Subchapter 1. Administrative Director--Administrative Rules
Article 3.6. Independent Medical Review
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§9768.9. Procedure for Requesting an Independent Medical Review
(a) If a covered employee disputes the diagnostic service, diagnosis, or medical treatment prescribed by the second opinion physician, the injured employee may seek the opinion of a third physician in the MPN. The covered employee and the employer or insurer shall comply with the requirements of section 9767.7(d). Additionally, at the time of the selection of the physician for a third opinion, the MPN Contact shall notify the covered employee about the Independent Medical Review process and provide the covered employee with an “Independent Medical Review Application” form set forth in section 9768.10. The MPN Contact shall fill out the “MPN Contact Section” of the form and list the specialty of the treating physician and an alternative specialty, if any, that is different from the specialty of the treating physician.
(b) If a covered employee disputes either the diagnostic service, diagnosis or medical treatment prescribed by the third opinion physician, the covered employee may request an Independent Medical Review by filing the completed Independent Medical Review Application form with the Administrative Director. The covered employee shall complete the “employee section” of the form, indicate on the form whether he or she requests an in-person examination or record review, and may list an alternative specialty, if any, that is different from the specialty of the treating physician.
(c) The Administrative Director shall select an IMR with an appropriate specialty within ten business days of receiving the Independent Medical Review Application form. The Administrative Director's selection of the IMR shall be based on the specialty of the treating physician, the alternative specialties listed by the covered employee and the MPN Contact, and the information submitted with the Independent Medical Review Application.
(d) If the covered employee requests an in-person examination, the Administrative Director shall randomly select a physician from the panel of available Independent Medical Reviewers, with an appropriate specialty, who has an office located within thirty miles of the employee's residence address, to be the Independent Medical Reviewer. If there is only one physician with an appropriate specialty within thirty miles of the employee's residence address, that physician shall be selected to be the Independent Medical Reviewer. If there are no physicians with an appropriate specialty who have offices located within thirty miles of the employee's residence address, the Administrative Director shall search in increasing five mile increments, until one physician is located. If there are no available physicians with this appropriate specialty, the Administrative Director may choose another specialty based on the information submitted.
(e) If the covered employee requests a record review, then the Administrative Director shall randomly select a physician with an appropriate specialty from the panel of available Independent Medical Reviewers to be the IMR. If there are no physicians with an appropriate specialty, the Administrative Director may choose another specialty based on the information submitted.
(f) The Administrative Director shall send written notification of the name and contact information of the IMR to the covered employee, the employee's attorney, if any, the MPN Contact and the IMR. The Administrative Director shall send a copy of the completed Independent Medical Review Application to the IMR.
(g) The covered employee, MPN Contact, or the selected IMR can object within 10 calendar days of receipt of the name of the IMR to the selection if there is a conflict of interest as defined by section 9768.2. If the IMR determines that he or she does not practice the appropriate specialty, the IMR shall withdraw within 10 calendar days of receipt of the notification of selection. If this conflict is verified or the IMR withdraws, the Administrative Director shall select another IMR from the same specialty. If there are no available physicians with the same specialty, the Administrative Director may select an IMR with another specialty based on the information submitted and in accordance with the procedure set forth in subdivision (d) for an in-person examination and subdivision (e) for a record review.
(h) If the covered employee requests an in-person exam, within 60 calendar days of receiving the name of the IMR, the covered employee shall contact the IMR to arrange an appointment. If the covered employee fails to contact the IMR for an appointment within 60 calendar days of receiving the name of the IMR, then the employee shall be deemed to have waived the IMR process with regard to this disputed diagnosis or treatment of this treating physician. The IMR shall schedule an appointment with the covered employee within 30 calendar days of the request for an appointment, unless all parties agree to a later date. The IMR shall notify the MPN Contact of the appointment date.
(i) The covered employee shall provide written notice to the Administrative Director and the MPN Contact if the covered employee decides to withdraw the request for an Independent Medical Reviewer.
(j) During this process, the employee shall remain within the MPN for treatment pursuant to section 9767.6.
NOTE
Authority cited: Sections 133 and 4616, Labor Code. Reference: Sections 4616.3 and 4616.4, Labor Code.
HISTORY
1. New section filed 12-31-2004 as an emergency; operative 1-1-2005 (Register 2004, No. 53). A Certificate of Compliance must be transmitted to OAL by 5-2-2005 or emergency language will be repealed by operation of law on the following day.
2. Certificate of Compliance as to 12-31-2004 order, including amendment of section,
transmitted to OAL 4-29-2005 and filed 6-10-2005 (Register 2005, No. 23).
