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CA Workers Comp Specialist practice questions

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Question 1California Workers' Compensation Claims Handling

Under California workers' compensation law, within how many days after receiving an injury claim form must an employer provide the employee with a claim form if one was not already given?

  1. Within five working days of learning of the injury
  2. Within ten calendar days of learning of the injury
  3. Immediately upon knowledge of the injury, but no later than one working day Correct answer.
  4. Within thirty calendar days of learning of the injury

Explanation

California law requires an employer to give the employee a claim form within one working day after learning of a workplace injury or illness. Providing it immediately upon notice satisfies this duty. Delaying beyond one working day exposes the employer to penalties.

Question 2California Workers' Compensation Claims Handling

An injured worker's claim form is received by the employer on March 3. By what date must the employer generally make its first decision to accept or deny the claim?

  1. April 2
  2. March 13 Correct answer.
  3. April 17
  4. March 18

Explanation

The employer generally has 30 days from the date the claim form is received to accept or deny the claim. Counting 30 calendar days from March 3 yields April 2, but the first decision deadline shown here is the ten-day option only when the employer chooses to delay; the standard acceptance window is 30 days, so March 13 is incorrect.

Question 3California Workers' Compensation Claims Handling

If an employer fails to accept or deny a claim within the statutory period after receiving the claim form, how is the claim generally treated?

  1. The claim is deemed accepted as to the injury Correct answer.
  2. The claim is automatically dismissed without prejudice
  3. The claim remains open but no benefits are owed
  4. The claim is referred directly to the appeals board for hearing

Explanation

When the employer does not timely accept or deny a claim, the injury claim is presumed accepted by operation of law. This presumption means benefits must be provided as though the claim were admitted. The employer may later seek to rebut the presumption but bears a heavy burden.

Question 4California Workers' Compensation Claims Handling

Which benefit is generally payable at the temporary disability rate while an injured worker is unable to return to work and is recovering?

  1. Permanent disability indemnity
  2. Vocational rehabilitation maintenance allowance
  3. Temporary disability indemnity Correct answer.
  4. Death benefits

Explanation

Temporary disability indemnity compensates lost wages during the period the worker cannot work and is not yet permanent and stationary. Permanent disability applies after the condition stabilizes. The maintenance allowance and death benefits serve different purposes.

Question 5California Workers' Compensation Claims Handling

An injured worker's treating physician declares the worker permanent and stationary. What does this determination primarily signify?

  1. The worker is permanently barred from any future medical treatment
  2. The worker's condition has stabilized and further recovery is not reasonably anticipated Correct answer.
  3. The worker must immediately return to the original job
  4. The claim must be closed within ten days

Explanation

Permanent and stationary means the injury has reached maximum medical improvement and the condition is unlikely to change substantially. It triggers evaluation for permanent disability. It does not end medical treatment or force return to work.

Question 6California Workers' Compensation Claims Handling

How are permanent disability ratings under the current schedule generally expressed?

  1. As a fixed dollar amount set by the employer
  2. As a percentage of the employee's annual salary
  3. As a number of workdays lost multiplied by the hourly wage
  4. As a whole-body impairment percentage adjusted by age and occupation Correct answer.

Explanation

The current permanent disability schedule uses whole-person impairment percentages, adjusted for age and occupation, to produce a disability rating. The rating is then converted to a monetary value using the statutory payment schedule. It is not based on salary or employer-set amounts.

Question 7California Workers' Compensation Claims Handling

An employer wishes to dispute the treating physician's opinion on the cause of an injury. Which mechanism is generally used to resolve a medical dispute in the California system?

  1. Qualified Medical Evaluator process Correct answer.
  2. Direct appeal to the Department of Insurance
  3. Binding arbitration before the insurer
  4. Jury trial in superior court

Explanation

Medical disputes in California workers' compensation are typically resolved through the Qualified Medical Evaluator or Agreed Medical Evaluator process. These physicians provide independent opinions for the parties and the appeals board. Courts and insurance regulators do not resolve these medical causation disputes.

Question 8California Workers' Compensation Claims Handling

Within how many days must an employer file the completed claim form with its claims administrator after receiving it from the employee?

  1. Within thirty working days
  2. Within one working day Correct answer.
  3. Within five working days
  4. Within ten working days

Explanation

The employer must forward the completed claim form to the claims administrator within one working day of receipt. Prompt transmission allows the administrator to begin the 30-day investigation. Missing this step can delay benefits and create penalties.

Question 9California Workers' Compensation Claims Handling

Which of the following best describes the role of the claims administrator in a California workers' compensation claim?

  1. Representing the injured worker at hearings
  2. Prosecuting fraudulent claims in criminal court
  3. Deciding the constitutionality of statutes
  4. Investigating the claim and arranging payment of benefits Correct answer.

Explanation

The claims administrator investigates the claim, determines compensability, and arranges payment of benefits owed. It does not represent the worker or exercise judicial functions. Criminal prosecution of fraud is handled by prosecutors.

Question 10California Workers' Compensation Claims Handling

An injured worker needs medical treatment before the claim is accepted. Under California law, what is the employer generally required to do?

  1. Require the worker to pay upfront and seek later reimbursement
  2. Provide up to a specified dollar amount of medical treatment while the claim is investigated Correct answer.
  3. Refer the worker to a private insurer of the worker's choice
  4. Withhold all treatment until the claim is formally accepted

Explanation

California law requires employers to provide medical treatment up to a statutory cap while a claim is being investigated. This ensures injured workers receive needed care without waiting for a final compensability decision. Treatment beyond the cap may require authorization or a decision on the claim.

Question 11California Workers' Compensation Claims Handling

Which statement accurately describes the employee's right to choose a treating physician in California workers' compensation?

  1. The employee has an unrestricted right to any physician at any time
  2. The claims administrator may veto the employee's choice without review
  3. The employee may generally predesignate a personal physician before injury under specified conditions Correct answer.
  4. The employer alone selects the treating physician in every case

Explanation

Employees may predesignate a personal physician before an injury if statutory conditions are met, such as a prior relationship and proper documentation. After an injury within a health care organization, the employee typically selects from that network. The employer does not have an absolute right to choose the physician.

Question 12California Workers' Compensation Claims Handling

An injured worker disagrees with a utilization review denial of requested treatment. What is the typical next step?

  1. Appeal directly to the Governor's office
  2. File for independent medical review Correct answer.
  3. File a criminal complaint against the insurer
  4. Request a jury trial in superior court

Explanation

A worker who disagrees with a utilization review modification or denial may request independent medical review by a physician reviewer. This process evaluates whether the treatment meets the medical necessity standard. Criminal complaints, jury trials, and executive appeals are not the proper route.

Question 13California Workers' Compensation Claims Handling

Which of the following is a key element an injured worker must establish to receive workers' compensation benefits?

  1. The injury arose out of and in the course of employment Correct answer.
  2. The injury occurred while the worker was on a personal vacation
  3. The injury happened before the worker was hired
  4. The injury was caused by the worker's intentional misconduct

Explanation

The fundamental requirement is that the injury arise out of and occur in the course of employment. This connects the harm to work activities. Injuries during personal vacations, intentional self-harm, or before employment generally fall outside coverage.

Question 14California Workers' Compensation Claims Handling

An employer believes an injury was caused by the employee's intoxication. What is the employer's best course of action?

  1. Stop paying all benefits immediately without a written decision
  2. Ask the claims administrator to ignore the claim
  3. Wait until the worker files a petition to raise the defense
  4. Deny the claim within the statutory period and state the basis for the denial Correct answer.

Explanation

The employer must issue a timely written denial stating the factual and legal basis, such as intoxication, to preserve the defense. Simply stopping benefits or ignoring the claim can lead to deemed acceptance. The defense should be raised through the proper claim decision process.

Question 15California Workers' Compensation Claims Handling

What is the primary purpose of the supplemental job displacement benefit voucher?

  1. To reimburse the employer for training costs
  2. To help an injured worker obtain retraining or skill enhancement when return to the prior job is unavailable Correct answer.
  3. To compensate for pain and suffering
  4. To pay the worker's ordinary living expenses during recovery

Explanation

The supplemental job displacement voucher provides funds for retraining or skill enhancement when the worker cannot return to the prior employment. It is not a wage replacement or pain-and-suffering payment. The voucher is used for education or training-related expenses.

Question 16California Workers' Compensation Claims Handling

An injured worker's claim is denied. Which step is generally available to challenge that denial?

  1. Sue the employer in small claims court
  2. File a complaint with the Better Business Bureau
  3. Request a hearing before the state legislature
  4. File an application for adjudication with the Workers' Compensation Appeals Board Correct answer.

Explanation

A worker disputing a denial files an application for adjudication with the Workers' Compensation Appeals Board. The board has jurisdiction over workers' compensation disputes. Small claims court, consumer agencies, and the legislature are not the proper forums.

Question 17California Workers' Compensation Claims Handling

Which of the following best describes the employer's obligation regarding a claim form that the employee has not yet completed?

  1. Discard the form if the employee hesitates
  2. Complete the form on the employee's behalf without consent
  3. Provide the form promptly so the employee can complete and return it Correct answer.
  4. Send the form only after the 30-day investigation ends

Explanation

The employer must furnish the claim form promptly so the employee can complete and submit it. The form initiates the formal claims process and starts decision deadlines. The employer cannot complete it for the employee without consent or discard it unilaterally.

Question 18California Workers' Compensation Claims Handling

What does the term "compensable consequence" generally refer to in California workers' compensation?

  1. An administrative fee charged by the appeals board
  2. A penalty imposed on the employer for late reporting
  3. A type of death benefit paid to dependents
  4. A new injury or condition resulting from the original work injury or its treatment Correct answer.

Explanation

A compensable consequence is a subsequent injury or condition that flows from the original work injury or its medical treatment. It may be covered even though it was not the initial injury. Penalties, death benefits, and administrative fees are distinct concepts.

Question 19California Workers' Compensation Claims Handling

An employer learns of a claimed injury three weeks after it allegedly occurred. What is the employer's obligation regarding the claim form?

  1. Wait thirty days before providing any form
  2. Refuse the form because the report was delayed
  3. Provide the form only if the employee requests it in writing
  4. Provide the claim form within one working day of learning of the injury Correct answer.

Explanation

The duty to provide the claim form is triggered when the employer learns of the injury, regardless of when the injury occurred. The form must be furnished within one working day of that knowledge. Delay in reporting does not eliminate the obligation.

Question 20California Workers' Compensation Claims Handling

Which factor most directly affects the monetary value of a permanent disability rating under the current schedule?

  1. The employer's annual revenue
  2. The worker's age and occupation Correct answer.
  3. The worker's length of commute
  4. The number of witnesses to the injury

Explanation

The permanent disability rating adjusts the whole-person impairment for age and occupation, reflecting diminished future earning capacity. Employer revenue, witness count, and commute length are irrelevant to the rating. These adjustments are built into the statutory schedule.

Question 21California Workers' Compensation Claims Handling

An injured worker receives temporary disability payments but the employer later discovers the injury is not work-related. What is the most appropriate action?

  1. Demand immediate repayment before any investigation
  2. Issue a timely denial and evaluate whether overpayment recovery is appropriate Correct answer.
  3. Stop payments without any written notice
  4. Continue payments indefinitely to avoid dispute

Explanation

If the employer determines the injury is not compensable, it should issue a timely written denial and assess overpayment recovery under the applicable rules. Simply continuing payments or stopping them without notice is improper. Recovery of overpayments is subject to statutory limits and procedures.

Question 22California Workers' Compensation Claims Handling

What is the function of the primary treating physician's report in the claims process?

  1. It transfers liability to the employee
  2. It serves as a binding judgment of the appeals board
  3. It documents the diagnosis, treatment, and work status used to determine benefits Correct answer.
  4. It replaces the need for any claim form

Explanation

The primary treating physician's report records diagnosis, treatment plan, and work status, which guide benefit determinations. It does not substitute for the claim form or function as a judicial ruling. Liability is not transferred to the employee by the report.

Question 23California Workers' Compensation Claims Handling

An employer wants to send an injured worker to a different physician within its medical network. Which statement is most accurate?

  1. The employee must always consent to any change
  2. The claims administrator can ignore the employee's objections entirely
  3. The employer may switch physicians at will without any notice
  4. The employer may direct care within its network subject to statutory rules and notice Correct answer.

Explanation

Employers may direct medical care within their established network, but must follow statutory notice and procedural rules. The employee retains rights to object and seek review in certain circumstances. Unilateral changes without notice are improper.

Question 24California Workers' Compensation Claims Handling

Which of the following best explains why timely claim decisions matter in California workers' compensation?

  1. Late decisions eliminate the worker's right to medical care
  2. Late decisions transfer the claim to federal jurisdiction
  3. Late decisions automatically reduce the employer's liability
  4. Late decisions can trigger deemed acceptance and additional benefit obligations Correct answer.

Explanation

Timely decisions protect the employer from deemed acceptance and related penalties. Missing a deadline can obligate the employer to pay benefits as though the claim were accepted. It does not reduce liability or shift the claim to federal jurisdiction.

Question 25California Workers' Compensation Claims Handling

What is the general rule regarding an employer's duty to provide a claim form when an employee reports a cumulative trauma injury?

  1. The duty arises only after the employee files a lawsuit
  2. The duty arises only after the worker stops working
  3. The duty arises when the employer has knowledge of the cumulative injury Correct answer.
  4. The duty never arises for cumulative trauma injuries

Explanation

For cumulative trauma, the employer's duty to provide the claim form is triggered by knowledge of the cumulative injury. The same prompt-notice principles apply as with specific injuries. A lawsuit or work stoppage is not a precondition.

Question 26California Workers' Compensation Claims Handling

Within how many days must an employer provide a workers' compensation claim form to an employee who reports an injury, under California rules?

  1. One working day Correct answer.
  2. Ten calendar days
  3. Five working days
  4. Thirty calendar days

Explanation

California law requires the employer to give the employee a claim form within one working day of learning about a work injury or illness. This short deadline ensures the employee can promptly begin the claims process.

Question 27California Workers' Compensation Claims Handling

After the employer receives a completed claim form from the injured worker, how long does the employer generally have to transmit it to the claims administrator?

  1. Within five working days
  2. Within ten working days
  3. Within one working day Correct answer.
  4. Within thirty calendar days

Explanation

The employer must forward a completed claim form to its claims administrator within one working day of receiving it. Prompt transmittal starts the clock for the claims administrator's decision.

Question 28California Workers' Compensation Claims Handling

How many days does a claims administrator generally have to decide whether to accept or deny a claim after receiving the completed claim form?

  1. Ninety days
  2. Forty-five days Correct answer.
  3. Fourteen days
  4. Thirty days

Explanation

The claims administrator generally must accept or deny the claim within forty-five days of receiving the completed claim form. This period allows investigation while protecting the worker from indefinite delay.

Question 29California Workers' Compensation Claims Handling

If a claims administrator fails to accept or deny a claim within the required period, what is the usual consequence under California law?

  1. The claim is deemed accepted Correct answer.
  2. The claim is transferred to the appeals board
  3. The claim is automatically denied
  4. The claim is dismissed without prejudice

Explanation

When the claims administrator does not timely accept or deny, the claim is generally deemed accepted by operation of law. This rule encourages prompt investigation and decision-making.

Question 30California Workers' Compensation Claims Handling

What is the maximum period for which temporary disability indemnity is generally payable for a single injury under California law?

  1. 52 weeks
  2. Five years
  3. 240 weeks
  4. 104 weeks Correct answer.

Explanation

Temporary disability payments are generally capped at 104 weeks for a single injury. Beyond that point, the worker may be evaluated for permanent disability instead.

Question 31California Workers' Compensation Claims Handling

Temporary disability payments are generally calculated as what percentage of the worker's average weekly earnings, subject to statutory minimums and maximums?

  1. One-half
  2. Two-thirds Correct answer.
  3. One hundred percent
  4. Three-quarters

Explanation

Temporary disability indemnity is generally set at two-thirds of the worker's average weekly earnings, bounded by statutory minimum and maximum rates. The rate is meant to partially replace lost wages.

Question 32California Workers' Compensation Claims Handling

Which benefit is intended to compensate an injured worker for lost future earning capacity after the injury becomes permanent and stationary?

  1. Medical treatment benefit
  2. Permanent disability indemnity Correct answer.
  3. Temporary disability indemnity
  4. Supplemental job displacement benefit

Explanation

Permanent disability indemnity compensates for the lasting loss of earning capacity once the condition is permanent and stationary. Temporary disability, by contrast, covers wage loss during recovery.

Question 33California Workers' Compensation Claims Handling

An injured worker's condition has been declared permanent and stationary. What does this determination primarily signal in the claims process?

  1. The worker may return to full duty without restrictions
  2. The claim must be closed immediately
  3. The worker's condition has stabilized and permanent disability can be evaluated Correct answer.
  4. Medical treatment must stop

Explanation

A permanent and stationary declaration means the condition has stabilized enough that further recovery is not expected, allowing permanent disability to be rated. It does not automatically end medical treatment or close the claim.

Question 34California Workers' Compensation Claims Handling

Which document typically serves as the foundation for determining the treating physician's opinions on diagnosis, treatment, and work restrictions?

  1. The employee's job description
  2. The claims administrator's denial letter
  3. The employer's first report of injury
  4. The primary treating physician's report Correct answer.

Explanation

The primary treating physician's report records the diagnosis, treatment plan, and work status that guide the claim. It is the central medical document for managing the case.

Question 35California Workers' Compensation Claims Handling

An injured worker wants to change treating physicians within the employer's medical provider network. What is generally required first?

  1. Approval from the claims administrator
  2. Consent from the employer's insurer
  3. A court order
  4. A written request and compliance with network change rules Correct answer.

Explanation

Changing physicians within a medical provider network typically requires a written request and adherence to the network's transfer procedures. The worker generally does not need insurer or court approval for a proper network change.

Question 36California Workers' Compensation Claims Handling

What is the primary purpose of utilization review in a California workers' compensation claim?

  1. To calculate the worker's permanent disability rating
  2. To investigate potential fraud by the employer
  3. To set the worker's temporary disability rate
  4. To determine whether requested medical treatment is medically necessary Correct answer.

Explanation

Utilization review evaluates whether a requested treatment is medically necessary based on accepted standards. It does not rate disability or set indemnity rates.

Question 37California Workers' Compensation Claims Handling

An injured worker disagrees with a utilization review decision denying treatment. What is the typical next step?

  1. Request independent medical review Correct answer.
  2. Appeal directly to the superior court
  3. Submit a new claim form
  4. File a lien against the employer

Explanation

A worker who disputes a utilization review denial generally seeks independent medical review by a physician reviewer. This provides an external check on the denial.

Question 38California Workers' Compensation Claims Handling

Which of the following is generally required for an injury to be compensable under California workers' compensation?

  1. The injury must be witnessed by a supervisor
  2. The injury must require surgery
  3. The injury must arise out of and occur in the course of employment Correct answer.
  4. The injury must result in at least one day of lost wages

Explanation

The core test is whether the injury arose out of and in the course of employment. Surgery, witnesses, and lost wages are not universal prerequisites to compensability.

Question 39California Workers' Compensation Claims Handling

What is the function of the employer's first report of injury?

  1. To formally deny the claim
  2. To establish the worker's permanent disability rating
  3. To authorize medical treatment
  4. To document the employer's initial notice of the injury to the claims administrator Correct answer.

Explanation

The first report of injury informs the claims administrator that a work injury has occurred and provides initial details. It starts the investigation and is not itself a denial or a rating document.

Question 40California Workers' Compensation Claims Handling

An injured worker's claim is denied, and the worker believes the denial is wrong. Which step is generally available to challenge the denial?

  1. File a lawsuit in federal court
  2. File an application for adjudication with the Workers' Compensation Appeals Board Correct answer.
  3. Request a new utilization review
  4. Submit a grievance to the employer's human resources department

Explanation

A worker who disputes a denial may file an application for adjudication with the Workers' Compensation Appeals Board. The board resolves disputes over benefits and compensability.

Question 41California Workers' Compensation Claims Handling

What is the general deadline for an injured worker to file a claim for workers' compensation benefits after an injury?

  1. Six months
  2. One year Correct answer.
  3. Two years
  4. Five years

Explanation

An injured worker generally must file a claim within one year of the injury or the date of last payment of benefits, whichever is later. Missing the deadline can bar the claim.

Question 42California Workers' Compensation Claims Handling

For a cumulative trauma injury, when does the one-year filing period generally begin to run?

  1. On the date of the first symptom
  2. On the date the worker knew or should have known the injury was work-related Correct answer.
  3. On the date the claim form is mailed
  4. On the date the employer learns of the injury

Explanation

For cumulative trauma, the filing period generally runs from when the worker knew or should have known the injury was caused by work. This accounts for the gradual onset of such conditions.

Question 43California Workers' Compensation Claims Handling

What is the role of the claims administrator when an employee submits a claim form?

  1. To set the employee's work schedule
  2. To determine the employee's immigration status
  3. To represent the employee in appeals
  4. To investigate the claim and make a timely accept-or-deny decision Correct answer.

Explanation

The claims administrator investigates the claim and must accept or deny it within the required period. The administrator does not represent the worker or manage scheduling.

Question 44California Workers' Compensation Claims Handling

An employer suspects that a reported injury was caused by the employee's intoxication. What is the employer's best course of action?

  1. Immediately terminate the employee
  2. Ignore the claim until the employee files an appeal
  3. Deny the claim without investigation
  4. Report the facts to the claims administrator and allow a proper investigation Correct answer.

Explanation

The employer should report the suspected intoxication to the claims administrator so the issue can be investigated and documented. Unilateral denial or discipline without investigation is inappropriate.

Question 45California Workers' Compensation Claims Handling

What does the term 'compensable consequence' generally refer to in California workers' compensation?

  1. An injury that results from medical treatment for a work injury Correct answer.
  2. A penalty imposed on the employer
  3. A benefit paid to the employer
  4. An injury caused by the worker's off-duty conduct

Explanation

A compensable consequence is an additional injury or condition that flows from the original work injury or its treatment. It can be compensable even though the later injury is not directly work-related.

Question 46California Workers' Compensation Claims Handling

Which of the following best describes the purpose of the supplemental job displacement benefit voucher?

  1. To help an injured worker obtain retraining or skill enhancement Correct answer.
  2. To pay for the worker's medical treatment
  3. To reimburse the employer for training costs
  4. To provide a cash payment for permanent disability

Explanation

The supplemental job displacement benefit voucher helps a worker who cannot return to the prior job obtain retraining or new skills. It is not a cash substitute for permanent disability.

Question 47California Workers' Compensation Claims Handling

An injured worker receives temporary disability payments, and the employer later discovers the injury was not work-related. What is the employer's best course of action?

  1. Demand repayment from the worker immediately
  2. File a lawsuit against the worker
  3. Continue payments until the claims administrator formally denies the claim Correct answer.
  4. Stop payments immediately without notice

Explanation

Payments should continue until the claims administrator formally denies the claim, because the worker is entitled to benefits during the investigation. Unilateral termination can expose the employer to penalties.

Question 48California Workers' Compensation Claims Handling

Which statement best describes the employer's obligation when an employee reports a cumulative trauma injury?

  1. The employer must deny the claim immediately
  2. The employer must provide a claim form within one working day of learning of the injury Correct answer.
  3. The employer must send the employee to a specialist before providing a claim form
  4. The employer may wait until the employee files a lawsuit

Explanation

The one-working-day rule applies to cumulative trauma reports as well as specific injuries. Providing the form promptly preserves the worker's ability to file a timely claim.

Question 49California Workers' Compensation Claims Handling

Why do timely claim decisions matter in California workers' compensation?

  1. They transfer the claim to federal jurisdiction
  2. They protect the worker's access to benefits and trigger statutory consequences for delay Correct answer.
  3. They eliminate the need for medical treatment
  4. They allow the employer to avoid all liability

Explanation

Timely decisions protect the worker's access to benefits and can trigger consequences such as deemed acceptance if the deadline is missed. They do not eliminate liability or medical needs.

Question 50California Workers' Compensation Claims Handling

An injured worker's treating physician recommends surgery, but the claims administrator disputes the recommendation. Which mechanism is generally used to resolve the medical necessity dispute?

  1. Independent medical review Correct answer.
  2. A jury trial
  3. The employer's disciplinary process
  4. A lien filing by the employer

Explanation

Disputes over the medical necessity of a proposed treatment are generally resolved through independent medical review. This provides an external determination of whether the treatment is appropriate.