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TITLE 8. INDUSTRIAL RELATIONS
DIVISION 1. DEPARTMENT OF INDUSTRIAL RELATIONS
CHAPTER 1. DIVISION OF WORKERS' COMPENSATION-QUALIFIED MEDICAL EVALUATOR
Article 1. General

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§1. Definitions.

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 or her 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 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 9795 of Title 8 of the California Code of Regulations for medical/legal evaluation procedures and medical testimony.

(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 9793(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 12 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 responsible for issuing summary disability ratings.

(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 9793(f) 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 or her 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 35 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 or her 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 9793( l ) 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.

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.

HISTORY

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).

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