries that occurred before January 1, 2013, concerning a dispute over a
utilization review decision if the decision is communicated to the requesting
physician on or before June 30, 2013, treatment for the employee's medical
condition;
(4) the existence,
nature, duration or extent of temporary or permanent disability caused by the
employee's medical condition; or
(5)
the employee's medical eligibility for rehabilitation
services.
(f)
"Explanation of review" means the document described in Labor Code sections
4603.3(a)
and
4622 that is
provided to a Qualified Medical Evaluator, Agreed Medical Evaluator, or the
primary treating physician when the claims administrator has objected to the
cost of a medical-legal expense.
(g) "Follow-up medical-legal evaluation"
means an evaluation which includes an examination of an employee which (A)
results in the preparation of a narrative medical report prepared and attested
to in accordance with Section
4628 of the
Labor Code, any applicable procedures promulgated under Section
139.2 of the
Labor Code, and the requirements of Section
10682, (B) is performed by a
qualified medical evaluator, agreed medical evaluator, or primary treating
physician within eighteen (18) months following the evaluator's examination of
the employee in a comprehensive medical-legal evaluation and (C) involves an
evaluation of the same injury or injuries evaluated in the comprehensive
medical-legal evaluation.
(h)
"Medical-legal expense" means any costs or expenses incurred by or on behalf of
any party or parties, the administrative director, or the appeals board for
X-rays, laboratory fees, other diagnostic tests, medical reports, medical
records, medical testimony, and as needed, interpreter's fees, for the purpose
of proving or disproving a contested claim. The cost of medical evaluations,
diagnostic tests, and interpreters is not a medical-legal expense unless it is
incidental to the production of a comprehensive medical-legal evaluation
report, follow-up medical-legal evaluation report, or a supplemental
medical-legal evaluation report and all of the following conditions exist:
(1) The report is prepared by a physician, as
defined in Section
3209.3 of the
Labor Code.
(2) The report is
obtained at the request of a party or parties, the administrative director, or
the appeals board for the purpose of proving or disproving a contested claim
and addresses the disputed medical fact or facts specified by the party, or
parties or other person who requested the comprehensive medical-legal
evaluation report. Nothing in this paragraph shall be construed to prohibit a
physician from addressing additional related medical issues.
(3) The report is capable of proving or
disproving a disputed medical fact essential to the resolution of a contested
claim, considering the substance as well as the form of the report, as required
by applicable statutes, regulations, and case law.
(4) The medical-legal examination is
performed prior to receipt of notice by the physician, the employee, or the
employee's attorney, that the disputed medical fact or facts for which the
report was requested have been resolved.
(5) In the event the comprehensive
medical-legal evaluation is served on the claims administrator after the
disputed medical fact or facts for which the report was requested have been
resolved, the report is served within the time frame specified in Section
139.2(j)(1)
of the Labor Code.
(i)
"Medical-legal testimony" means expert testimony provided by a physician at a
deposition or workers' compensation appeals board hearing, regarding the
medical opinion submitted by the physician.
(j) "Medical research" is the investigation
of medical issues. It includes investigating and reading medical and scientific
journals and texts. "Medical research" does not include reading or reading
about the Guides for the Evaluation of Permanent Impairment
(any edition), treatment guidelines (including guidelines of the American
College of Occupational and Environmental Medicine), the Labor Code,
regulations or publications of the Division of Workers' Compensation (including
the Physicians' Guide), or other legal materials.
(k) "Primary treating physician" is the
treating physician primarily responsible for managing the care of the injured
worker in accordance with subdivision (a) of Section
9785.
(l) "Reports and documents required by the
administrative director" means an itemized billing, a copy of the medical-legal
evaluation report, any correspondence received by the physician from the
parties to the action, and any verification required under Section
9795(c).
(m) "Supplemental medical-legal evaluation"
means an evaluation which (A) does not involve an examination of the patient,
(B) is based on the physician's review of records, test results or other
medically relevant information which was not available to the physician at the
time of the initial examination, or a request for factual correction pursuant
to Labor Code section
4061(d),
(C) results in the preparation of a narrative medical report prepared and
attested to in accordance with Section
4628 of the
Labor Code, any applicable procedures promulgated under Section
139.2 of the
Labor Code, and the requirements of Section
10682 and (D) is performed by a
qualified medical evaluator, agreed medical evaluator, or primary treating
physician following the evaluator's completion of a comprehensive medical-legal
evaluation.
(n) "Record Review"
means the review by a physician of documents sent to the physician in
connection with a medical-legal evaluation or request for report. The documents
may consist of medical records, legal transcripts, medical test results, and or
other relevant documents. For purposes of record review, a page is defined as
an 8 ½ by 11 single-sided document, chart or paper, whether in physical
or electronic form. Multiple condensed pages or documents displayed on a single
page shall be charged as separate pages. Any documents sent to the physician
for record review must be accompanied by a declaration under penalty of perjury
that the provider of the documents has complied with the provisions of Labor
Code section
4062.3 before
providing the documents to the physician. The declaration must also contain an
attestation as to the total page count of the documents provided. A physician
may not bill for review of documents that are not provided with this
accompanying required declaration from the document provider. Any documents or
records that are sent to the physician without the required declaration and
attestation shall not be considered available to the physician or received by
the physician for purposes of any regulatory or statutory duty of the physician
regarding records and report writing.
Notes
2. Change without regulatory effect filed 7-11-86; effective upon filing (Register 86, No. 28).
3. Repealer and new section filed 8-3-93; operative 8-3-93. Submitted to OAL for printing only pursuant to Government Code section 11351 (Register 93, No. 32).
4. Amendment of article heading, section and NOTE filed 12-31-93; operative 1-1-94. Submitted to OAL for printing only pursuant to Government Code section 11351 (Register 93, No. 53).
5. Change without regulatory effect amending subsections (f) and (i) filed 6-12-2002 pursuant to section 100, title 1, California Code of Regulations (Register 2002, No. 24).
6. Amendment of subsections (a) and (b)(3), new subsection (i), subsection relettering and amendment of newly designated subsection (j) filed 6-30-2006; operative 7-1-2006. Submitted to OAL for filing with the Secretary of State and printing only pursuant to Government Code section 11340.9(g) (Register 2006, No. 26).
7. Amendment of subsection (e), new subsection (f), subsection relettering, amendment of newly designated subsection (m) and amendment of NOTE 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.
8. Amendment of subsection (e), new subsection (f), subsection relettering, amendment of newly designated subsection (m) and amendment of NOTE 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.
9. Amendment of subsection (e), new subsection (f), subsection relettering, amendment of newly designated subsection (m) and amendment of NOTE 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.
10. Certificate of Compliance as to 9-30-2013 order, including amendment of subsections (c)(2) and (e), 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).
11. Amendment of subsections (c), (g), (l) and (m) and new subsection (n) filed 3-30-2021; operative 4-1-2021. Submitted to OAL for filing and printing only pursuant to Government Code section 11340.9(g) (Register 2021, No. 14).
Note: Authority cited: Sections 133, 4622, 4627, 5307.3 and 5307.6, Labor Code. Reference: Sections 4061, 4061.5, 4062, 4610.5, 4620, 4621, 4622, 4625, 4628, 4650, 5307.6 and 5402, Labor Code.
2. Change without regulatory effect filed 7-11-86; effective upon filing (Register 86, No. 28).
3. Repealer and new section filed 8-3-93; operative 8-3-93. Submitted to OAL for printing only pursuant to Government Code section 11351 (Register 93, No. 32).
4. Amendment of article heading, section and Note filed 12-31-93; operative 1-1-94. Submitted to OAL for printing only pursuant to Government Code section 11351 (Register 93, No. 53).
5. Change without regulatory effect amending subsections (f) and (i) filed 6-12-2002 pursuant to section 100, title 1, California Code of Regulations (Register 2002, No. 24).
6. Amendment of subsections (a) and (b)(3), new subsection (i), subsection relettering and amendment of newly designated subsection (j) filed 6-30-2006; operative 7-1-2006. Submitted to OAL for filing with the Secretary of State and printing only pursuant to Government Code section 11340.9(g) (Register 2006, No. 26).
7. Amendment of subsection (e), new subsection (f), subsection relettering, amendment of newly designated subsection (m) and amendment of Note 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.
8. Amendment of subsection (e), new subsection (f), subsection relettering, amendment of newly designated subsection (m) and amendment of Note 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.
9. Amendment of subsection (e), new subsection (f), subsection relettering, amendment of newly designated subsection (m) and amendment of Note 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.
10. Certificate of Compliance as to 9-30-2013 order, including amendment of subsections (c)(2) and (e), 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).
11. Amendment of subsections (c), (g), (l) and (m) and new subsection (n) filed 3-30-2021; operative
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