Chapter 4.5. Division of Workers' Compensation
Subchapter 1.5. Injuries on or After January 1, 1990
Article 1. Audit, General Definitions

§10100.1. Definitions--On or After January 1, 1994.

The following definitions apply in Articles 1 through 7 of this Subchapter for injuries occurring on or after January 1, 1994.
(a) Adjusting Location. The office where claims are administered.

(b) Administrative Director. The Administrative Director of the Division of Workers' Compensation or the Director's duly authorized representative, designee, or delegee.

(c) Audit. An audit performed under Labor Code Sections 129 and 129.5.

(d) Audit Subject. A single adjusting location of a claims administrator which has been selected for audit. If a claims administrator has more than one adjusting location, other locations may be selected as separate audit subjects. In its discretion, the Audit Unit may combine more than one adjusting location of a claims administrator as a single non-random audit subject.

(e) Audit Unit. The organizational unit within the Division of Workers' Compensation which audits insurers, self-insured employers and third-party administrators pursuant to Labor Code Sections 129 and 129.5.

(f) Claim. A request for compensation for an injury arising out of and in the course of employment, whether disputed or not, or notice or knowledge that such an injury has occurred or is alleged to have occurred.

(g) Claim File. A record in paper or electronic form, or a combination, containing all of the information specified in Section 10101.1 of these Regulations and all documents or entries related to the provision or denial of benefits.

(h) Claim Log. A handwritten or printed ledger maintained by the claims administrator listing each work-injury claim as specified in Section 10103.1 of these Regulations.

(i) Claims Administrator or Administrator. A self-administered workers' compensation insurer, a self-administered self-insured employer, a self-administered legally uninsured employer, a self-administered joint powers authority, or a third-party claims administrator for an insurer, a self-insured employer, a legally-uninsured employer or a joint powers authority.

(j) Closed Claim. A work-injury claim in which future payment of compensation cannot be reasonably expected to be due.

(k) Compensation. Every benefit or payment, including vocational rehabilitation, medical, and medical-legal expenses, conferred by Divisions 1 and 4 of the Labor Code on an injured employee or the employee's dependents.

( l ) Date of Knowledge of Injury and Disability. The date the employer had knowledge or reasonably can be expected to have had knowledge of (1) a worker's injury or claim for injury, and (2) the worker's inability or claimed inability to work because of the injury.

(m) Denied Claim. A claim for which all liability has been denied at any time, even if the claim was accepted before or after the denial. A claim which otherwise meets this definition is a denied claim even if medical-legal expenses were paid.

(n) Employee. An employee, or in the case of the employee's death, his or her dependent, as each is defined in Division 4 of the Labor Code, or the employee's or dependent's agent.

(o) First Payment of Temporary Disability Indemnity. (1) The first payment of temporary disability indemnity made to an injured worker for a work injury; or (2) the first resumed payment of temporary disability indemnity following any period of one or more days for which no temporary disability indemnity was payable for that work injury; or (3) the first resumed payment of temporary disability indemnity following issuance of a lawful notice that temporary disability benefits were ending.

(p) Indemnity Claim. A work-injury claim which has resulted or may result in entitlement to any of the following benefits: temporary disability indemnity or salary continuation in lieu of temporary disability indemnity, permanent disability indemnity, death benefits, or vocational rehabilitation.

(q) Insurer. Any company, group, or entity in, or which has been in, the business of transacting workers' compensation insurance for employers subject to the workers' compensation laws of this state. The term insurer includes the State Compensation Insurance Fund.

(r) Investigation. The process of examining and evaluating a claim to determine the nature and extent of all legally required benefits, if any, which are due under the claim. Investigation may include formal or informal methods of gathering information relevant to evaluating the claim such as: obtaining employment records; obtaining earnings records; informal or formal interviews of the employee, employer, or witnesses; deposition of parties or witnesses; obtaining expert opinion where an issue requires an expert opinion for its resolution, such as obtaining a medical-legal evaluation.

(s) Joint Powers Authority. Any county, city, city and county, municipal corporation, public district, public agency, or political subdivision of the state, but not the state itself, included in a pooling arrangement under a joint exercise of powers agreement for the purpose of securing a certificate of consent to self-insure workers' compensation claims under Labor Code Section 3700(c).

(t) Medical-Only Claim. A work-injury claim in which no indemnity benefits are payable.

(u) Non-Random. Any method of selecting an audit subject which is specific to that audit subject, based on any or all of the factors provided in Labor Code Section 129(b).

(v) Notice of Compensation Due. The Notice of Assessment issued pursuant to Labor Code Section 129(c).

(w) Open Claim. A work-injury claim in which future payment of compensation may be due or for which reserves for the future payment of compensation are maintained.

(x) Payment Schedule. Either:

(1) The two-week cycle of indemnity payments due on the day designated with the first payment as required by Labor Code Section 4650(c) or 4702(b), including any lawfully changed payment schedule; or

(2) The two-week cycle of payments of vocational rehabilitation maintenance allowance (VRMA) required by Title 8, California Code of Regulations, Division 1, Chapter 4.5, Subchapter 1.5, Article 7, Section 10125.1.

(y) Random. Any method of selecting an audit subject which is not based on factors specific to that audit subject, but instead which chooses subjects from a broad cross-section of possible subjects. Random selection methods may stratify by general groups and need not be statistically precise.

(z) Record of Payment. An accurate written or electronic record of all compensation payments in a claim file, including but not limited to:

(1) The check number, date the check was issued, name of the payee, amount, and for indemnity payments the time period(s) covered by the payment;

(2) All dates for which salary continuation as defined by Labor Code Section 4650(g) was provided instead of direct indemnity payments; the dates for which salary continuation was authorized; and documentation when applicable that sick leave or other leave credits were restored for any periods for which salary continuation was payable;

(3) A copy of each bill received which included a medical progress or work status report; and either a copy of each other bill received or documentation of the contents of that bill showing the date and description of the service provided, provider's name, amount billed, date the claims administrator received the bill, and date and amount paid.

(aa) Self-insured Employer. An employer, either as an individual employer or as a group of employers, that has been issued a certificate of consent to self-insure as provided by Labor Code Section 3700(b) or (c), including a joint powers authority or the State of California as a legally uninsured employer.

(bb) Third-Party Administrator. An agent under contract to administer the workers' compensation claims of an insurer, self-insured employer, or joint powers authority.

(cc) VRMA. Vocational rehabilitation maintenance allowance.

   Note: Authority cited: Sections 59, 133, 129.5, 138.4, 5307.3, Labor Code. Reference: Sections 7, 124(a), 129(a), (b), (c), 129.5(a), (b), 3700, 3702.1, 4636, 4650(c), 5307.1, 5402, Labor Code.

 HISTORY 

   

1. New section filed 1-28-94; operative 1-28-94.  Submitted to OAL for printing only pursuant to Government Code section 11351 (Register 94, No. 4).

2. Amendment of subsection (i) filed 2-14-96; operative 2-14-96. Submitted to OAL for printing only pursuant to Government Code section 11351 (Register 96, No. 7).

3. Editorial correction of subsection (d) (Register 2000, No. 45).