Chapter 4.5. Division of Workers' Compensation
Subchapter 1. Administrative Director--Administrative Rules
Article 5.5.1. Utilization Review Standards

§ 9792.12. Administrative Penalty Schedule for Utilization Review and Independent Medical Review Violations.

Notwithstanding Labor Code section 129.5(c)(1) through (c)(3), the following penalty amounts shall be assessed for each failure to comply with the utilization review process required by Labor Code section 4610, and sections 9792.6 through 9792.12 of Title 8 of the California Code of Regulations:

(a) For violations relating to utilization review plan requirements:

(1) For failure to establish a Labor Code section 4610 utilization review plan: $50,000;

(2) For failure to include all of the requirements of section 9792.7(a) in the utilization review plan: $5,000;

(3) For failure to file the utilization review plan or a letter in lieu of a utilization review plan with the Administrative Director as required by section 9792.7(c): $ 10,000;

(4) For utilization review plans that modify or deny treatment requests, failure to obtain approval of a utilization review plan with the Administrative Director prior to operation: $30,000;

(5) For failure to file a material modification of a utilization review plan with the Administrative Director as required by section 9792.7(c): $10,000;

(6) For failure to obtain or maintain URAC accreditation as required under Labor Code section 4610(g)(4) prior to commencing or continuing to function as a utilization review plan: $10,000;

(7) For failure to employ or designate a physician as a medical director, as defined in section 9792.6.1(o), of the utilization review process, as required by section 9792.7(b): $50,000;

(8) As required by Labor Code section 4610(g), for failure to comply with the laws prohibiting financial incentives or consideration to physicians conducting utilization review: $25,000;

(9) For failure to retain records as required under section 9792.7(n): $20,000;

(b) For violations relating to utilization review plan operations:

(1)(A) For failure to comply with the requirement that only a physician reviewer may modify, or deny requests for authorization of medical treatment for reasons of medical necessity to cure or relieve, except as provided for in Labor Code section 4604.5(c): $25,000;

(B) For failure to comply with the requirement that only a physician reviewer may deny requests for authorization of medical treatment where there has been a failure to obtain the necessary information, tests, or consultation under section 9792.9.6: $25,000;

(C) For failure to comply with the requirement as set forth in sections 9792.6.1(w) prohibiting a non-physician reviewer from denying or modifying a treatment request under section 9792.9.2(a)(2)(B) that would otherwise be subject to Labor Code section 4610(k): $25,000;

(2) For issuance of a decision to modify or deny a request for authorization regarding a medical treatment, procedure, service or product where the requested treatment, procedure or service is not within the reviewer's scope of practice (as set forth by the reviewer's licensing board): $25,000;

(3) For failure to comply with requirements at section 9792.9.2 (deferral) when the medical necessity of requested treatment cannot be determined after application of the medical treatment utilization schedule adopted pursuant to Labor Code section 5307.27: $5,000;

(4) For failure to discuss and/or document attempts to discuss reasonable options for a care plan with the requesting physician as required by Labor Code section 4610(i)(4)(C), prior to denying authorization of or discontinuing medical care, in the case of concurrent review: $10,000;

(5) For requiring prospective utilization review for each medical treatment that complies with the conditions set forth in section 9792.9.7(a): $3,000.

(6) For failure to respond to a complete or accepted request for authorization:

(A) In the case of a non-expedited concurrent review: $3,000;

(B) In the case of a non-expedited prospective review: $2,500;

(C) In the case of a retrospective review: $750.

(7) For each failure to timely make a decision under section 9792.9.3(b) for non-expedited prospective or concurrent review within 5 working days of receipt of a request for authorization, or after receipt of requested information, tests or examinations, or consultations under section 9792.9.6(d); or to communicate, whether initially or in writing, a decision to approve, modify, or deny a non-expedited prospective or concurrent request to the appropriate parties as required by sections 9792.9.4(b), 9792.9.5(c), and 9792.9.6(d): $250 for each day the failure is ongoing, up to a maximum of $5,000 at which point the violation may be deemed a failure to respond to a complete or accepted request for authorization as applicable under section 9792.12(b)(6) and the additional penalty for that failure attaches;

(8) Under sections 9792.9.3, 9792.9.4, or 9792.9.5, for the failure to timely make and/or issue written communication of a decision within 72 hours of receipt of a complete or accepted request for expedited review, as defined in section 9792.6.1(j), or upon receipt of the requested information under section 9792.9.6(d): $250 for each hour the response is untimely up to a maximum of $18,000;

(9) For each failure to timely make and/or communicate a retrospective review decision to approve, modify, or deny the request, within thirty (30) days of receipt of information that is reasonably necessary to make a determination, as required by sections 9792.9.4(c) or 9792.9.5(d), or upon receipt of the requested information under section 9792.9.6(d): $150 for each day that the failure is ongoing, up to a maximum of $3,000 at which point the violation may be deemed a failure to respond to a complete or accepted request for authorization as applicable under section 9792.12(b)(6) and the additional penalty for that failure attaches;

(10) For failure to timely communicate in writing the reason for extending the required timeframe for the issuance of a decision as required by section 9792.9.6(b): $250 for each day that passes without a response, up to a maximum of $5,000 at which point the violation may be deemed a failure to respond to a complete or accepted request for authorization as applicable under section 9792.12(b)(6) and the additional penalty for that failure attaches;

(11) For failure to document that one of the following events at section 9792.9.6(a) of Title 8 of the California Code of Regulations occurred prior to the claims administrator providing written notice for extending the timeframe for decision under section 9792.9.3: $200;

(12) For failure to comply with documentation requirements applicable to a denial of a request for authorization on the basis of lack of reasonable and necessary information as required under section 9792.9.5(e)(2): $200.

(13) For failure to include in the written decision that modifies or denies authorization, when applicable, all of the items required under section 9792.9.5(e): $300 for each item;

(14) For each failure to operate the plan in accordance with the plan filed and/or approved by the Administrative Director other than a failure already identified in this penalty schedule: $5,000.

(15) Reserved.

(c) For violations related to investigation procedures and miscellaneous violations:

(1) For failure to timely provide a complete copy of any document, file, or record, whether electronic or paper, that was requested by the Administrative Director pursuant to section 9792.11: $500 for each day the failure is ongoing up to a maximum of $10,000 unless a greater penalty is warranted under subdivision (e) of this section.

(2) For providing a backdated, altered, or fraudulent document to the Administrative Director, or his or her designee, or intentionally withholding a document, which would have the effect of avoiding liability for an obligation under this Article or for the assessment of an administrative penalty under this section: $5,000 for each backdated, altered, or withheld document, unless a greater penalty is warranted under subdivision (e) of this section.

(3) For failure to timely comply with any and each compliance requirement listed in a Final Report, if no timely answer was filed, or any compliance requirement listed in the Determination and Order after any and all appeals have become final: $500 for each day the failure is ongoing up to a maximum of $20,000 unless a greater penalty is warranted under subdivision (e) of this section.

(4) For failure to timely serve the Administrative Director with documentation of compliance pursuant to section 9792.11(x)(5): $500 for each day the failure is ongoing up to a maximum of $20,000 unless a greater penalty is warranted under subdivision (e) of this section.

(5) For failure to disclose or otherwise make available, if requested, the Utilization Review criteria or guidelines as required by Labor Code section 4610(h)(5): $200.

(6) For failure to disclose or otherwise make available the approved utilization review process descriptions and the accompanying written policies and procedures as required by Labor Code section 4610, subdivision (g)(5) and section 9792.7(m) of Title 8 of the California Code of Regulations: $200.

(d) Independent Medical Review Administrative Penalties. Notwithstanding Labor Code section 129.5(c)(1) through (c)(3), the penalty amount that shall be assessed for each failure to comply with the independent medical review process required by Labor Code sections 4610.5 and 4610.6, and sections 9792.6.1 through 9792.10.8 of this Article is:

(1) For the failure to provide the Application for Independent Medical Review, DWC Form IMR, set forth at section 9792.10.2, with a written decision modifying or denying a treatment authorization under section 9792.9.5(e): $2,000.

(2) For the failure to complete all applicable fields on the Application for Independent Medical Review, DWC Form IMR, set forth at section 9792.10.2, which is provided with a written decision modifying or denying a treatment authorization under section 9792.9.5:

(A) $500 for a failure to provide the Employee Name, Address, Phone Number, and Date of Injury;

(B) $500 for a failure to provide the Requesting Physician Name, Address, Specialty, and Phone Number;

(C) $500 for a failure to provide the Claims Administrator Name, Adjustor/Contact Name, Address, and Phone Number;

(D) $500 for a failure to complete any field under the section heading "Disputed Medical Treatment";

(E) $100 for a failure to provide any field not identified above.

(3) For the failure to include in a written decision modifying or denying a treatment authorization under section 9792.9.5 a clear statement that advising the injured employee that any dispute shall be resolved in accordance with the independent medical review provisions of Labor Code section 4610.5 and 4610.6, and that an objection to the utilization review decision must be communicated by the injured worker, the injured worker's representative, or the injured worker's attorney on behalf of the injured worker on the Application for Independent Medical Review, DWC Form IMR, set forth at section 9792.10.2, within 10 or 30 days of service of the utilization review decision in accordance with section 9792.10.1(a): $1,000.

(4) For the failure to include in a written decision modifying or denying a treatment authorization under section 9792.9.5 a statement detailing the claims administrator's internal utilization review appeals process for the requesting physician, if any, and a statement that the internal appeals process is a voluntary process that neither triggers nor bars use of the dispute resolution procedures of Labor Code section 4610.5 and 4610.6, but may be pursued on an optional basis: $1,000.

(5) For the failure to timely provide information requested by the Administrative Director under section 9792.10.3(b): $500.00 for each day the response is untimely under section 9792.10.3(c), up to a maximum of $7,500.00.

(6) For the failure to timely provide all information required by section 9792.10.5(a) and (c): $500.00 for each day the response is untimely up to a maximum of $7,500.00.

(7) For the failure to authorize services found to be medically necessary by the independent medical review organization in the final determination issued under section 9792.10.6 within either five (5) business days of receipt of the determination, or sooner if appropriate for the employee's medical condition, or five (5) business days from the date the determination is final, if an appeal of the determination has been filed under Labor Code section 4610.6(h): $1,000.00 for each day up to a maximum of $10,000.

(8) For the failure to reimburse for services already rendered that has been found to be medically necessary by the independent medical review organization in the final determination issued under section 9792.10.6 within twenty (20) days after receipt of the final determination, or within twenty (20) days from the date the determination is final if an appeal of the determination has been filed under Labor Code section 4610.6(h), subject to resolution of any remaining issue of the amount of payment pursuant to Labor Code sections 4603.2 to 4603.6, inclusive: $500.00 for each day up to a maximum of $10,000.

(9) For the failure to timely pay an invoice sent from the designated independent medical review organization under section 9792.10.8(c): $250.

(e)(1) For any other act or failure pertaining to utilization review in violation of Labor Code section 4610 and sections 9792.6.1 through 9792.12 of Title 8 of the California Code of Regulations: a penalty of up to $50,000 and/or revocation of approval or suspension of the utilization review plan, depending on the gravity of the violation; the characteristics or similarity of the violation to other violations listed in this penalty schedule; the history of previous violations; the frequency of violations uncovered during the investigation; the good faith behavior of the investigation subject; and other cause as determined by the Administrative Director.

(2) Where a violation under this article results in the inability of the Administrative Director to conduct a full investigation of any complaint or issue, additional penalties may be imposed in accordance with the penalty provision of subsection (1) of this subdivision.

(f) The penalty amounts specified for violations under this section may, in the discretion of the Administrative Director, be reduced after consideration of the factors set out in section 9792.13(a) of Title 8 of the California Code of Regulations.

Credits

Note: Authority cited: Sections 60, 133, 4610, 4610.5, 4610.6 and 5307.3, Labor Code. Reference: Sections 129, 129.5, 4062, 4600, 4600.4, 4604.5, 4610, 4610.5, 4610.6 and 4614, Labor Code.

History

1. New section filed 6-7-2007; operative 6-7-2007 pursuant to Government Code section 11343.4 (Register 2007, No. 23).

2. Amendment of section heading and subsections (a), (a)(7) and (a)(9), new subsections (a)-(18)-(25), amendment of subsections (b)(4)(A), (b)(4)(C)-(E), (b)(5)(A)-(B) and (b)(5)(D), repealer of subsection (b)(5)(E), subsection relettering, amendment of subsection (b)(5)(G) and amendment of Note 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.

3. Amendment of section heading and subsections (a), (a)(7) and (a)(9), new subsections (a)-(18)-(25), amendment of subsections (b)(4)(A), (b)(4)(C)-(E), (b)(5)(A)-(B) and (b)(5)(D), repealer of subsection (b)(5)(E), subsection relettering, amendment of newly designated subsection (b)(5)(F) and amendment of Note 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.

4. Amendment of section heading and subsections (a), (a)(7) and (a)(9), new subsections (a)-(18)-(25), amendment of subsections (b)(4)(A), (b)(4)(C)-(E), (b)(5)(A)-(B) and (b)(5)(D), repealer of subsection (b)(5)(E), subsection relettering, amendment of newly designated subsection (b)(5)(F) and amendment of Note 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.

5. Certificate of Compliance as to 9-30-2013 order, including amendment of section and Note, 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).

6. Amendment of section and Note filed 12-30-2025; operative 4-1-2026 (Register 2026, No. 1).