California Regulations 9792.10.4

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§ 9792.10.4 Independent Medical Review � Assignment and Notification

§ 9792.10.4. Independent Medical Review � Assignment and Notification.

Within one business day following a finding that the disputed medical treatment is eligible for independent medical review, the independent review organization delegated the responsibility by the Administrative Director to conduct independent medical review pursuant to Labor Code section 139.5 shall notify the parties in writing that the dispute has been assigned to that organization for review. The notification shall contain:

(a) The name and address of the independent review organization;

(b) Identification of the disputed medical treatment, including the date of the request for authorization, the name of the requesting physician, and the date of the claims administrator�s utilization review decision.

(c) The date the Application for Independent Medical Review, DWC Form IMR, was received by the Independent Review Organization.

(d) A statement whether the independent medical review will be conducted on a regular or expedited basis.

(e) For regular review, a statement that 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, the independent review organization must receive the documents indicated in section 9792.10.5. For the notification provided to the claims administrator, the statement shall provide that, pursuant to Labor Code section 4610.5(i), in addition to any other fines, penalties, and other remedies available to the Administrative Director, the failure to comply with section 9792.10.5 could result in the assessment of administrative penalties up to $5,000.00.

(f) For expedited review, a statement that within twenty-four (24) hours following receipt of the notification the independent review organization must receive the documents indicated in section 9792.10.5. For the notification provided to the claims administrator, the statement shall provide that, pursuant to Labor Code section 4610.5(i), in addition to any other fines, penalties, and other remedies available to the Administrative Director, the failure to comply with section 9792.10.5 could result in the assessment of administrative penalties up to $5,000.00.

(g) Review conducted on a regular basis shall be converted into an expedited review if, subsequent to the receipt of the Application for Independent Medical Review, DWC Form IMR, the independent review organization receives from the employee�s treating physician a certification that the employee faces an imminent and serious threat to his or her health as described in section 9792.10.1(a)(3). The independent review organization shall immediately notify the parties by the most efficient means available that the review has been converted from a regular review to an expedited review.

Authority: Sections 133, 4603.5 and 5307.3, Labor Code.

Reference: Sections 4062, 4600, 4600.4, 4604.5, 4610, and 4610.5, Labor Code.