Newsline No. 44-07
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June 7, 2007

Utilization review enforcement regulations approved

The Division of Workers' Compensation's utilization review enforcement regulations have been approved by the Office of Administrative Law (OAL). The utilization review (UR) enforcement regulations, which are found in Title 8, California Code of Regulations, sections 9792.11 through 9792.15, are authorized by Labor Code section 4610, which requires every employer to have and use a UR process, and sets out timelines and conditions to be met whenever a request for authorization of medical treatment will be delayed, modified or denied. Labor Code section 4610(i) authorizes the Division of Workers' Compensation (DWC) administrative director to assess penalties for UR violations.

The first routine investigation conducted by DWC pursuant to these regulations will take place four calendar months after the effective date. The regulations provide for a routine investigation to be initiated at each claims adjusting location at least once every five years, and at each utilization review organization at least once every three years. Target investigations may be conducted based on information indicating the possible existence of a violation of UR laws or regulations.

Penalties will be assessed as specified in the UR enforcement regulations and all penalties collected will be deposited into the Workers' Compensation Administrative Revolving Fund.

The final approved regulations were filed with the secretary of state on Jun. 7, 2007 and were immediately effective. The approved regulations, as filed with the secretary of state, can be found on the DWC Web site at http://www.dir.ca.gov/dwc/DWCPropRegs/UREnforcementRegulations/UR_EnforcementRegulations.htm.

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