Chapter 4.5. Division of Workers' Compensation
Subchapter 2. Workers' Compensation Appeals Board--Rules and Practice Procedure
Article 16. Liens

§ 10863. Verification of Compliance with Labor Code Section 4903.6 on Filing of Lien Claim or Application by Lien Claimant.

(a) Any section 4903(b) lien, any lien for medical-legal costs and any application related to any such lien shall have attached to it a verification under penalty of perjury which shall contain a statement specifying in detail the facts establishing that both of the following have occurred:

(1) Sixty days have elapsed since after the date of acceptance or rejection of liability for the claim, or the time provided for investigation of liability pursuant to Labor Code section 5402(b) has elapsed, whichever is earlier; and

(2) Either of the following:

(A) The time provided for payment of medical treatment bills pursuant to Labor Code section 4603.2 has expired and, if the employer objected to the amount of the bill, the reasonable fee has been determined pursuant to Labor Code section 4603.6, and, if authorization for the medical treatment has been disputed pursuant to Labor Code section 4610, the medical necessity of the medical treatment has been determined pursuant to Labor Code sections 4610.5 and 4610.6; or

(B) The time provided for payment of medical-legal expenses pursuant to Labor Code section 4622 has expired and, if the employer objected to the amount of the bill, the reasonable fee has been determined pursuant to Labor Code section 4603.6.

(b) The verification under penalty of perjury shall also contain a statement declaring that the lien is not being filed solely because of a dispute subject to the independent medical review and/or the independent bill review process.

(c) In addition, if an Application for Adjudication of Claim is also being filed, the verification under penalty of perjury shall contain:

(1) A statement specifying in detail the facts establishing that venue in the district office being designated is proper pursuant to Labor Code section 5501.5(a)(1) or Labor Code section 5501.5(a)(2); and

(2) A statement specifying in detail the facts establishing that the filing lien claimant has made a diligent search and has determined that no adjudication case number exists for the same injured worker and same date of injury at any district office. A diligent search shall include contacting the injured worker, contacting the employer or carrier, or inquiring at the district office with appropriate venue pursuant to Labor Code section 5501.5(a)(1) or Labor Code section 5501.5(a)(2).

(d) The verification shall be in the following form:

I declare under penalty of perjury under the laws of the State of California:

(1) That the time periods set forth in rule 10863(a) have elapsed;

(2) That the section 4903(b) lien, the lien for medical-legal costs, or the application is not being filed solely because of a dispute subject to the independent medical review and/or independent bill review process; and

(3) That, if an Application for Adjudication of Claim is being filed, that venue is proper as set forth in rule 10863(b) and that I have made a diligent search and have determined that no adjudication case number exists for the same injured worker and the same date of injury. In determining that no adjudication case number exists for the same injured worker and the same date of injury, I have made a diligent search consisting of the following efforts (specify):

______________________________________________________________

______________________________________________________________

______________________________________________________________

_____________________________________________________s/s

____________________________________________________________on

______________________________________________________________

Failure to attach the verification or an incorrect verification may be a basis for sanctions.

(e) If the Appeals Board approves an e-form or optical character recognition (OCR) form for this declaration, lien claimants shall file the declaration using the adopted form.

Note: Authority cited: Sections 133, 5307, 5309 and 5708, Labor Code. Reference: Sections 4603.2, 4603.6, 4610.5, 4610.6, 4622, 4903, 4903.6, 5402 and 5501.5, Labor Code.

HISTORY

1. Renumbering of former section 10770.5 to section 10863, including amendment of section heading, section and Note, filed 12-17-2019; operative 1-1-2020. Submitted to OAL for printing only pursuant to Government Code section 11351 (Register 2019, No. 51).