Difference between revisions of "California Regulations 10108"

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<td width="80%" valign="top">The following general rules apply to audits and audit processes under Labor Code [[California_Labor_Codes_129| 129]],[[California_Labor_Codes_129.5| 129.5]]:
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<td width="80%" valign="top">The following general rules apply to audits and audit processes under Labor Code [[California_Labor_Codes_129| 129]],&nbsp;[[California_Labor_Codes_129.5| 129.5]]:
  
(a) If the date or deadline (including any applicable extension) to perform any act falls on a�weekend or holiday, the act may be performed on the last business day before or the first�business day after the weekend or holiday. A payment date which is changed under this�provision shall not change the normal dates for later payments in an existing two-week�payment schedule.
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&nbsp;(a) If the date or deadline (including any applicable extension) to perform any act falls on a&nbsp;weekend or holiday, the act may be performed on the last business day before or the first&nbsp;business day after the weekend or holiday. A payment date which is changed under this&nbsp;provision shall not change the normal dates for later payments in an existing two-week&nbsp;payment schedule.
  
(b) For the purpose of imposing audit penalties, if the claims administrator does not record the�date it received a document, it shall be deemed received five days after the latest date the�sender wrote on the document.
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&nbsp;(b) For the purpose of imposing audit penalties, if the claims administrator does not record the&nbsp;date it received a document, it shall be deemed received five days after the latest date the&nbsp;sender wrote on the document.
  
(c) Unless these regulations specifically provide otherwise, the penalty for an unlawful delay of�more than 30 days in performing an act is the same as the penalty for not performing the act.�However, the penalty may be mitigated for good faith because the act, though late, was�eventually performed. There will be no mitigation for good faith, however, if the act was�performed after notification to the audit subject that the claim was selected for audit. In such�cases where there is an unlawful delay of more than 30 days in performing an act and the act�was performed only after the audit subject was notified that the claim was selected for audit,�violations will be calculated for frequency under Section [[California_Regulations_10111.1| 10111.1]](e)(3) as though there was a�failure to perform the act rather than late performance of the act. For example, if unpaid�indemnity was paid more than 30 days late only after the audit subject was notified that the�claim was selected for audit, violations will be classified as failure to pay indemnity under�Section [[California_Regulations_10111.1| 10111.1]](e)(3)(xviii) of these regulations rather than late paid indemnity, and will be�modified for frequency accordingly. A lawful delay is a delay permitted by law or regulation,�and for which the claims administrator has given a proper and timely notice of delay when�such a notice is required. Any other delay is an unlawful delay.
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&nbsp;(c) Unless these regulations specifically provide otherwise, the penalty for an unlawful delay of&nbsp;more than 30 days in performing an act is the same as the penalty for not performing the act.&nbsp;However, the penalty may be mitigated for good faith because the act, though late, was&nbsp;eventually performed. There will be no mitigation for good faith, however, if the act was&nbsp;performed after notification to the audit subject that the claim was selected for audit. In such&nbsp;cases where there is an unlawful delay of more than 30 days in performing an act and the act&nbsp;was performed only after the audit subject was notified that the claim was selected for audit,&nbsp;violations will be calculated for frequency under Section [[California_Regulations_10111.1| 10111.1]](e)(3) as though there was a&nbsp;failure to perform the act rather than late performance of the act. For example, if unpaid&nbsp;indemnity was paid more than 30 days late only after the audit subject was notified that the&nbsp;claim was selected for audit, violations will be classified as failure to pay indemnity under&nbsp;Section [[California_Regulations_10111.1| 10111.1]](e)(3)(xviii) of these regulations rather than late paid indemnity, and will be&nbsp;modified for frequency accordingly. A lawful delay is a delay permitted by law or regulation,&nbsp;and for which the claims administrator has given a proper and timely notice of delay when&nbsp;such a notice is required. Any other delay is an unlawful delay.
  
(d) Penalties will not be assessed during the period a claims administrator is actively�investigating its liability for provision of benefits or payment of compensation, provided that a�Notice of Delay has been timely and properly issued in accordance with [[California_Regulations_9812| 9812]] or [[California_Regulations_9813| 9813]].�However, penalties shall still be issued for violations during the period of delay for: failure to�object to medical treatment bills in accordance with [[California_Regulations_9792.5| 9792.5]], or failure to object to or pay bills�for medical legal expense in accordance with [[California_Regulations_9794| 9794]].
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&nbsp;(d) Penalties will not be assessed during the period a claims administrator is actively&nbsp;investigating its liability for provision of benefits or payment of compensation, provided that a&nbsp;Notice of Delay has been timely and properly issued in accordance with [[California_Regulations_9812| 9812]] or [[California_Regulations_9813| 9813]].&nbsp;However, penalties shall still be issued for violations during the period of delay for: failure to&nbsp;object to medical treatment bills in accordance with [[California_Regulations_9792.5| 9792.5]], or failure to object to or pay bills&nbsp;for medical legal expense in accordance with [[California_Regulations_9794| 9794]].
  
(e) Penalties will not be assessed for an act or omission where an injured worker's�unreasonable refusal to cooperate in the investigation has prevented the claims administrator�from determining its legal obligation to perform the act.
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&nbsp;(e) Penalties will not be assessed for an act or omission where an injured worker's&nbsp;unreasonable refusal to cooperate in the investigation has prevented the claims administrator&nbsp;from determining its legal obligation to perform the act.
  
(f) Where a penalty is provided for failure to pay mileage fees related to medical treatment or�evaluation, a penalty will be imposed if payment is not made at a rate that is at least the greater�of the following: (i) twenty one cents per mile, or (ii) the minimum rate adopted by the�Director of the Department of Personnel Administration pursuant to Section 1[[California_Regulations_9820| 9820]] of the�Government Code for non-represented (excluded) employees at Title 2, CCR 599.631(a).
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&nbsp;(f) Where a penalty is provided for failure to pay mileage fees related to medical treatment or&nbsp;evaluation, a penalty will be imposed if payment is not made at a rate that is at least the greater&nbsp;of the following: (i) twenty one cents per mile, or (ii) the minimum rate adopted by the&nbsp;Director of the Department of Personnel Administration pursuant to Section 1[[California_Regulations_9820| 9820]] of the&nbsp;Government Code for non-represented (excluded) employees at Title 2, CCR 599.631(a).
  
(g) Failure, delay, or refusal to pay compensation benefits or expenses shall be subject to the�applicable penalties under [[California_Regulations_10111| 10111]] or [[California_Regulations_10111.1| 10111.1]] unless the legal, factual, or medical basis for�the failure, refusal, or delay is documented in the claim file.
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&nbsp;(g) Failure, delay, or refusal to pay compensation benefits or expenses shall be subject to the&nbsp;applicable penalties under [[California_Regulations_10111| 10111]] or [[California_Regulations_10111.1| 10111.1]] unless the legal, factual, or medical basis for&nbsp;the failure, refusal, or delay is documented in the claim file.
 
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Revision as of 17:19, 20 May 2008

California > Regulations

§ 10108 Audit Violations--General Rules

The following general rules apply to audits and audit processes under Labor Code 129 129.5:

 (a) If the date or deadline (including any applicable extension) to perform any act falls on a weekend or holiday, the act may be performed on the last business day before or the first business day after the weekend or holiday. A payment date which is changed under this provision shall not change the normal dates for later payments in an existing two-week payment schedule.

 (b) For the purpose of imposing audit penalties, if the claims administrator does not record the date it received a document, it shall be deemed received five days after the latest date the sender wrote on the document.

 (c) Unless these regulations specifically provide otherwise, the penalty for an unlawful delay of more than 30 days in performing an act is the same as the penalty for not performing the act. However, the penalty may be mitigated for good faith because the act, though late, was eventually performed. There will be no mitigation for good faith, however, if the act was performed after notification to the audit subject that the claim was selected for audit. In such cases where there is an unlawful delay of more than 30 days in performing an act and the act was performed only after the audit subject was notified that the claim was selected for audit, violations will be calculated for frequency under Section 10111.1(e)(3) as though there was a failure to perform the act rather than late performance of the act. For example, if unpaid indemnity was paid more than 30 days late only after the audit subject was notified that the claim was selected for audit, violations will be classified as failure to pay indemnity under Section 10111.1(e)(3)(xviii) of these regulations rather than late paid indemnity, and will be modified for frequency accordingly. A lawful delay is a delay permitted by law or regulation, and for which the claims administrator has given a proper and timely notice of delay when such a notice is required. Any other delay is an unlawful delay.

 (d) Penalties will not be assessed during the period a claims administrator is actively investigating its liability for provision of benefits or payment of compensation, provided that a Notice of Delay has been timely and properly issued in accordance with 9812 or 9813. However, penalties shall still be issued for violations during the period of delay for: failure to object to medical treatment bills in accordance with 9792.5, or failure to object to or pay bills for medical legal expense in accordance with 9794.

 (e) Penalties will not be assessed for an act or omission where an injured worker's unreasonable refusal to cooperate in the investigation has prevented the claims administrator from determining its legal obligation to perform the act.

 (f) Where a penalty is provided for failure to pay mileage fees related to medical treatment or evaluation, a penalty will be imposed if payment is not made at a rate that is at least the greater of the following: (i) twenty one cents per mile, or (ii) the minimum rate adopted by the Director of the Department of Personnel Administration pursuant to Section 1 9820 of the Government Code for non-represented (excluded) employees at Title 2, CCR 599.631(a).

 (g) Failure, delay, or refusal to pay compensation benefits or expenses shall be subject to the applicable penalties under 10111 or 10111.1 unless the legal, factual, or medical basis for the failure, refusal, or delay is documented in the claim file.