§ 9792.5.4. Second Review and Independent Bill Review -- Definitions.
8 CA ADC § 9792.5.4Barclays Official California Code of Regulations
Barclays California Code of Regulations
Title 8. Industrial Relations
Division 1. Department of Industrial Relations
Chapter 4.5. Division of Workers' Compensation
Subchapter 1. Administrative Director--Administrative Rules
Article 5.5.0. Rules for Medical Treatment Billing and Payment on or After October 15, 2011
8 CCR § 9792.5.4
§ 9792.5.4. Second Review and Independent Bill Review -- Definitions.
This section is applicable to medical treatment services and goods rendered under Labor Code section 4600, or medical-legal expenses incurred under Labor Code section 4620, on or after January 1, 2013.
(1) Medical treatment services or goods rendered by a provider or goods supplied in accordance with Labor Code section 4600 that were authorized by Labor Code section 4610, and for which there exists an applicable fee schedule adopted by the Administrative Director for those categories of goods and services, including but not limited to those found at sections 9789.10 to 9789.111, or for which a contract for reimbursement rates exists under Labor Code section 5307.11.
(c) “Claims Administrator” means 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 administrator for a self-insured employer, insurer, legally uninsured employer, or joint powers authority.
(d) “Contested liability” means the existence of a good-faith issue which, if resolved against the injured worker, would defeat the right to any workers' compensation benefits or the existence of a good-faith issue that would defeat a provider's right to receive compensation for medical treatment services provided in accordance with Labor Code section 4600 or for medical-legal expenses defined in Labor Code section 4620.
(i) “Provider” means a provider of medical treatment services or goods, including a health care facility as defined in Section One of the California Division of Workers' Compensation Medical Billing and Payment Guide as incorporated by reference in section 9792.5.1, whose billing processes are governed by Labor Code section 4603.2 or 4603.4, or a provider of medical-legal services whose billing processes are governed by Labor Code sections 4620 and 4622, that has requested a second bill review and, if applicable, independent bill review to resolve a dispute over the amount of payment for services according to either a fee schedule established by the Administrative Director or a contract for reimbursement rates under Labor Code section 5307.11. A provider may utilize the services of a billing agent, a person or entity that has contracted with the provider to process bills under this article for services or goods rendered by the provider, to request a second bill review or independent bill review.
Credits
Note: Authority cited: Sections 133, 4603.6, 5307.3 and 5307.6, Labor Code. Reference: Sections 4060, 4061, 4061.5, 4062, 4600, 4603.2, 4603.3. 4603.4, 4603.6, 4620, 4621, 4622, 4625, 4628 and 5307.6, Labor Code.
History
1. New section filed 12-31-2012 as an emergency; operative 1-1-2013 pursuant to Government Code section 11346.1(d) (Register 2013, No. 1). A Certificate of Compliance must be transmitted to OAL by 7-1-2013 or emergency language will be repealed by operation of law on the following day.
2. New section refiled 7-1-2013 as an emergency; operative 7-1-2013 (Register 2013, No. 27). A Certificate of Compliance must be transmitted to OAL by 9-30-2013 or emergency language will be repealed by operation of law on the following day.
3. New section refiled 9-30-2013 as an emergency; operative 10-1-2013 (Register 2013, No. 40). A Certificate of Compliance must be transmitted to OAL by 12-30-2013 or emergency language will be repealed by operation of law on the following day.
4. Certificate of Compliance as to 9-30-2013 order, including amendment of first paragraph and subsections (a)(1)-(2), (d) and (i), transmitted to OAL 12-30-2013 and filed 2-12-2014; amendments effective 2-12-2014 pursuant to Government Code section 11343.4(b)(3) (Register 2014, No. 7).
This database is current through 6/21/24 Register 2024, No. 25.
Cal. Admin. Code tit. 8, § 9792.5.4, 8 CA ADC § 9792.5.4
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