CA Workers Comp Specialist key terms

The date an injury occurred or the date a worker knew or should have known that an injury was caused by work. It starts most claim deadlines and benefit calculations.

An injury caused by one incident at a definite time and place, such as a fall from a ladder. The incident date is generally the date of injury.

An injury occurring gradually from repetitive physical or mental stress over time rather than from a single event. The date of injury is generally the date of last injurious exposure or disability.

The state-mandated form an injured worker files to report a work injury and request benefits. Filing it generally starts the claims process and triggers the employer's response duties.

The insurer, self-insured employer, or third-party administrator that adjusts a workers' compensation claim. It investigates, pays benefits, and handles medical and indemnity decisions.

A written notice telling the injured worker that the claims administrator needs more time to decide whether to accept the claim. It must explain the reasons and what information is still needed.

A written notice rejecting liability for a claim and stating the factual and legal reasons for the rejection. It must inform the worker of appeal rights and available dispute processes.

A worker who has suffered a work injury and meets specific statutory conditions, including having worked for the employer for at least 90 days. QIW status protects against discriminatory termination.

Wage replacement paid while an injured worker is unable to work at all during recovery. It continues until the worker reaches maximum medical improvement or is released to work.

Wage replacement paid when a recovering worker can do some work but earns less than before the injury because of the injury. It bridges the gap between actual wages and pre-injury earnings.

Compensation for lasting impairment and reduced future earning capacity after a condition stabilizes. It is rated under the permanent disability schedule and paid in weekly installments.

The official guide used to convert medical findings into a permanent disability percentage. It combines impairment, age, occupation, and adjusted factors into a whole-person rating.

The percentage of permanent disability assigned to a claim after applying the rating schedule. The percentage determines the amount and duration of indemnity payments.

The process of separating the portion of permanent disability caused by the work injury from disability caused by other factors. Only the work-related share is compensable.

The point when an injured worker's condition has stabilized and further recovery is not reasonably expected. It typically ends temporary disability and triggers permanent disability evaluation.

A medical status meaning the condition has reached a stable plateau and is unlikely to change materially. It often serves as the basis for rating permanent disability.

The set of evidence-based treatment guidelines adopted for California workers' compensation. It defines what care is reasonable and necessary for various conditions and durations.

A prospective or concurrent review that decides whether requested medical treatment is medically necessary under the treatment guidelines. It must be timely and performed by qualified reviewers.

An appeal process where an outside physician reviews a utilization review denial of treatment. It gives the injured worker an independent check on whether care was wrongly withheld.

A physician certified by the state to perform medical-legal evaluations in disputed workers' compensation claims. QMEs issue reports on diagnosis, causation, and permanent disability.

A physician chosen jointly by the injured worker and the claims administrator to resolve medical disputes. The parties generally agree to be bound by the AME's findings.

A QME selected from a state-issued list when the parties cannot agree on an evaluator. The worker usually picks from a three-physician panel provided by the state.

Medical opinion that is credible, well-reasoned, and based on adequate history and examination. Ratings and disputed findings must rest on this level of evidence to be upheld.

The state-adopted schedule setting maximum allowable fees for medical services, goods, and procedures in workers' compensation. It controls how much providers may be paid.

A standardized numeric coding system used to describe medical procedures and services on bills. Payers use these codes with the fee schedule to determine allowed amounts.

Standardized diagnosis codes describing the nature of an injury or illness. They support medical necessity, billing accuracy, and outcome tracking on claim documents.

A document accompanying a payment or denial that explains how a medical bill was adjusted. It shows allowed amounts, paid amounts, and the reasons for any reduction.

A formal re-examination of a paid or adjusted medical bill at the provider's request. It checks whether the original payment correctly applied the fee schedule and coding rules.

A dispute process for disagreements over the amount paid for medical services after second bill review. An independent reviewer decides the correct payment under the fee schedule.

A payment methodology that assigns relative values to medical services based on the resources required to provide them. It is often used to calculate allowed amounts under the fee schedule.

Payments made toward an anticipated permanent disability award before the rating is finalized. They are credited against the eventual award to avoid duplicate payment.

An additional weekly payment owed after permanent disability payments end when disability exceeds a statutory threshold. It continues for the worker's lifetime at a reduced rate.

A voucher providing education or retraining for workers who cannot return to their former job because of permanent restrictions. Eligibility depends on timely offer of modified work.

A job assignment adjusted to fit an injured worker's medical restrictions, often used to end temporary disability. A timely written offer can affect supplemental benefit eligibility.

The state tribunal that resolves disputes over benefits, ratings, and medical issues. It holds hearings and issues decisions that can be reviewed by higher courts.

The deadline for filing a claim or petition, generally one year from the injury or last payment. Missing it can bar benefits unless an exception applies.

A settlement resolving a claim by paying a lump sum that closes all or specified issues. The worker gives up future benefits for the settled issues.

A settlement where the parties agree on specific benefits and future medical care remains open. Payments may be made over time rather than as a single lump sum.

A claim filed against a workers' compensation case by a provider or other party seeking payment from the award. It can reduce the injured worker's net recovery if upheld.