California Regulations 10100

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§ 10100 Article 1 - Audit, General Definitions Definitions-- Prior to January 1, 1994

The following definitions apply in Articles 1 through 7 of this Subchapter for injuries occurring on or after January 1, 1990 and before January 1, 1994.

 (a) Adjusting Location. The office where claims are administered.

 (b) Administrative Director. The Administrative Director of the Division of Workers' Compensation or his/her duly authorized representative.

 (c) Audit. Any audit performed by the Audit Unit of the Division of Workers' Compensation pursuant to Labor Code Sections 129 and 129.5.

 (d) Claims Administrator. A self-administered insurer providing security for the payment of compensation required by Divisions 4 and 4.5 of the Labor Code, a self-administered self-insured employer, or a third-party claims administrator for a self-insured employer, insurer, legally uninsured employer, or joint powers authority.

 (e) Claim File. A record, either in legible paper or electronic form which can be produced into legible paper, containing all of the information specified in Section 10101 and related documents pertaining to a given work-injury claim.

 (f) Claim Log. A handwritten or printed ledger maintained by the claims administrator listing each work injury case by the date the injury was reported to the claims administrator and listing the date of injury. The claim log contents are specified in Section 10103.

 (g) Compensation. Compensation as defined in Labor Code Section 3207.

 (h) Duly Authorized Representative. A designated employee or unit of the Department of Industrial Relations.

 (i) DWC. The Division of Workers' Compensation of the Department of Industrial Relations.

 (j) Employee. An employee, his or her dependents or his agent.

 (k) Indemnity Case. A work-injury claim which has or may result in any of the following benefits:  (1) Temporary Disability  (2) Permanent Disability  (3) Life Pension  (4) Death Benefits  (5) Vocational Rehabilitation

 (l) Insurer. Any company, group or entity in, or which has been in, the business of transacting workers' compensation insurance for employers subject to the workers' compensation laws of this state. The term insurer includes the State Compensation Insurance Fund.

 (m) Investigation. The process of examining and evaluating a claim to determine the nature and extent of all legally required benefits, if any, which are due under the claim. Investigation may include formal or informal methods of gathering information relevant to evaluating the claim such as: obtaining employment records, obtaining earnings records, informal or formal interviews of the employee, employer, or witnesses, deposition of parties or witnesses, obtaining expert opinion where an iss ue requires an expert opinion for its resolution, such as obtaining a medical-legal evaluation.

 (n) Issue Date. The date upon which a notice of penalty assessment or an order of the Administrative Director is served.

 (o) Joint Powers Authority. Any county, city, city and county, municipal corporation, public district, public agency, or political subdivision of the state, but not the state itself, including in a pooling arrangement under a joint exercise of powers agreement for the purpose of securing a certificate of consent to self-insure workers' compensation claims under Labor Code Section 3700(c).

 (p) Medical-Only Claim. A work-injury case which requires compensation only for medical treatment by a physician.

 (q) Medical Fee Schedule. Official schedule promulgated by the Administrative Director pursuant to Labor Code Section 5307.1. Refer to Title 8 of existing CCR Section 9791.1 through Section  9792.

 (r) Non-Random. Any method of selecting an audit subject which is specific to that audit subject, based on any or all of the factors provided in Labor Code Section 129(b).

 (s) Notice of Compensation Due. The Notice of Assessment issued pursuant to Labor Code Section 129(c).

 (t) Open Claim. A work-injury claim in which future payment of compensation may be due or for which reserves for the future payment of compensation are maintained.

 (u) Payment Schedule. The two-week cycle of indemnity payments due on the day designated with the first payment as required by Labor Code Section 4650(c) or 4702(b). (v) Random. Any method of selecting an audit subject which is not based on factors specific to that audit subject, but instead which chooses subjects from a broad cross-section of possible subjects. Random selection methods may stratify by general groups and need not be statistically precise.

 (w) Self-insured Employer. An employer that has been issued a certificate of consent to self-insure as provided by Labor Code Section 3700(b) or (c), including a joint powers authority or the State of California as a legally uninsured employer.

 (x) Third-Party Administrator. An agent under contract to administer the workers' compensation claims of an insurer, self-insured employer, or joint powers authority.

 (y) VRMA. Vocational rehabilitation maintenance allowance.

 (z) Work-Injury Claim. A claim for an injury that is reported or reportable to the Division of Labor Statistics and Research pursuant to Sections 6409, 6409.1 and 6413 of the Labor Code.