CA Workers Comp Specialist cheat sheet

Claim form (DWC-1) must be given to the employee within one working day of knowledge of injury; employee returns it and the employer delivers it to the claims administrator within one working day of receipt.

Claims administrator must send the employee a written notice of the decision to accept or deny the claim (DWC-7 style notice) within 14 days of receipt of the claim form, or 21 days if the claim is denied and additional investigation is needed.

A delay in accepting or denying within 90 days of the claim form being filed is presumptively an acceptance of the claim under Labor Code 5402.

Employer must provide the employee a claim form and, where applicable, the predesignated physician notice; failure to provide a claim form can extend the time to file a claim.

The claims administrator must authorize medical treatment within one working day of receiving a request (Utilization Review decision) and must pay or object to medical bills within 45 working days.

Penalties: up to 25% plus interest on unreasonably delayed or refused benefits (Labor Code 5814); failure to pay undisputed permanent disability may trigger additional 10% penalty under 4553/4554 in serious and willful cases.

Statute of limitations: one year from the date of injury, or one year from the date of last payment of benefits, whichever is later; occupational disease uses the date of disability or last injurious exposure.

Serious and willful misconduct claims require filing a petition (DWC-1A) and can add 50% to compensation; the employer's conduct must be knowing and intentional.

Temporary Disability (TD): payable at two-thirds of average weekly earnings, subject to minimum and maximum rates set annually; payable every two weeks until the employee reaches maximum medical improvement (MMI) or is deemed permanent and stationary.

TD maximum is generally 104 weeks within five years of injury, with exceptions for certain injuries (e.g., 240 weeks for specified conditions such as amputations, severe burns, or where the employee is unable to return to work).

Permanent Disability (PD): calculated as PD rating percentage × weekly PD rate (set by statute, adjusted annually) × 1.5 for injuries on or after 1/1/2013 under SB 863, subject to the statutory maximum and minimum.

Permanent Disability advances may be paid at 100% of the PD rate or 50% if the employee is receiving TD simultaneously, with credit against the final award.

Medical treatment: employer must provide all reasonably necessary medical treatment to cure or relieve the effects of the injury, including mileage reimbursement at the IRS rate.

Supplemental job displacement benefit (SJDB): voucher up to $6,000 for retraining, available when the employee is permanently unable to return to the pre-injury job and has been employed at least 12 months.

Death benefits: burial expenses up to a statutory cap and total death benefits payable to dependents, with rates based on the number of dependents.

Vocational rehabilitation was repealed for injuries on or after 1/1/2004; replaced by the SJDB voucher system.

Utilization Review (UR): prospective, concurrent, or retrospective review of treatment requests against the MTUS; decisions must be made within 5 working days (or 72 hours for expedited), with one working day for authorization of treatment.

Independent Medical Review (IMR): employee may appeal a UR denial within 30 days; IMR is binding and conducted by an independent reviewer; no cost to the employee.

Qualified Medical Evaluator (QME): a physician certified by the DWC Medical Unit to resolve medical disputes; employee may request a QME panel (3 names) after a dispute arises.

Panel QME: the employee selects a QME from the panel; if represented, the parties may agree or the employee's attorney selects; unrepresented injured workers may use a QME from the panel.

Medical-legal evaluations must be reported on the appropriate DWC form (e.g., PR-2, PR-3, PR-4) and include a summary of findings, diagnosis, and causation opinion.

Medical bill review: claims administrator reviews bills for compliance with the Official Medical Fee Schedule (OMFS), correct coding, and medical necessity; must pay, adjust, or object within 45 working days.

If a bill is not paid or objected to within the statutory time frame, the provider may file a lien; the claims administrator may be liable for the full amount plus penalties.

The Medical Fee Schedule (OMFS) governs fees for physician services, outpatient, and inpatient services, with separate schedules for different service categories.

Official Medical Fee Schedule (OMFS): sets maximum allowable fees for medical services; based on Medicare RBRVS for physician services, with a California-specific conversion factor.

Physician services are billed using CPT codes; the OMFS uses the Resource-Based Relative Value Scale (RBRVS) methodology with geographic adjustment.

Inpatient hospital services are reimbursed under the OMFS using the All Patient Refined Diagnosis Related Group (APR-DRG) methodology.

Outpatient hospital services use the Outpatient Prospective Payment System (OPPS) or the OMFS outpatient fee schedule, depending on the service.

Pharmacy: medications are reimbursed at the Medi-Cal rate plus a dispensing fee, with specific rules for repackaged drugs and compounded medications.

Durable Medical Equipment (DME) and prosthetics are reimbursed at the OMFS DME fee schedule, generally based on Medicare rates plus a markup.

Billing codes: use CPT for procedures, ICD-10-CM for diagnoses, HCPCS for supplies and DME; coding must match the service provided and be supported by documentation.

Electronic billing: providers must submit bills electronically using the standard 837P format; claims administrators must accept electronic bills and respond within 45 working days.

Permanent Disability (PD) is determined when the employee reaches maximum medical improvement (MMI) or is permanent and stationary.

The PD rating is based on the AMA Guides to the Evaluation of Permanent Impairment, 5th Edition, as required by the 2005 reforms, with the California Schedule for Rating Permanent Disabilities.

The rating formula: PD percentage × PD weekly rate × 1.5 (for injuries on or after 1/1/2013) = total PD benefit, subject to the statutory maximum.

The PD weekly rate is set by statute and adjusted annually; for 2024, the maximum is approximately $290 per week (check current DWC rate).

Apportionment: PD may be apportioned to pre-existing conditions or prior injuries, but only where the apportionment is based on substantial medical evidence (e.g., a QME or AME opinion).

The employee may dispute the PD rating by requesting a QME or AME evaluation; the rating is then determined by the agreed or selected physician.

Permanent disability payments may be made in a lump sum or in installments; the employee may request a lump sum settlement, subject to approval.

The Schedule for Rating Permanent Disabilities provides standardized ratings for various body parts and conditions; the 2005 Schedule is used for injuries on or after 1/1/2005.

DWC-1 claim form: employer must provide within one working day of knowledge of injury; employee returns it; employer sends to claims administrator within one working day of receipt.

Claims administrator must send notice of acceptance or denial within 14 days of receipt of the claim form (21 days if denying and investigating).

If no denial within 90 days of the claim form being filed, the claim is presumed accepted (Labor Code 5402).

Medical treatment authorization: UR decision within 5 working days (or 72 hours expedited); authorization within one working day of UR approval.

Medical bill payment: pay, adjust, or object within 45 working days of receipt of the bill.

Penalties: 25% plus interest for unreasonable delay (Labor Code 5814); 10% for serious and willful (4553/4554); up to $10,000 for failure to provide claim form.

Statute of limitations: one year from injury or last payment of benefits; occupational disease: one year from disability or last injurious exposure.

Serious and willful petition: file DWC-1A; employer conduct must be knowing and intentional; 50% increase in compensation.

TD rate = 2/3 × average weekly earnings, subject to statutory minimum and maximum; payable every two weeks.

TD maximum: 104 weeks within 5 years of injury; exceptions: 240 weeks for specified severe injuries (e.g., amputations, severe burns, where employee cannot return to work).

PD benefit = PD percentage × PD weekly rate × 1.5 (for injuries on/after 1/1/2013), subject to statutory maximum and minimum.

PD advances: 100% of PD rate, or 50% if receiving TD simultaneously; credited against final award.

SJDB voucher: up to $6,000 for retraining; employee must have worked 12 months and be permanently unable to return to pre-injury job.

Death benefits: burial expenses up to statutory cap; total death benefits based on number of dependents.

Medical mileage: reimbursed at IRS rate for travel to/from medical appointments.

Vocational rehabilitation: repealed for injuries on/after 1/1/2004; replaced by SJDB voucher.

UR: review treatment requests against MTUS; decisions within 5 working days (72 hours expedited); authorization within one working day.

IMR: employee may appeal UR denial within 30 days; binding decision; no cost to employee.

QME: DWC-certified physician; employee may request a panel of 3 QMEs after a medical dispute arises.

Panel QME: employee selects from panel; if represented, parties may agree or employee's attorney selects; unrepresented employee uses panel.

Medical-legal reports: use DWC forms (PR-2, PR-3, PR-4); must include findings, diagnosis, causation opinion.

Medical bill review: check OMFS compliance, coding accuracy, medical necessity; pay, adjust, or object within 45 working days.

Failure to pay/object within 45 working days: provider may file lien; claims administrator may be liable for full amount plus penalties.

OMFS: based on Medicare RBRVS for physician services; California-specific conversion factor; separate schedules for inpatient/outpatient.

OMFS physician services: based on Medicare RBRVS with California conversion factor; CPT codes used for procedures.

Inpatient hospital: reimbursed under OMFS using APR-DRG methodology.

Outpatient hospital: OPPS or OMFS outpatient fee schedule, depending on service.

Pharmacy: Medi-Cal rate plus dispensing fee; specific rules for repackaged and compounded drugs.

DME/prosthetics: OMFS DME fee schedule, generally Medicare rates plus markup.

Coding: CPT for procedures, ICD-10-CM for diagnoses, HCPCS for supplies/DME; must match service and documentation.

Electronic billing: 837P format required; claims administrators must accept electronic bills and respond within 45 working days.

Fee schedule updates: OMFS updated annually; providers must use current codes and rates.

PD determined at MMI or permanent and stationary status.

Rating based on AMA Guides 5th Edition and California Schedule for Rating Permanent Disabilities (2005 Schedule for injuries on/after 1/1/2005).

PD benefit = PD % × PD weekly rate × 1.5 (injuries on/after 1/1/2013), subject to statutory max/min.

PD weekly rate set by statute, adjusted annually; check current DWC rate for maximum.

Apportionment: PD may be apportioned to pre-existing conditions/prior injuries only with substantial medical evidence (QME/AME opinion).

Employee may dispute PD rating by requesting QME or AME; rating determined by agreed or selected physician.

PD payments: lump sum or installments; lump sum settlement requires approval.

Schedule for Rating Permanent Disabilities: standardized ratings for body parts/conditions; 2005 Schedule applies to injuries on/after 1/1/2005.