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TITLE 8. INDUSTRIAL RELATIONS
DIVISION 1. DEPARTMENT OF INDUSTRIAL RELATIONS
CHAPTER 1. DIVISION OF WORKERS' COMPENSATION-QUALIFIED MEDICAL EVALUATOR
Article 3. Assignment of Qualified Medical Evaluators, Evaluation Procedure
(a) Unrepresented cases. Whenever an employee is not represented by an attorney and either the employee or the claims administrator requests a QME panel pursuant to Labor Code section 4062.1, the request shall be submitted on the Request for Qualified Medical Evaluator Panel Form (Unrepresented Employee), QME Form 105, in section 105.
(1) For disputes covered by Labor Code section 4060, the requesting party shall attach the claims administrator's notice that the claim was denied or a copy of the claims administrator's request for an examination to determine compensability to the QME Form 105;
(2) For disputes covered by Labor Code section 4061 or 4062, if the requesting party is the claims administrator, the claims administrator shall attach a written objection indicating the identity of the primary treating physician, the date of the primary treating physician's report that is the subject of the objection and a description of the medical determination that requires a comprehensive medical-legal report to resolve to the QME Form 105.
(3) The claims administrator (or if none the employer) shall provide QME Form 105 to the unrepresented employee pursuant to Labor Code sections 4060, 4061, and 4062, by means of personal delivery or by first class or certified mailing.
(4) If the form is incomplete, so that a QME panel selection cannot be made, the request form shall be returned to the requesting party with an explanation of why the QME panel selection could not be made. The Medical Director may delay issuing a QME panel until the Medical Director receives additional information, requested from a party or both parties, needed to resolve the panel request.
(b) Represented cases. Effective October 1, 2015, requests for an initial QME panel in a represented case, for all cases with a date of injury on or after January 1, 2005, shall be submitted electronically utilizing the Division of Workers' Compensation internet site at www.dwc.ca.gov. The Medical Unit will not accept or process panel requests on the QME Form 106 postmarked after September 3, 2015, except as to those cases with dates of injury prior to January 1, 2005 where represented parties agree to obtain a panel of Qualified Medical Evaluators pursuant to the process in Labor Code section 4062.2.
(1) The party requesting a QME panel online shall:
(A) Identify the following elements in the appropriate sections:
1. Panel Request Information Section
i. Date of Injury
ii. Claim Number
iii. Requesting Party
iv. Reason QME Panel is being Requested
v. Dispute type
vi. Name of primary treating physician
vii. Date of report being objected to
viii. Date of objection communication
ix. Specialty of treating physician
x. QME Specialty Requested
xi. Opposing Party's QME Specialty Preferred (if known)
2. Employee Information Section
i. Employee First Name
ii. Employee Middle Name
iii. Employee Last Name
iv. Mailing Address
vi. Zip Code
3. Applicant's Attorney Information Section
i. First Name
ii. Last Name
v. State Zip
vi. Phone Number
vii. Electronic Adjudication Management System (EAMS) Uniform Assigned Names (UAN)
viii. Firm Name
4. Employee and Claims Administrator Information Section
i. Employer Name
ii. Claims Administrator First Name
iii. Claims Administrator Last Name
iv. Claims Administrator Company Name
ix. Phone Number
x. Electronic Adjudication Management System (EAMS) Uniform Assigned Names (UAN)
5. Defense Attorney Information Section
i. First name
ii. Last name
iii. Defense Attorney Firm Name
iv. Address/P.O. Box
vi. State Zip
vii. Phone Number
viii. EAMS UAN Number
(B) Scan and upload the following supporting documentation when prompted:
1. a written request for an examination to determine compensability for disputes covered by Labor Code section 4060; or
2. a written objection indicating the identity of the primary treating physician, the date of the primary treating physician's report that is the subject of the objection and a description of the medical determination that requires a comprehensive medical - legal report to resolve, for disputes covered by Labor Code sections 4061 and 4062;
(C) Print and serve a paper copy of the online request, the panel list, and a copy of any supporting documentation that was submitted online, upon the opposing party with a proof of service, within 1 (one) working day after generating the QME panel list. Within 10 (ten) days of service of the panel, each party may strike one name from the panel.
(2) Requests may be made twenty-four hours a day, seven days a week. For determining the timeliness of requests under Labor Code section 4062.2, requests made on Saturday, Sunday or a holiday will be deemed to have been made at 8:00 a.m. on the next business day. Requests made Monday through Friday after 5:00 p.m. and before 12:00 a.m. will be deemed to have been made at 8:00 a.m. on the next business day, and requests made between 12:00 a.m. and 8:00 a.m. will be deemed to have been made at 8:00 a.m. on the same business day.
(3) Upon submission of the request online, the QME panel selection will be generated automatically. After issuance of a panel, any subsequent request on the same claim, whether made on the same day or not, is a duplicate request. In the event of technical difficulties, such that a panel QME selection cannot be generated on-line, the requesting party may contact the Medical Unit and shall reference the error code or message.
(c) If after the issuance of a panel it appears to the satisfaction of the Medical Director that the panel was issued by mistake, misrepresentation of fact contained in the forms or document filed in support of the request, or the parties have agreed to resolve their dispute using an AME or by other agreement, the issued panel may be revoked. Notice of the revocation shall be sent to parties listed on the panel request.
(d)(1) After a claim form has been filed, the claims administrator, or if none the employer, may request a panel of Qualified Medical Evaluators only as provided in Labor Code section 4060, to determine whether to accept or reject a claim within the ninety (90) day period for rejecting liability in Labor Code section 5402(b), and only after providing evidence of compliance with Labor Code Section 4062.1 or 4062.2.
(2) Once the claims administrator, or if none, the employer, has accepted as compensable injury to any body part in the claim, a request for a panel QME may only be filed based on a dispute arising under Labor Code section 4061 or 4062.
(e) If the request is submitted by or on behalf of an employee who does not reside within the state of California, the geographic area of the QME panel selection within the state shall be determined by agreement between the claims administrator, or if none the employer, and the employee. If no agreement can be reached, the geographic area of the QME panel selection shall be determined for an unrepresented employee by the employee's former residence within the state or, if the employee never resided in the state, by the geographic location of the employer's place of business where the employee was employed, and for a represented employee by the office of the employee's attorney.
(f) To compile a panel list of three (3) independent QMEs randomly selected from the specialty designated by the party holding the legal right to request a QME panel, the Medical Director shall exclude from the panel, to the extent feasible, any QME who is listed by another QME as a business partner or as having a shared specified financial interest, as those terms are defined in sections 1 and 29 of Title 8 of the California Code of Regulations.
(g) The time periods specified in Labor Code sections 4062.1(c) and 4062.2(c), respectively, for selecting an evaluator from a QME panel and for scheduling an appointment, shall be tolled whenever the Medical Director asks a party for additional information needed to resolve the panel request. These time periods shall remain tolled until the date the Medical Director issues either a new QME panel or a decision on the panel request.
NOTE: Forms referred to above are available at no charge by downloading from the web at www.dir.ca.gov/dwc/forms.html or by requesting at 1-800-794-6900.
1. New article 3 and section filed 8-1-94; operative 8-31-94 (Register 94, No. 31).
2. Amendment of subsection (b) and new subsections (d)-(e) filed 8-23-96; operative 9-22-96 (Register 96, No. 34).
3. Amendment of subsections (a), (c) and (d)(1) filed 4-14-2000; operative 5-14-2000 (Register 2000, No. 15).
4. Amendment of section and Note filed 1-13-2009; operative 2-17-2009 (Register 2009, No. 3).
5. Amendment of subsection (b)(1), repealer of subsection (b)(2), subsection renumbering, amendment of newly designated subsection (b)(4) and repealer of subsections (d)(3)-(4) 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.
6. Amendment of subsection (b)(1), repealer of subsection (b)(2), subsection renumbering, amendment of newly designated subsection (b)(4) and repealer of subsections (d)(3)-(4) 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.
7. Certificate of Compliance as to 7-1-2013 order, including further amendment of section, transmitted to OAL 8-2-2013 and filed 9-16-2013; amendments operative 9-16-2013 pursuant to Government Code section 11343.4(b)(3) (Register 2013, No. 38).
8. Amendment of section and Note filed 8-12-2015; operative 9-1-2015 pursuant to Government Code section 11343.4(b)(3) (Register 2015, No. 33).