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(a) The HCO must include a timely and accurate method to report to the administrative
director the following information, in a standardized format to be prescribed
by the administrative director:
(1) Cost of services under the plan, specific to particular industries and occupations,
diagnoses, and procedures.
(2) Aggregated information on the number of HCO enrollees and their age, sex,
geographical distribution, occupation, and SIC, by federal employer identification
number.
(b) The HCO shall provide the following information on each injured enrollee.
i. For HCO enrollee claims opened in the calendar year:
(1) Patient's Employer's Federal Identification Number and SIC code.
(2) Injured enrollee name, date of birth, gender, social security number, and
occupation.
(3) Date of injury.
(4) Diagnosis (ICD-9).
ii. For HCO enrollee claims closed during a calendar year, the following information
linked with enrollee name, date of birth, and social security number:
(5) Medical Treatment, including dates of surgery and hospitalization.
(6) Date injured HCO enrollee released to return to work by the primary treating
physician.
(7) Date injured HCO enrollee actually returned to work (not “released
to work”).
(8) HCO enrollee's job status at time of return to work (full or modified duty,
or job different from pre-injury job), and employee's job status, including
no longer employed, at time of close of claim.
(9) Permanent Disability rating.
(10) Whether injured HCO enrollee was represented by an attorney at any time
through the claims process.
(c) Effective March 1, 2000, data elements required pursuant to paragraph (b)
may instead be provided to the administrative director directly by the claims
administrator in the format specified in Article 1.1 (commencing with section
9700), provided that:
(1) The claims administrator provides the data for all injured HCO enrollees
for whom it contracts for medical care; and
(2) The HCO provides to the administrative director all information required
by this section which is not provided by the claims administrator.
Information on claims opened and closed in the previous calendar year shall
be made available by the HCO to the administrative director, in a form and manner
to be prescribed by the administrative director, annually, on March 1, commencing
with March 1, 1995.
NOTE: Authority cited: Sections 133, 4600.5, 4603.5 and 5307.3, Labor Code. Reference: Sections 4600 and 4600.5, Labor Code.
HISTORY
1. New 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).
2. New subsections (c)-(c)(2) filed 10-7-99; operative 3-1-2000 (Register 99, No. 41).
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