Chapter 1. Industrial Medical Council
Article 3. Assignment of Qualified Medical Evaluators, Evaluation Procedure

§38. Medical Evaluation Time Frames; Extensions for QMEs and AMEs.

(a) For a late report, regardless of the date of injury, if any of the following occur, the unrepresented injured worker shall be entitled to a new three-member QME panel:

(1) the QME fails to request an extension

(2) the timeframe extension is denied

(3) the QME does not issue the report by the approved extension date.

The injured worker shall have 15 days from the date of notice by the Medical Director to complete, sign and return IMC Forms 113, 115, 116 as applicable. If the employee requests a new panel, the claims administrator or, if none, the employer shall have no liability for the late report. If the employee is represented by an attorney and the extension is denied to an AME, either party may withdraw from the AME and no party shall be liable for payment to the AME.

(b) For injuries between January 1, 1991 and December 31, 1993, the time frame for comprehensive medical-legal evaluations to be prepared and submitted shall not exceed 45 days after the QME or AME has seen the employee or otherwise commenced the comprehensive medical-legal evaluation procedure. Extension of the 45-day limit shall be approved when the evaluator has good cause or has not received test results or consulting physicians' evaluations necessary to address all disputed medical issues in time to meet the initial 45-day deadline. If the evaluation is not completed on the scheduled date through no fault of the QME, the QME may request an extension not to exceed an additional 45 days from the Medical Director. The evaluator shall notify the employee and the claims administrator or, if none, the employer not later than 5 days before the initial 45-day period expires that an extension is warranted. A copy of the notice shall be sent to the Medical Director. The notice shall be on the form in Section 112. If the extension of time requires additional days greater than 90 days from the date of the evaluation for the submission of the report, approval or denial shall be granted within 10 days by the Medical Director.

(c) For injuries on or after January 1, 1994, the time frame for comprehensive medical-legal evaluations to be prepared and submitted shall not exceed 30 days after the QME or AME has seen the employee or otherwise commenced the comprehensive medical-legal evaluation procedure. Extension of the 30-day limit shall be approved when the evaluator has good cause or not received test results or consulting physicians' evaluations necessary to address all disputed medical issues in time to meet the initial 30-day deadline. If the evaluation is not completed on the scheduled date through no fault of the QME, the QME may request an extension not to exceed an additional 30 days from the Medical Director. The evaluator shall notify the employee and the claims administrator, or if none, the employer not later than 5 days before the initial 30-day period expires that an extension is warranted. A copy of the notice shall be sent to the Medical Director. The notice shall be on the form in Section 112. If the extension of time requires additional days greater than 60 days from the date of the evaluation for the submission of the report, approval or denial shall be granted within 10 days by the Medical Director.

(d) Extensions for good cause shall not exceed an additional 15 days from the date the report is to be served. Good cause means:

(1) medical emergencies of the evaluator or the evaluator's family;

(2) death in the evaluator's family;

(3) natural disasters or other community catastrophies that interrupt the operation of the evaluator's office operations;

(e) Extensions shall not be granted because relevant medical information/records (including Disability Evaluation Form 101 8 CCR §10161(b)) have not been received. The evaluator shall complete the report based on the information available and state that the opinions and/or conclusions may or may not change after review of the relevant medical information/records.

(f) The time frame for supplemental reports in unrepresented cases shall be no more than 60 days from the date of a written or electronically transmitted request to the physician by a party. The request for a supplemental report shall be accompanied by any new medical records unavailable to the QME at the time of the original QME evaluation in compliance with section 10160(f) of this Title. An extension of the 60 days may be agreed to by the parties.

(g) Evaluators giving notice of time extensions will be monitored and advised by the Medical Director when such notices appear unreasonable or excessive. Failure to comply with this section may constitute grounds for denial of the QME's request for reappointment pursuant to Section 51.

NOTE: Authority cited: Sections 139.2, 4061 and 4062, Labor Code. Reference: Sections 139.2, 4061, 4062 and 4067.5, Labor Code.

HISTORY

1. New section filed 8-1-94; operative 8-31-94 (Register 94, No. 31).

2. Amendment of subsections (a) and (b), new subsections (c)-(c)(3) and subsection relettering, and amendment of newly designated subsection (d) filed 8-23-96; operative 9-22-96 (Register 96, No. 34).

3. Amendment filed 4-14-2000; operative 5-14-2000 (Register 2000, No. 15).