Division 1. Department of Industrial Relations
Chapter 1. Division of Workers' Compensation -- Qualified Medical Evaluator Regulations
Article 10.5. QME Process Forms

§108 .The Qualified Medical Evaluator Panel Selection Instruction Form.

STATE OF CALIFORNIA

DEPARTMENT OF INDUSTRAIL RELATIONS

DIVISION OF WORKERS' COMPENSATION-MEDICAL UNIT

P.O. Box 71010

Oakland, CA 94612

[phone] or [phone]

TO: THE INJURED WORKER

The list of Qualified Medical Evaluators (QMEs) enclosed with this letter is being sent to you because either you or your claims administrator requested a QME panel (list of QMEs). If you have an attorney, contact your attorney. If you do not have an attorney, please take the following steps:

1) Select a QME physician from the list within ten (10) days of the date the list was issued (shown at the top of the panel list).

Your claims administrator should not select the QME or try to influence your decision. You may ask your treating physician for assistance, they cannot act as the QME. You have the right to consult with an Information and Assistance Officer at DWC Information and Assistance Unit https://www.dir.ca.gov/dwc/landA.html#landAoffices or 1-800-736-6401.

2) Call the QME's office, listed on the panel form, within ten (10) days of the date the QME list was issued by the Medical Unit and make an appointment for an examination.

Tell the office staff for the QME that you are calling for a “QME exam”. If you will need an interpreter, tell the QME's office. The staff will ask you for information that you will find at the top of the QME panel list. The examination can occur by agreement at an office location listed with the medical director or by a remote health evaluation in accordance with regulation section 46.3. If the QME you call is unable to schedule an appointment within ninety (90) days of the date of your call, the QME's office may not suggest another physician in that office to do the QME evaluation. You may:

a) agree to wait as long as the QME you selected is able to schedule your appointment within one-hundred twenty (120) days of the date of your first call for an appointment; or

b) select a different QME on the panel list.

If you decide to ask for a replacement QME from the Medical Unit, tell the claims administrator to avoid having duplicate requests for replacement QME's. To obtain a replacement panel you will need to complete Replacement Panel Request Form 31.5 and mail your request to the Medical Unit with a copy to your claims examiner. This Form can be found on the DWC website at: https://www.dir.ca.gov/dwc/FORMS/QMEForms/QMEForm31_5.pdf. If you need assistance requesting a replacement panel contact an Information and Assistance Officer.

3) If the Medical Unit returns the panel request form to ask for additional information, the time limits for selecting a QME and scheduling the appointment are tolled (delayed). (See, 8 Cal. Code Regs. § 30(h)).

4) Call the Claim Administrator in your case within ten (10) days of the date the QME list was issued by the Medical Unit. Tell the claims administrator the time, date and location of your appointment with the QME.

5) Review all of the medical records and other non-medical records sent by the claims administrator.

Once you have scheduled an appointment with a QME, the claims administrator must send you, at least twenty (20) days before the information is sent to the QME, copies of all medical and non-medical records (videos, photos, interview transcripts, non-medical paperwork) the administrator plans to send to the QME in your case. If you believe some of the non-medical records or materials should not go to the QME, you must notify the claims administrator within ten (10) days that you object and the reasons for your objection.

You also must send to the claims administrator copies of any medical records and other materials you plan to send to the QME at least 20 days before sending it to the QME, and the claims administrator also may object within 10 days to non-medical records by notifying you in writing. Once you or the claims administrator object, the non-medical records objected to should not be sent to the QME until or unless a Workers' Compensation Judge makes an order. You may call the Information and Assistance Officer for information about this process.

6) Communication with the QME before and after your examination must be in writing.

You may send the QME a letter listing the disputed medical issues you believe the evaluator should address in your claim. If you wish, or the claims administrator wishes, to send a letter to the QME about your case before the examination, it must be written and mailed to the QME and the other party at least twenty (20) days before the exam. After the examination, a copy of any letter to the QME must be mailed to the other party the same day it is sent to the QME. If the QME contacts you, you may answer questions.

7) Your employer will pay for the QME exam, an interpreter if required and reasonable transportation including lodging costs if necessary.

There is no charge to you and no co-payment for a QME exam or interpreter fees. The claims administrator will either send you a check in advance or reimburse you for any reasonable transportation costs. If you must miss work to attend the QME exam, you are entitled to temporary disability benefits for any lost wages that day.

8) If you are not represented by an attorney and do not receive a QME panel list that was assigned within 20 business days after we receive the request for a panel, you may choose any QME (with the proper specialty) to do your examination from the QMEdatabase which is available at https://www.dir.ca.gov/databases/dwc/qmestartnew.asp. The panel is assigned and mailed on the same date, which is shown as the “Date Issued” at the top of the QME panel list, QME Form 107 (See, 8 Cal. Code Regs. § 107).

9) A QME may not offer to treat you or solicit to become your treating physician. However, you have the right to request the QME to become your treating physician. If you are covered by a Medical Provider Network (“MPN”), you may choose to treat with the QME if the QME is an MPN physician for your employer. If the QME is not in the MPN, you will need authorization from your claims administrator to treat with the QME. In addition, you may need to have another QME examination by a different QME. You may wish to consult with an Information and Assistance Officer before you make this decision.

10) If the QME does not send you a copy of the report within 30 calendar days after your examination, or within the extension of time approved by the Medical Director of DWC, contact the Medical Unit at 1-800-794-6900.

11) If your claim eventually goes to court, the Workers' Compensation Administrative Law Judge will consider the evaluation prepared by the QME you select to decide your claim.

12) For more information call the nearest Information and Assistance Office to request pamphlets, fact sheets and guides for injured workers, including “Guide Book for Injured Workers”. These publications are free. To get copies, call the nearest Information and Assistance Officer at the number listed in your local phone book, or look up the number by computer on the internet at DWC Information and Assistance Unit (ca.gov) https://www.dir.ca.gov/dwc/landA.html#landAoffices.

To download a free copy of the publications regarding Fact Sheets and Guides for Injured Workers from the internet, go to: http://www.dir.ca.gov/dwc/iwguides.html, or the DWC Home Page at http://www.dir.ca.gov/DWC/dwc_home_page.htm or Commission on Health and Safety and Workers' Compensation Educational Materials at http://www.dir.ca.gov/chswc/EduMaterials.html.

Note: Authority cited: Sections 53, 133, 139.2 and 5307.3, Labor Code. Reference: Sections 139.2, 4060, 4061, 4062, 4062.1, 4062.2, 4064 and 4067, Labor Code.

History

1. New section filed 4-14-2000; operative 5-14-2000 (Register 2000, No. 15). For prior history see Register 94, No. 31.

2. Amendment of section heading, repealer and new section and new Note filed 1-13-2009; operative 2-17-2009 (Register 2009, No. 3).

3. Repealer and new section filed 2-2-2023; operative 2-2-2023 (Register 2023, No. 5).