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Claims administrator information

Workers' compensation is the nation's oldest social insurance program: It was adopted in most states, including California, during the second decade of the 20th century. The workers' compensation system is based on a trade-off between employers and employees. Employees are entitled to receive prompt, effective medical treatment for on-the-job injuries or illnesses no matter who is at fault and, in return, are prevented from suing employers over those injuries.

Unlike most social insurance programs, workers' compensation benefits are not administered by a government agency. They are administered primarily by insurance companies and those employers secure enough to self-insure their workers' compensation liability.

When an employer becomes aware of a work-related injury or illness, it is expected to begin providing benefits to the injured worker. That's where you come in.

You are charged with expediting the delivery of workers' compensation benefits and services to injured workers' without unnecessary litigation or delays. While your job has changed with recent workers' compensation reforms and resulting case law and regulations, the Division of Workers' Compensation (DWC) can help you do your job effectively.

The vast majority of workers' compensation claims are resolved between you and the injured worker without any problems. However, sometimes a disagreement can arise over issues such as whether the injury was sustained on-the-job or what benefits the injured worker should receive.

When a dispute like that arises, the DWC can help resolve it through its Information and Assistance Unit or by going before a judge at one of the division's 23 local offices plus satellites.

Effective Feb. 22, 2006 all workers' compensation claims adjusters must be certified under state rules administered by the California Department of Insurance.

Topics on this page include:
General information
Medical treatment information
Disability ratings

General information

Frequently asked questions for claims administrators

Educational conference - the largest workers' compensation educational event in the state. It is held in February in both Northern and Southern California, speakers from the Division of Workers’ Compensation and the private sector will address the most current topics and issues confronting claims administrators, medical providers, attorneys, rehabilitation counselors and others involved in workers’ compensation.

Workers' compensation benefits - Overview of benefits, including currents rates, available for injured workers.

Time of hire pamphlet acrobat image version Word image text only version
Un folleto para el nuevo empleado versión versión de sólo texto

ZIP code locator tool will help you locate the DWC district office serving your ZIP code

Revised benefit notices manual, sample benefit notices and fact sheets Adobe Acrobat image icon

Reporting suspected medical care provider fraud

Workers' compensation reference materials
Libros de referencia de compensacion de trabajadores

Simplified flow chart for claims process acrobat image

Workers' compensation information system (WCIS) uses electronic data interchange (EDI) to collect comprehensive information from claims administrators to help the Department of Industrial Relations oversee the state's workers' compensation system. Beginning in September of 2006, claims administrators are required to provide medical information to the WCIS via EDI.

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Doctors in California's workers' compensation system are required to provide evidence-based medical treatment. That means they must choose treatments scientifically proven to cure or relieve work-related injuries and illnesses. Those treatments are laid out in a set of guidelines that provide details on which treatments are effective for certain injuries, as well as how often the treatment should be given (frequency), the extent of the treatment (intensity), and for how long (duration), among other things.

To comply with the evidence-based medical treatment requirement, the state of California has adopted a medical treatment utilization schedule (MTUS). The MTUS includes specific body regions guidelines adopted from the American College of Occupational and Environmental Medicine's (ACOEM) Practice Guidelines, plus guidelines for acupuncture, chronic pain, and therapy after surgery. The Division of Workers' Compensation also has a committee that continuously evaluates new medical evidence about treatments and incorporates that evidence into its guidelines.

Copies of the ACOEM guidelines are available for review at your local DWC district office. Other guidelines not adopted from ACOEM can be reviewed and downloaded from the DWC Web site: http://www.dir.ca.gov/dwc/DWCPropRegs/MTUS_Regulations/MTUS_Regulations.htm.

Copies may also be obtained from:

Division of Workers' Compensation
Medical Unit
P.O. Box 71010
Oakland, CA 94612-1486

Additionally, claims administrators are required to have a program called utilization review (UR). UR was implemented as a way to confirm the treating physician's plan for the injured worker is medically sound. To ensure prompt and effective medical treatment is provided to injured workers, UR must be completed within strict timelines. Claims administrators who don't meet the timelines or the criteria for a proper UR program are subject to audits and penalties

If you have established a medical provider network (MPN) or a health care organization (HCO) the employees in your network will be treated by a network doctor. If an employee in your network qualified to pre-designate a personal physician and did so prior to being injured, he or she can go to their regular doctor for their workers' compensation care.

Submitted utilization review plans acrobat image version
This is a list of the groups that have sent actual utilization review plans to the Division of Workers' Compensation. The list does not contain the names of individual employers that might be covered by these plans. The plans have not been reviewed by DWC staff.
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Current list of approved MPNs by name of applicant acrobat image version

Current list of approved MPNs by approval date acrobat image version
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Certified Health Care Organizations (HCO)
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You and/or the injured worker might disagree with what the treating doctor says about the injury or treatment. There could be other disagreements over medical issues in a claim. A doctor has to address those disagreements. In that case you may need to use a qualified medical evaluator (QME) or use the independent medical review (IMR) process, if the dispute is over a medical treatment request.

Frequently asked questions about QMEs for injured workers

QME database
How to Successfully Request a Represented Panel
Discipline unit
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Official medical fee schedule
Information for employers, physicians and insurers concerning first aid treatment for workers' compensation injuries
e-billing
Standardized paper billing

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Disability ratings

Most workers fully recover from job injuries but some continue to have medical problems. Permanent disability (PD) is any lasting disability an injured employee experiences, which results in reduced earning capacity after maximum medical improvement is reached. If an injured employee’s injury or illness results in PD they are entitled to PD benefits. Check out our fact sheets and guides page and click on fact sheet D for more information on PD.

For injuries occurring on or after Jan. 1, 2013, there will be a new method for calculating an injured employee’s PD rating. A QME or treating physician can no longer increase an injured employee’s PD by adding impairment in the form of sleep disorder or sexual impairment unless such impairments were a direct result of the injury. In addition, no increase in an injured employee’s PD on account of a psychiatric injury is allowed unless the physical injury was catastrophic or the injured employee was the victim of or a witness to a violent crime.

Permanent disability rating schedule - 2005 acrobat image
This schedule is effective for dates of injury on or after Jan. 1, 2005. This schedule will also be used to rate permanent disability in injuries that occurred before Jan. 1, 2005 when there has been either no comprehensive medical-legal report, or no report by a treating physician indicating the existence of permanent disability, or when the employer is not required to provide a notice to the injured worker under Labor Code section 4061.

For dates of injury on or after Jan. 1, 2013, there are changes in how PD is calculated under the 2005 rating schedule.  The Future Earning Capacity Adjustment Table on pages 2-6 and 2-7 of the schedule has been replaced with a multiplier of 1.4 to be applied to all claims.  You can find information on the application of the 1.4 multiplier on the benefits chart.

Permanent disability rating schedule - 1997 acrobat image
This schedule is effective for dates of injury on or after Apr. 1, 1997

Permanent disability rating schedule - 1988 acrobat image
This schedule is effective for dates of injury on or after Jul. 1988

Medical report reference materials acrobat image
For cases rated under the 1997 or earlier rating schedules

Commutation templates and instructions .zip file
Templates and instructions to facilitate the calculation of life pension and permanent disability benefit commutations. When properly used, the templates assure that calculations are done in accordance with commutation calculation methods and tables that went into effect Jan. 17, 2001. The regulations and tables can be found in section 10169 and 10169.1 of Title 8, California Code of Regulations.
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Evaluation protocols - for injuries rated under 1997 permanent disability rating schedule and prior

Cardiac
Foot and ankle
Immunologic
Neuromusculoskeletal
Psychiatry
Pulmonary

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January 2014