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Chapter 4.5. Division of Workers' Compensation
Subchapter 1. Administrative Director--Administrative Rules
Article 3.6. Certification Standards for Health Care Organizations

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§9768.1. Definitions



(a) As used in this article, the following definitions apply:

(1) “American College of Occupational and Environmental Medicine's Occupational Medicine Practice Guidelines” (“ACOEM”) means the American College of Occupational and Environmental Medicine's Occupational Medicine Practice Guidelines, 2nd Edition (2004), published by OEM Press. The Administrative Director incorporates ACOEM by reference. A copy may be obtained from OEM Press, 8 West Street, Beverly Farms, Massachusetts 01915 (www.oempress.com).

(2) “Appropriate specialty” means a medical specialty in an area or areas appropriate to the condition or treatment under review.

(3) “Independent Medical Reviewer” (“IMR”) means the physician who is randomly selected pursuant to subdivision (b) of Labor Code section 4616.4.

(4) “In-person examination” means an examination of an injured employee by a physician which involves more than a review of records, and may include a physical examination, discussing the employee's medical condition with the employee, taking a history and performing an examination.

(5) “Material familial affiliation” means a relationship in which one of the persons or entities listed in section 9768.2 is the parent, child, grandparent, grandchild, sibling, uncle, aunt, nephew, niece, spouse, or cohabitant of the Independent Medical Reviewer.

(6) “Material financial affiliation” means a financial interest (owns a legal or equitable interest of more than 1% interest in the party, or a fair market value in excess of $2000, or relationship of director, advisor, or active participant) in any person or entity listed in section 9768.2. It also means any gift or income of more than $300 in the preceding year except for income for services as a second opinion physician, third opinion physician, treating physician, Agreed Medical Evaluator, Qualified Medical Evaluator, or Independent Medical Reviewer.

(7) “Material professional affiliation” means any relationship in which the Independent Medical Reviewer shares office space with, or works in the same office of, any person or entity listed in section 9768.2.

(8) “Medical emergency” means a medical condition manifesting itself by acute symptoms of sufficient severity such that the absence of immediate medical attention could reasonably be expected to place the patient's health in serious jeopardy.

(9) “Medical Provider Network Contact” (“MPN Contact”) means the individual(s) designated by the MPN Applicant in the employee notification who is responsible for answering employees' questions about the Medical Provider Network and is responsible for assisting the employee in arranging for an Independent Medical Review.

(10) “Panel” means the contracted providers in a specific specialty.

(11) “Relevant medical records” means all information that was considered in relation to the disputed treatment or diagnostic service, including: (A) a copy of all correspondence from, and received by, any treating physician who provided a treatment or diagnostic service to the injured employee in connection with the injury; (B) a complete and legible copy of all medical records and other information used by the physicians in making a decision regarding the disputed treatment or diagnostic service; (C) the treating physician's report with the disputed treatment or diagnosis; and (D) the second and third opinion physicians' reports.

(12) “Residence” means the covered employee's primary residence.

NOTE

Authority cited: Sections 133 and 4616, Labor Code. Reference: Section 4616.4, Labor Code.

HISTORY

1. New article 3.6 (sections 9768.1-9768.17) and section filed 12-31-2004 as an emergency; operative 1-1-2005 (Register 2004, No. 53). A Certificate of Compliance must be transmitted to OAL by 5-2-2005 or emergency language will be repealed by operation of law on the following day.

2. Certificate of Compliance as to 12-31-2004 order, including amendment of section, transmitted to OAL 4-29-2005 and filed 6-10-2005 (Register 2005, No. 23).

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