CA Workers Comp Specialist flashcards

32 cards. Read the term and the definition here. The deck at the top of this page is optional.

DWC-1 claim form

The employee's claim form that the employer must provide within one working day of knowledge of injury and deliver to the claims administrator within one working day of receipt.

14-day acceptance notice

The claims administrator must send a written notice of acceptance or denial of the claim within 14 days of receiving the claim form, or 21 days if denying and investigating.

90-day presumption

If the claims administrator fails to accept or deny the claim within 90 days of the claim form being filed, the claim is presumptively accepted under Labor Code 5402.

Labor Code 5814 penalty

A penalty of up to 25% plus interest may be imposed on benefits unreasonably delayed or refused by the claims administrator.

Serious and willful petition

Filed on form DWC-1A; requires knowing and intentional employer misconduct and can increase compensation by 50% under Labor Code 4553/4554.

Statute of limitations

Generally one year from the date of injury or last payment of benefits; for occupational disease, one year from disability or last injurious exposure.

Temporary disability rate

Two-thirds of average weekly earnings, subject to statutory minimum and maximum rates set annually, payable every two weeks until maximum medical improvement.

104-week TD cap

Temporary disability is generally limited to 104 weeks within five years of injury, with exceptions extending to 240 weeks for specified severe conditions.

Permanent disability formula

PD benefit equals PD percentage times the PD weekly rate times 1.5 for injuries on or after 1/1/2013, subject to statutory maximum and minimum.

Supplemental job displacement benefit

A voucher up to $6,000 for retraining, available when the employee is permanently unable to return to the pre-injury job after 12 months of employment.

Death benefits

Burial expenses up to a statutory cap plus total death benefits paid to dependents, with amounts based on the number of dependents.

Vocational rehabilitation repeal

Vocational rehabilitation was repealed for injuries on or after 1/1/2004 and replaced by the supplemental job displacement benefit voucher system.

Utilization Review timeline

UR decisions must be made within 5 working days, or 72 hours for expedited review, with treatment authorized within one working day of approval.

Independent Medical Review

The employee may appeal a UR denial within 30 days; IMR is binding, conducted by an independent reviewer, and free to the employee.

Qualified Medical Evaluator

A physician certified by the DWC Medical Unit to resolve medical disputes; the employee may request a panel of three QMEs after a dispute arises.

Panel QME selection

The employee selects a QME from the three-name panel; if represented, the parties may agree or the employee's attorney selects; unrepresented employees use the panel.

Medical bill review timeline

The claims administrator must pay, adjust, or object to a medical bill within 45 working days of receipt, checking OMFS compliance, coding, and necessity.

Medical-legal report forms

Evaluations are reported on DWC forms such as PR-2, PR-3, and PR-4, and must include findings, diagnosis, and a causation opinion.

Official Medical Fee Schedule

Sets maximum allowable fees for medical services, based on Medicare RBRVS for physician services with a California-specific conversion factor.

Inpatient hospital reimbursement

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

Outpatient hospital reimbursement

Outpatient hospital services are reimbursed under the Outpatient Prospective Payment System or the OMFS outpatient fee schedule, depending on the service.

Pharmacy reimbursement

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

DME fee schedule

Durable medical equipment and prosthetics are reimbursed under the OMFS DME fee schedule, generally based on Medicare rates plus a markup.

Billing code types

CPT codes are used for procedures, ICD-10-CM for diagnoses, and HCPCS for supplies and DME; coding must match the service and documentation.

Electronic billing format

Providers must submit bills electronically using the standard 837P format, and claims administrators must accept electronic bills and respond within 45 working days.

Maximum medical improvement

The point at which the employee's condition has stabilized and further treatment is not expected to improve it; permanent disability is then determined.

AMA Guides 5th Edition

The rating basis required by the 2005 reforms, used with the California Schedule for Rating Permanent Disabilities to determine PD percentages.

Apportionment

PD may be apportioned to pre-existing conditions or prior injuries only where supported by substantial medical evidence, such as a QME or AME opinion.

PD weekly rate

A statutory rate adjusted annually that is multiplied by the PD percentage and by 1.5 for injuries on or after 1/1/2013 to calculate benefits.

Lump sum settlement

Permanent disability payments may be made in a lump sum or installments; a lump sum settlement requires approval by the Workers' Compensation Appeals Board.

2005 Rating Schedule

The California Schedule for Rating Permanent Disabilities that provides standardized ratings for body parts and conditions for injuries on or after 1/1/2005.

PD dispute resolution

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