California Regulations 10112.1
§ 10112.1 Definitions
|As used in this article:
(a) "Adjusting location" means the office where claims are administered. Separate underwriting companies, employers that are both self-administered and self-insured, and/or third-party administrators operating at one location shall be combined as one adjusting location only if claims are administered under the same management at that location. Where claims are administered from an office that includes a satellite office at another location, claims administered at the satellite office(s) will be considered as part of the single adjusting location for investigation and auditing purposes under this article when it is demonstrated that the claims are under the same immediate management.
(b) "Administrative Director" means the Administrative Director of the Division of Workers' Compensation, including his or her designee.
(c) "Claim" means a request for compensation, or record of an occurrence in which compensation reasonably would be expected to be payable for an injury arising out of and in the course of employment.
(d) "Claim file" means a record in paper or electronic form, or any combination, containing all of the information specified in section 10101.1 of Title 8 of the California Code of Regulations and all documents or entries related to the provision, payment, delay, or denial of benefits or compensation under Divisions 1, 4 or 4.5 of the Labor Code.
(e) "Claims administrator" means a self-administered workers' compensation insurer; a self-administered self-insured employer; a self-administered legally uninsured employer; a self-administered joint powers authority; or a third-party claims administrator for an insurer, a self-insured employer, a legally uninsured employer or a joint powers authority.
(f) "Compensation" means every benefit or payment, including vocational rehabilitation, supplemental job displacement benefits, medical treatment, medical and medical-legal expenses, conferred by Divisions 1 and 4 of the Labor Code on an injured employee or the employee's dependents.
(g) "Compensation order" means any award, order or decision issued by the Workers' Compensation Appeals Board or the Division of Workers' Compensation vocational rehabilitation unit by which a party is entitled to payment of compensation.
(h) "Concurrent medical treatment authorization" means authorization requested or provided during an inpatient stay.
(i) "Determination and Order" means Determination and Order in re Labor Code § 5814.6 Administrative Penalties.
(j) "Employee" means every person in the service of another, as defined under Article 2 of Chapter 2 of Part 1 of Division 4 of the Labor Code (Sections 3350 et seq.), or in the case of the employee's death, his or her dependent, as each is defined in Division 4 of the Labor Code, or the employee's or dependent's agent or attorney.
(k) "Employer" shall have the same meaning as the word 'employer' as defined in Division 4 of the Labor Code (sections 3300 et seq.).
(l) "General business practice" means a pattern of violations of Labor Code section 5814 at a single adjusting location that can be distinguished by a reasonable person from an isolated event. The pattern of violations must occur in the handling of more than one claim. The pattern of violations may consist of one type of act or omission, or separate, discrete acts or omissions in the handling of more than one claim. However, where a claim file with a violation of Labor Code section 5814 has been adjusted at multiple adjusting locations, that claim file may be considered when determining the general business practice of any of the adjusting locations where the conduct that caused the violation occurred even if the file has been transferred to a different adjusting location.
(m) "Indemnity" means payments made directly to an eligible person as a result of a work injury and as required under Division 4 of the Labor Code, including but not limited to temporary disability indemnity, salary continuation in lieu of temporary disability indemnity, permanent disability indemnity, vocational rehabilitation temporary disability indemnity, vocational rehabilitation maintenance allowance, life pension and death benefits.
(n) "Insurer" means any company, group, or entity in, or which has been in, the business of transacting workers' compensation insurance for one or more employers subject to the workers' compensation laws of this state. The term insurer includes the State Compensation Insurance Fund.
(o) "Investigation" means the process used by the Administrative Director, or his or her designee, pursuant to Section 10225.1 and/or Government Code sections 11180 through 11191, to determine whether a violation of Labor Code section 5814.6 has occurred, including but not limited to reviewing, evaluating, copying and preserving electronic and paper records, files, accounts and other things, and interviewing potential witnesses.
(p) "Joint powers authority" means any county, city, city and county, municipal corporation, public district, public agency, or political subdivision of the state, but not the state itself, included 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).
(q) "Knowingly" means acting with knowledge of the facts of the conduct at issue. For the purposes of this article, a corporation has knowledge of the facts an employee receives while acting within the scope of his or her authority. A corporation has knowledge of information contained in its records and of the actions of its employees performed in the scope and course of employment. An employer or insurer has knowledge of information contained in the records of its third-party administrator and of the actions of the employees of the third-party administrator performed in the scope and course of employment.
(r) "Notice of Assessment" means Notice of Labor Code § 5814.6 Administrative Penalty Assessment.
(s) "Penalty award" means a final order or final award by the Workers' Compensation Appeals Board to pay penalties due to a violation of section 5814 of the Labor Code.
(t) "Petition Appealing Determination and Order" means Petition Appealing Determination and Order of the Administrative Director in re Labor Code § 5814.6 Administrative Penalties.
(u) "Proof of service" means an affidavit or declaration made under penalty of perjury and filed with one or more documents required to be filed, setting out a description of the document(s) being served, the names and addresses of all persons served, whether service was made personally or by mail, the date of service, and the place of service or the address to which mailing was made.
(v) "Prospective medical treatment authorization" means authorization requested or provided prior to the delivery of the medical services.
(w) "Recommended Determination and Order" means Recommended Determination and Order in re Labor Code § 5814.6 Administrative Penalties.
(x) "Retrospective medical treatment authorization" means authorization requested or provided after medical services have been provided and for which services approval has not already been given.
(y) "Salary continuation" means payment made to an injured employee as provided under Division 4 of the Labor Code.
(z) "Serve" means to file or deliver a document or to cause it to be delivered to the Administrative Director or his or her designee, or to such other person as is required under this article.
(aa) "Stipulated Order" means a Notice of Assessment that was timely paid.
(cc) "Third-party administrator" means an agent under contract to administer the workers' compensation claims of an insurer, a self-insured employer, a legally uninsured employer, a self-insured joint powers authority or on behalf of the California Insurance Guarantee Association. The term third-party administrator includes the State Compensation Insurance Fund for locations that administer claims for legally uninsured and self-insured employers, and also includes managing general agents.
(dd) "Utilization review files" means those files, documents or records, whether paper or electronic, containing information that documents an employer or insurer utilization review process required under Division 4 of the Labor Code.
(ee) "Workers' Compensation Appeals Board" means the Appeals Board, commissioners, deputy commissioners, presiding workers' compensation judges and workers' compensation administrative law judges.
History: added to be effective May 26, 2007.
Formerly section 10225