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Chapter 4.5. Division of Workers' Compensation
Subchapter 1. Administrative Director--Administrative Rules
Article 5.5.0. Rules For Medical Treatment Billing and Payment on or After October 15, 2011
9792.5.4. Second Review and Independent Bill Review - Definitions.
This section is applicable to medical treatment services and goods rendered under Labor Code section 4600, or medical-legal expenses incurred under Labor Code section 4620, on or after January 1, 2013.
(a) "Amount of payment" means the amount of money paid by the claims administrator for either:
(1) Medical treatment services or goods rendered by a provider or goods supplied in accordance with Labor Code section 4600 that were authorized by Labor Code section 4610, and for which there exists an applicable fee schedule adopted by the Administrative Director for those categories of goods and services, including but not limited to those found at sections 9789.10 to 9789.111, or for which a contract for reimbursement rates exists under Labor Code section 5307.11.
(2) Medical-legal expenses, as defined by Labor Code section 4620, where the payment is determined in accordance with sections 9793-9795 and 9795.1-9795.4.
(b) "Billing Code" means those codes adopted by the Administrative Director for use in the Official Medical Fee Schedule, located at sections 9789.10 to 9789.111, or in the Medical-Legal Fee Schedule, located at sections 9795(c) and 9795(d).
(c) "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 administrator for a self-insured employer, insurer, legally uninsured employer, or joint powers authority.
(d) "Contested liability" means the existence of a good-faith issue which, if resolved against the injured worker, would defeat the right to any workers' compensation benefits or the existence of a good-faith issue that would defeat a provider's right to receive compensation for medical treatment services provided in accordance with Labor Code section 4600 or for medical-legal expenses defined in Labor Code section 4620.
(e) "Consolidation" means combining two or more requests for independent bill review together for the purpose of having the payment reductions contested in each request resolved in a single determination.
(f) "Explanation of review" means the document described in Labor Code section 4603.3 provided by a claims administrator to a provider upon the payment, adjustment, or denial of a complete or incomplete itemization of medical services.
(g) "Independent bill review organization" or "IBRO" means the organization or the organizations designated by the Administrative Director pursuant to Labor Code section 139.5 to perform independent bill review under Labor Code section 4603.6.
(h) "Independent bill reviewer" means an individual retained by the IBRO and subject to the provisions of Labor Code section 139.5 to review a request for independent bill review, with supporting documentation, and issue a determination under the Article.
(i) "Provider" means a provider of medical treatment services or goods, including a health care facility as defined in Section One of the California Division of Workers' Compensation Medical Billing and Payment Guide as incorporated by reference in section 9792.5.1, whose billing processes are governed by Labor Code section 4603.2 or 4603.4, or a provider of medical-legal services whose billing processes are governed by Labor Code sections 4620 and 4622, that has requested a second bill review and, if applicable, independent bill review to resolve a dispute over the amount of payment for services according to either a fee schedule established by the Administrative Director or a contract for reimbursement rates under Labor Code section 5307.11. A provider may utilize the services of a billing agent, a person or entity that has contracted with the provider to process bills under this article for services or goods rendered by the provider, to request a second bill review or independent bill review.
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.
2. New section refiled 7-1-2013 as an emergency; operative 7-1-2013 (Register 2013, No. 27). A Certificate of Compliance must be transmitted to OAL by 9-30-2013 or emergency language will be repealed by operation of law on the following day.
3. New section refiled 9-30-2013 as an emergency; operative 10-1-2013 (Register 2013, No. 40). A Certificate of Compliance must be transmitted to OAL by 12-30-2013 or emergency language will be repealed by operation of law on the following day.
4. Certificate of Compliance as to 9-30-2013 order, including amendment of first paragraph and subsections (a)(1)-(2), (d) and (i), transmitted to OAL 12-30-2013 and filed 2-12-2014; amendments effective 2-12-2014 pursuant to Government Code section 11343.4(b)(3) (Register 2014, No. 7).