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Chapter 4.5. Division of Workers' Compensation
Subchapter 2. Workers' Compensation Appeals Board--Rules and Practice Procedure
Article 5. Pleadings and Forms

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§10451.2. Determination of Medical Treatment Disputes.

(a) The following procedures shall be utilized for the determination of all disputes over medical treatment and related goods and services.

(b) For purposes of this section, “medical treatment” means any goods or services provided in accordance with Labor Code section 4600 et seq., including but not limited to services rendered by an interpreter at a medical treatment appointment.

(c) Medical Treatment Disputes Not Subject to Independent Medical Review and/or Independent Bill Review

(1) Where applicable, independent medical review (IMR) applies solely to disputes over the necessity of medical treatment where a defendant has conducted a timely and otherwise procedurally proper utilization review (UR). Where applicable, independent bill review (IBR) applies solely to disputes directly related to the amount payable to a medical treatment provider under an official fee schedule in effect on the date the medical treatment was provided. All other medical treatment disputes are non-IMR/IBR disputes. Such non-IMR/IBR disputes shall include, but are not limited to:

(A) any threshold issue that would entirely defeat a medical treatment claim (e.g., injury, injury to the body part for which treatment is disputed, employment, statute of limitations, insurance coverage, personal or subject matter jurisdiction);

(B) a dispute over a UR determination if the employee's date of injury is prior to January 1, 2013 and the decision is communicated to the requesting physician prior to July 1, 2013;

(C) a dispute over whether UR was timely undertaken or was otherwise procedurally deficient; however, if the employee prevails in this assertion, the employee or provider still has the burden of showing entitlement to the recommended treatment;

(D) an assertion by the medical treatment provider that the defendant has waived any objection to the amount of the bill because the defendant allegedly breached a duty prescribed by Labor Code sections 4603.2 or 4603.3 or by the related Rules of the Administrative Director;

(E) an assertion by the defendant that the medical treatment provider has waived any claim to further payment because the provider allegedly breached a duty prescribed by Labor Code section 4603.2 or by the related Rules of the Administrative Director;

(F) a dispute over whether the employee was entitled to select a treating physician not within the defendant's medical provider network (MPN);

(G) an assertion by the defendant that an interpreter who rendered services at a medical treatment appointment did not meet the criteria established by Labor Code sections 4600(f) and (g) and 5811(b)(2) and the Rules of the Administrative Director, as applicable; and

(H) an assertion by the defendant that an interpreter was not reasonably required at a medical treatment appointment because the employee proficiently speaks and understands the English language.

(2) Medical treatment disputes not subject to IMR and/or IBR shall be resolved as follows:

(A) if the dispute is between an employee and a defendant, the procedures for claims for ordinary benefits shall be utilized, including the procedures for an expedited hearing, if applicable; and

(B) if the dispute is between a medical treatment provider and a defendant, the procedures applicable to lien claims shall be utilized, including the filing of a lien claim under Labor Code section 4903(b) and the payment of a lien filing fee or lien activation fee, if applicable.

(3) If a non-IMR/IBR dispute is resolved in favor of the employee or the medical treatment provider, then any applicable IMR and/or IBR procedures established by the Labor Code and the Rules of the Administrative Director shall be followed. In addition:

(A) Any appeal of an IMR determination of the Administrative Director shall comply with the procedures of section 10957.1; and

(B) Any appeal of an IBR determination of the Administrative Director shall comply with the procedures of section 10957.

Note: Authority: Sections 133, 4603.2(f), 4604, 5304, 5307, 5309 and 5708, Labor Code. Reference: Sections 4061, 4061.5, 4062, 4600, 4603.2, 4603.3, 4603.6, 4604.5, 4610, 4610.5, 4610.6, 4616.3, 4616.4 and 4903(b), Labor Code.

HISTORY

1. New section filed 9-23-2013; operative 10-23-2013. Submitted as a file and print by the Workers' Compensation Appeals Board pursuant to Government Code section 11351 (Register 2013, No. 39).

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