{"id":2565,"date":"2022-04-29T03:51:51","date_gmt":"2022-04-29T03:51:51","guid":{"rendered":"https:\/\/crowdsourcelawyers.com\/california-statutes\/?page_id=2565"},"modified":"2022-05-20T23:45:41","modified_gmt":"2022-05-20T23:45:41","slug":"labor-code-4610","status":"publish","type":"page","link":"https:\/\/crowdsourcelawyers.com\/california-statutes\/california-statutes\/labor-code-4610\/","title":{"rendered":"Labor Code 4610"},"content":{"rendered":"\n<style type=\"text\/css\" data-created_by=\"avia_inline_auto\" id=\"style-css-av-l2jw9mxu-84717583f519d780dec4be72fbd608b5\">\n#top .av-special-heading.av-l2jw9mxu-84717583f519d780dec4be72fbd608b5{\npadding-bottom:10px;\n}\nbody .av-special-heading.av-l2jw9mxu-84717583f519d780dec4be72fbd608b5 .av-special-heading-tag .heading-char{\nfont-size:25px;\n}\n.av-special-heading.av-l2jw9mxu-84717583f519d780dec4be72fbd608b5 .av-subheading{\nfont-size:22px;\n}\n<\/style>\n<div  class='av-special-heading av-l2jw9mxu-84717583f519d780dec4be72fbd608b5 av-special-heading-h1 blockquote modern-quote  avia-builder-el-0  el_before_av_hr  avia-builder-el-first '><div class='av-subheading av-subheading_above'><p>California<\/p>\n<\/div><h1 class='av-special-heading-tag '  itemprop=\"headline\"  >Labor Code &#8211; LAB \u00a7 4610<\/h1><div class=\"special-heading-border\"><div class=\"special-heading-inner-border\"><\/div><\/div><\/div>\n\n<style type=\"text\/css\" data-created_by=\"avia_inline_auto\" id=\"style-css-av-av_hr-3a876428eececa9d35452247ddb053af\">\n#top .hr.hr-invisible.av-av_hr-3a876428eececa9d35452247ddb053af{\nheight:50px;\n}\n<\/style>\n<div  class='hr av-av_hr-3a876428eececa9d35452247ddb053af hr-invisible  avia-builder-el-1  el_after_av_heading  el_before_av_textblock '><span class='hr-inner '><span class=\"hr-inner-style\"><\/span><\/span><\/div>\n<section  class='av_textblock_section av-av_textblock-e878f05c31dff72941bf1e49a00d9ff5 '   itemscope=\"itemscope\" itemtype=\"https:\/\/schema.org\/CreativeWork\" ><div class='avia_textblock'  itemprop=\"text\" ><p><a href=\"https:\/\/crowdsourcelawyers.com\/\">CrowdSourceLawyers.com<\/a><\/p>\n<\/div><\/section>\n\n<style type=\"text\/css\" data-created_by=\"avia_inline_auto\" id=\"style-css-av-avia_sc_search-4ee94ae86cde3b232e718bb4ac84e6ad\">\n#top .avia_search_element.av-avia_sc_search-4ee94ae86cde3b232e718bb4ac84e6ad .av_searchform_wrapper{\nborder-color:#edae44;\nbackground-color:#edae44;\n}\n#top .avia_search_element.av-avia_sc_search-4ee94ae86cde3b232e718bb4ac84e6ad #s.av-input-field{\ncolor:#edae44;\n}\n#top .avia_search_element.av-avia_sc_search-4ee94ae86cde3b232e718bb4ac84e6ad .av-input-field-icon.av-search-icon{\ncolor:#edae44;\n}\n#top .avia_search_element.av-avia_sc_search-4ee94ae86cde3b232e718bb4ac84e6ad .av-input-field-icon.av-search-icon.avia-svg-icon svg:first-child{\nfill:#edae44;\nstroke:#edae44;\n}\n#top .avia_search_element.av-avia_sc_search-4ee94ae86cde3b232e718bb4ac84e6ad #searchsubmit{\nbackground-color:#edae44;\n}\n#top .avia_search_element.av-avia_sc_search-4ee94ae86cde3b232e718bb4ac84e6ad .av_searchsubmit_wrapper{\nbackground-color:#edae44;\n}\n<\/style>\n<div  class='avia_search_element av-avia_sc_search-4ee94ae86cde3b232e718bb4ac84e6ad  avia-builder-el-3  el_after_av_textblock  el_before_av_hr '><search><form action='https:\/\/crowdsourcelawyers.com\/california-statutes\/' id='searchform_element' method='get' class='' data-element_id='av-avia_sc_search-4ee94ae86cde3b232e718bb4ac84e6ad' ><div class='av_searchform_wrapper'><input type='search' value='' id='s' name='s' placeholder='Search CA statutes' aria-label='Search CA statutes' class='av-input-field ' required \/><div class='av_searchsubmit_wrapper '><input type='submit' value='Find' id='searchsubmit' class='button ' title='View results on search page' aria-label='View results on search page' \/><\/div><input type='hidden' name='numberposts' value='10' \/><input type='hidden' name='results_hide_fields' value='' \/><\/div><\/form><\/search><\/div>\n\n<style type=\"text\/css\" data-created_by=\"avia_inline_auto\" id=\"style-css-av-av_hr-3a876428eececa9d35452247ddb053af\">\n#top .hr.hr-invisible.av-av_hr-3a876428eececa9d35452247ddb053af{\nheight:50px;\n}\n<\/style>\n<div  class='hr av-av_hr-3a876428eececa9d35452247ddb053af hr-invisible  avia-builder-el-4  el_after_avia_sc_search  el_before_av_textblock '><span class='hr-inner '><span class=\"hr-inner-style\"><\/span><\/span><\/div>\n<section  class='av_textblock_section av-l2jwelkx-ed2871317968fff462b1cb8182d48117 '   itemscope=\"itemscope\" itemtype=\"https:\/\/schema.org\/CreativeWork\" ><div class='avia_textblock'  itemprop=\"text\" ><div class=\"row\">\n<div class=\"subsection\"><\/div>\n<div class=\"subsection\">\n<div class=\"subsection\">\n<p>(a)\u2002For purposes of this section, \u201c<span class=\"wordphrase\">utilization review<\/span>\u201d means utilization review or utilization management functions that prospectively, retrospectively, or concurrently review and approve, modify, or deny, based in whole or in part on medical necessity to cure and relieve, treatment recommendations by physicians, as defined in\u00a0<span class=\"cite\">Section 3209.3\u00a0<\/span>, prior to, retrospectively, or concurrent with the provision of medical treatment services pursuant to\u00a0<span class=\"cite\">Section 4600\u00a0<\/span>.<\/p>\n<\/div>\n<div class=\"subsection\">\n<p>(b)\u2002For all dates of injury occurring on or after January 1, 2018, emergency treatment services and medical treatment rendered for a body part or condition that is accepted as compensable by the employer and is addressed by the medical treatment utilization schedule adopted pursuant to\u00a0<span class=\"cite\">Section 5307.7\u00a0<\/span>, by a member of the medical provider network or health care organization, or by a physician predesignated pursuant to\u00a0<span class=\"cite\">subdivision (d) of Section 4600\u00a0<\/span>, within the 30 days following the initial date of injury, shall be authorized without prospective utilization review, except as provided in subdivision (c). \u2002The services rendered under this subdivision shall be consistent with the medical treatment utilization schedule. \u2002In the event that the employee is not subject to treatment with a medical provider network, health care organization, or predesignated physician pursuant to\u00a0<span class=\"cite\">subdivision (d) of Section 4600\u00a0<\/span>, the employee shall be eligible for treatment under this section within 30 days following the initial date of injury if the treatment is rendered by a physician or facility selected by the employer. \u2002For treatment rendered by a medical provider network physician, health care organization physician, a physician predesignated pursuant to\u00a0<span class=\"cite\">subdivision (d) of Section 4600\u00a0<\/span>, or an employer-selected physician, the report required under\u00a0<span class=\"cite\">Section 6409\u00a0<\/span>and a complete request for authorization shall be submitted by the physician within five days following the employee&#8217;s initial visit and evaluation.<\/p>\n<\/div>\n<div class=\"subsection\">\n<p>(c)\u2002Unless authorized by the employer or rendered as emergency medical treatment, the following medical treatment services, as defined in rules adopted by the administrative director, that are rendered through a member of the medical provider network or health care organization, a predesignated physician, an employer-selected physician, or an employer-selected facility, within the 30 days following the initial date of injury, shall be subject to prospective utilization review under this section:<\/p>\n<div class=\"subsection\">\n<p style=\"padding-left: 40px\">(1)\u2002Pharmaceuticals, to the extent they are neither expressly exempted from prospective review nor authorized by the drug formulary adopted pursuant to\u00a0<span class=\"cite\">Section 5307.27\u00a0<\/span>.<\/p>\n<\/div>\n<div class=\"subsection\">\n<p style=\"padding-left: 40px\">(2)\u2002Nonemergency inpatient and outpatient surgery, including all presurgical and postsurgical services.<\/p>\n<\/div>\n<div class=\"subsection\">\n<p style=\"padding-left: 40px\">(3)\u2002Psychological treatment services.<\/p>\n<\/div>\n<div class=\"subsection\">\n<p style=\"padding-left: 40px\">(4)\u2002Home health care services.<\/p>\n<\/div>\n<div class=\"subsection\">\n<p style=\"padding-left: 40px\">(5)\u2002Imaging and radiology services, excluding X-rays.<\/p>\n<\/div>\n<div class=\"subsection\">\n<p style=\"padding-left: 40px\">(6)\u2002All durable medical equipment, whose combined total value exceeds two hundred fifty dollars ($250), as determined by the official medical fee schedule.<\/p>\n<\/div>\n<div class=\"subsection\">\n<p style=\"padding-left: 40px\">(7)\u2002Electrodiagnostic medicine, including, but not limited to, electromyography and nerve conduction studies.<\/p>\n<\/div>\n<div class=\"subsection\">\n<p style=\"padding-left: 40px\">(8)\u2002Any other service designated and defined through rules adopted by the administrative director.<\/p>\n<\/div>\n<\/div>\n<div class=\"subsection\">\n<div class=\"subsection\">\n<p>(d)<span class=\"added-material\">(1)\u2002Except for emergency treatment services, any<\/span>\u00a0request for payment for treatment provided under subdivision (b) shall comply with\u00a0<span class=\"cite\">Section 4603.2\u00a0<\/span>and be submitted to the employer, or its insurer or claims administrator, within 30 days of the date the service was provided.<\/p>\n<\/div>\n<div class=\"subsection\">\n<div class=\"subsection\">\n<p style=\"padding-left: 40px\"><span class=\"added-material\">(2)(A)\u2002In the case of emergency treatment services, any request for payment for treatment provided under subdivision (b) shall comply with\u00a0<span class=\"cite\">Section 4603.2\u00a0<\/span>and be submitted to the employer, or its insurer or claims administrator, within 180 days of the date the service was provided.<\/span><\/p>\n<\/div>\n<div class=\"subsection\">\n<p style=\"padding-left: 40px\"><span class=\"added-material\">(B)\u2002For the purposes of this subdivision, \u201c<span class=\"wordphrase\">emergency treatment services<\/span>\u201d means treatment for an emergency medical condition defined in\u00a0<span class=\"cite\">subdivision (b) of Section 1317.1 of the Health and Safety Code\u00a0<\/span>and provided in a licensed general acute care hospital, as defined in\u00a0<span class=\"cite\">Section 1250 of the Health and Safety Code\u00a0<\/span>.<\/span><\/p>\n<\/div>\n<\/div>\n<\/div>\n<div class=\"subsection\">\n<p>(e)\u2002If a physician fails to submit the report required under\u00a0<span class=\"cite\">Section 6409\u00a0<\/span>and a complete request for authorization, as described in subdivision (b), an employer may remove the physician&#8217;s ability under this subdivision to provide further medical treatment to the employee that is exempt from prospective utilization review.<\/p>\n<\/div>\n<div class=\"subsection\">\n<p>(f)\u2002An employer may perform retrospective utilization review for any treatment provided pursuant to subdivision (b) solely for the purpose of determining if the physician is prescribing treatment consistent with the schedule for medical treatment utilization, including, but not limited to, the drug formulary adopted pursuant to\u00a0<span class=\"cite\">Section 5307.27\u00a0<\/span>.<\/p>\n<div class=\"subsection\">\n<p style=\"padding-left: 40px\">(1)\u2002If it is found after retrospective utilization reviews that there is a pattern and practice of the physician or provider failing to render treatment consistent with the schedule for medical treatment utilization, including the drug formulary, the employer may remove the ability of the predesignated physician, employer-selected physician, or the member of the medical provider network or health care organization under this subdivision to provide further medical treatment to any employee that is exempt from prospective utilization review. \u2002The employer shall notify the physician or provider of the results of the retrospective utilization review and the requirement for prospective utilization review for all subsequent medical treatment.<\/p>\n<\/div>\n<div class=\"subsection\">\n<p style=\"padding-left: 40px\">(2)\u2002The results of retrospective utilization review may constitute a showing of good cause for an employer&#8217;s petition requesting a change of physician or provider pursuant to\u00a0<span class=\"cite\">Section 4603\u00a0<\/span>and may serve as grounds for termination of the physician or provider from the medical provider network or health care organization.<\/p>\n<\/div>\n<\/div>\n<div class=\"subsection\">\n<p>(g)\u2002Each employer shall establish a utilization review process in compliance with this section, either directly or through its insurer or an entity with which an employer or insurer contracts for these services.<\/p>\n<div class=\"subsection\">\n<p style=\"padding-left: 40px\">(1)\u2002Each utilization review process that modifies or denies requests for authorization of medical treatment shall be governed by written policies and procedures. \u2002These policies and procedures shall ensure that decisions based on the medical necessity to cure and relieve of proposed medical treatment services are consistent with the schedule for medical treatment utilization, including the drug formulary, adopted pursuant to\u00a0<span class=\"cite\">Section 5307.27\u00a0<\/span>.<\/p>\n<\/div>\n<div class=\"subsection\">\n<p style=\"padding-left: 40px\">(2)\u2002Unless otherwise indicated in this section, a physician providing treatment under\u00a0<span class=\"cite\">Section 4600\u00a0<\/span>shall send any request for authorization for medical treatment, with supporting documentation, to the claims administrator for the employer, insurer, or other entity according to rules adopted by the administrative director. \u2002The employer, insurer, or other entity shall employ or designate a medical director who holds an unrestricted license to practice medicine in this state issued pursuant to\u00a0<span class=\"cite\">Section 2050\u00a0<\/span>or\u00a0<span class=\"cite\">2450 of the Business and Professions Code\u00a0<\/span>. \u2002The medical director shall ensure that the process by which the employer or other entity reviews and approves, modifies, or denies requests by physicians prior to, retrospectively, or concurrent with the provision of medical treatment services complies with the requirements of this section. \u2002Nothing in this section shall be construed as restricting the existing authority of the Medical Board of California.<\/p>\n<\/div>\n<div class=\"subsection\">\n<div class=\"subsection\">\n<p style=\"padding-left: 40px\">(3)(A)\u2002A person other than a licensed physician who is competent to evaluate the specific clinical issues involved in the medical treatment services, if these services are within the scope of the physician&#8217;s practice, requested by the physician, shall not modify or deny requests for authorization of medical treatment for reasons of medical necessity to cure and relieve or due to incomplete or insufficient information under subdivisions (i) and (j).<\/p>\n<\/div>\n<div class=\"subsection\">\n<div class=\"subsection\">\n<p style=\"padding-left: 40px\">(B)(i)\u2002The employer, or any entity conducting utilization review on behalf of the employer, shall neither offer nor provide any financial incentive or consideration to a physician based on the number of modifications or denials made by the physician under this section.<\/p>\n<\/div>\n<div class=\"subsection\">\n<p style=\"padding-left: 40px\">(ii)\u2002An insurer or third-party administrator shall not refer utilization review services conducted on behalf of an employer under this section to an entity in which the insurer or third-party administrator has a financial interest as defined under\u00a0<span class=\"cite\">Section 139.32\u00a0<\/span>. \u2002This prohibition does not apply if the insurer or third-party administrator provides the employer and the administrative director with prior written disclosure of both of the following:<\/p>\n<div class=\"subsection\">\n<p style=\"padding-left: 40px\">(I)\u2002The entity conducting the utilization review services.<\/p>\n<\/div>\n<div class=\"subsection\">\n<p style=\"padding-left: 40px\">(II)\u2002The insurer or third-party administrator&#8217;s financial interest in the entity.<\/p>\n<\/div>\n<\/div>\n<\/div>\n<div class=\"subsection\">\n<p style=\"padding-left: 40px\">(C)\u2002The administrative director has authority pursuant to this section to review any compensation agreement, payment schedule, or contract between the employer, or any entity conducting utilization review on behalf of the employer, and the utilization review physician. \u2002Any information disclosed to the administrative director pursuant to this paragraph shall be considered confidential information and not subject to disclosure pursuant to the California Public Records Act (Chapter 3.5 (commencing with\u00a0<span class=\"cite\">Section 6250) of Division 7 of Title 1 of the Government Code\u00a0<\/span>). \u2002Disclosure of the information to the administrative director pursuant to this subdivision shall not waive the provisions of the Evidence Code relating to privilege.<\/p>\n<\/div>\n<\/div>\n<div class=\"subsection\">\n<p style=\"padding-left: 40px\">(4)\u2002A utilization review process that modifies or denies requests for authorization of medical treatment shall be accredited on or before July 1, 2018, and shall retain active accreditation while providing utilization review services, by an independent, nonprofit organization to certify that the utilization review process meets specified criteria, including, but not limited to, timeliness in issuing a utilization review decision, the scope of medical material used in issuing a utilization review decision, peer-to-peer consultation, internal appeal procedure, and requiring a policy preventing financial incentives to doctors and other providers based on the utilization review decision. \u2002The administrative director shall adopt rules to implement the selection of an independent, nonprofit organization for those accreditation purposes. \u2002Until those rules are adopted, the administrative director shall designate URAC as the accrediting organization. \u2002The administrative director may adopt rules to do any of the following:<\/p>\n<div class=\"subsection\">\n<p style=\"padding-left: 40px\">(A)\u2002Require additional specific criteria for measuring the quality of a utilization review process for purposes of accreditation.<\/p>\n<\/div>\n<div class=\"subsection\">\n<p style=\"padding-left: 40px\">(B)\u2002Exempt nonprofit, public sector internal utilization review programs from the accreditation requirement pursuant to this section, if the administrative director has adopted minimum standards applicable to nonprofit, public sector internal utilization review programs that meet or exceed the accreditation standards developed pursuant to this section.<\/p>\n<\/div>\n<\/div>\n<div class=\"subsection\">\n<p style=\"padding-left: 40px\">(5)\u2002On or before July 1, 2018, each employer, either directly or through its insurer or an entity with which an employer or insurer contracts for utilization review services, shall submit a description of the utilization review process that modifies or denies requests for authorization of medical treatment and the written policies and procedures to the administrative director for approval. \u2002Approved utilization review process descriptions and the accompanying written policies and procedures shall be disclosed by the employer to employees and physicians and made available to the public by posting on the employer&#8217;s, claims administrator&#8217;s, or utilization review organization&#8217;s Internet Web site.<\/p>\n<\/div>\n<\/div>\n<div class=\"subsection\">\n<p>(h)\u2002The criteria or guidelines used in the utilization review process to determine whether to approve, modify, or deny medical treatment services shall be all of the following:<\/p>\n<div class=\"subsection\">\n<p style=\"padding-left: 40px\">(1)\u2002Developed with involvement from actively practicing physicians.<\/p>\n<\/div>\n<div class=\"subsection\">\n<p style=\"padding-left: 40px\">(2)\u2002Consistent with the schedule for medical treatment utilization, including the drug formulary, adopted pursuant to\u00a0<span class=\"cite\">Section 5307.27\u00a0<\/span>.<\/p>\n<\/div>\n<div class=\"subsection\">\n<p style=\"padding-left: 40px\">(3)\u2002Evaluated at least annually, and updated if necessary.<\/p>\n<\/div>\n<div class=\"subsection\">\n<p style=\"padding-left: 40px\">(4)\u2002Disclosed to the physician and the employee, if used as the basis of a decision to modify or deny services in a specified case under review.<\/p>\n<\/div>\n<div class=\"subsection\">\n<p style=\"padding-left: 40px\">(5)\u2002Available to the public upon request. \u2002An employer shall only be required to disclose the criteria or guidelines for the specific procedures or conditions requested. \u2002An employer may charge members of the public reasonable copying and postage expenses related to disclosing criteria or guidelines pursuant to this paragraph. \u2002Criteria or guidelines may also be made available through electronic means. \u2002A charge shall not be required for an employee whose physician&#8217;s request for medical treatment services is under review.<\/p>\n<\/div>\n<\/div>\n<div class=\"subsection\">\n<p>(i)\u2002In determining whether to approve, modify, or deny requests by physicians prior to, retrospectively, or concurrent with the provisions of medical treatment services to employees, all of the following requirements shall be met:<\/p>\n<div class=\"subsection\">\n<p style=\"padding-left: 40px\">(1)\u2002Except for treatment requests made pursuant to the formulary, prospective or concurrent decisions shall be made in a timely fashion that is appropriate for the nature of the employee&#8217;s condition, not to exceed five working days from the receipt of a request for authorization for medical treatment and supporting information reasonably necessary to make the determination, but in no event more than 14 days from the date of the medical treatment recommendation by the physician. \u2002Prospective decisions regarding requests for treatment covered by the formulary shall be made no more than five working days from the date of receipt of the medical treatment request. \u2002The request for authorization and supporting documentation may be submitted electronically under rules adopted by the administrative director.<\/p>\n<\/div>\n<div class=\"subsection\">\n<p style=\"padding-left: 40px\">(2)\u2002In cases where the review is retrospective, a decision resulting in denial of all or part of the medical treatment service shall be communicated to the individual who received services, or to the individual&#8217;s designee, within 30 days of the receipt of the information that is reasonably necessary to make this determination. \u2002If payment for a medical treatment service is made within the time prescribed by\u00a0<span class=\"cite\">Section 4603.2\u00a0<\/span>, a retrospective decision to approve the service need not otherwise be communicated.<\/p>\n<\/div>\n<div class=\"subsection\">\n<p style=\"padding-left: 40px\">(3)\u2002If the employee&#8217;s condition is one in which the employee faces an imminent and serious threat to his or her health, including, but not limited to, the potential loss of life, limb, or other major bodily function, or the normal timeframe for the decisionmaking process, as described in paragraph (1), would be detrimental to the employee&#8217;s life or health or could jeopardize the employee&#8217;s ability to regain maximum function, decisions to approve, modify, or deny requests by physicians prior to, or concurrent with, the provision of medical treatment services to employees shall be made in a timely fashion that is appropriate for the nature of the employee&#8217;s condition, but not to exceed 72 hours after the receipt of the information reasonably necessary to make the determination.<\/p>\n<\/div>\n<div class=\"subsection\">\n<div class=\"subsection\">\n<p style=\"padding-left: 40px\">(4)(A)\u2002Final decisions to approve, modify, or deny requests by physicians for authorization prior to, or concurrent with, the provision of medical treatment services to employees shall be communicated to the requesting physician within 24 hours of the decision by telephone, facsimile, or, if agreed to by the parties, secure email.<\/p>\n<\/div>\n<div class=\"subsection\">\n<p style=\"padding-left: 40px\">(B)\u2002Decisions resulting in modification or denial of all or part of the requested health care service shall be communicated in writing to the employee, and to the physician if the initial communication under subparagraph (A) was by telephone, within 24 hours for concurrent review, or within two business days of the decision for prospective review, as prescribed by the administrative director. \u2002If the request is modified or denied, disputes shall be resolved in accordance with\u00a0<span class=\"cite\">Section 4610.5\u00a0<\/span>, if applicable, or otherwise in accordance with\u00a0<span class=\"cite\">Section 4062\u00a0<\/span>.<\/p>\n<\/div>\n<div class=\"subsection\">\n<p style=\"padding-left: 40px\">(C)\u2002In the case of concurrent review, medical care shall not be discontinued until the employee&#8217;s physician has been notified of the decision and a care plan has been agreed upon by the physician that is appropriate for the medical needs of the employee. \u2002Medical care provided during a concurrent review shall be care that is medically necessary to cure and relieve, and an insurer or self-insured employer shall only be liable for those services determined medically necessary to cure and relieve. \u2002If the insurer or self-insured employer disputes whether or not one or more services offered concurrently with a utilization review were medically necessary to cure and relieve, the dispute shall be resolved pursuant to\u00a0<span class=\"cite\">Section 4610.5\u00a0<\/span>, if applicable, or otherwise pursuant to\u00a0<span class=\"cite\">Section 4062\u00a0<\/span>. \u2002A compromise between the parties that an insurer or self-insured employer believes may result in payment for services that were not medically necessary to cure and relieve shall be reported by the insurer or the self-insured employer to the licensing board of the provider or providers who received the payments, in a manner set forth by the respective board and in a way that minimizes reporting costs both to the board and to the insurer or self-insured employer, for evaluation as to possible violations of the statutes governing appropriate professional practices. \u2002Fees shall not be levied upon insurers or self-insured employers making reports required by this section.<\/p>\n<\/div>\n<\/div>\n<div class=\"subsection\">\n<p style=\"padding-left: 40px\">(5)\u2002Communications regarding decisions to approve requests by physicians shall specify the specific medical treatment service approved. \u2002Responses regarding decisions to modify or deny medical treatment services requested by physicians shall include a clear and concise explanation of the reasons for the employer&#8217;s decision, a description of the criteria or guidelines used, and the clinical reasons for the decisions regarding medical necessity. \u2002If a utilization review decision to deny a medical service is due to incomplete or insufficient information, the decision shall specify all of the following:<\/p>\n<div class=\"subsection\">\n<p style=\"padding-left: 40px\">(A)\u2002The reason for the decision.<\/p>\n<\/div>\n<div class=\"subsection\">\n<p style=\"padding-left: 40px\">(B)\u2002A specific description of the information that is needed.<\/p>\n<\/div>\n<div class=\"subsection\">\n<p style=\"padding-left: 40px\">(C)\u2002The date(s) and time(s) of attempts made to contact the physician to obtain the necessary information.<\/p>\n<\/div>\n<div class=\"subsection\">\n<p style=\"padding-left: 40px\">(D)\u2002A description of the manner in which the request was communicated.<\/p>\n<\/div>\n<\/div>\n<\/div>\n<div class=\"subsection\">\n<div class=\"subsection\">\n<p>(j)(1)\u2002Unless otherwise indicated in this section, a physician providing treatment under\u00a0<span class=\"cite\">Section 4600\u00a0<\/span>shall send any request for authorization for medical treatment, with supporting documentation, to the claims administrator for the employer, insurer, or other entity according to rules adopted by the administrative director. \u2002If an employer, insurer, or other entity subject to this section requests medical information from a physician in order to determine whether to approve, modify, or deny requests for authorization, that employer, insurer, or other entity shall request only the information reasonably necessary to make the determination.<\/p>\n<\/div>\n<div class=\"subsection\">\n<p style=\"padding-left: 40px\">(2)\u2002If the employer, insurer, or other entity cannot make a decision within the timeframes specified in paragraph (1), (2), or (3) of subdivision (i) because the employer or other entity is not in receipt of, or in possession of, all of the information reasonably necessary to make a determination, the employer shall immediately notify the physician and the employee, in writing, that the employer cannot make a decision within the required timeframe, and specify the information that must be provided by the physician for a determination to be made. \u2002Upon receipt of all information reasonably necessary and requested by the employer, the employer shall approve, modify, or deny the request for authorization within the timeframes specified in paragraph (1), (2), or (3) of subdivision (i).<\/p>\n<\/div>\n<\/div>\n<div class=\"subsection\">\n<p>(k)\u2002A utilization review decision to modify or deny a treatment recommendation shall remain effective for 12 months from the date of the decision without further action by the employer with regard to a further recommendation by the same physician, or another physician within the requesting physician&#8217;s practice group, for the same treatment unless the further recommendation is supported by a documented change in the facts material to the basis of the utilization review decision.<\/p>\n<\/div>\n<div class=\"subsection\">\n<p>(<i>l<\/i>)\u2002Utilization review of a treatment recommendation shall not be required while the employer is disputing liability for injury or treatment of the condition for which treatment is recommended pursuant to\u00a0<span class=\"cite\">Section 4062\u00a0<\/span>.<\/p>\n<\/div>\n<div class=\"subsection\">\n<p>(m)\u2002If utilization review is deferred pursuant to subdivision (<i>l<\/i>), and it is finally determined that the employer is liable for treatment of the condition for which treatment is recommended, the time for the employer to conduct retrospective utilization review in accordance with paragraph (2) of subdivision (i) shall begin on the date the determination of the employer&#8217;s liability becomes final, and the time for the employer to conduct prospective utilization review shall commence from the date of the employer&#8217;s receipt of a treatment recommendation after the determination of the employer&#8217;s liability.<\/p>\n<\/div>\n<div class=\"subsection\">\n<p>(n)\u2002Each employer, insurer, or other entity subject to this section shall maintain telephone access during California business hours for physicians to request authorization for health care services and to conduct peer-to-peer discussions regarding issues, including the appropriateness of a requested treatment, modification of a treatment request, or obtaining additional information needed to make a medical necessity decision.<\/p>\n<\/div>\n<div class=\"subsection\">\n<p>(<i>o<\/i>)\u2002The administrative director shall develop a system for the mandatory electronic reporting of documents related to every utilization review performed by each employer, which shall be administered by the Division of Workers&#8217; Compensation. \u2002The administrative director shall adopt regulations specifying the documents to be submitted by the employer and the authorized transmission format and timeframe for their submission. \u2002For purposes of this subdivision, \u201c<span class=\"wordphrase\">employer<\/span>\u201d means the employer, the insurer of an insured employer, a claims administrator, or a utilization review organization, or other entity acting on behalf of any of them.<\/p>\n<\/div>\n<div class=\"subsection\">\n<p>(p)\u2002If the administrative director determines that the employer, insurer, or other entity subject to this section has failed to meet any of the timeframes in this section, or has failed to meet any other requirement of this section, the administrative director may assess, by order, administrative penalties for each failure. \u2002A proceeding for the issuance of an order assessing administrative penalties shall be subject to appropriate notice to, and an opportunity for a hearing with regard to, the person affected. \u2002The administrative penalties shall not be deemed to be an exclusive remedy for the administrative director. \u2002These penalties shall be deposited in the Workers&#8217; Compensation Administration Revolving Fund.<\/p>\n<\/div>\n<div class=\"subsection\">\n<p>(q)\u2002The administrative director shall contract with an outside, independent research organization on or after March 1, 2019, to evaluate the impact of the provision of medical treatment within the first 30 days after a claim is filed, for a claim filed on or after January 1, 2017, and before January 1, 2019. \u2002The report shall be provided to the administrative director, the Senate Committee on Labor and Industrial Relations, and the Assembly Committee on Insurance before January 1, 2020.<\/p>\n<\/div>\n<div class=\"subsection\">\n<p>(r)\u2002This section shall become operative on January 1, 2018.<\/p>\n<\/div>\n<p><br class=\"avia-permanent-lb\" \/><br class=\"avia-permanent-lb\" \/><\/p>\n<\/div>\n<\/div>\n<hr \/>\n<p><a href=\"https:\/\/crowdsourcelawyers.com\/\">CrowdSourceLawyers.com<\/a><\/p>\n<\/div><\/section>\n","protected":false},"excerpt":{"rendered":"","protected":false},"author":9,"featured_media":0,"parent":2019,"menu_order":0,"comment_status":"closed","ping_status":"closed","template":"","meta":{"footnotes":""},"class_list":["post-2565","page","type-page","status-publish","hentry"],"yoast_head":"<!-- This site is optimized with the Yoast SEO plugin v27.7 - https:\/\/yoast.com\/product\/yoast-seo-wordpress\/ -->\n<title>Labor Code 4610 - California Statutes<\/title>\n<meta name=\"robots\" content=\"index, follow, max-snippet:-1, max-image-preview:large, max-video-preview:-1\" \/>\n<link rel=\"canonical\" href=\"https:\/\/crowdsourcelawyers.com\/california-statutes\/california-statutes\/labor-code-4610\/\" \/>\n<meta property=\"og:locale\" content=\"en_US\" \/>\n<meta property=\"og:type\" content=\"article\" \/>\n<meta property=\"og:title\" content=\"Labor Code 4610 - California Statutes\" 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