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Chapter 4.5. Division of Workers' Compensation
Subchapter 1. Administrative Director--Administrative Rules
Article 4. Certification Standards for Health Care Organizations

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§9770. Definitions.

(a) "Administrative Director" means the administrative director of the Division of Workers' Compensation.

(b) "Claims Administrator" means a self-administered insurer providing security for the payment of compensation required by Divisions 4 and 4.5 of the Labor Code, a self-administered self-insured employer, or a third-party claims administrator for a self-insured employer, insurer, legally uninsured employer, or joint powers authority.

(c) "Division" means the Division of Workers' Compensation.

(d) "Employer" means an employer as defined in Section 3300 of the Labor Code.

(e) "HCO Enrollee" means a person who is eligible to receive services from an HCO.

(f) "Health care organization" ("HCO") means any entity certified as a health care organization by the administrative director pursuant to Section 4600.5 of the Labor Code and this article.

(g) "International Classification of Diseases--9th Revision (ICD-9) code" means the 4 or 5 digit number which identifies the illness, injury, disease, cause of death, or other morbid state of an enrollee that corresponds to the numeric classifications and descriptions listed in International Classification of Diseases. Clinical Modification. 9th Revision (ICD-9CM) US Department of Health and Human Services, Health Care Financing Administration. Washington DC: Superintendent of Documents, and updated successor revised manuals.

(h) "Material": A factor is "material" with respect to a matter if it is one to which a reasonable person would attach importance in determining the action to be taken upon the matter.

(i) "Participating provider" means a provider who is employed by or under contract with an HCO for purposes of providing occupational medical or health services or services required by this article.

(j) "Patient" means an HCO enrollee who is currently obtaining treatment or services for a work-related injury or illness.

(k) "Primary treating physician" means the treating physician primarily responsible for managing the care of the injured worker in accordance with Section 9785.5.

(l) "Professionally recognized standards of care" means health care practice encompassing the learning, skill and clinical judgment ordinarily possessed and and used by a provider of good standing in similar circumstances.

(m) "Provider" means any professional person, organization, health facility, or other person or institution licensed by the state to deliver or furnish health care services.

(n) "Revocation" means the termination of a health care organization's certification to provide services pursuant to Section 4600.5 of the Labor Code and this article.

(o) "Standard Industrial Classification code" means the 4 digit number which identifies the primary type of economic activity which the employer is engaged in that corresponds to the numeric classifications and descriptions listed in The Standard Industrial Classification Manual 1987, Office of Management and Budget, Washington DC: Superintendent of Documents, US Government Printing Office, 1989, and updated successor revised manuals.

(p) "Suspension" means the health care organization's authority to enter into new, renewed, or amended contracts with claims administrators has been suspended by the administrative director for a specific period of time.

(q) "Utilization review" or "Utilization Management" is the system used to manage, assess, improve, or review patient care and decision-making through case by case assessments of the medical reasonableness or medical necessity of the frequency, duration, level and appropriateness of medical care and services, based upon professionally recognized standards of care. Utilization review may include, but is not limited to, prospective, concurrent, and retrospective review of a request for authorization of medical treatment.

NOTE: Authority cited: Sections 133, 4600.5, 4603.5 and 5307.3, Labor Code. Reference: Sections 3300, 4061.5, 4600.5, 5400, 5401 and 5402, Labor Code.

HISTORY

1. New article 4 and section filed 12-31-93; operative 1-1-94. Submitted to OAL for printing only pursuant to Government Code section 11351 (Register 93, No. 53). For prior history, see Register 84, No. 35.

2. New subsection (h) and subsection relettering filed 2-14-96; operative 2-14-96. Submitted to OAL for printing only pursuant to Government Code section 11351 (Register 96, No. 7).

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