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Chapter 4.5. Division of Workers' Compensation
Subchapter 1. Administrative Director--Administrative Rules
Article 5.5.1. Utilization Review Standards
§92.10.7. Independent Medical Review - Implementation of Determination and Appeal.
(a) Upon receiving the final determination of the Administrative Director that a disputed medical treatment is medically necessary, the claims administrator shall, unless an appeal is filed under subdivision (c), promptly implement the decision unless the claims administrator has also disputed liability for any reason besides medical necessity.
(1) In the case of reimbursement for services already rendered, the claims administrator shall reimburse the provider or employee, whichever applies, within twenty (20) days after receipt of the final determination, subject to resolution of any remaining issue of the amount of payment pursuant to Labor Code sections 4603.2 to 4603.6, inclusive.
(2) In the case of services not yet rendered, the claims administrator shall authorize the services within five (5) working days of receipt of the final determination, or sooner if appropriate for the nature of the employee's medical condition, and shall inform the employee and provider of the authorization.
(b) The failure to pay for services already provided or to authorize services not yet rendered within the time prescribed by this section is subject to, in addition to any other fines, penalties, and other remedies available to the Administrative Director, an administrative penalty as set forth in section 9792.12(a) for each day the decision is not implemented.
(c) The parties may appeal a final determination of the Administrative Director by filing a petition with the Workers' Compensation Appeals Board.
(d) If the final determination of the Administrative Director is reversed by the Workers' Compensation Appeals Board, the dispute shall be remanded to the Administrative Director. The Administrative Director shall:
(1) Submit the dispute to independent medical review by a different independent review organization, if available;
(2) If a different independent medical review organization is not available after remand, the Administrative Director shall submit the dispute to the original independent review organization for review by a different reviewer in the organization.
Note: Authority: Sections 133, 4603.5 and 5307.3, Labor Code. Reference: Sections 4062, 4600, 4600.4, 4604.5, 4610 and 4610.5, Labor Code.
1. New section filed 12-31-2012 as an emergency; operative 1-1-2013 pursuant to Government Code section 11346.1(d) (Register 2013, No. 1). A Certificate of Compliance must be transmitted to OAL by 7-1-2013 or emergency language will be repealed by operation of law on the following day.
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