Chapter 4.5. Division of Workers' Compensation
Subchapter 1. Administrative Director--Administrative Rules
Article 5.5.0. Rules For Medical Treatment Billing and Payment on or After October 15, 2011

9792.5.9. Initial Review and Assignment of Request for Independent Bill Review to IBRO.

(a) Upon receipt of the Request for Independent Bill Review under section 9792.5.7, the Administrative Director, or his or her designee, shall conduct a preliminary review to determine whether the request is ineligible for review. In making this determination, the Administrative Director shall consider:

(1) The timeliness and completeness of the request;

(2) The date the medical treatment services or goods were rendered or the medical-legal expenses incurred;

(3) Whether the second request for review of the bill under section 9792.5.5 was timely requested by the provider;

(4) Whether the second review of the bill under section 9792.5.5 was timely completed by the claims administrator;

(5) Whether, for a bill for medical treatment services or goods, the medical treatment was authorized by the claims administrator under Labor Code section 4610.

(6) If the required fee for the review was paid pursuant to section 9792.5.7(d)(1)(A) or (B);

(7) Any previous or duplicate requests for independent bill review of the same bill for medical treatment services or bill for medical-legal expenses.

(8) If the dispute between the provider and the claims administrator is ineligible under section 9792.5.7(b) or contains any other issue than the amount of payment of the bill.

(b) If the request appears eligible for review, the Administrative Director, or his or her designee, shall within fifteen (15) days of the determination, notify the provider and the claims administrator by the most efficient means available that request for independent bill review has been submitted and appears eligible for assignment to an IBRO. The notification shall contain:

(1) An independent bill review case or identification number;

(2) The date the Request for Independent Bill Review, DWC Form IBR-1, was received by the Administrative Director

(3) A statement that the claims administrator may dispute both eligibility of the request for independent bill review under subdivision (a) and the provider's reason for requesting independent bill review by submitting a statement with supporting documents, and that the Administrative Director or his or her designee must receive the statement and supporting documents within fifteen (15) calendar days of the date designated on the notification, if the notification was provided by mail, or within twelve (12) calendar days of the date designated on the notification if the notification was provided electronically.

(c) Any document filed with the Administrative Director, or his or her designee, under subdivision (b)(3) must be concurrently served on the provider. Any document that was previously provided to the provider or originated from the provider need not be served if a written description of the document and its date is served.

(d) Upon receipt of the documents requested in subdivision (b)(3), or, if no documents have been received, upon the expiration of fifteen (15) days of the date designated on the notification, if the notification was provided by mail, or within twelve (12) days of the date designated on the notification if the notification was provided electronically, the Administrative Director, or his or her designee, shall conduct a further review in order to make a determination as to whether the request is ineligible for independent bill review under subdivision (a).

(e) If the review conducted under either subdivision (a) or subdivision (d) finds that the request is ineligible for independent bill review, the Administrative Director shall, within fifteen (15) days following receipt of the documents requested in subdivision (b)(3) or, if no documents are received, the expiration of the time period indicated above, issue a written determination informing the provider and claims administrator that the request is not eligible for independent bill review and the reasons therefor.

(1) If a request is deemed ineligible under this section, the provider shall be reimbursed the amount of $270.00.

(2) The provider or the claims administrator may appeal an eligibility determination by the Administrative Director by filing a petition with the Workers' Compensation Appeals Board and serving a copy on all interested parties, including the Administrative Director, within 30 days of receipt of the determination.

(f) If the Administrative Director or his or her designee determines from the review conducted under subdivision (d), that the request is eligible for independent bill review, the Administrative Director shall assign the request to an IBRO for an independent bill review. Upon assignment of the request, the IBRO shall notify the parties in writing that the request has been assigned to that organization for review. The notification shall contain:

(1) The name and address of the IBRO;

(2) An independent bill review case or identification number;

(3) Identification of the claim and disputed amount of payment made by the claims administrator on a bill for medical treatment services submitted pursuant to Labor Code sections 4603.2 or 4603.4, or bill for medical-legal expenses submitted pursuant to Labor Code section 4622,

(g) After the assignment to the IBRO, the request shall immediately be assigned to an independent bill reviewer who does not have any material professional, familial, or financial affiliation with any of the individuals, institutions, facilities, services or products as described in Labor Code section 139.5 (c) (2) to review and resolve the dispute.

(h) If in the course of conducting an independent bill review it is determined that the bill reviewer assigned to the dispute has a prohibited interest as described in in Labor Code Section 139.5 (c) (2), the IBRO shall reassign the matter to a different independent bill reviewer.

(i) Upon reassignment under subdivision (h), the IBRO shall immediately notify the Administrative Director, the provider, and claims administrator of the reassignment of the dispute to a different independent bill reviewer.

Note: Authority cited: Sections 133, 4603.6, 5307.3 and 5307.6, Labor Code. Reference: Sections 4060, 4061, 4061.5, 4062, 4600, 4603.2, 4603.3. 4603.4, 4603.6, 4620, 4621, 4622, 4625, 4628 and 5307.6, Labor Code.

HISTORY

1. New section 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.

2. New section 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.

3. New section 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.

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