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Chapter 4.5. Division of Workers' Compensation
Subchapter 1. Administrative Director--Administrative Rules
Article 3.6. Independent Medical Review

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§9768.11. In-Person Examination or Record Review IMR Procedure

(a) The MPN Contact shall send all relevant medical records to the IMR. The MPN Contact shall also send a copy of the documents to the covered employee. The employee may furnish any relevant medical records or additional materials to the Independent Medical Reviewer, with a copy to the MPN Contact. If an in-person examination is requested and if a special form of transportation is required because of the employee's medical condition, it is the obligation of the MPN Contact to arrange for it. The MPN Contact shall furnish transportation and arrange for an interpreter, if necessary, in advance of the in-person examination. All reasonable expenses of transportation shall be incurred by the insurer or employer pursuant to Labor Code section 4600. Except for the in-person examination itself, the Independent Medical Reviewer shall have no ex parte contact with any party. Except for matters dealing with scheduling appointments, scheduling medical tests and obtaining medical records, all communications between the Independent Medical Reviewer and any party shall be in writing, with copies served on all parties.

(b) If the IMR requires further tests, the IMR shall notify the MPN Contact within one working day of the appointment. All tests shall be consistent with the medical treatment utilization schedule adopted pursuant to Labor Code section 5307.27 or, prior to the adoption of this schedule, the ACOEM guidelines, and for all injuries not covered by the medical treatment utilization schedule or the ACOEM guidelines, in accordance with other evidence based medical treatment guidelines generally recognized by the national medical community and that are scientifically based.

(c) The IMR may order any diagnostic tests necessary to make his or her determination regarding medical treatment or diagnostic services for the injury or illness but shall not request the employee to submit to an unnecessary exam or procedure. If a test duplicates a test already given, the IMR shall provide justification for the duplicative test in his or her report.

(d) If the employee fails to attend an examination with the IMR and fails to reschedule the appointment within five business days of the missed appointment, the IMR shall perform a review of the record and make a determination based on those records.

(e) The IMR shall serve the report on the Administrative Director, the MPN Contact, the employee and the employee's attorney, if any, within 20 days after the in-person examination or completion of the record review.

(f) If the disputed health care service has not been provided and the IMR certifies in writing that an imminent and serious threat to the health of the injured employee exists, including, but not limited to, the potential loss of life, limb, or bodily function, or the immediate and serious deterioration of the injured employee, the report shall be expedited and rendered within three business days of the in-person examination by the IMR.

(g) Subject to approval by the Administrative Director, reviews not covered under subdivision (f) may be extended for up to three business days in extraordinary circumstances or for good cause.

(h) Extensions for good cause shall be granted for:

(1) Medical emergencies of the IMR or the IMR's family;

(2) Death in the IMR's family; or

(3) Natural disasters or other community catastrophes that interrupt the operation of the IMR's office operations.

(i) Utilizing the medical treatment utilization schedule established pursuant to Labor Code section 5307.27 or, prior to the adoption of this schedule, the ACOEM guidelines, and taking into account any reports and information provided, the IMR shall determine whether the disputed health care service is consistent with the recommended standards. For injuries not covered by the medical treatment utilization schedule or by the ACOEM guidelines, the treatment rendered shall be in accordance with other evidence-based medical treatment guidelines which are generally recognized by the national medical community and scientifically based.

(j) The IMR shall not treat or offer to provide medical treatment for that injury or illness for which he or she has done an Independent Medical Review evaluation for the employee unless a medical emergency arises during the in-person examination.

(k) Neither the employee nor the employer nor the insurer shall have any liability for payment for the Independent Medical Review which was not completed within the required timeframes unless the employee and the employer each waive the right to a new Independent Medical Review and elect to accept the original evaluation.

Note: Authority cited: Sections 133 and 4616, Labor Code. Reference: Sections 4616.4 and 5307.27, Labor Code.

HISTORY

1. New 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 subsections (a), (e), (j) and (k), transmitted to OAL 4-29-2005 and filed 6-10-2005 (Register 2005, No. 23).

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