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Chapter 4.5. Division of Workers' Compensation
Subchapter 1. Administrative Director--Administrative Rules
Article 5.5. Application of the Official Medical Fee Schedule (Treatment)

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§9792.5. Payment for Medical Treatment.

This section is applicable to medical treatment rendered before October 15, 2011.

(a) As used in this section:

(1) “Claims Administrator” has the same meaning specified in Section 9785(a)(3).

(2) “Medical treatment” means the treatment to which an employee is entitled under Labor Code Section 4600.

(3) “Physician” has the same meaning specified in Labor Code Section 3209.3.

(4) “Required report” means a report which must be submitted pursuant to Section 9785.

(5) “Treating physician” means the “primary treating physician” as that term is defined by Section 9785(a)(1).

(b) Any properly documented bill for medical treatment within the planned course, scope and duration of treatment reported under Section 9785 which is provided or authorized by the treating physician shall be paid by the claims administrator within forty five working days from receipt of each separate itemized bill and any required reports, or within sixty working days if the employer is a governmental entity, unless the bill is contested, as specified in subdivisions (d), and (e), within thirty working days of receipt of the bill. Any amount not contested within the thirty working days or not paid within the forty five working day period, or within sixty working days if the employer is a governmental entity, shall be increased 15%, and shall carry interest at the same rate as judgments in civil actions retroactive to the date of receipt of the bill.

For purposes of this Section, treatment which is provided or authorized by the treating physician includes but is not limited to treatment provided by a “secondary physician” as that term is defined by Section 9785(a)(2).

(c) A claims administrator who objects to all or any part of a bill for medical treatment shall notify the physician or other authorized provider of the objection within thirty working days after receipt of the bill and any required report and shall pay any uncontested amount within forty five working days, or within sixty working days if the employer is a governmental entity, after receipt of the bill. If a required report is not received with the bill, the periods to object or pay shall commence on the date of receipt of the bill or report, whichever is received later. If the claims administrator receives a bill and believes that it has not received a required report to support the bill, the claims administrator shall so inform the medical provider within thirty working days of receipt of the bill. An objection will be deemed timely if sent by first class mail and postmarked on or before the thirtieth working day after receipt, or if personally delivered or sent by electronic facsimile on or before the thirtieth working day after receipt. Any notice of objection shall include or be accompanied by all of the following:

(1) An explanation of the basis for the objection to each contested procedure and charge. The original procedure codes used by the physician or authorized provider shall not be altered. If the objection is based on appropriate coding of a procedure, the explanation shall include both the code reported by the provider and the code believed reasonable by the claims administrator.

(2) If additional information is necessary as a prerequisite to payment of the contested bill or portions thereof, a clear description of the information required.

(3) The name, address, and telephone number of the person or office to contact for additional information concerning the objection.

(4) A statement that the treating physician or authorized provider may adjudicate the issue of the contested charges before the Workers' Compensation Appeals Board.

(d) An objection to charges from a hospital, outpatient surgery center, or independent diagnostic facility shall be deemed sufficient if the provider is advised, within the thirty working day period specified in subdivision (d), that a request has been made for an audit of the billing, when the results of the audit are expected, and contains the name, address, and telephone number of the person or office to contact for additional information concerning the audit.

(e) The above provisions are altered for services rendered prior to January 1, 2004, as follows:

(1) Claims administrators shall pay any uncontested amount within sixty days after receipt of the bill, and

(2) Any amount not contested within the thirty working days or not paid within the sixty day period shall be increased 10% and shall carry interest at the same rate as judgments in civil actions retroactive to the date of receipt of the bill.

Note: Authority cited: Sections 133, 4603.5 and 5307.3, Labor Code. Reference: Sections 4603.2 and 5307.1, Labor Code.

HISTORY

1. New section filed 4-13-93; operative 4-13-93. Submitted to OAL for printing only pursuant to Government Code section 11351 (Register 93, No. 16).

2. Amendment of subsections (b), (d), (d)(1), (f) and (g) filed 9-25-95; operative 9-25-95. Submitted to OAL for printing only pursuant to Government Code section 11351 (Register 95, No. 39).

3. Change without regulatory effect amending section and Note filed 6-12-2002 pursuant to section 100, title 1, California Code of Regulations (Register 2002, No. 24).

4. New first paragraph, amendment of subsection (b), repealer of subsection (c), subsection relettering, amendment of newly designated subsection (c) and new subsections (e)-(e)(2) filed 4-18-2011; operative 4-18-2011 pursuant to Government Code section 11343.4 (Register 2011, No. 16).

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