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

§ 9792.7. Utilization Review Standards--Applicability

(a) Every claims administrator shall establish and maintain a utilization review process for medically necessary treatment in compliance with Labor Code section 4610. Each utilization review process shall be set forth in a utilization review plan which shall contain:

(1) The name, address, phone number, and medical license number of the employed or designated medical director, who holds an unrestricted license to practice medicine in the state of California issued pursuant to section 2050 or section 2450 of the Business and Professions Code.

(2) A description of the process whereby requests for authorization are reviewed, and decisions on such requests are made, and a description of the process for handling expedited reviews.

(3) A description of the specific criteria utilized routinely in the review and throughout the decision-making process, including treatment protocols or standards used in the process. The treatment protocols or standards governing the utilization review process shall be consistent with the Medical Treatment Utilization Schedule adopted by the Administrative Director pursuant to Labor Code section 5307.27.

(4) A description of the qualifications and functions of the personnel involved in decision-making and implementation of the utilization review plan.

(5) A description of the claims administrator's practice, if applicable, of any prior authorization process, including but not limited to, where authorization is provided without the submission of the request for authorization.

(6)(A) For utilization review plans that modify or deny treatment requests, proof of accreditation through the Workers' Compensation Utilization Management Accreditation program administered by URAC.

(B) A public sector internal utilization review plan that modifies or denies treatment requests need not obtain URAC accreditation under subdivision (a)(6) if it provides in its plan submission to the Administrative Director a statement under penalty of perjury by the plan's medical director that the plan meets or exceeds the standards established by URAC's Workers' Compensation Utilization Management Accreditation program.

(b)(1) The medical director shall ensure that the process by which the claims administrator reviews and approves, modifies, or denies requests by physicians prior to, retrospectively, or concurrent with the provision of medical services, complies with Labor Code section 4610 and these implementing regulations.

(2) A reviewer who is competent to evaluate the specific clinical issues involved in the medical treatment services, and where these services are within the reviewer's scope of practice, may, except as indicated below, modify or deny requests for authorization of medical treatment for reasons of medical necessity to cure or relieve the effects of the industrial injury.

(3) A non-physician reviewer may be used to initially apply specified criteria to requests for authorization for medical services. A non-physician reviewer may approve requests for authorization of medical services. A non-physician reviewer may discuss applicable criteria with the requesting physician, should the treatment for which authorization is sought appear to be inconsistent with the criteria. In such instances, the requesting physician may voluntarily withdraw a portion or all of the treatment in question and submit an amended request for treatment authorization, and the non-physician reviewer may approve the amended request for treatment authorization. Additionally, a non-physician reviewer may reasonably request appropriate additional information that is necessary to render a decision but in no event shall this exceed the time limitations imposed in section 9792.9.3 and 9792.9.4. Any time beyond the time specified in these sections is subject to the provisions of section 9792.9.6.

(c)(1) The complete utilization review plan, consisting of the policies and procedures, and a description of the utilization review process, shall be filed by the claims administrator, or by the external utilization review organization contracted by the claims administrator to perform the utilization review, with the Administrative Director. In lieu of filing the utilization review plan, the claims administrator may submit a letter identifying the external utilization review organization which has been contracted to perform the utilization review functions, provided that the utilization review organization has an approved utilization review plan on file with the Administrative Director, which also identifies the claims administrator client(s) on whose behalf it performs any utilization review functions.

(2) Utilization review plans that modify or deny treatment requests shall submit with their plan a completed DWC Form UR-01, “Utilization Review Plan Application or Modification,” set forth in section 9792.7.1, with an original signature by the applicant's medical director. The utilization review plan shall be submitted in compact discs or flash drives, or other electronic format agreed to by the Administrative Director and the applicant, in word-searchable PDF format. The hard copy of the completed, signed original shall be maintained by the applicant and made available for review by the Administrative Director upon request. Electronic signatures in compliance with California Labor Code section 110.5 or 3206.5 are acceptable.

(3) A utilization review plan that submits an application for approval thereby releases URAC from any obligation it may have, contractual or other, regarding nondisclosure of any of its files relating to the utilization review plan's accreditation or audits with URAC. Accordingly, the Division of Workers' Compensation may obtain such documents from URAC for the purpose of ensuring or enforcing compliance with the rules governing utilization review at sections 9792.6.1 through 9792.12.

(4) All utilization review plan entities shall file a material modification of its utilization review plan with the Administrative Director within 30 calendar days of the material modification. The material modification shall include a DWC Form UR-01 set forth in section 9792.7.1, completed as applicable with an original signature by the applicant's medical director, and an attached statement certifying that the utilization review plan, as modified, continues to be in compliance with the rules governing utilization review at sections 9792.6.1 through 9792.12. The modified utilization review plan shall be submitted in compact discs or flash drives, or other electronic format agreed to by the Administrative Director and the applicant, in word searchable PDF format. Electronic signatures in compliance with California Labor Code section 110.5 or 3206.5 are acceptable.

(d) Within 30 days after receipt of the utilization review plan or plan modification submitted under subdivision (c), the Administrative Director shall notify the organization in writing that the plan is complete and has been accepted for filing or that the plan is not complete. If the plan is not complete, the Administrative Director shall specify in the notice what additional information or documents are needed from the organization in order for the plan to be deemed complete. Notice that a utilization review plan submission is complete does not preclude the Administrative Director from later requesting additional documentation or records necessary for determining a utilization review plan's compliance with the law.

(e)(1) For utilization review plans that deny or modify treatment requests, the Administrative Director shall approve or deny the plan or plan modification within 60 days following the issuance of the Administrative Director's notice that a utilization review plan filing or filing of plan modification is complete.

(A) The Administrative Director may extend the time for review for another 60 days by notifying the plan in writing that an extension is required. If the Administrative Director takes no action after the 60-day extension has elapsed, the utilization review plan shall be deemed to be provisionally approved until a final determination to approve, conditionally approve, or deny the plan is made.

(B) If specific deficiencies are identified but the applicant substantially complies with the requirements of Labor Code section 4610 and this Article, a conditional approval may be granted for a period not to exceed six (6) months to permit the applicant the opportunity to correct those deficiencies. If the deficiencies are not corrected after the first period of conditional approval, or the condition upon which an approval may be granted is not satisfied, the conditional authorization to operate may be extended for a period not to exceed six (6) months if the applicant demonstrates a good faith effort and ability to correct the deficiencies.

(C) A conditional authorization to operate shall expire at the end of its stated period and the application shall be deemed denied, unless the deficiencies are removed prior to its expiration and an approval has been granted before that date.

(2) The Administrative Director shall notify a utilization review plan applicant of a denial under subdivision (e) in writing and shall state the reasons for non-approval. The denial shall be transmitted to the plan by certified mail and shall be in effect for 12 months unless a lesser timeframe is agreed upon for good cause by the Administrative Director.

(f) A utilization review plan applicant may appeal the Administrative Director's denial under subdivision (e) by filing, within twenty-five (25) days of the issuance of the denial, a petition with the Workers' Compensation Appeals Board pursuant to California Code of Regulations, title 8, section 10560. A copy of the petition shall be concurrently served on the Administrative Director.

(g) The Administrative Director may require an organization to update its approved plan if it is determined that a change in the plan is required in order to bring the plan into compliance with the law. An organization that receives a Notice of Required Update shall have 30 days from the receipt of the notice to bring its plan into compliance. Failure to adopt and implement required changes may result in the probation or suspension of a plan or revocation of plan approval.

(h)(1) The Administrative Director may place on probation, suspend, or revoke approval of a utilization review plan for any one or more of the following reasons:

(A) The UR program is operating out of compliance with the terms of its approved plan or the law;

(B) The plan fails to timely adopt and implement updates to its UR plan as specified by the Administrative Director;

(C) The plan knowingly makes false statements or representations to the Administrative Director or fails to submit plan modifications or updates as required by this Article;

(D) The plan fails to respond to at least two or more repeated requests or inquires by the Administrative Director concerning plan compliance.

(2) If the Administrative Director determines that one or more of the circumstances in subdivision (h)(1) applies, the Administrative Director shall issue written notice of the violation(s). Upon receipt of such notice, the organization shall have 14 days to correct the violation or respond with a plan of action to timely correct the violation.

(3)(A) If the Administrative Director determines that the violations have not been remediated in a timely manner, a Findings and Notice of Action shall issue to the organization specifying the time period for which probation, suspension, or revocation will take effect. A plan whose approval has been revoked shall be barred from applying again for approval for 12 months following the date of revocation, unless a lesser timeframe is agreed upon for good cause by the Administrative Director.

(B) Where the Findings and Notice of Action are for the suspension or revocation of a UR plan, the UR plan shall issue a copy of the Findings and Notice of Action to all organizations for which it performs utilization review.

(i)(1) Within 14 days of the issuance of the Findings and Notice of Action, a UR plan may request a re-evaluation of the probation, suspension or revocation by submitting to the Administrative Director, under penalty of perjury, a written explanation accompanied by documentary evidence supportive of the request for re-evaluation.

(2) Within 45 days of the request for re-evaluation, the Administrative Director shall issue a Decision and Order affirming, modifying, or rescinding the Notice of Action, which shall include an explanation for the decision. The Administrative Director may extend the time for issuing a Decision and Order for a period of 30 days. At any time during re-evaluation, the Administrative Director may order a plan to submit additional documentation or information.

(j) A utilization review plan entity may, as an alternative to requesting re-evaluation under subdivision (i), appeal a Notice of Action to the Workers' Compensation Appeals Board by filing a petition within 20 days of the issuance of such notice under California Code of Regulations, title 8, section 10560. A copy of the petition shall be concurrently served on the Administrative Director.

(k) Nothing in this section shall prevent the Administrative Director from imposing penalties as applicable under section 9792.12.

(l) The Administrative Director shall post on the Division's website a list of all entities who have filed a complete utilization review plan under this section, indicating the plans' statuses as they evolve including, but not limited to, approved, denied, inactive, probation, suspended, or revoked. Utilization review plan entities who cease to perform utilization review under its own name for a period of 12 consecutive months following the last UR activity performed under its own name may be marked as inactive.

(m)(1) Upon request by the public, the claims administrator shall make available the complete utilization review plan, consisting of the policies and procedures, and a description of the utilization review process.

(2) The claims administrator may make available the complete utilization review plan, consisting of the policies and procedures and a description of the utilization review process, through electronic means. If a member of the public requests a hard copy of the utilization review plan, the claims administrator may charge reasonable copying and postage expenses related to disclosing the complete utilization review plan. Such charge shall not exceed $0.25 per page plus actual postage costs.

(n) For utilization review organizations: The files and other records, whether electronic or paper, that pertain to the utilization review process shall be retained for at least three (3) years following either: (1) the most recent utilization review decision for each injured employee, or (2) the date on which any appeal from the assessment of penalties for violations of Labor Code section 4610 or sections 9792.6 through 9792.12 is final, whichever date is later. Claims administrators shall retain their claim files as set forth in section 10102 of Title 8 of the California Code of Regulations.

Credits

Note: Authority cited: Sections 133, 4603.5, 4610 and 5307.3, Labor Code. Reference: Sections 4062, 4600, 4600.4, 4604.5 and 4610, Labor Code.

History

1. New section filed 12-9-2004 as an emergency; operative 12-13-2004 (Register 2004, No. 50). A Certificate of Compliance must be transmitted to OAL by 4-12-2005 or emergency language will be repealed by operation of law on the following day.

2. New section refiled 4-6-2005 as an emergency; operative 4-12-2005 (Register 2005, No. 14). A Certificate of Compliance must be transmitted to OAL by 8-10-2005 or emergency language will be repealed by operation of law on the following day.

3. Certificate of Compliance as to 4-6-2005 order, including amendment of section, transmitted to OAL 8-10-2005 and filed 9-22-2005 (Register 2005, No. 38).

4. Amendment filed 2-12-2014; operative 2-12-2014 pursuant to Government Code section 11343.4(b)(3) (Register 2014, No. 7).

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