California Labor Code 4600-4856

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4600.  (a) Medical, surgical, chiropractic, acupuncture, and
hospital treatment, including nursing, medicines, medical and
surgical supplies, crutches, and apparatuses, including orthotic and
prosthetic devices and services, that is reasonably required to cure
or relieve the injured worker from the effects of his or her injury
shall be provided by the employer. In the case of his or her neglect
or refusal reasonably to do so, the employer is liable for the
reasonable expense incurred by or on behalf of the employee in
providing treatment.
   (b) As used in this division and notwithstanding any other
provision of law, medical treatment that is reasonably required to
cure or relieve the injured worker from the effects of his or her
injury means treatment that is based upon the guidelines adopted by
the administrative director pursuant to Section 5307.27.
   (c) Unless the employer or the employer's insurer has established
or contracted with a medical provider network as provided for in
Section 4616, after 30 days from the date the injury is reported, the
employee may be treated by a physician of his or her own choice or
at a facility of his or her own choice within a reasonable geographic
area. A chiropractor shall not be a treating physician after the
employee has received the maximum number of chiropractic visits
allowed by subdivision (d) of Section 4604.5.
   (d) (1) If an employee has notified his or her employer in writing
prior to the date of injury that he or she has a personal physician,
the employee shall have the right to be treated by that physician
from the date of injury if the employee has health care coverage for
nonoccupational injuries or illnesses on the date of injury in a
plan, policy, or fund as described in subdivisions (b), (c), and (d)
of Section 4616.7.
   (2) For purposes of paragraph (1), a personal physician shall meet
all of the following conditions:
   (A) Be the employee's regular physician and surgeon, licensed
pursuant to Chapter 5 (commencing with Section 2000) of Division 2 of
the Business and Professions Code.
   (B) Be the employee's primary care physician and has previously
directed the medical treatment of the employee, and who retains the
employee's medical records, including his or her medical history.
"Personal physician" includes a medical group, if the medical group
is a single corporation or partnership composed of licensed doctors
of medicine or osteopathy, which operates an integrated
multispecialty medical group providing comprehensive medical services
predominantly for nonoccupational illnesses and injuries.
   (C) The physician agrees to be predesignated.
   (3) If the employee has health care coverage for nonoccupational
injuries or illnesses on the date of injury in a health care service
plan licensed pursuant to Chapter 2.2 (commencing with Section 1340)
of Division 2 of the Health and Safety Code, and the employer is
notified pursuant to paragraph (1), all medical treatment,
utilization review of medical treatment, access to medical treatment,
and other medical treatment issues shall be governed by Chapter 2.2
(commencing with Section 1340) of Division 2 of the Health and Safety
Code. Disputes regarding the provision of medical treatment shall be
resolved pursuant to Article 5.55 (commencing with Section 1374.30)
of Chapter 2.2 of Division 2 of the Health and Safety Code.
   (4) If the employee has health care coverage for nonoccupational
injuries or illnesses on the date of injury in a group health
insurance policy as described in Section 4616.7, all medical
treatment, utilization review of medical treatment, access to medical
treatment, and other medical treatment issues shall be governed by
the applicable provisions of the Insurance Code.
   (5) The insurer may require prior authorization of any
nonemergency treatment or diagnostic service and may conduct
reasonably necessary utilization review pursuant to Section 4610.
   (6) An employee shall be entitled to all medically appropriate
referrals by the personal physician to other physicians or medical
providers within the nonoccupational health care plan. An employee
shall be entitled to treatment by physicians or other medical
providers outside of the nonoccupational health care plan pursuant to
standards established in Article 5 (commencing with Section 1367) of
Chapter 2.2 of Division 2 of the Health and Safety Code.
   (e) (1) When at the request of the employer, the employer's
insurer, the administrative director, the appeals board, or a workers'
compensation administrative law judge, the employee submits to
examination by a physician, he or she shall be entitled to receive,
in addition to all other benefits herein provided, all reasonable
expenses of transportation, meals, and lodging incident to reporting
for the examination, together with one day of temporary disability
indemnity for each day of wages lost in submitting to the
examination.
   (2) Regardless of the date of injury, "reasonable expenses of
transportation" includes mileage fees from the employee's home to the
place of the examination and back at the rate of twenty-one cents
($0.21) a mile or the mileage rate adopted by the Director of Human
Resources pursuant to Section 19820 of the Government Code, whichever
is higher, plus any bridge tolls. The mileage and tolls shall be
paid to the employee at the time he or she is given notification of
the time and place of the examination.
   (f) When at the request of the employer, the employer's insurer,
the administrative director, the appeals board, or a workers'
compensation administrative law judge, an employee submits to
examination by a physician and the employee does not proficiently
speak or understand the English language, he or she shall be entitled
to the services of a qualified interpreter in accordance with
conditions and a fee schedule prescribed by the administrative
director. These services shall be provided by the employer. For
purposes of this section, "qualified interpreter" means a language
interpreter certified, or deemed certified, pursuant to Article 8
(commencing with Section 11435.05) of Chapter 4.5 of Part 1 of
Division 3 of Title 2 of, or Section 68566 of, the Government Code.
   (g) If the injured employee cannot effectively communicate with
his or her treating physician because he or she cannot proficiently
speak or understand the English language, the injured employee is
entitled to the services of a qualified interpreter during medical
treatment appointments. To be a qualified interpreter for purposes of
medical treatment appointments, an interpreter is not required to
meet the requirements of subdivision (f), but shall meet any
requirements established by rule by the administrative director that
are substantially similar to the requirements set forth in Section
1367.04 of the Health and Safety Code. The administrative director
shall adopt a fee schedule for qualified interpreter fees in
accordance with this section. Upon request of the injured employee,
the employer or insurance carrier shall pay for interpreter services.
An employer shall not be required to pay for the services of an
interpreter who is not certified or is provisionally certified by the
person conducting the medical treatment or examination unless either
the employer consents in advance to the selection of the individual
who provides the interpreting service or the injured worker requires
interpreting service in a language other than the languages
designated pursuant to Section 11435.40 of the Government Code.
   (h) Home health care services shall be provided as medical
treatment only if reasonably required to cure or relieve the injured
employee from the effects of his or her injury and prescribed by a
physician and surgeon licensed pursuant to Chapter 5 (commencing with
Section 2000) of Division 2 of the Business and Professions Code,
and subject to Section 5307.1 or 5703.8. The employer shall not be
liable for home health care services that are provided more than 14
days prior to the date of the employer's receipt of the physician's
prescription.



4600.1.  (a) Subject to subdivision (b), any person or entity that
dispenses medicines and medical supplies, as required by Section
4600, shall dispense the generic drug equivalent.
   (b) A person or entity shall not be required to dispense a generic
drug equivalent under either of the following circumstances:
   (1) When a generic drug equivalent is unavailable.
   (2) When the prescribing physician specifically provides in
writing that a nongeneric drug must be dispensed.
   (c) For purposes of this section, "dispense" has the same meaning
as the definition contained in Section 4024 of the Business and
Professions Code.
   (d) Nothing in this section shall be construed to preclude a
prescribing physician, who is also the dispensing physician, from
dispensing a generic drug equivalent.


4600.2.  (a) Notwithstanding Section 4600, when a self-insured
employer, group of self-insured employers, insurer of an employer, or
group of insurers contracts with a pharmacy, group of pharmacies, or
pharmacy benefit network to provide medicines and medical supplies
required by this article to be provided to injured employees, those
injured employees that are subject to the contract shall be provided
medicines and medical supplies in the manner prescribed in the
contract for as long as medicines or medical supplies are reasonably
required to cure or relieve the injured employee from the effects of
the injury.
   (b) Nothing in this section shall affect the ability of
employee-selected physicians to continue to prescribe and have the
employer provide medicines and medical supplies that the physicians
deem reasonably required to cure or relieve the injured employee from
the effects of the injury.
   (c) Each contract described in subdivision (a) shall comply with
standards adopted by the administrative director. In adopting those
standards, the administrative director shall seek to reduce
pharmaceutical costs and may consult any relevant studies or
practices in other states. The standards shall provide for access to
a pharmacy within a reasonable geographic distance from an injured
employee's residence.



4600.3.  (a) (1) Notwithstanding Section 4600, when a self-insured
employer, group of self-insured employers, or the insurer of an
employer contracts with a health care organization certified pursuant
to Section 4600.5 for health care services required by this article
to be provided to injured employees, those employees who are subject
to the contract shall receive medical services in the manner
prescribed in the contract, providing that the employee may choose to
be treated by a personal physician, personal chiropractor, or
personal acupuncturist that he or she has designated prior to the
injury, in which case the employee shall not be treated by the health
care organization. Every employee shall be given an affirmative
choice at the time of employment and at least annually thereafter to
designate or change the designation of a health care organization or
a personal physician, personal chiropractor, or personal
acupuncturist. The choice shall be memorialized in writing and
maintained in the employee's personnel records. The employee who has
designated a personal physician, personal chiropractor, or personal
acupuncturist may change their designated caregiver at any time prior
to the injury. Any employee who fails to designate a personal
physician, personal chiropractor, or personal acupuncturist shall be
treated by the health care organization selected by the employer. If
the health care organization offered by the employer is the workers'
compensation insurer that covers the employee or is an entity that
controls or is controlled by that insurer, as defined by Section 1215
of the Insurance Code, this information shall be included in the
notice of contract with a health care organization.
   (2) Each contract described in paragraph (1) shall comply with the
certification standards provided in Section 4600.5, and shall
provide all medical, surgical, chiropractic, acupuncture, and
hospital treatment, including nursing, medicines, medical and
surgical supplies, crutches, and apparatus, including artificial
members, that is reasonably required to cure or relieve the effects
of the injury, as required by this division, without any payment by
the employee of deductibles, copayments, or any share of the premium.
However, an employee may receive immediate emergency medical
treatment that is compensable from a medical service or health care
provider who is not a member of the health care organization.
   (3) Insured employers, a group of self-insured employers, or
self-insured employers who contract with a health care organization
for medical services shall give notice to employees of eligible
medical service providers and any other information regarding the
contract and manner of receiving medical services as the
administrative director may prescribe. Employees shall be duly
notified that if they choose to receive care from the health care
organization they must receive treatment for all occupational
injuries and illnesses as prescribed by this section.
   (b) Notwithstanding subdivision (a), no employer which is required
to bargain with an exclusive or certified bargaining agent which
represents employees of the employer in accordance with state or
federal employer-employee relations law shall contract with a health
care organization for purposes of Section 4600.5 with regard to
employees whom the bargaining agent is recognized or certified to
represent for collective bargaining purposes pursuant to state or
federal employer-employee relations law unless authorized to do so by
mutual agreement between the bargaining agent and the employer. If
the collective bargaining agreement is subject to the National Labor
Relations Act, the employer may contract with a health care
organization for purposes of Section 4600.5 at any time when the
employer and bargaining agent have bargained to impasse to the extent
required by federal law.
   (c) (1) When an employee is not receiving or is not eligible to
receive health care coverage for nonoccupational injuries or
illnesses provided by the employer, if 90 days from the date the
injury is reported the employee who has been receiving treatment from
a health care organization or his or her physician, chiropractor,
acupuncturist, or other agent notifies his or her employer in writing
that he or she desires to stop treatment by the health care
organization, he or she shall have the right to be treated by a
physician, chiropractor, or acupuncturist or at a facility of his or
her own choosing within a reasonable geographic area.
   (2) When an employee is receiving or is eligible to receive health
care coverage for nonoccupational injuries or illnesses provided by
the employer, and has agreed to receive care for occupational
injuries and illnesses from a health care organization provided by
the employer, the employee may be treated for occupational injuries
and diseases by a physician, chiropractor, or acupuncturist of his or
her own choice or at a facility of his or her own choice within a
reasonable geographic area if the employee or his or her physician,
chiropractor, acupuncturist, or other agent notifies his or her
employer in writing only after 180 days from the date the injury was
reported, or upon the date of contract renewal or open enrollment of
the health care organization, whichever occurs first, but in no case
until 90 days from the date the injury was reported.
   (3) For purposes of this subdivision, an employer shall be deemed
to provide health care coverage for nonoccupational injuries and
illnesses if the employer pays more than one-half the costs of the
coverage, or if the plan is established pursuant to collective
bargaining.
   (d) An employee and employer may agree to other forms of therapy
pursuant to Section 3209.7.
   (e) An employee enrolled in a health care organization shall have
the right to no less than one change of physician on request, and
shall be given a choice of physicians affiliated with the health care
organization. The health care organization shall provide the
employee a choice of participating physicians within five days of
receiving a request. In addition, the employee shall have the right
to a second opinion from a participating physician on a matter
pertaining to diagnosis or treatment from a participating physician.
   (f) Nothing in this section or Section 4600.5 shall be construed
to prohibit a self-insured employer, a group of self-insured
employers, or insurer from engaging in any activities permitted by
Section 4600.
   (g) Notwithstanding subdivision (c), in the event that the
employer, group of employers, or the employer's workers' compensation
insurer no longer contracts with the health care organization that
has been treating an injured employee, the employee may continue
treatment provided or arranged by the health care organization. If
the employee does not choose to continue treatment by the health care
organization, the employer may control the employee's treatment for
30 days from the date the injury was reported. After that period, the
employee may be treated by a physician of his or her own choice or
at a facility of his or her own choice within a reasonable geographic
area.


4600.35.  Any entity seeking to reimburse health care providers for
health care services rendered to injured workers on a capitated, or
per person per month basis, shall be licensed pursuant to the
Knox-Keene Health Care Service Plan Act of 1975 (Chapter 2.2
(commencing with Section 1340) of Division 2 of the Health and Safety
Code).



4600.4.  (a) A workers' compensation insurer, third-party
administrator, or other entity that requires, or pursuant to
regulation requires, a treating physician to obtain either
utilization review or prior authorization in order to diagnose or
treat injuries or diseases compensable under this article, shall
ensure the availability of those services from 9 a.m. to 5:30 p.m.
Pacific coast time of each normal business day.
   (b) For purposes of this section "normal business day" means a
business day as defined in Section 9 of the Civil Code.



4600.5.  (a) Any health care service plan licensed pursuant to the
Knox-Keene Health Care Service Plan Act, a disability insurer
licensed by the Department of Insurance, or any entity, including,
but not limited to, workers' compensation insurers and third-party
administrators authorized by the administrative director under
subdivision (e), may make written application to the administrative
director to become certified as a health care organization to provide
health care to injured employees for injuries and diseases
compensable under this article.
   (b) Each application for certification shall be accompanied by a
reasonable fee prescribed by the administrative director, sufficient
to cover the actual cost of processing the application. A certificate
is valid for the period that the director may prescribe unless
sooner revoked or suspended.
   (c) If the health care organization is a health care service plan
licensed pursuant to the Knox-Keene Health Care Service Plan Act, and
has provided the Managed Care Unit of the Division of Workers'
Compensation with the necessary documentation to comply with this
subdivision, that organization shall be deemed to be a health care
organization able to provide health care pursuant to Section 4600.3,
without further application duplicating the documentation already
filed with the Department of Managed Health Care. These plans shall
be required to remain in good standing with the Department of Managed
Health Care, and shall meet the following additional requirements:
   (1) Proposes to provide all medical and health care services that
may be required by this article.
   (2) Provides a program involving cooperative efforts by the
employees, the employer, and the health plan to promote workplace
health and safety, consultative and other services, and early return
to work for injured employees.
   (3) Proposes a timely and accurate method to meet the requirements
set forth by the administrative director for all carriers of workers'
compensation coverage to report necessary information regarding
medical and health care service cost and utilization, rates of return
to work, average time in medical treatment, and other measures as
determined by the administrative director to enable the director to
determine the effectiveness of the plan.
   (4) Agrees to provide the administrative director with
information, reports, and records prepared and submitted to the
Department of Managed Health Care in compliance with the Knox-Keene
Health Care Service Plan Act, relating to financial solvency,
provider accessibility, peer review, utilization review, and quality
assurance, upon request, if the administrative director determines
the information is necessary to verify that the plan is providing
medical treatment to injured employees in compliance with the
requirements of this code.
   Disclosure of peer review proceedings and records to the
administrative director shall not alter the status of the proceedings
or records as privileged and confidential communications pursuant to
Sections 1370 and 1370.1 of the Health and Safety Code.
   (5) Demonstrates the capability to provide occupational medicine
and related disciplines.
   (6) Complies with any other requirement the administrative
director determines is necessary to provide medical services to
injured employees consistent with the intent of this article,
including, but not limited to, a written patient grievance policy.
   (d) If the health care organization is a disability insurer
licensed by the Department of Insurance, and is in compliance with
subdivision (d) of Sections 10133 and 10133.5 of the Insurance Code,
the administrative director shall certify the organization to provide
health care pursuant to Section 4600.3 if the director finds that
the plan is in good standing with the Department of Insurance and
meets the following additional requirements:
   (1) Proposes to provide all medical and health care services that
may be required by this article.
   (2) Provides a program involving cooperative efforts by the
employees, the employer, and the health plan to promote workplace
health and safety, consultative and other services, and early return
to work for injured employees.
   (3) Proposes a timely and accurate method to meet the requirements
set forth by the administrative director for all carriers of workers'
compensation coverage to report necessary information regarding
medical and health care service cost and utilization, rates of return
to work, average time in medical treatment, and other measures as
determined by the administrative director to enable the director to
determine the effectiveness of the plan.
   (4) Agrees to provide the administrative director with
information, reports, and records prepared and submitted to the
Department of Insurance in compliance with the Insurance Code
relating to financial solvency, provider accessibility, peer review,
utilization review, and quality assurance, upon request, if the
administrative director determines the information is necessary to
verify that the plan is providing medical treatment to injured
employees consistent with the intent of this article.
   Disclosure of peer review proceedings and records to the
administrative director shall not alter the status of the proceedings
or records as privileged and confidential communications pursuant to
subdivision (d) of Section 10133 of the Insurance Code.
   (5) Demonstrates the capability to provide occupational medicine
and related disciplines.
   (6) Complies with any other requirement the administrative
director determines is necessary to provide medical services to
injured employees consistent with the intent of this article,
including, but not limited to, a written patient grievance policy.
   (e) If the health care organization is a workers' compensation
insurer, third-party administrator, or any other entity that the
administrative director determines meets the requirements of Section
4600.6, the administrative director shall certify the organization to
provide health care pursuant to Section 4600.3 if the director finds
that it meets the following additional requirements:
   (1) Proposes to provide all medical and health care services that
may be required by this article.
   (2) Provides a program involving cooperative efforts by the
employees, the employer, and the health plan to promote workplace
health and safety, consultative and other services, and early return
to work for injured employees.
   (3) Proposes a timely and accurate method to meet the requirements
set forth by the administrative director for all carriers of workers'
compensation coverage to report necessary information regarding
medical and health care service cost and utilization, rates of return
to work, average time in medical treatment, and other measures as
determined by the administrative director to enable the director to
determine the effectiveness of the plan.
   (4) Agrees to provide the administrative director with
information, reports, and records relating to provider accessibility,
peer review, utilization review, quality assurance, advertising,
disclosure, medical and financial audits, and grievance systems, upon
request, if the administrative director determines the information
is necessary to verify that the plan is providing medical treatment
to injured employees consistent with the intent of this article.
   Disclosure of peer review proceedings and records to the
administrative director shall not alter the status of the proceedings
or records as privileged and confidential communications pursuant to
subdivision (d) of Section 10133 of the Insurance Code.
   (5) Demonstrates the capability to provide occupational medicine
and related disciplines.
   (6) Complies with any other requirement the administrative
director determines is necessary to provide medical services to
injured employees consistent with the intent of this article,
including, but not limited to, a written patient grievance policy.
   (7) Complies with the following requirements:
   (A) An organization certified by the administrative director under
this subdivision may not provide or undertake to arrange for the
provision of health care to employees, or to pay for or to reimburse
any part of the cost of that health care in return for a prepaid or
periodic charge paid by or on behalf of those employees.
   (B) Every organization certified under this subdivision shall
operate on a fee-for-service basis. As used in this section, fee for
service refers to the situation where the amount of reimbursement
paid by the employer to the organization or providers of health care
is determined by the amount and type of health care rendered by the
organization or provider of health care.
   (C) An organization certified under this subdivision is prohibited
from assuming risk.
   (f) (1) A workers' compensation health care provider organization
authorized by the Department of Corporations on December 31, 1997,
shall be eligible for certification as a health care organization
under subdivision (e).
   (2) An entity that had, on December 31, 1997, submitted an
application with the Commissioner of Corporations under Part 3.2
(commencing with Section 5150) shall be considered an applicant for
certification under subdivision (e) and shall be entitled to priority
in consideration of its application. The Commissioner of
Corporations shall provide complete files for all pending
applications to the administrative director on or before January 31,
1998.
   (g) The provisions of this section shall not affect the
confidentiality or admission in evidence of a claimant's medical
treatment records.
   (h) Charges for services arranged for or provided by health care
service plans certified by this section and that are paid on a
per-enrollee-periodic-charge basis shall not be subject to the
schedules adopted by the administrative director pursuant to Section
5307.1.
   (i) Nothing in this section shall be construed to expand or
constrict any requirements imposed by law on a health care service
plan or insurer when operating as other than a health care
organization pursuant to this section.
   (j) In consultation with interested parties, including the
Department of Corporations and the Department of Insurance, the
administrative director shall adopt rules necessary to carry out this
section.
   (k) The administrative director shall refuse to certify or may
revoke or suspend the certification of any health care organization
under this section if the director finds that:
   (1) The plan for providing medical treatment fails to meet the
requirements of this section.
   (2) A health care service plan licensed by the Department of
Managed Health Care, a workers' compensation health care provider
organization authorized by the Department of Corporations, or a
carrier licensed by the Department of Insurance is not in good
standing with its licensing agency.
   (3) Services under the plan are not being provided in accordance
with the terms of a certified plan.
   (l) (1) When an injured employee requests chiropractic treatment
for work-related injuries, the health care organization shall provide
the injured worker with access to the services of a chiropractor
pursuant to guidelines for chiropractic care established by paragraph
(2). Within five working days of the employee's request to see a
chiropractor, the health care organization and any person or entity
who directs the kind or manner of health care services for the plan
shall refer an injured employee to an affiliated chiropractor for
work-related injuries that are within the guidelines for chiropractic
care established by paragraph (2). Chiropractic care rendered in
accordance with guidelines for chiropractic care established pursuant
to paragraph (2) shall be provided by duly licensed chiropractors
affiliated with the plan.
   (2) The health care organization shall establish guidelines for
chiropractic care in consultation with affiliated chiropractors who
are participants in the health care organization's utilization review
process for chiropractic care, which may include qualified medical
evaluators knowledgeable in the treatment of chiropractic conditions.
The guidelines for chiropractic care shall, at a minimum, explicitly
require the referral of any injured employee who so requests to an
affiliated chiropractor for the evaluation or treatment, or both, of
neuromusculoskeletal conditions.
   (3) Whenever a dispute concerning the appropriateness or necessity
of chiropractic care for work-related injuries arises, the dispute
shall be resolved by the health care organization's utilization
review process for chiropractic care in accordance with the health
care organization's guidelines for chiropractic care established by
paragraph (2).
   Chiropractic utilization review for work-related injuries shall be
conducted in accordance with the health care organization's approved
quality assurance standards and utilization review process for
chiropractic care. Chiropractors affiliated with the plan shall have
access to the health care organization's provider appeals process
and, in the case of chiropractic care for work-related injuries, the
review shall include review by a chiropractor affiliated with the
health care organization, as determined by the health care
organization.
   (4) The health care organization shall inform employees of the
procedures for processing and resolving grievances, including those
related to chiropractic care, including the location and telephone
number where grievances may be submitted.
   (5) All guidelines for chiropractic care and utilization review
shall be consistent with the standards of this code that require care
to cure or relieve the effects of the industrial injury.
   (m) Individually identifiable medical information on patients
submitted to the division shall not be subject to the California
Public Records Act (Chapter 3.5 (commencing with Section 6250) of
Division 7 of Title 1 of the Government Code).
   (n) (1) When an injured employee requests acupuncture treatment
for work-related injuries, the health care organization shall provide
the injured worker with access to the services of an acupuncturist
pursuant to guidelines for acupuncture care established by paragraph
(2). Within five working days of the employee's request to see an
acupuncturist, the health care organization and any person or entity
who directs the kind or manner of health care services for the plan
shall refer an injured employee to an affiliated acupuncturist for
work-related injuries that are within the guidelines for acupuncture
care established by paragraph (2). Acupuncture care rendered in
accordance with guidelines for acupuncture care established pursuant
to paragraph (2) shall be provided by duly licensed acupuncturists
affiliated with the plan.
   (2) The health care organization shall establish guidelines for
acupuncture care in consultation with affiliated acupuncturists who
are participants in the health care organization's utilization review
process for acupuncture care, which may include qualified medical
evaluators. The guidelines for acupuncture care shall, at a minimum,
explicitly require the referral of any injured employee who so
requests to an affiliated acupuncturist for the evaluation or
treatment, or both, of neuromusculoskeletal conditions.
   (3) Whenever a dispute concerning the appropriateness or necessity
of acupuncture care for work-related injuries arises, the dispute
shall be resolved by the health care organization's utilization
review process for acupuncture care in accordance with the health
care organization's guidelines for acupuncture care established by
paragraph (2).
   Acupuncture utilization review for work-related injuries shall be
conducted in accordance with the health care organization's approved
quality assurance standards and utilization review process for
acupuncture care. Acupuncturists affiliated with the plan shall have
access to the health care organization's provider appeals process
and, in the case of acupuncture care for work-related injuries, the
review shall include review by an acupuncturist affiliated with the
health care organization, as determined by the health care
organization.
   (4) The health care organization shall inform employees of the
procedures for processing and resolving grievances, including those
related to acupuncture care, including the location and telephone
number where grievances may be submitted.
   (5) All guidelines for acupuncture care and utilization review
shall be consistent with the standards of this code that require care
to cure or relieve the effects of the industrial injury.



4600.6.  Any workers' compensation insurer, third-party
administrator, or other entity seeking certification as a health care
organization under subdivision (e) of Section 4600.5 shall be
subject to the following rules and procedures:
   (a) Each application for authorization as an organization under
subdivision (e) of Section 4600.5 shall be verified by an authorized
representative of the applicant and shall be in a form prescribed by
the administrative director. The application shall be accompanied by
the prescribed fee and shall set forth or be accompanied by each and
all of the following:
   (1) The basic organizational documents of the applicant, such as
the articles of incorporation, articles of association, partnership
agreement, trust agreement, or other applicable documents and all
amendments thereto.
   (2) A copy of the bylaws, rules, and regulations, or similar
documents regulating the conduct of the internal affairs of the
applicant.
   (3) A list of the names, addresses, and official positions of the
persons who are to be responsible for the conduct of the affairs of
the applicant, which shall include, among others, all members of the
board of directors, board of trustees, executive committee, or other
governing board or committee, the principal officers, each
shareholder with over 5 percent interest in the case of a
corporation, and all partners or members in the case of a partnership
or association, and each person who has loaned funds to the
applicant for the operation of its business.
   (4) A copy of any contract made, or to be made, between the
applicant and any provider of health care, or persons listed in
paragraph (3), or any other person or organization agreeing to
perform an administrative function or service for the plan. The
administrative director by rule may identify contracts excluded from
this requirement and make provision for the submission of form
contracts. The payment rendered or to be rendered to the provider of
health care services shall be deemed confidential information that
shall not be divulged by the administrative director, except that the
payment may be disclosed and become a public record in any
legislative, administrative, or judicial proceeding or inquiry. The
organization shall also submit the name and address of each provider
employed by, or contracting with, the organization, together with his
or her license number.
   (5) A statement describing the organization, its method of
providing for health services, and its physical facilities. If
applicable, this statement shall include the health care delivery
capabilities of the organization, including the number of full-time
and part-time physicians under Section 3209.3, the numbers and types
of licensed or state-certified health care support staff, the number
of hospital beds contracted for, and the arrangements and the methods
by which health care will be provided, as defined by the
administrative director under Sections 4600.3 and 4600.5.
   (6) A copy of the disclosure forms or materials that are to be
issued to employees.
   (7) A copy of the form of the contract that is to be issued to any
employer, insurer of an employer, or a group of self-insured
employers.
   (8) Financial statements accompanied by a report, certificate, or
opinion of an independent certified public accountant. However, the
financial statements from public entities or political subdivisions
of the state need not include a report, certificate, or opinion by an
independent certified public accountant if the financial statement
complies with any requirements that may be established by regulation
of the administrative director.
   (9) A description of the proposed method of marketing the
organization and a copy of any contract made with any person to
solicit on behalf of the organization or a copy of the form of
agreement used and a list of the contracting parties.
   (10) A statement describing the service area or areas to be
served, including the service location for each provider rendering
professional services on behalf of the organization and the location
of any other organization facilities where required by the
administrative director.
   (11) A description of organization grievance procedures to be
utilized as required by this part, and a copy of the form specified
by paragraph (3) of subdivision (j).
   (12) A description of the procedures and programs for internal
review of the quality of health care pursuant to the requirements set
forth in this part.
   (13) Evidence of adequate insurance coverage or self-insurance to
respond to claims for damages arising out of the furnishing of
workers' compensation health care.
   (14) Evidence of adequate insurance coverage or self-insurance to
protect against losses of facilities where required by the
administrative director.
   (15) Evidence of adequate workers' compensation coverage to
protect against claims arising out of work-related injuries that
might be brought by the employees and staff of an organization
against the organization.
   (16) Evidence of fidelity bonds in such amount as the
administrative director prescribes by regulation.
   (17) Other information that the administrative director may
reasonably require.
   (b) (1) An organization, solicitor, solicitor firm, or
representative may not use or permit the use of any advertising or
solicitation that is untrue or misleading, or any form of disclosure
that is deceptive. For purposes of this chapter:
   (A) A written or printed statement or item of information shall be
deemed untrue if it does not conform to fact in any respect that is
or may be significant to an employer or employee, or potential
employer or employee.
   (B) A written or printed statement or item of information shall be
deemed misleading whether or not it may be literally true, if, in
the total context in which the statement is made or the item of
information is communicated, the statement or item of information may
be understood by a person not possessing special knowledge regarding
health care coverage, as indicating any benefit or advantage, or the
absence of any exclusion, limitation, or disadvantage of possible
significance to an employer or employee, or potential employer or
employee.
   (C) A disclosure form shall be deemed to be deceptive if the
disclosure form taken as a whole and with consideration given to
typography and format, as well as language, shall be such as to cause
a reasonable person, not possessing special knowledge of workers'
compensation health care, and the disclosure form therefor, to expect
benefits, service charges, or other advantages that the disclosure
form does not provide or that the organization issuing that
disclosure form does not regularly make available to employees.
   (2) An organization, solicitor, or representative may not use or
permit the use of any verbal statement that is untrue, misleading, or
deceptive or make any representations about health care offered by
the organization or its cost that does not conform to fact. All
verbal statements are to be held to the same standards as those for
printed matter provided in paragraph (1).
   (c) It is unlawful for any person, including an organization,
subject to this part, to represent or imply in any manner that the
person or organization has been sponsored, recommended, or approved,
or that the person's or organization's abilities or qualifications
have in any respect been passed upon, by the administrative director.
   (d) (1) An organization may not publish or distribute, or allow to
be published or distributed on its behalf, any advertisement unless
(A) a true copy thereof has first been filed with the administrative
director, at least 30 days prior to any such use, or any shorter
period as the administrative director by rule or order may allow, and
(B) the administrative director by notice has not found the
advertisement, wholly or in part, to be untrue, misleading,
deceptive, or otherwise not in compliance with this part or the rules
thereunder, and specified the deficiencies, within the 30 days or
any shorter time as the administrative director by rule or order may
allow.
   (2) If the administrative director finds that any advertisement of
an organization has materially failed to comply with this part or
the rules thereunder, the administrative director may, by order,
require the organization to publish in the same or similar medium, an
approved correction or retraction of any untrue, misleading, or
deceptive statement contained in the advertising.
   (3) The administrative director by rule or order may classify
organizations and advertisements and exempt certain classes, wholly
or in part, either unconditionally or upon specified terms and
conditions or for specified periods, from the application of
subdivision (a).
   (e) (1) The administrative director shall require the use by each
organization of disclosure forms or materials containing any
information regarding the health care and terms of the workers'
compensation health care contract that the administrative director
may require, so as to afford the public, employers, and employees
with a full and fair disclosure of the provisions of the contract in
readily understood language and in a clearly organized manner. The
administrative director may require that the materials be presented
in a reasonably uniform manner so as to facilitate comparisons
between contracts of the same or other types of organizations. The
disclosure form shall describe the health care that is required by
the administrative director under Sections 4600.3 and 4600.5, and
shall provide that all information be in concise and specific terms,
relative to the contract, together with any additional information as
may be required by the administrative director, in connection with
the organization or contract.
   (2) All organizations, solicitors, and representatives of a
workers' compensation health care provider organization shall, when
presenting any contract for examination or sale to a prospective
employee, provide the employee with a properly completed disclosure
form, as prescribed by the administrative director pursuant to this
section for each contract so examined or sold.
   (3) In addition to the other disclosures required by this section,
every organization and any agent or employee of the organization
shall, when representing an organization for examination or sale to
any individual purchaser or the representative of a group consisting
of 25 or fewer individuals, disclose in writing the ratio of premium
cost to health care paid for contracts with individuals and with
groups of the same or similar size for the organization's preceding
fiscal year. An organization may report that information by
geographic area, provided the organization identifies the geographic
area and reports information applicable to that geographic area.
   (4) Where the administrative director finds it necessary in the
interest of full and fair disclosure, all advertising and other
consumer information disseminated by an organization for the purpose
of influencing persons to become members of an organization shall
contain any supplemental disclosure information that the
administrative director may require.
   (f) When the administrative director finds it necessary in the
interest of full and fair disclosure, all advertising and other
consumer information disseminated by an organization for the purpose
of influencing persons to become members of an organization shall
contain any supplemental disclosure information that the
administrative director may require.
   (g) (1) An organization may not refuse to enter into any contract,
or may not cancel or decline to renew or reinstate any contract,
because of the age or any characteristic listed or defined in
subdivision (b) or (e) of Section 51 of the Civil Code of any
contracting party, prospective contracting party, or person
reasonably expected to benefit from that contract as an employee or
otherwise.
   (2) The terms of any contract shall not be modified, and the
benefits or coverage of any contract shall not be subject to any
limitations, exceptions, exclusions, reductions, copayments,
coinsurance, deductibles, reservations, or premium, price, or charge
differentials, or other modifications because of the age or any
characteristic listed or defined in subdivision (b) or (e) of Section
51 of the Civil Code of any contracting party, potential contracting
party, or person reasonably expected to benefit from that contract
as an employee or otherwise; except that premium, price, or charge
differentials because of the sex or age of any individual when based
on objective, valid, and up-to-date statistical and actuarial data
are not prohibited. Nothing in this section shall be construed to
permit an organization to charge different rates to individual
employees within the same group solely on the basis of the employee's
sex.
   (3) It shall be deemed a violation of subdivision (a) for any
organization to utilize marital status, living arrangements,
occupation, gender, beneficiary designation, ZIP Codes or other
territorial classification, or any combination thereof for the
purpose of establishing sexual orientation. Nothing in this section
shall be construed to alter in any manner the existing law
prohibiting organizations from conducting tests for the presence of
human immunodeficiency virus or evidence thereof.
   (4) This section shall not be construed to limit the authority of
the administrative director to adopt or enforce regulations
prohibiting discrimination because of sex, marital status, or sexual
orientation.
   (h) (1) An organization may not use in its name any of the words
"insurance," "casualty," "health care service plan," "health plan,"
"surety," "mutual," or any other words descriptive of the health
plan, insurance, casualty, or surety business or use any name similar
to the name or description of any health care service plan,
insurance, or surety corporation doing business in this state unless
that organization controls or is controlled by an entity licensed as
a health care service plan or insurer pursuant to the Health and
Safety Code or the Insurance Code and the organization employs a name
related to that of the controlled or controlling entity.
   (2) Section 2415 of the Business and Professions Code, pertaining
to fictitious names, does not apply to organizations certified under
this section.
   (3) An organization or solicitor firm may not adopt a name style
that is deceptive, or one that could cause the public to believe the
organization is affiliated with or recommended by any governmental or
private entity unless this affiliation or endorsement exists.
   (i) Each organization shall meet the following requirements:
   (1) All facilities located in this state, including, but not
limited to, clinics, hospitals, and skilled nursing facilities, to be
utilized by the organization shall be licensed by the State
Department of Health Services, if that licensure is required by law.
Facilities not located in this state shall conform to all licensing
and other requirements of the jurisdiction in which they are located.
   (2) All personnel employed by or under contract to the
organization shall be licensed or certified by their respective board
or agency, where that licensure or certification is required by law.
   (3) All equipment required to be licensed or registered by law
shall be so licensed or registered and the operating personnel for
that equipment shall be licensed or certified as required by law.
   (4) The organization shall furnish services in a manner providing
continuity of care and ready referral of patients to other providers
at any time as may be appropriate and consistent with good
professional practice.
   (5) All health care shall be readily available at reasonable times
to all employees. To the extent feasible, the organization shall
make all health care readily accessible to all employees.
   (6) The organization shall employ and utilize allied health
manpower for the furnishing of health care to the extent permitted by
law and consistent with good health care practice.
   (7) The organization shall have the organizational and
administrative capacity to provide services to employees. The
organization shall be able to demonstrate to the department that
health care decisions are rendered by qualified providers, unhindered
by fiscal and administrative management.
   (8) All contracts with employers, insurers of employers, and
self-insured employers and all contracts with providers, and other
persons furnishing services, equipment, or facilities to or in
connection with the workers' compensation health care organization,
shall be fair, reasonable, and consistent with the objectives of this
part.
   (9) Each organization shall provide to employees all workers'
compensation health care required by this code. The administrative
director shall not determine the scope of workers' compensation
health care to be offered by an organization.
   (j) (1) Every organization shall establish and maintain a
grievance system approved by the administrative director under which
employees may submit their grievances to the organization. Each
system shall provide reasonable procedures in accordance with
regulations adopted by the administrative director that shall ensure
adequate consideration of employee grievances and rectification when
appropriate.
   (2) Every organization shall inform employees upon enrollment and
annually thereafter of the procedures for processing and resolving
grievances. The information shall include the location and telephone
number where grievances may be submitted.
   (3) Every organization shall provide forms for complaints to be
given to employees who wish to register written complaints. The forms
used by organizations shall be approved by the administrative
director in advance as to format.
   (4) The organization shall keep in its files all copies of
complaints, and the responses thereto, for a period of five years.
   (k) Every organization shall establish procedures in accordance
with regulations of the administrative director for continuously
reviewing the quality of care, performance of medical personnel,
utilization of services and facilities, and costs. Notwithstanding
any other provision of law, there shall be no monetary liability on
the part of, and no cause of action for damages shall arise against,
any person who participates in quality of care or utilization reviews
by peer review committees that are composed chiefly of physicians,
as defined by Section 3209.3, for any act performed during the
reviews if the person acts without malice, has made a reasonable
effort to obtain the facts of the matter, and believes that the
action taken is warranted by the facts, and neither the proceedings
nor the records of the reviews shall be subject to discovery, nor
shall any person in attendance at the reviews be required to testify
as to what transpired thereat. Disclosure of the proceedings or
records to the governing body of an organization or to any person or
entity designated by the organization to review activities of the
committees shall not alter the status of the records or of the
proceedings as privileged communications.
   The above prohibition relating to discovery or testimony does not
apply to the statements made by any person in attendance at a review
who is a party to an action or proceeding the subject matter of which
was reviewed, or to any person requesting hospital staff privileges,
or in any action against an insurance carrier alleging bad faith by
the carrier in refusing to accept a settlement offer within the
policy limits, or to the administrative director in conducting
surveys pursuant to subdivision (o).
   This section shall not be construed to confer immunity from
liability on any workers' compensation health care organization. In
any case in which, but for the enactment of the preceding provisions
of this section, a cause of action would arise against an
organization, the cause of action shall exist notwithstanding the
provisions of this section.
   (l) Nothing in this chapter shall be construed to prevent an
organization from utilizing subcommittees to participate in peer
review activities, nor to prevent an organization from delegating the
responsibilities required by subdivision (i) as it determines to be
appropriate, to subcommittees including subcommittees composed of a
majority of nonphysician health care providers licensed pursuant to
the Business and Professions Code, as long as the organization
controls the scope of authority delegated and may revoke all or part
of this authority at any time. Persons who participate in the
subcommittees shall be entitled to the same immunity from monetary
liability and actions for civil damages as persons who participate in
organization or provider peer review committees pursuant to
subdivision (i).
   (m) Every organization shall have and shall demonstrate to the
administrative director that it has all of the following:
   (1) Adequate provision for continuity of care.
   (2) A procedure for prompt payment and denial of provider claims.
   (n) Every contract between an organization and an employer or
insurer of an employer, and every contract between any organization
and a provider of health care, shall be in writing.
   (o) (1) The administrative director shall conduct periodically an
onsite medical survey of the health care delivery system of each
organization. The survey shall include a review of the procedures for
obtaining health care, the procedures for regulating utilization,
peer review mechanisms, internal procedures for assuring quality of
care, and the overall performance of the organization in providing
health care and meeting the health needs of employees.
   (2) The survey shall be conducted by a panel of qualified health
professionals experienced in evaluating the delivery of workers'
compensation health care. The administrative director shall be
authorized to contract with professional organizations or outside
personnel to conduct medical surveys. These organizations or
personnel shall have demonstrated the ability to objectively evaluate
the delivery of this health care.
   (3) Surveys performed pursuant to this section shall be conducted
as often as deemed necessary by the administrative director to assure
the protection of employees, but not less frequently than once every
three years. Nothing in this section shall be construed to require
the survey team to visit each clinic, hospital, office, or facility
of the organization.
   (4) Nothing in this section shall be construed to require the
medical survey team to review peer review proceedings and records
conducted and compiled under this section or in medical records.
However, the administrative director shall be authorized to require
onsite review of these peer review proceedings and records or medical
records where necessary to determine that quality health care is
being delivered to employees. Where medical record review is
authorized, the survey team shall ensure that the confidentiality of
the physician-patient relationship is safeguarded in accordance with
existing law and neither the survey team nor the administrative
director or the administrative director's staff may be compelled to
disclose this information except in accordance with the
physician-patient relationship. The administrative director shall
ensure that the confidentiality of the peer review proceedings and
records is maintained. The disclosure of the peer review proceedings
and records to the administrative director or the medical survey team
shall not alter the status of the proceedings or records as
privileged and confidential communications.
   (5) The procedures and standards utilized by the survey team shall
be made available to the organizations prior to the conducting of
medical surveys.
   (6) During the survey, the members of the survey team shall offer
such advice and assistance to the organization as deemed appropriate.
   (7) The administrative director shall notify the organization of
deficiencies found by the survey team. The administrative director
shall give the organization a reasonable time to correct the
deficiencies, and failure on the part of the organization to comply
to the administrative director's satisfaction shall constitute cause
for disciplinary action against the organization.
   (8) Reports of all surveys, deficiencies, and correction plans
shall be open to public inspection, except that no surveys,
deficiencies or correction plans shall be made public unless the
organization has had an opportunity to review the survey and file a
statement of response within 30 days, to be attached to the report.
   (p) (1) All records, books, and papers of an organization,
management company, solicitor, solicitor firm, and any provider or
subcontractor providing medical or other services to an organization,
management company, solicitor, or solicitor firm shall be open to
inspection during normal business hours by the administrative
director.
   (2) To the extent feasible, all the records, books, and papers
described in paragraph (1) shall be located in this state. In
examining those records outside this state, the administrative
director shall consider the cost to the organization, consistent with
the effectiveness of the administrative director's examination, and
may upon reasonable notice require that these records, books, and
papers, or a specified portion thereof, be made available for
examination in this state, or that a true and accurate copy of these
records, books, and papers, or a specified portion thereof, be
furnished to the administrative director.
   (q) (1) The administrative director shall conduct an examination
of the administrative affairs of any organization, and each person
with whom the organization has made arrangements for administrative,
or management services, as often as deemed necessary to protect the
interest of employees, but not less frequently than once every five
years.
   (2) The expense of conducting any additional or nonroutine
examinations pursuant to this section, and the expense of conducting
any additional or nonroutine medical surveys pursuant to subdivision
(o) shall be charged against the organization being examined or
surveyed. The amount shall include the actual salaries or
compensation paid to the persons making the examination or survey,
the expenses incurred in the course thereof, and overhead costs in
connection therewith as fixed by the administrative director. In
determining the cost of examinations or surveys, the administrative
director may use the estimated average hourly cost for all persons
performing examinations or surveys of workers' compensation health
care organizations for the fiscal year. The amount charged shall be
remitted by the organization to the administrative director.
   (3) Reports of all examinations shall be open to public
inspection, except that no examination shall be made public, unless
the organization has had an opportunity to review the examination
report and file a statement or response within 30 days, to be
attached to the report.



4600.7.  (a) The Workers' Compensation Managed Care Fund is hereby
created in the State Treasury for the administration of Sections
4600.3 and 4600.5 by the Division of Workers' Compensation. The
administrative director shall establish a schedule of fees and
revenues to be charged to certified health care organizations and
applicants for certification to fully fund the administration of
these provisions and to repay amounts received as a loan from the
General Fund. All fees and revenues shall be deposited in the Workers'
Compensation Managed Care Fund and shall be used when appropriated
by the Legislature solely for the purpose of carrying out the
responsibilities of the Division of Workers' Compensation under
Section 4600.3 or 4600.5.
   (b) On and after July 1, 1998, no funds received as a loan from
the General Fund shall be used to support the administration of
Sections 4600.3 and 4600.5. The loan amount shall be repaid to the
General Fund by assessing a surcharge on the enrollment fee for each
of the next five fiscal years. In the event the surcharge does not
produce sufficient revenue over this period, the surcharge shall be
adjusted to fully repay the loan over the following three fiscal
years, with the final assessment calculated by dividing the balance
of the loan by the enrollees at the end of the final fiscal year.



4601.  (a) If the employee so requests, the employer shall tender
the employee one change of physician. The employee at any time may
request that the employer tender this one-time change of physician.
Upon request of the employee for a change of physician, the maximum
amount of time permitted by law for the employer or insurance carrier
to provide the employee an alternative physician or, if requested by
the employee, a chiropractor, or an acupuncturist shall be five
working days from the date of the request. Notwithstanding the 30-day
time period specified in Section 4600, a request for a change of
physician pursuant to this section may be made at any time. The
employee is entitled, in any serious case, upon request, to the
services of a consulting physician, chiropractor, or acupuncturist of
his or her choice at the expense of the employer. The treatment
shall be at the expense of the employer.
   (b) If an employee requesting a change of physician pursuant to
subdivision (a) has notified his or her employer in writing prior to
the date of injury that he or she has a personal chiropractor, the
alternative physician tendered by the employer to the employee, if
the employee so requests, shall be the employee's personal
chiropractor. For the purpose of this article, "personal chiropractor"
means the employee's regular chiropractor licensed pursuant to
Chapter 2 (commencing with Section 1000) of Division 2 of the
Business and Professions Code, who has previously directed treatment
of the employee, and who retains the employee's chiropractic
treatment records, including his or her chiropractic history.
   (c) If an employee requesting a change of physician pursuant to
subdivision (a) has notified his or her employer in writing prior to
the date of injury that he or she has a personal acupuncturist, the
alternative physician tendered by the employer to the employee, if
the employee so requests, shall be the employee's personal
acupuncturist. For the purpose of this article, "personal
acupuncturist" means the employee's regular acupuncturist licensed
pursuant to Chapter 12 (commencing with Section 4935) of Division 2
of the Business and Professions Code, who has previously directed
treatment of the employee, and who retains the employee's acupuncture
treatment records, including his or her acupuncture history.



4602.  If the employee so requests, the employer shall procure
certification by either the administrative director or the appeals
board as the case may be of the competency, for the particular case,
of the consulting or additional physicians.




4603.  If the employer desires a change of physicians or
chiropractor, he may petition the administrative director who, upon a
showing of good cause by the employer, may order the employer to
provide a panel of five physicians, or if requested by the employee,
four physicians and one chiropractor competent to treat the
particular case, from which the employee must select one.



4603.2.  (a) (1) Upon selecting a physician pursuant to Section
4600, the employee or physician shall notify the employer of the name
and address, including the name of the medical group, if applicable,
of the physician. The physician shall submit a report to the
employer within five working days from the date of the initial
examination, as required by Section 6409, and shall submit periodic
reports at intervals that may be prescribed by rules and regulations
adopted by the administrative director.
   (2) If the employer objects to the employee's selection of the
physician on the grounds that the physician is not within the medical
provider network used by the employer, and there is a final
determination that the employee was entitled to select the physician
pursuant to Section 4600, the employee shall be entitled to continue
treatment with that physician at the employer's expense in accordance
with this division, notwithstanding Section 4616.2. The employer
shall be required to pay from the date of the initial examination if
the physician's report was submitted within five working days of the
initial examination. If the physician's report was submitted more
than five working days after the initial examination, the employer
and the employee shall not be required to pay for any services prior
to the date the physician's report was submitted.
   (3) If the employer objects to the employee's selection of the
physician on the grounds that the physician is not within the medical
provider network used by the employer, and there is a final
determination that the employee was not entitled to select a
physician outside of the medical provider network, the employer shall
have no liability for treatment provided by or at the direction of
that physician or for any consequences of the treatment obtained
outside the network.
   (b) (1) Any provider of services provided pursuant to Section
4600, including, but not limited to, physicians, hospitals,
pharmacies, interpreters, copy services, transportation services, and
home health care services, shall submit its request for payment with
an itemization of services provided and the charge for each service,
a copy of all reports showing the services performed, the
prescription or referral from the primary treating physician if the
services were performed by a person other than the primary treating
physician, and any evidence of authorization for the services that
may have been received. Nothing in this section shall prohibit an
employer, insurer, or third-party claims administrator from
establishing, through written agreement, an alternative manual or
electronic request for payment with providers for services provided
pursuant to Section 4600.
   (2) Except as provided in subdivision (d) of Section 4603.4, or
under contracts authorized under Section 5307.11, payment for medical
treatment provided or prescribed by the treating physician selected
by the employee or designated by the employer shall be made at
reasonable maximum amounts in the official medical fee schedule,
pursuant to Section 5307.1, in effect on the date of service.
Payments shall be made by the employer with an explanation of review
pursuant to Section 4603.3 within 45 days after receipt of each
separate, itemization of medical services provided, together with any
required reports and any written authorization for services that may
have been received by the physician. If the itemization or a portion
thereof is contested, denied, or considered incomplete, the
physician shall be notified, in the explanation of review, that the
itemization is contested, denied, or considered incomplete, within 30
days after receipt of the itemization by the employer. An
explanation of review that states an itemization is incomplete shall
also state all additional information required to make a decision.
Any properly documented list of services provided and not paid at the
rates then in effect under Section 5307.1 within the 45-day period
shall be paid at the rates then in effect and increased by 15
percent, together with interest at the same rate as judgments in
civil actions retroactive to the date of receipt of the itemization,
unless the employer does both of the following:
   (A) Pays the provider at the rates in effect within the 45-day
period.
   (B) Advises, in an explanation of review pursuant to Section
4603.3, the physician, or another provider of the items being
contested, the reasons for contesting these items, and the remedies
available to the physician or the other provider if he or she
disagrees. In the case of an itemization that includes services
provided by a hospital, outpatient surgery center, or independent
diagnostic facility, advice that a request has been made for an audit
of the itemization shall satisfy the requirements of this paragraph.
   An employer's liability to a physician or another provider under
this section for delayed payments shall not affect its liability to
an employee under Section 5814 or any other provision of this
division.
   (3) Notwithstanding paragraph (1), if the employer is a
governmental entity, payment for medical treatment provided or
prescribed by the treating physician selected by the employee or
designated by the employer shall be made within 60 days after receipt
of each separate itemization, together with any required reports and
any written authorization for services that may have been received
by the physician.
   (4) Duplicate submissions of medical services itemizations, for
which an explanation of review was previously provided, shall require
no further or additional notification or objection by the employer
to the medical provider and shall not subject the employer to any
additional penalties or interest pursuant to this section for failing
to respond to the duplicate submission. This paragraph shall apply
only to duplicate submissions and does not apply to any other
penalties or interest that may be applicable to the original
submission.
   (c) Any interest or increase in compensation paid by an insurer
pursuant to this section shall be treated in the same manner as an
increase in compensation under subdivision (d) of Section 4650 for
the purposes of any classification of risks and premium rates, and
any system of merit rating approved or issued pursuant to Article 2
(commencing with Section 11730) of Chapter 3 of Part 3 of Division 2
of the Insurance Code.
   (d) (1) Whenever an employer or insurer employs an individual or
contracts with an entity to conduct a review of an itemization
submitted by a physician or medical provider, the employer or insurer
shall make available to that individual or entity all documentation
submitted together with that itemization by the physician or medical
provider. When an individual or entity conducting a itemization
review determines that additional information or documentation is
necessary to review the itemization, the individual or entity shall
contact the claims administrator or insurer to obtain the necessary
information or documentation that was submitted by the physician or
medical provider pursuant to subdivision (b).
   (2) An individual or entity reviewing an itemization of service
submitted by a physician or medical provider shall not alter the
procedure codes listed or recommend reduction of the amount of the
payment unless the documentation submitted by the physician or
medical provider with the itemization of service has been reviewed by
that individual or entity. If the reviewer does not recommend
payment for services as itemized by the physician or medical
provider, the explanation of review shall provide the physician or
medical provider with a specific explanation as to why the reviewer
altered the procedure code or changed other parts of the itemization
and the specific deficiency in the itemization or documentation that
caused the reviewer to conclude that the altered procedure code or
amount recommended for payment more accurately represents the service
performed.
   (e) (1) If the provider disputes the amount paid, the provider may
request a second review within 90 days of service of the explanation
of review or an order of the appeals board resolving the threshold
issue as stated in the explanation of review pursuant to paragraph
(5) of subdivision (a) of Section 4603.3. The request for a second
review shall be submitted to the employer on a form prescribed by the
administrative director and shall include all of the following:
   (A) The date of the explanation of review and the claim number or
other unique identifying number provided on the explanation of
review.
   (B) The item and amount in dispute.
   (C) The additional payment requested and the reason therefor.
   (D) The additional information provided in response to a request
in the first explanation of review or any other additional
information provided in support of the additional payment requested.
   (2) If the only dispute is the amount of payment and the provider
does not request a second review within 90 days, the bill shall be
deemed satisfied and neither the employer nor the employee shall be
liable for any further payment.
   (3) Within 14 days of a request for second review, the employer
shall respond with a final written determination on each of the items
or amounts in dispute. Payment of any balance not in dispute shall
be made within 21 days of receipt of the request for second review.
This time limit may be extended by mutual written agreement.
   (4) If the provider contests the amount paid, after receipt of the
second review, the provider shall request an independent bill review
as provided for in Section 4603.6.
   (f) Except as provided in paragraph (4) of subdivision (e), the
appeals board shall have jurisdiction over disputes arising out of
this subdivision pursuant to Section 5304.



4603.3.  (a) Upon payment, adjustment, or denial of a complete or
incomplete itemization of medical services, an employer shall provide
an explanation of review in the manner prescribed by the
administrative director that shall include all of the following:
   (1) A statement of the items or procedures billed and the amounts
requested by the provider to be paid.
   (2) The amount paid.
   (3) The basis for any adjustment, change, or denial of the item or
procedure billed.
   (4) The additional information required to make a decision for an
incomplete itemization.
   (5) If a denial of payment is for some reason other than a fee
dispute, the reason for the denial.
   (6) Information on whom to contact on behalf of the employer if a
dispute arises over the payment of the billing. The explanation of
review shall inform the medical provider of the time limit to raise
any objection regarding the items or procedures paid or disputed and
how to obtain an independent review of the medical bill pursuant to
Section 4603.6.
   (b) The administrative director may adopt regulations requiring
the use of electronic explanations of review.



4603.4.  (a) The administrative director shall adopt rules and
regulations to do all of the following:
   (1) Ensure that all health care providers and facilities submit
medical bills for payment on standardized forms.
   (2) Require acceptance by employers of electronic claims for
payment of medical services.
   (3) Ensure confidentiality of medical information submitted on
electronic claims for payment of medical services.
   (b) To the extent feasible, standards adopted pursuant to
subdivision (a) shall be consistent with existing standards under the
federal Health Insurance Portability and Accountability Act of 1996.
   (c) The rules and regulations requiring employers to accept
electronic claims for payment of medical services shall be adopted on
or before January 1, 2005, and shall require all employers to accept
electronic claims for payment of medical services on or before July
1, 2006.
   (d) Payment for medical treatment provided or prescribed by the
treating physician selected by the employee or designated by the
employer shall be made with an explanation of review by the employer
within 15 working days after electronic receipt of an itemized
electronic billing for services at or below the maximum fees provided
in the official medical fee schedule adopted pursuant to Section
5307.1. If the billing is contested, denied, or incomplete, payment
shall be made with an explanation of review of any uncontested
amounts within 15 working days after electronic receipt of the
billing, and payment of the balance shall be made in accordance with
Section 4603.2.


4603.5.  The administrative director shall adopt rules pertaining to
the format and content of notices required by this article; define
reasonable geographic areas for the purposes of Section 4600; specify
time limits for all such notices, and responses thereto; and adopt
any other rules necessary to make effective the requirements of this
article.
   Employers shall notify all employees of their rights under this
section.



4603.6.  (a) If the only dispute is the amount of payment and the
provider has received a second review that did not resolve the
dispute, the provider may request an independent bill review within
30 calendar days of service of the second review pursuant to Section
4603.2 or 4622. If the provider fails to request an independent bill
review within 30 days, the bill shall be deemed satisfied, and
neither the employer nor the employee shall be liable for any further
payment. If the employer has contested liability for any issue other
than the reasonable amount payable for services, that issue shall be
resolved prior to filing a request for independent bill review, and
the time limit for requesting independent bill review shall not begin
to run until the resolution of that issue becomes final, except as
provided for in Section 4622.
   (b) A request for independent review shall be made on a form
prescribed by the administrative director, and shall include copies
of the original billing itemization, any supporting documents that
were furnished with the original billing, the explanation of review,
the request for second review together with any supporting
documentation submitted with that request, and the final explanation
of the second review. The administrative director may require that
requests for independent bill review be submitted electronically. A
copy of the request, together with all required documents, shall be
served on the employer. Only the request form and the proof of
payment of the fee required by subdivision (c) shall be filed with
the administrative director. Upon notice of assignment of the
independent bill reviewer, the requesting party shall submit the
documents listed in this subdivision to the independent bill reviewer
within 10 days.
   (c) The provider shall pay to the administrative director a fee
determined by the administrative director to cover no more than the
reasonable estimated cost of independent bill review and
administration of the independent bill review program. The
administrative director may prescribe different fees depending on the
number of items in the bill or other criteria determined by
regulation adopted by the administrative director. If any additional
payment is found owing from the employer to the medical provider, the
employer shall reimburse the provider for the fee in addition to the
amount found owing.
   (d) Upon receipt of a request for independent bill review and the
required fee, the administrative director or the administrative
director's designee shall assign the request to an independent bill
reviewer within 30 days and notify the medical provider and employer
of the independent reviewer assigned.
   (e) The independent bill reviewer shall review the materials
submitted by the parties and make a written determination of any
additional amounts to be paid to the medical provider and state the
reasons for the determination. If the independent bill reviewer deems
necessary, the independent bill reviewer may request additional
documents from the medical provider or employer. The employer shall
have no obligation to serve medical reports on the provider unless
the reports are requested by the independent bill reviewer. If
additional documents are requested, the parties shall respond with
the documents requested within 30 days and shall provide the other
party with copies of any documents submitted to the independent
reviewer, and the independent reviewer shall make a written
determination of any additional amounts to be paid to the medical
provider and state the reasons for the determination within 60 days
of the receipt of the administrative director's assignment. The
written determination of the independent bill reviewer shall be sent
to the administrative director and provided to both the medical
provider and the employer.
   (f) The determination of the independent bill reviewer shall be
deemed a determination and order of the administrative director. The
determination is final and binding on all parties unless an aggrieved
party files with the appeals board a verified appeal from the
medical bill review determination of the administrative director
within 20 days of the service of the determination. The medical bill
review determination of the administrative director shall be presumed
to be correct and shall be set aside only upon clear and convincing
evidence of one or more of the following grounds for appeal:
   (1) The administrative director acted without or in excess of his
or her powers.
   (2) The determination of the administrative director was procured
by fraud.
   (3) The independent bill reviewer was subject to a material
conflict of interest that is in violation of Section 139.5.
   (4) The determination was the result of bias on the basis of race,
national origin, ethnic group identification, religion, age, sex,
sexual orientation, color, or disability.
   (5) The determination was the result of a plainly erroneous
express or implied finding of fact, provided that the mistake of fact
is a matter of ordinary knowledge based on the information submitted
for review and not a matter that is subject to expert opinion.
   (g) If the determination of the administrative director is
reversed, the dispute shall be remanded to the administrative
director to submit the dispute to independent bill review by a
different independent review organization. In the event that a
different independent bill review organization is not available after
remand, the administrative director shall submit the dispute to the
original bill review organization for review by a different reviewer
within the organization. In no event shall the appeals board or any
higher court make a determination of ultimate fact contrary to the
determination of the bill review organization.
   (h) Once the independent bill reviewer has made a determination
regarding additional amounts to be paid to the medical provider, the
employer shall pay the additional amounts per the timely payment
requirements set forth in Sections 4603.2 and 4603.4.



4604.  Controversies between employer and employee arising under
this chapter shall be determined by the appeals board, upon the
request of either party, except as otherwise provided by Section
4610.5.


4604.5.  (a) The recommended guidelines set forth in the medical
treatment utilization schedule adopted by the administrative director
pursuant to Section 5307.27 shall be presumptively correct on the
issue of extent and scope of medical treatment. The presumption is
rebuttable and may be controverted by a preponderance of the
scientific medical evidence establishing that a variance from the
guidelines reasonably is required to cure or relieve the injured
worker from the effects of his or her injury. The presumption created
is one affecting the burden of proof.
   (b) The recommended guidelines set forth in the schedule adopted
pursuant to subdivision (a) shall reflect practices that are evidence
and scientifically based, nationally recognized, and peer reviewed.
The guidelines shall be designed to assist providers by offering an
analytical framework for the evaluation and treatment of injured
workers, and shall constitute care in accordance with Section 4600
for all injured workers diagnosed with industrial conditions.
   (c) (1) Notwithstanding the medical treatment utilization
schedule, for injuries occurring on and after January 1, 2004, an
employee shall be entitled to no more than 24 chiropractic, 24
occupational therapy, and 24 physical therapy visits per industrial
injury.
   (2) (A) Paragraph (1) shall not apply when an employer authorizes,
in writing, additional visits to a health care practitioner for
physical medicine services. Payment or authorization for treatment
beyond the limits set forth in paragraph (1) shall not be deemed a
waiver of the limits set forth by paragraph (1) with respect to
future requests for authorization.
   (B) The Legislature finds and declares that the amendments made to
subparagraph (A) by the act adding this subparagraph are declaratory
of existing law.
   (3) Paragraph (1) shall not apply to visits for postsurgical
physical medicine and postsurgical rehabilitation services provided
in compliance with a postsurgical treatment utilization schedule
established by the administrative director pursuant to Section
5307.27.
   (d) For all injuries not covered by the official utilization
schedule adopted pursuant to Section 5307.27, authorized treatment
shall be in accordance with other evidence-based medical treatment
guidelines that are recognized generally by the national medical
community and scientifically based.


4605.  Nothing contained in this chapter shall limit the right of
the employee to provide, at his or her own expense, a consulting
physician or any attending physicians whom he or she desires. Any
report prepared by consulting or attending physicians pursuant to
this section shall not be the sole basis of an award of compensation.
A qualified medical evaluator or authorized treating physician shall
address any report procured pursuant to this section and shall
indicate whether he or she agrees or disagrees with the findings or
opinions stated in the report, and shall identify the bases for this
opinion.


4606.  Any county, city and county, city, school district, or other
public corporation within the state which was a self-insured employer
under the "Workmen's Compensation, Insurance and Safety Act,"
enacted by Chapter 176 of the Statutes of 1913, may provide such
medical, and hospital treatment, including nursing, medicines,
medical and surgical supplies, crutches, and apparatus, including
artificial members, which is reasonably required to cure or relieve
from the effects of an injury to a former employee who was covered
under such act, without regard to the 90-day limitation of
subdivision (a) of Section 15 of such act for medical treatment. The
provisions of this section shall not be operative in any such county,
city and county, city, school district, or other public corporation
unless adopted by a resolution of the governing body of such public
entity.


4607.  Where a party to a proceeding institutes proceedings to
terminate an award made by the appeals board to an applicant for
continuing medical treatment and is unsuccessful in such proceedings,
the appeals board may determine the amount of attorney's fees
reasonably incurred by the applicant in resisting the proceeding to
terminate the medical treatment, and may assess such reasonable
attorney's fees as a cost upon the party instituting the proceedings
to terminate the award of the appeals board.



4608.  No workers' compensation insurer, self-insured employer, or
agent of an insurer or self-insured employer, shall refuse to pay
pharmacy benefits solely because the claim form utilized is
reproduced by the person providing the pharmacy benefits, provided
the reproduced form is an exact copy of that used by the insurer,
self-insured employer, or agent.



4609.  (a) In order to prevent the improper selling, leasing, or
transferring of a health care provider's contract, it is the intent
of the Legislature that every arrangement that results in any payor
paying a health care provider a reduced rate for health care services
based on the health care provider's participation in a network or
panel shall be disclosed by the contracting agent to the provider in
advance and shall actively encourage employees to use the network,
unless the health care provider agrees to provide discounts without
that active encouragement.
   (b) Beginning July 1, 2000, every contracting agent that sells,
leases, assigns, transfers, or conveys its list of contracted health
care providers and their contracted reimbursement rates to a payor,
as defined in subparagraph (A) of paragraph (3) of subdivision (d),
or another contracting agent shall, upon entering or renewing a
provider contract, do all of the following:
   (1) Disclose whether the list of contracted providers may be sold,
leased, transferred, or conveyed to other payors or other
contracting agents, and specify whether those payors or contracting
agents include workers' compensation insurers or automobile insurers.
   (2) Disclose what specific practices, if any, payors utilize to
actively encourage employees to use the list of contracted providers
when obtaining medical care that entitles a payor to claim a
contracted rate. For purposes of this paragraph, a payor is deemed to
have actively encouraged employees to use the list of contracted
providers if the employer provides information directly to employees
during the period the employer has medical control advising them of
the existence of the list of contracted providers through the use of
a variety of advertising or marketing approaches that supply the
names, addresses, and telephone numbers of contracted providers to
employees; or in advance of a workplace injury, or upon notice of an
injury or claim by an employee, the approaches may include, but are
not limited to, the use of provider directories, the use of a list of
all contracted providers in an area geographically accessible to the
posting site, the use of wall cards that direct employees to a
readily accessible listing of those providers at the same location as
the wall cards, the use of wall cards that direct employees to a
toll-free telephone number or Internet Web site address, or the use
of toll-free telephone numbers or Internet Web site addresses
supplied directly during the period the employer has medical control.
However, Internet Web site addresses alone shall not be deemed to
satisfy the requirements of this paragraph. Nothing in this paragraph
shall prevent contracting agents or payors from providing only
listings of providers located within a reasonable geographic range of
an employee. A payor who otherwise meets the requirements of this
paragraph is deemed to have met the requirements of this paragraph
regardless of the employer's ability to control medical treatment
pursuant to Sections 4600 and 4600.3.
   (3) Disclose whether payors to which the list of contracted
providers may be sold, leased, transferred, or conveyed may be
permitted to pay a provider's contracted rate without actively
encouraging the employees to use the list of contracted providers
when obtaining medical care. Nothing in this subdivision shall be
construed to require a payor to actively encourage the employees to
use the list of contracted providers when obtaining medical care in
the case of an emergency.
   (4) Disclose, upon the initial signing of a contract, and within
15 business days of receipt of a written request from a provider or
provider panel, a payor summary of all payors currently eligible to
claim a provider's contracted rate due to the provider's and payor's
respective written agreements with any contracting agent.
   (5) Allow providers, upon the initial signing, renewal, or
amendment of a provider contract, to decline to be included in any
list of contracted providers that is sold, leased, transferred, or
conveyed to payors that do not actively encourage the employees to
use the list of contracted providers when obtaining medical care as
described in paragraph (2). Each provider's election under this
paragraph shall be binding on the contracting agent with which the
provider has the contract and any other contracting agent that buys,
leases, or otherwise obtains the list of contracted providers.
   A provider shall not be excluded from any list of contracted
providers that is sold, leased, transferred, or conveyed to payors
that actively encourage the employees to use the list of contracted
providers when obtaining medical care, based upon the provider's
refusal to be included on any list of contracted providers that is
sold, leased, transferred, or conveyed to payors that do not actively
encourage the employees to use the list of contracted providers when
obtaining medical care.
   (6) If the payor's explanation of benefits or explanation of
review does not identify the name of the network that has a written
agreement signed by the provider whereby the payor is entitled,
directly or indirectly, to pay a preferred rate for the services
rendered, the contracting agent shall do the following:
   (A) Maintain a Web site that is accessible to all contracted
providers and updated at least quarterly and maintain a toll-free
telephone number accessible to all contracted providers whereby
providers may access payor summary information.
   (B) Disclose through the use of an Internet Web site, a toll-free
telephone number, or through a delivery or mail service to its
contracted providers, within 30 days, any sale, lease assignment,
transfer or conveyance of the contracted reimbursement rates to
another contracting agent or payor.
   (7) Nothing in this subdivision shall be construed to impose
requirements or regulations upon payors, as defined in subparagraph
(A) of paragraph (3) of subdivision (d).
   (c) Beginning July 1, 2000, a payor, as defined in subparagraph
(B) of paragraph (3) of subdivision (d), shall do all of the
following:
   (1) Provide an explanation of benefits or explanation of review
that identifies the name of the network with which the payor has an
agreement that entitles them to pay a preferred rate for the services
rendered.
   (2) Demonstrate that it is entitled to pay a contracted rate
within 30 business days of receipt of a written request from a
provider who has received a claim payment from the payor. The
provider shall include in the request a statement explaining why the
payment is not at the correct contracted rate for the services
provided. The failure of the provider to include a statement shall
relieve the payor from the responsibility of demonstrating that it is
entitled to pay the disputed contracted rate. The failure of a payor
to make the demonstration to a properly documented request of the
provider within 30 business days shall render the payor responsible
for the lesser of the provider's actual fee or, as applicable, any
fee schedule pursuant to this division, which amount shall be due and
payable within 10 days of receipt of written notice from the
provider, and shall bar the payor from taking any future discounts
from that provider without the provider's express written consent
until the payor can demonstrate to the provider that it is entitled
to pay a contracted rate as provided in this subdivision. A payor
shall be deemed to have demonstrated that it is entitled to pay a
contracted rate if it complies with either of the following:
   (A) Describes the specific practices the payor utilizes to comply
with paragraph (2) of subdivision (b), and demonstrates compliance
with paragraph (1).
   (B) Identifies the contracting agent with whom the payor has a
written agreement whereby the payor is not required to actively
encourage employees to use the list of contracted providers pursuant
to paragraph (5) of subdivision (b).
   (d) For the purposes of this section, the following terms have the
following meanings:
   (1) "Contracting agent" means an insurer licensed under the
Insurance Code to provide workers' compensation insurance, a health
care service plan, including a specialized health care service plan,
a preferred provider organization, or a self-insured employer, while
engaged, for monetary or other consideration, in the act of selling,
leasing, transferring, assigning, or conveying a provider or provider
panel to provide health care services to employees for work-related
injuries.
   (2) "Employee" means a person entitled to seek health care
services for a work-related injury.
   (3) (A) For the purposes of subdivision (b), "payor" means a
health care service plan, including a specialized health care service
plan, an insurer licensed under the Insurance Code to provide
disability insurance that covers hospital, medical, or surgical
benefits, automobile insurance, or workers' compensation insurance,
or a self-insured employer that is responsible to pay for health care
services provided to beneficiaries.
   (B) For the purposes of subdivision (c), "payor" means an insurer
licensed under the Insurance Code to provide workers' compensation
insurance, a self-insured employer, a third-party administrator or
trust, or any other third party that is responsible to pay health
care services provided to employees for work-related injuries, or an
agent of an entity included in this definition.
   (4) "Payor summary" means a written summary that includes the
payor's name and the type of plan, including, but not limited to, a
group health plan, an automobile insurance plan, and a workers'
compensation insurance plan.
   (5) "Provider" means any of the following:
   (A) Any person licensed or certified pursuant to Division 2
(commencing with Section 500) of the Business and Professions Code.
   (B) Any person licensed pursuant to the Chiropractic Initiative
Act or the Osteopathic Initiative Act.
   (C) Any person licensed pursuant to Chapter 2.5 (commencing with
Section 1440) of Division 2 of the Health and Safety Code.
   (D) A clinic, health dispensary, or health facility licensed
pursuant to Division 2 (commencing with Section 1200) of the Health
and Safety Code.
   (E) Any entity exempt from licensure pursuant to Section 1206 of
the Health and Safety Code.
   (e) This section shall become operative on July 1, 2000.



4610.  (a) For purposes of this section, "utilization review" means
utilization review or utilization management functions that
prospectively, retrospectively, or concurrently review and approve,
modify, delay, or deny, based in whole or in part on medical
necessity to cure and relieve, treatment recommendations by
physicians, as defined in Section 3209.3, prior to, retrospectively,
or concurrent with the provision of medical treatment services
pursuant to Section 4600.
   (b) Every 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.
   (c) Each utilization review process shall be governed by written
policies and procedures. These 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 adopted pursuant to Section
5307.27. These policies and procedures, and a description of the
utilization process, shall be filed with the administrative director
and shall be disclosed by the employer to employees, physicians, and
the public upon request.
   (d) If an employer, insurer, or other entity subject to this
section requests medical information from a physician in order to
determine whether to approve, modify, delay, or deny requests for
authorization, the employer shall request only the information
reasonably necessary to make the determination. The 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 Section 2050 or Section 2450 of the Business and
Professions Code. The medical director shall ensure that the process
by which the employer or other entity reviews and approves, modifies,
delays, or denies requests by physicians prior to, retrospectively,
or concurrent with the provision of medical treatment services,
complies with the requirements of this section. Nothing in this
section shall be construed as restricting the existing authority of
the Medical Board of California.
   (e) No person other than a licensed physician who is competent to
evaluate the specific clinical issues involved in the medical
treatment services, and where these services are within the scope of
the physician's practice, requested by the physician may modify,
delay, or deny requests for authorization of medical treatment for
reasons of medical necessity to cure and relieve.
   (f) The criteria or guidelines used in the utilization review
process to determine whether to approve, modify, delay, or deny
medical treatment services shall be all of the following:
   (1) Developed with involvement from actively practicing
physicians.
   (2) Consistent with the schedule for medical treatment utilization
adopted pursuant to Section 5307.27.
   (3) Evaluated at least annually, and updated if necessary.
   (4) Disclosed to the physician and the employee, if used as the
basis of a decision to modify, delay, or deny services in a specified
case under review.
   (5) Available to the public upon request. An employer shall only
be required to disclose the criteria or guidelines for the specific
procedures or conditions requested. An employer may charge members of
the public reasonable copying and postage expenses related to
disclosing criteria or guidelines pursuant to this paragraph.
Criteria or guidelines may also be made available through electronic
means. No charge shall be required for an employee whose physician's
request for medical treatment services is under review.
   (g) In determining whether to approve, modify, delay, 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:
   (1) Prospective or concurrent decisions shall be made in a timely
fashion that is appropriate for the nature of the employee's
condition, not to exceed five working days from the receipt of the
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. In 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's designee, within 30 days
of receipt of information that is reasonably necessary to make this
determination. If payment for a medical treatment service is made
within the time prescribed by Section 4603.2, a retrospective
decision to approve the service need not otherwise be communicated.
   (2) When the employee's condition is such that 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's life or health or could jeopardize the employee's ability
to regain maximum function, decisions to approve, modify, delay, 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'
s condition, but not to exceed 72 hours after the receipt of the
information reasonably necessary to make the determination.
   (3) (A) Decisions to approve, modify, delay, 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. Decisions resulting in modification, delay, or denial of
all or part of the requested health care service shall be
communicated to physicians initially by telephone or facsimile, and
to the physician and employee in writing within 24 hours for
concurrent review, or within two business days of the decision for
prospective review, as prescribed by the administrative director. If
the request is not approved in full, disputes shall be resolved in
accordance with Section 4610.5, if applicable, or otherwise in
accordance with Section 4062.
   (B) In the case of concurrent review, medical care shall not be
discontinued until the employee'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. Medical 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. If 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 Section
4610.5, if applicable, or otherwise pursuant to Section 4062. Any
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 such a way as to minimize
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. No fees shall be levied
upon insurers or self-insured employers making reports required by
this section.
   (4) Communications regarding decisions to approve requests by
physicians shall specify the specific medical treatment service
approved. Responses regarding decisions to modify, delay, or deny
medical treatment services requested by physicians shall include a
clear and concise explanation of the reasons for the employer's
decision, a description of the criteria or guidelines used, and the
clinical reasons for the decisions regarding medical necessity. If a
utilization review decision to deny or delay a medical service is due
to incomplete or insufficient information, the decision shall
specify the reason for the decision and specify the information that
is needed.
   (5) If the employer, insurer, or other entity cannot make a
decision within the timeframes specified in paragraph (1) or (2)
because the employer or other entity is not in receipt of all of the
information reasonably necessary and requested, because the employer
requires consultation by an expert reviewer, or because the employer
has asked that an additional examination or test be performed upon
the employee that is reasonable and consistent with good medical
practice, 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 requested
but not received, the expert reviewer to be consulted, or the
additional examinations or tests required. The employer shall also
notify the physician and employee of the anticipated date on which a
decision may be rendered. Upon 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) or (2).
   (6) A utilization review decision to modify, delay, 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 any further recommendation by the same physician 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.
   (7) Utilization 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 Section 4062.
   (8) If utilization review is deferred pursuant to paragraph (7),
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 (1) shall begin on the date the
determination of the employer's liability becomes final, and the time
for the employer to conduct prospective utilization review shall
commence from the date of the employer's receipt of a treatment
recommendation after the determination of the employer's liability.
   (h) Every employer, insurer, or other entity subject to this
section shall maintain telephone access for physicians to request
authorization for health care services.
   (i) If 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. A
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. The
administrative penalties shall not be deemed to be an exclusive
remedy for the administrative director. These penalties shall be
deposited in the Workers' Compensation Administration Revolving Fund.



4610.1.  An employee shall not be entitled to an increase in
compensation under Section 5814 for unreasonable delay in the
provision of medical treatment for periods of time necessary to
complete the utilization review process in compliance with Section
4610. A determination by the appeals board or a final determination
of the administrative director pursuant to independent medical review
that medical treatment is appropriate shall not be conclusive
evidence that medical treatment was unreasonably delayed or denied
for purposes of penalties under Section 5814. In no case shall this
section preclude an employee from entitlement to an increase in
compensation under Section 5814 when an employer has unreasonably
delayed or denied medical treatment due to an unreasonable delay in
completion of the utilization review process set forth in Section
4610.


4610.3.  (a) Regardless of whether an employer has established a
medical provider network pursuant to Section 4616 or entered into a
contract with a health care organization pursuant to Section 4600.5,
an employer that authorizes medical treatment shall not rescind or
modify that authorization after the medical treatment has been
provided based on that authorization for any reason, including, but
not limited to, the employer's subsequent determination that the
physician who treated the employee was not eligible to treat that
injured employee. If the authorized medical treatment consists of a
series of treatments or services, the employer may rescind or modify
the authorization only for the treatments or services that have not
already been provided.
   (b) This section shall not be construed to expand or alter the
benefits available under, or the terms and conditions of, any
contract, including, but not limited to, existing medical provider
network and health care organization contracts.
   (c) This section shall not be construed to impact the ability of
the employer to transfer treatment of an injured employee into a
medical provider network or health care organization. This
subdivision is declaratory of existing law.
   (d) This section shall not be construed to establish that a
provider of authorized medical treatment is the physician primarily
responsible for managing the injured employee's care for purposes of
rendering opinions on all medical issues necessary to determine
eligibility for compensation.



4610.5.  (a) This section applies to the following disputes:
   (1) Any dispute over a utilization review decision regarding
treatment for an injury occurring on or after January 1, 2013.
   (2) Any dispute over a utilization review decision if the decision
is communicated to the requesting physician on or after July 1,
2013, regardless of the date of injury.
   (b) A dispute described in subdivision (a) shall be resolved only
in accordance with this section.
   (c) For purposes of this section and Section 4610.6, the following
definitions apply:
   (1) "Disputed medical treatment" means medical treatment that has
been modified, delayed, or denied by a utilization review decision.
   (2) "Medically necessary" and "medical necessity" mean medical
treatment that is reasonably required to cure or relieve the injured
employee of the effects of his or her injury and based on the
following standards, which shall be applied in the order listed,
allowing reliance on a lower ranked standard only if every higher
ranked standard is inapplicable to the employee's medical condition:
   (A) The guidelines adopted by the administrative director pursuant
to Section 5307.27.
   (B) Peer-reviewed scientific and medical evidence regarding the
effectiveness of the disputed service.
   (C) Nationally recognized professional standards.
   (D) Expert opinion.
   (E) Generally accepted standards of medical practice.
   (F) Treatments that are likely to provide a benefit to a patient
for conditions for which other treatments are not clinically
efficacious.
   (3) "Utilization review decision" means a decision pursuant to
Section 4610 to modify, delay, or deny, based in whole or in part on
medical necessity to cure or relieve, a treatment recommendation or
recommendations by a physician prior to, retrospectively, or
concurrent with the provision of medical treatment services pursuant
to Section 4600 or subdivision (c) of Section 5402.
   (4) Unless otherwise indicated by context, "employer" 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.
   (d) If a utilization review decision denies, modifies, or delays a
treatment recommendation, the employee may request an independent
medical review as provided by this section.
   (e) A utilization review decision may be reviewed or appealed only
by independent medical review pursuant to this section. Neither the
employee nor the employer shall have any liability for medical
treatment furnished without the authorization of the employer if the
treatment is delayed, modified, or denied by a utilization review
decision unless the utilization review decision is overturned by
independent medical review in accordance with this section.
   (f) As part of its notification to the employee regarding an
initial utilization review decision that denies, modifies, or delays
a treatment recommendation, the employer shall provide the employee
with
    a one-page form prescribed by the administrative director, and an
addressed envelope, which the employee may return to the
administrative director or the administrative director's designee to
initiate an independent medical review. The employer shall include on
the form any information required by the administrative director to
facilitate the completion of the independent medical review. The form
shall also include all of the following:
   (1) Notice that the utilization review decision is final unless
the employee requests independent medical review.
   (2) A statement indicating the employee's consent to obtain any
necessary medical records from the employer or insurer and from any
medical provider the employee may have consulted on the matter, to be
signed by the employee.
   (3) Notice of the employee's right to provide information or
documentation, either directly or through the employee's physician,
regarding the following:
   (A) The treating physician's recommendation indicating that the
disputed medical treatment is medically necessary for the employee's
medical condition.
   (B) Medical information or justification that a disputed medical
treatment, on an urgent care or emergency basis, was medically
necessary for the employee's medical condition.
   (C) Reasonable information supporting the employee's position that
the disputed medical treatment is or was medically necessary for the
employee's medical condition, including all information provided to
the employee by the employer or by the treating physician, still in
the employee's possession, concerning the employer's or the physician'
s decision regarding the disputed medical treatment, as well as any
additional material that the employee believes is relevant.
   (g) The independent medical review process may be terminated at
any time upon the employer's written authorization of the disputed
medical treatment.
   (h) (1) The employee may submit a request for independent medical
review to the division no later than 30 days after the service of the
utilization review decision to the employee.
   (2) If at the time of a utilization review decision the employer
is also disputing liability for the treatment for any reason besides
medical necessity, the time for the employee to submit a request for
independent medical review to the administrative director or
administrative director's designee is extended to 30 days after
service of a notice to the employee showing that the other dispute of
liability has been resolved.
   (3) If the employer fails to comply with subdivision (e) at the
time of notification of its utilization review decision, the time
limitations for the employee to submit a request for independent
medical review shall not begin to run until the employer provides the
required notice to the employee.
   (4) A provider of emergency medical treatment when the employee
faced 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, may submit a request for independent medical review
on its own behalf. A request submitted by a provider pursuant to
this paragraph shall be submitted to the administrative director or
administrative director's designee within the time limitations
applicable for an employee to submit a request for independent
medical review.
   (i) An employer shall not engage in any conduct that has the
effect of delaying the independent review process. Engaging in that
conduct or failure of the plan to promptly comply with this section
is a violation of this section and, in addition to any other fines,
penalties, and other remedies available to the administrative
director, the employer shall be subject to an administrative penalty
in an amount determined pursuant to regulations to be adopted by the
administrative director, not to exceed five thousand dollars ($5,000)
for each day that proper notification to the employee is delayed.
The administrative penalties shall be paid to the Workers'
Compensation Administration Revolving Fund.
   (j) For purposes of this section, an employee may designate a
parent, guardian, conservator, relative, or other designee of the
employee as an agent to act on his or her behalf. A designation of an
agent executed prior to the utilization review decision shall not be
valid. The requesting physician may join with or otherwise assist
the employee in seeking an independent medical review, and may
advocate on behalf of the employee.
   (k) The administrative director or his or her designee shall
expeditiously review requests and immediately notify the employee and
the employer in writing as to whether the request for an independent
medical review has been approved, in whole or in part, and, if not
approved, the reasons therefor. If there appears to be any medical
necessity issue, the dispute shall be resolved pursuant to an
independent medical review, except that, unless the employer agrees
that the case is eligible for independent medical review, a request
for independent medical review shall be deferred if at the time of a
utilization review decision the employer is also disputing liability
for the treatment for any reason besides medical necessity.
   (l) Upon notice from the administrative director that an
independent review organization has been assigned, the employer shall
provide to the independent medical review organization all of the
following documents within 10 days of notice of assignment:
   (1) A copy of all of the employee's medical records in the
possession of the employer or under the control of the employer
relevant to each of the following:
   (A) The employee's current medical condition.
   (B) The medical treatment being provided by the employer.
   (C) The disputed medical treatment requested by the employee.
   (2) A copy of all information provided to the employee by the
employer concerning employer and provider decisions regarding the
disputed treatment.
   (3) A copy of any materials the employee or the employee's
provider submitted to the employer in support of the employee's
request for the disputed treatment.
   (4) A copy of any other relevant documents or information used by
the employer or its utilization review organization in determining
whether the disputed treatment should have been provided, and any
statements by the employer or its utilization review organization
explaining the reasons for the decision to deny, modify, or delay the
recommended treatment on the basis of medical necessity. The
employer shall concurrently provide a copy of the documents required
by this paragraph to the employee and the requesting physician,
except that documents previously provided to the employee or
physician need not be provided again if a list of those documents is
provided.
    (m) Any newly developed or discovered relevant medical records in
the possession of the employer after the initial documents are
provided to the independent medical review organization shall be
forwarded immediately to the independent medical review organization.
The employer shall concurrently provide a copy of medical records
required by this subdivision to the employee or the employee's
treating physician, unless the offer of medical records is declined
or otherwise prohibited by law. The confidentiality of medical
records shall be maintained pursuant to applicable state and federal
laws.
   (n) If there is an imminent and serious threat to the health of
the employee, as specified in subdivision (c) of Section 1374.33 of
the Health and Safety Code, all necessary information and documents
required by subdivision (l) shall be delivered to the independent
medical review organization within 24 hours of approval of the
request for review.
   (o) The employer shall promptly issue a notification to the
employee, after submitting all of the required material to the
independent medical review organization, that lists documents
submitted and includes copies of material not previously provided to
the employee or the employee's designee.



4610.6.  (a) Upon receipt of a case pursuant to Section 4610.5, an
independent medical review organization shall conduct the review in
accordance with this article and any regulations or orders of the
administrative director. The organization's review shall be limited
to an examination of the medical necessity of the disputed medical
treatment.
   (b) Upon receipt of information and documents related to a case,
the medical reviewer or reviewers selected to conduct the review by
the independent medical review organization shall promptly review all
pertinent medical records of the employee, provider reports, and any
other information submitted to the organization or requested from
any of the parties to the dispute by the reviewers. If the reviewers
request information from any of the parties, a copy of the request
and the response shall be provided to all of the parties. The
reviewer or reviewers shall also review relevant information related
to the criteria set forth in subdivision (c).
   (c) Following its review, the reviewer or reviewers shall
determine whether the disputed health care service was medically
necessary based on the specific medical needs of the employee and the
standards of medical necessity as defined in subdivision (c) of
Section 4610.5.
   (d) The organization shall complete its review and make its
determination in writing, and in layperson's terms to the maximum
extent practicable, within 30 days of the receipt of the request for
review and supporting documentation, or within less time as
prescribed by the administrative director. If the disputed medical
treatment has not been provided and the employee's provider or the
administrative director certifies in writing that an imminent and
serious threat to the health of the employee may exist, including,
but not limited to, serious pain, the potential loss of life, limb,
or major bodily function, or the immediate and serious deterioration
of the health of the employee, the analyses and determinations of the
reviewers shall be expedited and rendered within three days of the
receipt of the information. Subject to the approval of the
administrative director, the deadlines for analyses and
determinations involving both regular and expedited reviews may be
extended for up to three days in extraordinary circumstances or for
good cause.
   (e) The medical professionals' analyses and determinations shall
state whether the disputed health care service is medically
necessary. Each analysis shall cite the employee's medical condition,
the relevant documents in the record, and the relevant findings
associated with the provisions of subdivision (c) to support the
determination. If more than one medical professional reviews the
case, the recommendation of the majority shall prevail. If the
medical professionals reviewing the case are evenly split as to
whether the disputed health care service should be provided, the
decision shall be in favor of providing the service.
   (f) The independent medical review organization shall provide the
administrative director, the employer, the employee, and the employee'
s provider with the analyses and determinations of the medical
professionals reviewing the case, and a description of the
qualifications of the medical professionals. The independent medical
review organization shall keep the names of the reviewers
confidential in all communications with entities or individuals
outside the independent medical review organization. If more than one
medical professional reviewed the case and the result was differing
determinations, the independent medical review organization shall
provide each of the separate reviewer's analyses and determinations.
   (g) The determination of the independent medical review
organization shall be deemed to be the determination of the
administrative director and shall be binding on all parties.
   (h) A determination of the administrative director pursuant to
this section may be reviewed only by a verified appeal from the
medical review determination of the administrative director, filed
with the appeals board for hearing pursuant to Chapter 3 (commencing
with Section 5500) of Part 4 and served on all interested parties
within 30 days of the date of mailing of the determination to the
aggrieved employee or the aggrieved employer. The determination of
the administrative director shall be presumed to be correct and shall
be set aside only upon proof by clear and convincing evidence of one
or more of the following grounds for appeal:
   (1) The administrative director acted without or in excess of the
administrative director's powers.
   (2) The determination of the administrative director was procured
by fraud.
   (3) The independent medical reviewer was subject to a material
conflict of interest that is in violation of Section 139.5.
   (4) The determination was the result of bias on the basis of race,
national origin, ethnic group identification, religion, age, sex,
sexual orientation, color, or disability.
   (5) The determination was the result of a plainly erroneous
express or implied finding of fact, provided that the mistake of fact
is a matter of ordinary knowledge based on the information submitted
for review pursuant to Section 4610.5 and not a matter that is
subject to expert opinion.
   (i) If the determination of the administrative director is
reversed, the dispute shall be remanded to the administrative
director to submit the dispute to independent medical review by a
different independent review organization. In the event that a
different independent medical review organization is not available
after remand, the administrative director shall submit the dispute to
the original medical review organization for review by a different
reviewer in the organization. In no event shall a workers'
compensation administrative law judge, the appeals board, or any
higher court make a determination of medical necessity contrary to
the determination of the independent medical review organization.
   (j) Upon receiving the determination of the administrative
director that a disputed health care service is medically necessary,
the employer shall promptly implement the decision as provided by
this section unless the employer has also disputed liability for any
reason besides medical necessity. In the case of reimbursement for
services already rendered, the employer shall reimburse the provider
or employee, whichever applies, within 20 days, subject to resolution
of any remaining issue of the amount of payment pursuant to Sections
4603.2 to 4603.6, inclusive. In the case of services not yet
rendered, the employer shall authorize the services within five
working days of receipt of the written determination from the
independent medical review organization, or sooner if appropriate for
the nature of the employee's medical condition, and shall inform the
employee and provider of the authorization.
   (k) Failure to pay for services already provided or to authorize
services not yet rendered within the time prescribed by subdivision
(l) is a violation of this section and, in addition to any other
fines, penalties, and other remedies available to the administrative
director, the employer shall be subject to an administrative penalty
in an amount determined pursuant to regulations to be adopted by the
administrative director, not to exceed five thousand dollars ($5,000)
for each day the decision is not implemented. The administrative
penalties shall be paid to the Workers' Compensation Administration
Revolving Fund.
   (l) The costs of independent medical review and the administration
of the independent medical review system shall be borne by employers
through a fee system established by the administrative director.
After considering any relevant information on program costs, the
administrative director shall establish a reasonable, per-case
reimbursement schedule to pay the costs of independent medical review
organization reviews and the cost of administering the independent
medical review system, which may vary depending on the type of
medical condition under review and on other relevant factors.
   (m) The administrative director may publish the results of
independent medical review determinations after removing individually
identifiable information.
   (n) If any provision of this section, or the application thereof
to any person or circumstances, is held invalid, the remainder of the
section, and the application of its provisions to other persons or
circumstances, shall not be affected thereby.




4611.  (a) When a contracting agent sells, leases, or transfers a
health provider's contract to a payor, the rights and obligations of
the provider shall be governed by the underlying contract between the
health care provider and the contracting agent.
   (b) For purposes of this section, the following terms have the
following meanings:
   (1) "Contracting agent" has the meaning set forth in paragraph (2)
of subdivision (d) of Section 4609.
   (2) "Payor" has the meaning set forth in paragraph (3) of
subdivision (d) of Section 4609.



4614.  (a) (1) Notwithstanding Section 5307.1, where the employee's
individual or organizational provider of health care services
rendered under this division and paid on a fee-for-service basis is
also the provider of health care services under contract with the
employee's health benefit program, and the service or treatment
provided is included within the range of benefits of the employee's
health benefit program, and paid on a fee-for-service basis, the
amount of payment for services provided under this division, for a
work-related occurrence or illness, shall be no more than the amount
that would have been paid for the same services under the health
benefit plan, for a non-work-related occurrence or illness.
   (2) A health care service plan that arranges for health care
services to be rendered to an employee under this division under a
contract, and which is also the employee's organizational provider
for nonoccupational injuries and illnesses, with the exception of a
nonprofit health care service plan that exclusively contracts with a
medical group to provide or arrange for medical services to its
enrollees in a designated geographic area, shall be paid by the
employer for services rendered under this division only on a
capitated basis.
   (b) (1) Where the employee's individual or organizational provider
of health care services rendered under this division who is not
providing services under a contract is not the provider of health
care services under contract with the employee's health benefit
program or where the services rendered under this division are not
within the benefits provided under the employer-sponsored health
benefit program, the provider shall receive payment that is no more
than the average of the payment that would have been paid by five of
the largest preferred provider organizations by geographic region.
Physicians, as defined in Section 3209.3, shall be reimbursed at the
same averaged rates, regardless of licensure, for the delivery of
services under the same procedure code. This subdivision shall not
apply to a health care service plan that provides its services on a
capitated basis.
   (2) The administrative director shall identify the regions and the
five largest carriers in each region. The carriers shall provide the
necessary information to the administrative director in the form and
manner requested by the administrative director. The administrative
director shall make this information available to the affected
providers on an annual basis.
   (c) Nothing in this section shall prohibit an individual or
organizational health care provider from being paid fees different
from those set forth in the official medical fee schedule by an
employer, insurance carrier, third-party administrator on behalf of
employers, or preferred provider organization representing an
employer or insurance carrier provided that the administrative
director has determined that the alternative negotiated rates between
the organizational or individual provider and a payer, a third-party
administrator on behalf of employers, or a preferred provider
organization will produce greater savings in the aggregate than if
each item on billings were to be charged at the scheduled rate.
   (d) For the purposes of this section, "organizational provider"
means an entity that arranges for health care services to be rendered
directly by individual caregivers. An organizational provider may be
a health care service plan, disability insurer, health care
organization, preferred provider organization, or workers'
compensation insurer arranging for care through a managed care
network or on a fee-for-service basis. An individual provider is
either an individual or institution that provides care directly to
the injured worker.



4614.1.  Notwithstanding subdivision (f) of Section 1345 of the
Health and Safety Code, a health care service plan licensed pursuant
to the Knox-Keene Health Care Service Plan Act and certified by the
administrative director pursuant to Section 4600.5 to provide health
care pursuant to Section 4600.3 shall be permitted to accept payment
from a self-insured employer, a group of self-insured employers, or
the insurer of an employer on a fee-for-service basis for the
provision of such health care as long as the health care service plan
is not both the health care organization in which the employee is
enrolled and the plan through which the employee receives regular
health benefits.

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4616.  (a) (1) On or after January 1, 2005, an insurer, employer, or
entity that provides physician network services may establish or
modify a medical provider network for the provision of medical
treatment to injured employees. The network shall include physicians
primarily engaged in the treatment of occupational injuries. The
administrative director shall encourage the integration of
occupational and nonoccupational providers. The number of physicians
in the medical provider network shall be sufficient to enable
treatment for injuries or conditions to be provided in a timely
manner. The provider network shall include an adequate number and
type of physicians, as described in Section 3209.3, or other
providers, as described in Section 3209.5, to treat common injuries
experienced by injured employees based on the type of occupation or
industry in which the employee is engaged, and the geographic area
where the employees are employed.
   (2) Medical treatment for injuries shall be readily available at
reasonable times to all employees. To the extent feasible, all
medical treatment for injuries shall be readily accessible to all
employees. With respect to availability and accessibility of
treatment, the administrative director shall consider the needs of
rural areas, specifically those in which health facilities are
located at least 30 miles apart and areas in which there is a health
care shortage.
   (3) Commencing January 1, 2014, a treating physician shall be
included in the network only if, at the time of entering into or
renewing an agreement by which the physician would be in the network,
the physician, or an authorized employee of the physician or the
physician's office, provides a separate written acknowledgment in
which the physician affirmatively elects to be a member of the
network. Copies of the written acknowledgment shall be provided to
the administrative director upon the administrative director's
request. This paragraph shall not apply to a physician who is a
shareholder, partner, or employee of a medical group that elects to
be part of the network.
   (4) Commencing January 1, 2014, every medical provider network
shall post on its Internet Web site a roster of all treating
physicians in the medical provider network and shall update the
roster at least quarterly. Every network shall provide to the
administrative director the Internet Web site address of the network
and of its roster of treating physicians. The administrative director
shall post, on the division's Internet Web site, the Internet Web
site address of every approved medical provider network.
   (5) Commencing January 1, 2014, every medical provider network
shall provide one or more persons within the United States to serve
as medical access assistants to help an injured employee find an
available physician of the employee's choice, and subsequent
physicians if necessary, under Section 4616.3. Medical access
assistants shall have a toll-free telephone number that injured
employees may use and shall be available at least from 7 a.m. to 8
p.m. Pacific Standard Time, Monday through Saturday, inclusive, to
respond to injured employees, contact physicians' offices during
regular business hours, and schedule appointments. The administrative
director shall promulgate regulations on or before July 1, 2013,
governing the provision of medical access assistants.
   (b) (1) An insurer, employer, or entity that provides physician
network services shall submit a plan for the medical provider network
to the administrative director for approval. The administrative
director shall approve the plan for a period of four years if he or
she determines that the plan meets the requirements of this section.
If the administrative director does not act on the plan within 60
days of submitting the plan, it shall be deemed approved. Commencing
January 1, 2014, existing approved plans shall be deemed approved for
a period of four years from the most recent application or
modification approval date. Plans for reapproval for medical provider
networks shall be submitted at least six months before the
expiration of the four-year approval period. Upon a showing that the
medical provider network was approved or deemed approved by the
administrative director, there shall be a conclusive presumption on
the part of the appeals board that the medical provider network was
validly formed.
   (2) Every medical provider network shall establish and follow
procedures to continuously review the quality of care, performance of
medical personnel, utilization of services and facilities, and
costs.
   (3) Every medical provider network shall submit geocoding of its
network for reapproval to establish that the number and geographic
location of physicians in the network meets the required access
standards.
   (4) The administrative director shall at any time have the
discretion to investigate complaints and to conduct random reviews of
approved medical provider networks.
   (5) Approval of a plan may be denied, revoked, or suspended if the
medical provider network fails to meet the requirements of this
article. Any person contending that a medical provider network is not
validly constituted may petition the administrative director to
suspend or revoke the approval of the medical provider network. The
administrative director may adopt regulations establishing a schedule
of administrative penalties not to exceed five thousand dollars
($5,000) per violation, or probation, or both, in lieu of revocation
or suspension for less severe violations of the requirements of this
article. Penalties, probation, suspension, or revocation shall be
ordered by the administrative director only after notice and
opportunity to be heard. Unless suspended or revoked by the
administrative director, the administrative director's approval of a
medical provider network shall be binding on all persons and all
courts. A determination of the administrative director may be
reviewed only by an appeal of the determination of the administrative
director filed as an original proceeding before the reconsideration
unit of the workers' compensation appeals board on the same grounds
and within the same time limits after issuance of the determination
as would be applicable to a petition for reconsideration of a
decision of a workers' compensation administrative law judge.
   (c) Physician compensation may not be structured in order to
achieve the goal of reducing, delaying, or denying medical treatment
or restricting access to medical treatment.
   (d) If the employer or insurer meets the requirements of this
section, the administrative director may not withhold approval or
disapprove an employer's or insurer's medical provider network based
solely on the selection of providers. In developing a medical
provider network, an employer or insurer shall have the exclusive
right to determine the members of their network.
   (e) All treatment provided shall be provided in accordance with
the medical treatment utilization schedule established pursuant to
Section 5307.27.
   (f) No person other than a licensed physician who is competent to
evaluate the specific clinical issues involved in the medical
treatment services, when these services are within the scope of the
physician's practice, may modify, delay, or deny requests for
authorization of medical treatment.
   (g) Commencing January 1, 2013, every contracting agent that
sells, leases, assigns, transfers, or conveys its medical provider
networks and their contracted reimbursement rates to an insurer,
employer, entity that provides physician network services, or another
contracting agent shall, upon entering or renewing a provider
contract, disclose to the provider whether the medical provider
network may be sold, leased, transferred, or conveyed to other
insurers, employers, entities that provide physician network
services, or another contracting agent, and specify whether those
insurers, employers, entities that provide physician network
services, or contracting agents include workers' compensation
insurers.
   (h) On or before November 1, 2004, the administrative director, in
consultation with the Department of Managed Health Care, shall adopt
regulations implementing this article. The administrative director
shall develop regulations that establish procedures for purposes of
making medical provider network modifications.



4616.1.  (a) An insurer, employer, or entity that provides physician
network services that offers a medical provider network under this
division and that uses economic profiling shall file with the
administrative director a description of any policies and procedures
related to economic profiling utilized. The filing shall describe how
these policies and procedures are used in utilization review, peer
review, incentive and penalty programs, and in provider retention and
termination decisions. The insurer, employer, or entity that
provides physician network services shall provide a copy of the
filing to an individual physician, provider, medical group, or
individual practice association.
   (b) The administrative director shall make each approved medical
provider network economic profiling policy filing available to the
public upon request. The administrative director may not publicly
disclose any information submitted pursuant to this section that is
determined by the administrative director to be confidential pursuant
to state or federal law.
   (c) For the purposes of this article, "economic profiling" shall
mean any evaluation of a particular physician, provider, medical
group, or individual practice association based in whole or in part
on the economic costs or utilization of services associated with
medical care provided or authorized by the physician, provider,
medical group, or individual practice association.




4616.2.  (a) An insurer, employer, or entity that provides physician
network services that arranges for care for injured employees
through a medical provider network shall file a written continuity of
care policy with the administrative director.
   (b) If approved by the administrative director, the provisions of
the written continuity of care policy shall replace all prior
continuity of care policies. The insurer, employer, or entity that
provides physician network services shall file a revision of the
continuity of care policy with the administrative director if it
makes a material change to the policy.
   (c) The insurer, employer, or entity that provides physician
network services shall provide to all employees entering the workers'
compensation system notice of its written continuity of care policy
and information regarding the process for an employee to request a
review under the policy and shall provide, upon request, a copy of
the written policy to an employee.
   (d) (1) An insurer, employer, or entity that provides physician
network services that offers a medical provider network shall, at the
request of an injured employee, provide the completion of treatment
as set forth in this section by a terminated provider.
   (2) The completion of treatment shall be provided by a terminated
provider to an injured employee who, at the time of the contract's
termination, was receiving services from that provider for one of the
conditions described in paragraph (3).
   (3) The insurer, employer, or entity that provides physician
network services shall provide for the completion of treatment for
the following conditions subject to coverage through the workers'
compensation system:
   (A) An acute condition. An acute condition is a medical condition
that involves a sudden onset of symptoms due to an illness, injury,
or other medical problem that requires prompt medical attention and
that has a limited duration. Completion of treatment shall be
provided for the duration of the acute condition.
   (B) A serious chronic condition. A serious chronic condition is a
medical condition due to a disease, illness, or other medical problem
or medical disorder that is serious in nature and that persists
without full cure or worsens over an extended period of time or
requires ongoing treatment to maintain remission or prevent
deterioration. Completion of treatment shall be provided for a period
of time necessary to complete a course of treatment and to arrange
for a safe transfer to another provider, as determined by the
insurer, employer, or entity that provides physician network
services, in consultation with the injured employee and the
terminated provider and consistent with good professional practice.
Completion of treatment under this paragraph shall not exceed 12
months from the contract termination date.
   (C) A terminal illness. A terminal illness is an incurable or
irreversible condition that has a high probability of causing death
within one year or less. Completion of treatment shall be provided
for the duration of a terminal illness.
   (D) Performance of a surgery or other procedure that is authorized
by the insurer, employer, or entity that provides physician network
services as part of a documented course of treatment and has been
recommended and documented by the provider to occur within 180 days
of the contract's termination date.
   (4) (A) The insurer, employer, or entity that provides physician
network services may require the terminated provider whose services
are continued beyond the contract termination date pursuant to this
section to agree in writing to be subject to the same contractual
terms and conditions that were imposed upon the provider prior to
termination. If the terminated provider does not agree to comply or
does not comply with these contractual terms and conditions, the
insurer, employer, or entity that provides physician network services
is not required to continue the provider's services beyond the
contract termination date.
   (B) Unless otherwise agreed by the terminated provider and the
insurer, employer, or entity that provides physician network
services, the services rendered pursuant to this section shall be
compensated at rates and methods of payment similar to those used by
the insurer, employer, or entity that provides physician network
services for currently contracting providers providing similar
services who are practicing in the same or a similar geographic area
as the terminated provider. The insurer, employer, or entity that
provides physician network services is not required to continue the
services of a terminated provider if the provider does not accept the
payment rates provided for in this paragraph.
   (5) An insurer or employer shall ensure that the requirements of
this section are met.
   (6) This section shall not require an insurer, employer, or entity
that provides physician network services to provide for completion
of treatment by a provider whose contract with the insurer, employer,
or entity that provides physician network services has been
terminated or not renewed for reasons relating to a medical
disciplinary cause or reason, as defined in paragraph (6) of
subdivision (a) of Section 805 of the Business and Profession Code,
or fraud or other criminal activity.
   (7) Nothing in this section shall preclude an insurer, employer,
or entity that provides physician network services from providing
continuity of care beyond the requirements of this section.
   (e) The insurer, employer, or entity that provides physician
network services may require the terminated provider whose services
are continued beyond the contract termination date pursuant to this
section to agree in writing to be subject to the same contractual
terms and conditions that were imposed upon the provider prior to
termination. If the terminated provider does not agree to comply or
does not comply with these contractual terms and conditions, the
insurer, employer, or entity that provides physician network services
is not required to continue the provider's services beyond the
contract termination date.



4616.3.  (a) If the injured employee notifies the employer of the
injury or files a claim for workers' compensation with the employer,
the employer shall arrange an initial medical evaluation and begin
treatment as required by Section 4600.
   (b) The employer shall notify the employee of the existence of the
medical provider network established pursuant to this article, the
employee's right to change treating physicians within the network
after the first visit, and the method by which the list of
participating providers may be accessed by the employee. The employer'
s failure to provide notice as required by this subdivision or
failure to post the notice as required by Section 3550 shall not be a
basis for the employee to treat outside the network unless it is
shown that the failure to provide notice resulted in a denial of
medical care.
   (c) If an injured employee disputes either the diagnosis or the
treatment prescribed by the treating physician, the employee may seek
the opinion of another physician in the medical provider network. If
the injured employee disputes the diagnosis or treatment prescribed
by the second physician, the employee may seek the opinion of a third
physician in the medical provider network.
   (d) (1) Selection by the injured employee of a treating physician
and any subsequent physicians shall be based on the physician's
specialty or recognized expertise in treating the particular injury
or condition in question.
   (2) Treatment by a specialist who is not a member of the medical
provider network may be permitted on a case-by-case basis if the
medical provider network does not contain a physician who can provide
the approved treatment and the treatment is approved by the employer
or the insurer.


4616.4.  (a) (1) The administrative director shall contract with
individual physicians, as described in paragraph (2), or an
independent medical review organization to perform independent
medical reviews pursuant to this section.
   (2) Only physicians licensed pursuant to Chapter 5 (commencing
with Section 2000) of the Business and Professions Code may be
independent medical reviewers.
   (3) The administrative director shall ensure that the independent
medical reviewers or those within the review organization shall do
all of the following:
   (A) Be appropriately credentialed and privileged.
   (B) Ensure that the reviews provided by the medical professionals
are timely, clear, and credible, and that reviews are monitored for
quality on an ongoing basis.
   (C) Ensure that the method of selecting medical professionals for
individual cases achieves a fair and impartial panel of medical
professionals who are qualified to render recommendations regarding
the clinical conditions consistent with the medical utilization
schedule established pursuant to Section 5307.27, or the American
College of Occupational and Environmental Medicine's Occupational
Medicine Practice Guidelines.
   (D) Ensure that confidentiality of medical records and the review
materials, consistent with the requirements of this section and
applicable state and federal law.
   (E) Ensure the independence of the medical professionals retained
to perform the reviews through conflict-of-interest policies and
prohibitions, and ensure adequate screening for conflicts of
interest.
   (4) Medical professionals selected by the administrative director
or the independent medical review organizations to review medical
treatment decisions shall be physicians, as specified in paragraph
(2) of subdivision (a), who meet the following minimum requirements:
   (A) The medical professional shall be a clinician knowledgeable in
the treatment of the employee's medical condition, knowledgeable
about the proposed treatment, and familiar with guidelines and
protocols in the area of treatment under review.
   (B) Notwithstanding any other provision of law, the medical
professional shall hold a nonrestricted license in any state of the
United States, and for physicians, a current certification by a
recognized American medical specialty board in the area or areas
appropriate to the condition or treatment under review.
   (C) The medical professional shall have no history of disciplinary
action or sanctions, including, but not limited to, loss of staff
privileges or participation restrictions taken or pending by any
hospital, government, or regulatory body.
   (b) If, after the third physician's opinion, the treatment or
diagnostic service remains disputed, the injured employee may request
independent medical review regarding the disputed treatment or
diagnostic service still in dispute after the third physician's
opinion in accordance with Section 4616.3. The standard to be
utilized for independent medical review is identical to that
contained in the medical treatment utilization schedule established
in Section 5307.27, or the American College of Occupational and
Environmental Medicine's Occupational Medicine Practice Guidelines,
as appropriate.
   (c) Applications for independent medical review shall be submitted
to the administrative director on a one-page form provided by the
administrative director entitled "Independent Medical Review
Application." The form shall contain a signed release from the
injured employee, or a person authorized pursuant to law to act on
behalf of the injured employee, authorizing the release of medical
and treatment information. The injured employee may provide any
relevant material or documentation with the application. The
administrative director or the independent medical review
organization shall assign the independent medical reviewer.
   (d) Following receipt of the application for independent medical
review, the employer or insurer shall provide the independent medical
reviewer, assigned pursuant to subdivision (c), with all information
that was considered in relation to the disputed treatment or
diagnostic service, including both of the following:
   (1) A copy of all correspondence from, and received by, any
treating physician who provided a treatment or diagnostic service to
the injured employee in connection with the injury.
   (2) A complete and legible copy of all medical records and other
information used by the physicians in making a decision regarding the
disputed treatment or diagnostic service.
   (e) Upon receipt of information and documents related to the
application for independent medical review, the independent medical
reviewer shall conduct a physical examination of the injured employee
at the employee's discretion. The reviewer may order any diagnostic
tests necessary to make his or her determination regarding medical
treatment. Utilizing the medical treatment utilization schedule
established pursuant to Section 5307.27, or the American College of
Occupational and Environmental Medicine's Occupational Medicine
Practice Guidelines, as appropriate, and taking into account any
reports and information provided, the reviewer shall determine
whether the disputed health care service was consistent with Section
5307.27 or the American College of Occupational and Environmental
Medicine's Occupational Medicine Practice Guidelines based on the
specific medical needs of the injured employee.
   (f) The independent medical reviewer shall issue a report to the
administrative director, in writing, and in layperson's terms to the
maximum extent practicable, containing his or her analysis and
determination whether the disputed health care service was consistent
with the medical treatment utilization schedule established pursuant
to Section 5307.27, or the American College of Occupational and
Environmental Medicine's Occupational Medicine Practice Guidelines,
as appropriate, within 30 days of the examination of the injured
employee, or within less time as prescribed by the administrative
director. If the disputed health care service has not been provided
and the independent medical reviewer certifies in writing that an
imminent and serious threat to the health of the injured employee may
exist, including, but not limited to, serious pain, the potential
loss of life, limb, or major bodily function, or the immediate and
serious deterioration of the injured employee, the report shall be
expedited and rendered within three days of the examination by the
independent medical reviewer. Subject to the approval of the
administrative director, the deadlines for analyses and
determinations involving both regular and expedited reviews may be
extended by the administrative director for up to three days in
extraordinary circumstances or for good cause.
   (g) The independent medical reviewer's analysis shall cite the
injured employee's medical condition, the relevant documents in the
record, and the relevant findings associated with the documents or
any other information submitted to the reviewer in order to support
the determination.
   (h) The administrative director shall immediately adopt the
determination of the independent medical reviewer, and shall promptly
issue a written decision to the parties.
   (i) If the determination of the independent medical reviewer finds
that the disputed treatment or diagnostic service is consistent with
Section 5307.27 or the American College of Occupational and
Environmental Medicine's Occupational Medicine Practice Guidelines,
the injured employee may seek the disputed treatment or diagnostic
service from a physician of his or her choice from within or outside
the medical provider network. Treatment outside the medical provider
network shall be provided consistent with Section 5307.27 or the
American College of Occupational and Environmental Medicine's
Occupational Practice Guidelines. The employer shall be liable for
the cost of any approved medical treatment in accordance with Section
5307.1 or 5307.11.


4616.5.  For purposes of this article, "employer" means a
self-insured employer, joint powers authority, or the state.



4616.6.  No additional examinations shall be ordered by the appeals
board and no other reports shall be admissable to resolve any
controversy arising out of this article.



4616.7.  (a) A health care organization certified pursuant to
Section 4600.5 shall be deemed approved pursuant to this article if
the requirements of this article are met, as determined by the
administrative director.
   (b) A health care service plan, licensed pursuant to Chapter 2.2
(commencing with Section 1340) of Division 2 of the Health and Safety
Code, shall be deemed approved for purposes of this article if it
has a reasonable number of physicians with competency in occupational
medicine, as determined by the administrative director.
   (c) A group disability insurance policy, as defined in subdivision
(b) of Section 106 of the Insurance Code, that covers hospital,
surgical, and medical care expenses shall be deemed approved for
purposes of this article if it has a reasonable number of physicians
with competency in occupational medicine, as determined by the
administrative director. For the purposes of this section, a group
disability insurance policy shall not include Medicare supplement,
vision-only, dental-only, and Champus-supplement insurance. For
purposes of this section, a group disability insurance policy shall
not include hospital indemnity, accident-only, and specified disease
insurance that pays benefits on a fixed benefit, cash-payment-only
basis.
   (d) Any Taft-Hartley health and welfare fund shall be deemed
approved for purposes of this article if it has a reasonable number
of physicians with competency in occupational medicine, as determined
by the administrative director.

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4620.  (a) For purposes of this article, a medical-legal expense
means any costs and expenses incurred by or on behalf of any party,
the administrative director, or the board, which expenses may include
X-rays, laboratory fees, other diagnostic tests, medical reports,
medical records, medical testimony, and, as needed, interpreter's
fees by a certified interpreter pursuant to Article 8 (commencing
with Section 11435.05) of Chapter 4.5 of Part 1 of Division 3 of
Title 2 of, or Section 68566 of, the Government Code, for the purpose
of proving or disproving a contested claim.
   (b) A contested claim exists when the employer knows or reasonably
should know that the employee is claiming entitlement to any benefit
arising out of a claimed industrial injury and one of the following
conditions exists:
   (1) The employer rejects liability for a claimed benefit.
   (2) The employer fails to accept liability for benefits after the
expiration of a reasonable period of time within which to decide if
it will contest the claim.
   (3) The employer fails to respond to a demand for payment of
benefits after the expiration of any time period fixed by statute for
the payment of indemnity.
   (c) Costs of medical evaluations, diagnostic tests, and
interpreters incidental to the production of a medical report do not
constitute medical-legal expenses unless the medical report is
capable of proving or disproving a disputed medical fact, the
determination of which is essential to an adjudication of the
employee's claim for benefits. In determining whether a report meets
the requirements of this subdivision, a judge shall give full
consideration to the substance as well as the form of the report, as
required by applicable statutes and regulations.
   (d) If the injured employee cannot effectively communicate with an
examining physician because he or she cannot proficiently speak or
understand the English language, the injured employee is entitled to
the services of a qualified interpreter during the medical
examination. Upon request of the injured employee, the employer or
insurance carrier shall pay the costs of the interpreter services, as
set forth in the fee schedule adopted by the administrative director
pursuant to Section 5811. An employer shall not be required to pay
for the services of an interpreter who is provisionally certified
unless either the employer consents in advance to the selection of
the individual who provides the interpreting service or the injured
worker requires interpreting service in a language other than the
languages designated pursuant to Section 11435.40 of the Government
Code.


4621.  (a) In accordance with the rules of practice and procedure of
the appeals board, the employee, or the dependents of a deceased
employee, shall be reimbursed for his or her medical-legal expenses
and reasonably, actually, and necessarily incurred, except as
provided in Section 4064. The reasonableness of, and necessity for,
incurring these expenses shall be determined with respect to the time
when the expenses were actually incurred. Costs for medical
evaluations, diagnostic tests, and interpreters' services incidental
to the production of a medical report shall not be incurred earlier
than the date of receipt by the employer, the employer's insurance
carrier, or, if represented, the attorney of record, of all reports
and documents required by the administrative director incidental to
the services. This subdivision is not applicable unless there has
been compliance with Section 4620.
   (b) Except as provided in subdivision (c) and Sections 4061 and
4062, no comprehensive medical-legal evaluations, except those at the
request of an employer, shall be performed during the first 60 days
after the notice of claim has been filed pursuant to Section 5401,
and neither the employer nor the employee shall be liable for any
expenses incurred for comprehensive medical-legal evaluations
performed within the first 60 days after the notice of claim has been
filed pursuant to Section 5401.
   (c) Comprehensive medical-legal evaluations may be performed at
any time after the claim form has been filed pursuant to Section 5401
if the employer has rejected the claim.
   (d) Where, at the request of the employer, the employer's
insurance carrier, the administrative director, the appeals board, or
a referee, the employee submits to examination by a physician, he or
she shall be entitled to receive, in addition to all other benefits
herein provided, all reasonable expenses of transportation, meals,
and lodging incident to reporting for the examination to the same
extent and manner as provided for in Section 4600.



4622.  All medical-legal expenses for which the employer is liable
shall, upon receipt by the employer of all reports and documents
required by the administrative director incident to the services, be
paid to whom the funds and expenses are due, as follows:
   (a) (1) Except as provided in subdivision (b), within 60 days
after receipt by the employer of each separate, written billing and
report, and if payment is not made within this period, that portion
of the billed sum then unreasonably unpaid shall be increased by 10
percent, together with interest thereon at the rate of 7 percent per
annum retroactive to the date of receipt of the bill and report by
the employer. If the employer, within the 60-day period, contests the
reasonableness and necessity for incurring the fees, services, and
expenses using the explanation of review required by Section 4603.3,
payment shall be made within 20 days of the service of an order of
the appeals board or the administrative director pursuant to Section
4603.6 directing payment.
   (2) The penalty provided for in paragraph (1) shall not apply if
both of the following occur:
    (A) The employer pays the provider that portion of his or her
charges that do not exceed the amount deemed reasonable pursuant to
subdivision (e) within 60 days of receipt of the report and itemized
billing.
   (B) The employer prevails.
   (b) (1) If the provider contests the amount paid, the provider may
request a second review within 90 days of the service of the
explanation of review. The request for a second review shall be
submitted to the employer on a form prescribed by the administrative
director and shall include all of the following:
   (A) The date of the explanation of review and the claim number or
other unique identifying number provided on the explanation of
review.
   (B) The party or parties requesting the service.
   (C) Any item and amount in dispute.
   (D) The additional payment requested and the reason therefor.
   (E) Any additional information requested in the original
explanation of review and any other information provided in support
of the additional payment requested.
   (2) If the provider does not request a second review within 90
days, the bill will be deemed satisfied and neither the employer nor
the employee shall be liable for any further payment.
   (3) Within 14 days of the request for second review, the employer
shall respond with a final written determination on each of the items
or amounts in dispute, including whether additional payment will be
made.
   (4) If the provider contests the amount paid, after receipt of the
second review, the provider shall request an independent bill review
as provided for in Section 4603.6.
   (c) If the employer denies all or a portion of the amount billed
for any reason other than the amount to be paid pursuant to the fee
schedules in effect on the date of service, the provider may object
to the denial within 90 days of the service of the explanation of
review. If the provider does not object to the denial within 90 days,
neither the employer nor the employee shall be liable for the amount
that was denied. If the provider objects to the denial within 90
days of the service of the explanation of review, the employer shall
file a petition and a declaration of readiness to proceed with the
appeals board within 60 days of service of the objection. If the
employer prevails before the appeals board, the appeals board shall
order the physician to reimburse the employer for the amount of the
paid charges found to be unreasonable.
   (d) If requested by the employee, or the dependents of a deceased
employee, within 20 days from the filing of an order of the appeals
board directing payment, and where payment is not made within that
period, that portion of the billed sum then unpaid shall be increased
by 10 percent, together with interest thereon at the rate of 7
percent per annum retroactive to the date of the filing of the order
of the board directing payment.
   (e) (1) Using the explanation of review as described in Section
4603.3, the employer shall notify the provider of the services, the
employee, or if represented, his or her attorney, if the employer
contests the reasonableness or necessity of incurring these expenses,
and shall indicate the reasons therefor.
   (2) The appeals board shall promulgate all necessary and
reasonable rules and regulations to insure compliance with this
section, and shall take such further steps as may be necessary to
guarantee that the rules and regulations are enforced.
   (3) The provisions of Sections 5800 and 5814 shall not apply to
this section.
   (f) Nothing contained in this section shall be construed to create
a rebuttable presumption of entitlement to payment of an expense
upon receipt by the employer of the required reports and documents.
This section is not applicable unless there has been compliance with
Sections 4620 and 4621.


4625.  (a) Notwithstanding subdivision (d) of Section 4628, all
charges for medical-legal expenses for which the employer is liable
that are not in excess of those set forth in the official
medical-legal fee schedule adopted pursuant to Section 5307.6 shall
be paid promptly pursuant to Section 4622.
   (b) If the employer contests the reasonableness of the charges it
has paid, the employer may file a petition with the appeals board to
obtain reimbursement of the charges from the physician that are
considered to be unreasonable.



4626.  All charges for X-rays, laboratory services, and other
diagnostic tests provided in connection with an industrial
medical-legal evaluation shall be billed in accordance with the
official medical fee schedule adopted by the administrative director
pursuant to Section 5307.1 and shall be itemized separately in
accordance with rules promulgated by the administrative director.



4627.  The board and the administrative director may promulgate such
reasonable rules and regulations as may be necessary to interpret
this article and compel compliance with its provisions.



4628.  (a) Except as provided in subdivision (c), no person, other
than the physician who signs the medical-legal report, except a nurse
performing those functions routinely performed by a nurse, such as
taking blood pressure, shall examine the injured employee or
participate in the nonclerical preparation of the report, including
all of the following:
   (1) Taking a complete history.
   (2) Reviewing and summarizing prior medical records.
   (3) Composing and drafting the conclusions of the report.
   (b) The report shall disclose the date when and location where the
evaluation was performed; that the physician or physicians signing
the report actually performed the evaluation; whether the evaluation
performed and the time spent performing the evaluation was in
compliance with the guidelines established by the administrative
director pursuant to paragraph (5) of subdivision (j) of Section
139.2 or Section 5307.6 and shall disclose the name and
qualifications of each person who performed any services in
connection with the report, including diagnostic studies, other than
its clerical preparation. If the report discloses that the evaluation
performed or the time spent performing the evaluation was not in
compliance with the guidelines established by the administrative
director, the report shall explain, in detail, any variance and the
reason or reasons therefor.
   (c) If the initial outline of a patient's history or excerpting of
prior medical records is not done by the physician, the physician
shall review the excerpts and the entire outline and shall make
additional inquiries and examinations as are necessary and
appropriate to identify and determine the relevant medical issues.
   (d) No amount may be charged in excess of the direct charges for
the physician's professional services and the reasonable costs of
laboratory examinations, diagnostic studies, and other medical tests,
and reasonable costs of clerical expense necessary to producing the
report. Direct charges for the physician's professional services
shall include reasonable overhead expense.
   (e) Failure to comply with the requirements of this section shall
make the report inadmissible as evidence and shall eliminate any
liability for payment of any medical-legal expense incurred in
connection with the report.
   (f) Knowing failure to comply with the requirements of this
section shall subject the physician to a civil penalty of up to one
thousand dollars ($1,000) for each violation to be assessed by a
workers' compensation judge or the appeals board. All civil penalties
collected under this section shall be deposited in the Workers'
Compensation Administration Revolving Fund.
   (g) A physician who is assessed a civil penalty under this section
may be terminated, suspended, or placed on probation as a qualified
medical evaluator pursuant to subdivisions (k) and (l) of Section
139.2.
   (h) Knowing failure to comply with the requirements of this
section shall subject the physician to contempt pursuant to the
judicial powers vested in the appeals board.
   (i) Any person billing for medical-legal evaluations, diagnostic
procedures, or diagnostic services performed by persons other than
those employed by the reporting physician or physicians, or a medical
corporation owned by the reporting physician or physicians shall
specify the amount paid or to be paid to those persons for the
evaluations, procedures, or services. This subdivision shall not
apply to any procedure or service defined or valued pursuant to
Section 5307.1.
   (j) The report shall contain a declaration by the physician
signing the report, under penalty of perjury, stating:
   "I declare under penalty of perjury that the information contained
in this report and its attachments, if any, is true and correct to
the best of my knowledge and belief, except as to information that I
have indicated I received from others. As to that information, I
declare under penalty of perjury that the information accurately
describes the information provided to me and, except as noted herein,
that I believe it to be true."
   The foregoing declaration shall be dated and signed by the
reporting physician and shall indicate the county wherein it was
signed.
   (k) The physician shall provide a curriculum vitae upon request by
a party and include a statement concerning the percent of the
physician's total practice time that is annually devoted to medical
treatment.

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4650.  (a) If an injury causes temporary disability, the first
payment of temporary disability indemnity shall be made not later
than 14 days after knowledge of the injury and disability, on which
date all indemnity then due shall be paid, unless liability for the
injury is earlier denied.
   (b) (1) If the injury causes permanent disability, the first
payment shall be made within 14 days after the date of last payment
of temporary disability indemnity, except as provided in paragraph
(2). When the last payment of temporary disability indemnity has been
made pursuant to subdivision (c) of Section 4656, and regardless of
whether the extent of permanent disability can be determined at that
date, the employer nevertheless shall commence the timely payment
required by this subdivision and shall continue to make these
payments until the employer's reasonable estimate of permanent
disability indemnity due has been paid, and if the amount of
permanent disability indemnity due has been determined, until that
amount has been paid.
   (2) Prior to an award of permanent disability indemnity, a
permanent disability indemnity payment shall not be required if the
employer has offered the employee a position that pays at least 85
percent of the wages and compensation paid to the employee at the
time of injury or if the employee is employed in a position that pays
at least 100 percent of the wages and compensation paid to the
employee at the time of injury, provided that when an award of
permanent disability indemnity is made, the amount then due shall be
calculated from the last date for which temporary disability
indemnity was paid, or the date the employee's disability became
permanent and stationary, whichever is earlier.
   (c) Payment of temporary or permanent disability indemnity
subsequent to the first payment shall be made as due every two weeks
on the day designated with the first payment.
   (d) If any indemnity payment is not made timely as required by
this section, the amount of the late payment shall be increased 10
percent and shall be paid, without application, to the employee,
unless the employer continues the employee's wages under a salary
continuation plan, as defined in subdivision (g). No increase shall
apply to any payment due prior to or within 14 days after the date
the claim form was submitted to the employer under Section 5401. No
increase shall apply when, within the 14-day period specified under
subdivision (a), the employer is unable to determine whether
temporary disability indemnity payments are owed and advises the
employee, in the manner prescribed in rules and regulations adopted
pursuant to Section 138.4, why payments cannot be made within the
14-day period, what additional information is required to make the
decision whether temporary disability indemnity payments are owed,
and when the employer expects to have the information required to
make the decision.
   (e) If the employer is insured for its obligation to provide
compensation, the employer shall be obligated to reimburse the
insurer for the amount of increase in indemnity payments, made
pursuant to subdivision (d), if the late payment which gives rise to
the increase in indemnity payments, is due less than seven days after
the insurer receives the completed claim form from the employer.
Except as specified in this subdivision, an employer shall not be
obligated to reimburse an insurer nor shall an insurer be permitted
to seek reimbursement, directly or indirectly, for the amount of
increase in indemnity payments specified in this section.
   (f) If an employer is obligated under subdivision (e) to reimburse
the insurer for the amount of increase in indemnity payments, the
insurer shall notify the employer in writing, within 30 days of the
payment, that the employer is obligated to reimburse the insurer and
shall bill and collect the amount of the payment no later than at
final audit. However, the insurer shall not be obligated to collect,
and the employer shall not be obligated to reimburse, amounts paid
pursuant to subdivision (d) unless the aggregate total paid in a
policy year exceeds one hundred dollars ($100). The employer shall
have 60 days, following notice of the obligation to reimburse, to
appeal the decision of the insurer to the Department of Insurance.
The notice of the obligation to reimburse shall specify that the
employer has the right to appeal the decision of the insurer as
provided in this subdivision.
   (g) For purposes of this section, "salary continuation plan" means
a plan that meets both of the following requirements:
   (1) The plan is paid for by the employer pursuant to statute,
collective bargaining agreement, memorandum of understanding, or
established employer policy.
   (2) The plan provides the employee on his or her regular payday
with salary not less than the employee is entitled to receive
pursuant to statute, collective bargaining agreement, memorandum of
understanding, or established employer policy and not less than the
employee would otherwise receive in indemnity payments.



4650.5.  Notwithstanding Section 4650, in the case of state civil
service employees, employees of the Regents of the University of
California, and employees of the Board of Trustees of the California
State University, the disability payment shall be made from the first
day the injured employee leaves work as a result of the injury, if
the injury is the result of a criminal act of violence against the
employee.



4651.  (a) No disability indemnity payment shall be made by any
written instrument unless it is immediately negotiable and payable in
cash, on demand, without discount at some established place of
business in the state.
   Nothing in this section shall prohibit an employer from depositing
the disability indemnity payment in an account in any bank, savings
and loan association or credit union of the employee's choice in this
state, provided the employee has voluntarily authorized the deposit,
nor shall it prohibit an employer from electronically depositing the
disability indemnity payment in an account in any bank, savings and
loan association, or credit union, that the employee has previously
authorized to receive electronic deposits of payroll, unless the
employee has requested, in writing, that disability indemnity
benefits not be electronically deposited in the account.
   (b) It is not a violation of this section if a delay in the
negotiation of a written instrument is caused solely by the
application of state or federal banking laws or regulations.
   (c) On or before July 1, 2004, the administrative director shall
present to the Governor recommendations on how to provide better
access to funds paid to injured workers in light of the requirements
of federal and state laws and regulations governing the negotiability
of disability indemnity payments. The administrative director shall
make specific recommendations regarding payments to migratory and
seasonal farmworkers. The Commission on Health and Safety and Workers'
Compensation and the Employment Development Department shall assist
the administrative director in the completion of this report.



4651.1.  Where a petition is filed with the appeals board concerning
a continuing award of such appeals board, in which it is alleged
that the disability has decreased or terminated, there shall be a
rebuttable presumption that such temporary disability continues for
at least one week following the filing of such petition. In such
case, payment for such week shall be made in accordance with the
provisions of Sections 4650 and 4651 of this code.
   Where the employee has returned to work at or prior to the date of
such filing, however, no such presumption shall apply.
   Service of a copy of such petition on the employee shall be made
as provided by Section 5316 of this code.



4651.2.  No petitions filed under Section 4651.1 shall be granted
while the injured workman is pursuing a rehabilitation plan under
Section 139.5 of this code.



4651.3.  Where a petition is filed with the appeals board pursuant
to the provisions of Section 4651.1, and is subsequently denied
wholly by the appeals board, the board may determine the amount of
attorney's fees reasonably incurred by the applicant in resisting the
petition and may assess such reasonable attorney's fees as a cost
upon the party filing the petition to decrease or terminate the award
of the appeals board.



4652.  Except as otherwise provided by Section 4650.5, no temporary
disability indemnity is recoverable for the disability suffered
during the first three days after the employee leaves work as a
result of the injury unless temporary disability continues for more
than 14 days or the employee is hospitalized as an inpatient for
treatment required by the injury, in either of which cases temporary
disability indemnity shall be payable from the date of disability.
For purposes of calculating the waiting period, the day of the injury
shall be included unless the employee was paid full wages for that
day.


4653.  If the injury causes temporary total disability, the
disability payment is two-thirds of the average weekly earnings
during the period of such disability, consideration being given to
the ability of the injured employee to compete in an open labor
market.



4654.  If the injury causes temporary partial disability, the
disability payment is two-thirds of the weekly loss in wages during
the period of such disability. However, such disability payment shall
be reduced by the sum of unemployment compensation benefits and
extended duration benefits received by the employee during the period
of temporary partial disability.



4655.  If the injury causes temporary disability which is at times
total and at times partial, the weekly disability payment during the
period of each total or partial disability is in accordance with
sections 4653 and 4654 respectively.


4656.  (a) Aggregate disability payments for a single injury
occurring prior to January 1, 1979, causing temporary disability
shall not extend for more than 240 compensable weeks within a period
of five years from the date of the injury.
   (b) Aggregate disability payments for a single injury occurring on
or after January 1, 1979, and prior to April 19, 2004, causing
temporary partial disability shall not extend for more than 240
compensable weeks within a period of five years from the date of the
injury.
   (c) (1) Aggregate disability payments for a single injury
occurring on or after April 19, 2004, causing temporary disability
shall not extend for more than 104 compensable weeks within a period
of two years from the date of commencement of temporary disability
payment.
   (2) Aggregate disability payments for a single injury occurring on
or after January 1, 2008, causing temporary disability shall not
extend for more than 104 compensable weeks within a period of five
years from the date of injury.
   (3) Notwithstanding paragraphs (1) and (2), for an employee who
suffers from the following injuries or conditions, aggregate
disability payments for a single injury occurring on or after April
19, 2004, causing temporary disability shall not extend for more than
240 compensable weeks within a period of five years from the date of
the injury:
   (A) Acute and chronic hepatitis B.
   (B) Acute and chronic hepatitis C.
   (C) Amputations.
   (D) Severe burns.
   (E) Human immunodeficiency virus (HIV).
   (F) High-velocity eye injuries.
   (G) Chemical burns to the eyes.
   (H) Pulmonary fibrosis.
   (I) Chronic lung disease.



4657.  In case of temporary partial disability the weekly loss in
wages shall consist of the difference between the average weekly
earnings of the injured employee and the weekly amount which the
injured employee will probably be able to earn during the disability,
to be determined in view of the nature and extent of the injury. In
computing such probable earnings, due regard shall be given to the
ability of the injured employee to compete in an open labor market.
If evidence of exact loss of earnings is lacking, such weekly loss in
wages may be computed from the proportionate loss of physical
ability or earning power caused by the injury.




4658.  (a) For injuries occurring prior to January 1, 1992, if the
injury causes permanent disability, the percentage of disability to
total disability shall be determined, and the disability payment
computed and allowed, according to paragraph (1). However, in no
event shall the disability payment allowed be less than the
disability payment computed according to paragraph (2).
   (1)

                             Column 2--Number of
                                    weeks
                            for which two-thirds
                                     of
                               average weekly
                                  earnings
  Column 1-                  allowed for each 1
  -Range                           percent
  of percentage                 of permanent
                                 disability
  of
  permanent                   within percentage
  disability incurred:             range:
  Under 10................            3
  10-19.75................            4
  20-29.75................            5
  30-49.75................            6
  50-69.75................            7
  70-99.75................            8

   The number of weeks for which payments shall be allowed set forth
in column 2 above based upon the percentage of permanent disability
set forth in column 1 above shall be cumulative, and the number of
benefit weeks shall increase with the severity of the disability. The
following schedule is illustrative of the computation of the number
of benefit weeks:

  Column 1-
  -                          Column 2-
  Percentage                     -
  of                        Cumulative
  permanent                   number
  disability                    of
  incurred:               benefit weeks:
  5.....................       15.00
  10....................       30.25
  15....................       50.25
  20....................       70.50
  25....................       95.50
  30....................      120.75
  35....................      150.75
  40....................      180.75
  45....................      210.75
  50....................      241.00
  55....................      276.00
  60....................      311.00
  65....................      346.00
  70....................      381.25
  75....................      421.25
  80....................      461.25
  85....................      501.25
  90....................      541.25
  95....................      581.25
  100...................     for life

   (2) Two-thirds of the average weekly earnings for four weeks for
each 1 percent of disability, where, for the purposes of this
subdivision, the average weekly earnings shall be taken at not more
than seventy-eight dollars and seventy-five cents ($78.75).
   (b) This subdivision shall apply to injuries occurring on or after
January 1, 1992. If the injury causes permanent disability, the
percentage of disability to total disability shall be determined, and
the disability payment computed and allowed, according to paragraph
(1). However, in no event shall the disability payment allowed be
less than the disability payment computed according to paragraph (2).
   (1)

                             Column 2--Number of
                                    weeks
                            for which two-thirds
                                     of
                               average weekly
                                  earnings
  Column 1-                  allowed for each 1
  -Range                           percent
  of percentage                 of permanent
                                 disability
  of
  permanent                   within percentage
  disability incurred:             range:
  Under 10................            3
  10-19.75................            4
  20-24.75................            5
  25-29.75................            6
  30-49.75................            7
  50-69.75................            8
  70-99.75................            9

   The numbers set forth in column 2 above are based upon the
percentage of permanent disability set forth in column 1 above and
shall be cumulative, and shall increase with the severity of the
disability in the manner illustrated in subdivision (a).
   (2) Two-thirds of the average weekly earnings for four weeks for
each 1 percent of disability, where, for the purposes of this
subdivision, the average weekly earnings shall be taken at not more
than seventy-eight dollars and seventy-five cents ($78.75).
   (c) This subdivision shall apply to injuries occurring on or after
January 1, 2004. If the injury causes permanent disability, the
percentage of disability to total disability shall be determined, and
the disability payment computed and allowed as follows:

                             Column 2--Number of
                                    weeks
                            for which two-thirds
                                     of
                               average weekly
                                  earnings
  Column 1-                  allowed for each 1
  -Range                           percent
  of percentage                 of permanent
                                 disability
  of
  permanent                   within percentage
  disability incurred:             range:
  Under 10................            4
  10-19.75................            5
  20-24.75................            5
  25-29.75................            6
  30-49.75................            7
  50-69.75................            8
  70-99.75................            9

   The numbers set forth in column 2 above are based upon the
percentage of permanent disability set forth in column 1 above and
shall be cumulative, and shall increase with the severity of the
disability in the manner illustrated in subdivision (a).
   (d) (1) This subdivision shall apply to injuries occurring on or
after January 1, 2005, and as additionally provided in paragraph (4).
If the injury causes permanent disability, the percentage of
disability to total disability shall be determined, and the basic
disability payment computed as follows:

                             Column 2--Number of
                                    weeks
                            for which two-thirds
                                     of
                               average weekly
                                  earnings
  Column 1-                  allowed for each 1
  -Range                           percent
  of percentage                 of permanent
                                 disability
  of
  permanent                   within percentage
  disability incurred:             range:
  0.25-9.75...............            3
  10-14.75................            4
  15-24.75................            5
  25-29.75................            6
  30-49.75................            7
  50-69.75................            8
  70-99.75................           16

   The numbers set forth in column 2 above are based upon the
percentage of permanent disability set forth in column 1 above and
shall be cumulative, and shall increase with the severity of the
disability in the manner illustrated in subdivision (a).
   (2) If, within 60 days of a disability becoming permanent and
stationary, an employer does not offer the injured employee regular
work, modified work, or alternative work, in the form and manner
prescribed by the administrative director, for a period of at least
12 months, each disability payment remaining to be paid to the
injured employee from the date of the end of the 60-day period shall
be paid in accordance with paragraph (1) and increased by 15 percent.
This paragraph shall not apply to an employer that employs fewer
than 50 employees.
   (3) (A) If, within 60 days of a disability becoming permanent and
stationary, an employer offers the injured employee regular work,
modified work, or alternative work, in the form and manner prescribed
by the administrative director, for a period of at least 12 months,
and regardless of whether the injured employee accepts or rejects the
offer, each disability payment remaining to be paid to the injured
employee from the date the offer was made shall be paid in accordance
with paragraph (1) and decreased by 15 percent.
   (B) If the regular work, modified work, or alternative work is
terminated by the employer before the end of the period for which
disability payments are due the injured employee, the amount of each
of the remaining disability payments shall be paid in accordance with
paragraph (1) and increased by 15 percent. An employee who
voluntarily terminates employment shall not be eligible for payment
under this subparagraph. This paragraph shall not apply to an
employer that employs fewer than 50 employees.
   (4) For compensable claims arising before April 30, 2004, the
schedule provided in this subdivision shall not apply to the
determination of permanent disabilities when there has been either a
comprehensive medical-legal report or a report by a treating
physician, indicating the existence of permanent disability, or when
the employer is required to provide the notice required by Section
4061 to the injured worker.
   (e) This subdivision shall apply to injuries occurring on or after
January 1, 2013. If the injury causes permanent disability, the
percentage of disability to total disability shall be determined, and
the disability payment computed and allowed as follows:


                             Column 2--Number of
                            weeks for which two-
                              thirds of average
                               weekly earnings
  Column 1-                  allowed for each 1
  -Range                           percent
  of percentage                 of permanent
                                 disability
  of
  permanent                   within percentage
  disability incurred:             range:
  0.25-9.75...............            3
  10-14.75................            4
  15-24.75................            5
  25-29.75................            6
  30-49.75................            7
  50-69.75................            8
  70-99.75................           16

   (1) The numbers set forth in column 2 above are based upon the
percentage of permanent disability set forth in column 1 above and
shall be cumulative, and shall increase with the severity of the
disability in the manner illustrated in subdivision (a).


   (2) If the permanent disability directly caused by the industrial
injury is total, payment shall be made as provided in Section 4659.




4658.1.  As used in this article, the following definitions apply:
   (a) "Regular work" means the employee's usual occupation or the
position in which the employee was engaged at the time of injury and
that offers wages and compensation equivalent to those paid to the
employee at the time of injury, and located within a reasonable
commuting distance of the employee's residence at the time of injury.
   (b) "Modified work" means regular work modified so that the
employee has the ability to perform all the functions of the job and
that offers wages and compensation that are at least 85 percent of
those paid to the employee at the time of injury, and located within
a reasonable commuting distance of the employee's residence at the
time of injury.
   (c) "Alternative work" means work that the employee has the
ability to perform, that offers wages and compensation that are at
least 85 percent of those paid to the employee at the time of injury,
and that is located within reasonable commuting distance of the
employee's residence at the time of injury.
   (d) For the purpose of determining whether wages and compensation
are equivalent to those paid at the time of injury, the wages and
compensation for any increase in working hours over the average hours
worked at the time of injury shall not be considered.
   (e) For the purpose of determining whether wages and compensation
are equivalent to those paid at the time of injury, actual wages and
compensation shall be determined without regard to the minimums and
maximums set forth in Chapter 1 (commencing with Section 4451).
   (f) The condition that regular work, modified work, or alternative
work be located within a reasonable distance of the employee's
residence at the time of injury may be waived by the employee. The
condition shall be deemed to be waived if the employee accepts the
regular work, modified work, or alternative work and does not object
to the location within 20 days of being informed of the right to
object. The condition shall be conclusively deemed to be satisfied if
the offered work is at the same location and the same shift as the
employment at the time of injury.



4658.5.  (a) This section shall apply to injuries occurring on or
after January 1, 2004, and before January 1, 2013.
   (b) Except as provided in Section 4658.6, if the injury causes
permanent partial disability and the injured employee does not return
to work for the employer within 60 days of the termination of
temporary disability, the injured employee shall be eligible for a
supplemental job displacement benefit in the form of a
nontransferable voucher for education-related retraining or skill
enhancement, or both, at state-approved or accredited schools, as
follows:
   (1) Up to four thousand dollars ($4,000) for permanent partial
disability awards of less than 15 percent.
   (2) Up to six thousand dollars ($6,000) for permanent partial
disability awards between 15 and 25 percent.
   (3) Up to eight thousand dollars ($8,000) for permanent partial
disability awards between 26 and 49 percent.
   (4) Up to ten thousand dollars ($10,000) for permanent partial
disability awards between 50 and 99 percent.
   (c) The voucher may be used for payment of tuition, fees, books,
and other expenses required by the school for retraining or skill
enhancement. No more than 10 percent of the voucher moneys may be
used for vocational or return-to-work counseling. The administrative
director shall adopt regulations governing the form of payment,
direct reimbursement to the injured employee upon presentation to the
employer of appropriate documentation and receipts, and other
matters necessary to the proper administration of the supplemental
job displacement benefit.
   (d) A voucher issued on or after January 1, 2013, shall expire two
years after the date the voucher is furnished to the employee or
five years after the date of injury, whichever is later. The employee
shall not be entitled to payment or reimbursement of any expenses
that have not been incurred and submitted with appropriate
documentation to the employer prior to the expiration date.
   (e) An employer shall not be liable for compensation for injuries
incurred by the employee while utilizing the voucher.




4658.6.  The employer shall not be liable for the supplemental job
displacement benefit pursuant to Section 4658.5 if the employer meets
either of the following conditions:
   (a) Within 30 days of the termination of temporary disability
indemnity payments, the employer offers, and the employee rejects, or
fails to accept, in the form and manner prescribed by the
administrative director, modified work, accommodating the employee's
work restrictions, lasting at least 12 months.
   (b) Within 30 days of the termination of temporary disability
indemnity payments, the employer offers, and the employee rejects, or
fails to accept, in the form and manner prescribed by the
administrative director, alternative work meeting all of the
following conditions:
   (1) The employee has the ability to perform the essential
functions of the job provided.
   (2) The job provided is in a regular position lasting at least 12
months.
   (3) The job provided offers wages and compensation that are within
15 percent of those paid to the employee at the time of injury.
   (4) The job is located within reasonable commuting distance of the
employee's residence at the time of injury.



4658.7.  (a) This section shall apply to injuries occurring on or
after January 1, 2013.
   (b) If the injury causes permanent partial disability, the injured
employee shall be entitled to a supplemental job displacement
benefit as provided in this section unless the employer makes an
offer of regular, modified, or alternative work, as defined in
Section 4658.1, that meets both of the following criteria:
   (1) The offer is made no later than 60 days after receipt by the
claims administrator of the first report received from either the
primary treating physician, an agreed medical evaluator, or a
qualified medical evaluator, in the form created by the
administrative director pursuant to subdivision (h), finding that the
disability from all conditions for which compensation is claimed has
become permanent and stationary and that the injury has caused
permanent partial disability.
   (A) If the employer or claims administrator has provided the
physician with a job description of the employee's regular work,
proposed modified work, or proposed alternative work, the physician
shall evaluate and describe in the form whether the work capacities
and activity restrictions are compatible with the physical
requirements set forth in that job description.
   (B) The claims administrator shall forward the form to the
employer for the purpose of fully informing the employer of work
capacities and activity restrictions resulting from the injury that
are relevant to potential regular, modified, or alternative work.
   (2) The offer is for regular work, modified work, or alternative
work lasting at least 12 months.
   (c) The supplemental job displacement benefit shall be offered to
the employee within 20 days after the expiration of the time for
making an offer of regular, modified, or alternative work pursuant to
paragraph (1) of subdivision (b).
   (d) The supplemental job displacement benefit shall be in the form
of a voucher redeemable as provided in this section up to an
aggregate of six thousand dollars ($6,000).
   (e) The voucher may be applied to any of the following expenses at
the choice of the injured employee:
   (1) Payment for education-related retraining or skill enhancement,
or both, at a California public school or with a provider that is
certified and on the state's Eligible Training Provider List (EPTL),
as authorized by the federal Workforce Investment Act (P.L. 105-220),
including payment of tuition, fees, books, and other expenses
required by the school for retraining or skill enhancement.
   (2) Payment for occupational licensing or professional
certification fees, related examination fees, and examination
preparation course fees.
   (3) Payment for the services of licensed placement agencies,
vocational or return-to-work counseling, and résumé preparation, all
up to a combined limit of 10 percent of the amount of the voucher.
   (4) Purchase of tools required by a training or educational
program in which the employee is enrolled.
   (5) Purchase of computer equipment, up to one thousand dollars
($1,000).
   (6) Up to five hundred dollars ($500) as a miscellaneous expense
reimbursement or advance, payable upon request and without need for
itemized documentation or accounting. The employee shall not be
entitled to any other voucher payment for transportation, travel
expenses, telephone or Internet access, clothing or uniforms, or
incidental expenses.
   (f) The voucher shall expire two years after the date the voucher
is furnished to the employee, or five years after the date of injury,
whichever is later. The employee shall not be entitled to payment or
reimbursement of any expenses that have not been incurred and
submitted with appropriate documentation to the employer prior to the
expiration date.
   (g) Settlement or commutation of a claim for the supplemental job
displacement benefit shall not be permitted under Chapter 2
(commencing with Section 5000) or Chapter 3 (commencing with Section
5100) of Part 3.
   (h) The administrative director shall adopt regulations for the
administration of this section, including, but not limited to, both
of the following:
   (1) The time, manner, and content of notices of rights under this
section.
   (2) The form of a mandatory attachment to a medical report to be
forwarded to the employer pursuant to paragraph (1) of subdivision
(b) for the purpose of fully informing the employer of work
capacities and of activity restrictions resulting from the injury
that are relevant to potential regular work, modified work, or
alternative work.
   (i) An employer shall not be liable for compensation for injuries
incurred by the employee while utilizing the voucher.



4659.  (a) If the permanent disability is at least 70 percent, but
less than 100 percent, 1.5 percent of the average weekly earnings for
each 1 percent of disability in excess of 60 percent is to be paid
during the remainder of life, after payment for the maximum number of
weeks specified in Section 4658 has been made. For the purposes of
this subdivision only, average weekly earnings shall be taken at not
more than one hundred seven dollars and sixty-nine cents ($107.69).
For injuries occurring on or after July 1, 1994, average weekly wages
shall not be taken at more than one hundred fifty-seven dollars and
sixty-nine cents ($157.69). For injuries occurring on or after July
1, 1995, average weekly wages shall not be taken at more than two
hundred seven dollars and sixty-nine cents ($207.69). For injuries
occurring on or after July 1, 1996, average weekly wages shall not be
taken at more than two hundred fifty-seven dollars and sixty-nine
cents ($257.69). For injuries occurring on or after January 1, 2006,
average weekly wages shall not be taken at more than five hundred
fifteen dollars and thirty-eight cents ($515.38).
   (b) If the permanent disability is total, the indemnity based upon
the average weekly earnings determined under Section 4453 shall be
paid during the remainder of life.
   (c) For injuries occurring on or after January 1, 2003, an
employee who becomes entitled to receive a life pension or total
permanent disability indemnity as set forth in subdivisions (a) and
(b) shall have that payment increased annually commencing on January
1, 2004, and each January 1 thereafter, by an amount equal to the
percentage increase in the "state average weekly wage" as compared to
the prior year. For purposes of this subdivision, "state average
weekly wage" means the average weekly wage paid by employers to
employees covered by unemployment insurance as reported by the United
States Department of Labor for California for the 12 months ending
March 31 of the calendar year preceding the year in which the injury
occurred.


4660.  This section shall only apply to injuries occurring before
January 1, 2013.
   (a) In determining the percentages of permanent disability,
account shall be taken of the nature of the physical injury or
disfigurement, the occupation of the injured employee, and his or her
age at the time of the injury, consideration being given to an
employee's diminished future earning capacity.
   (b) (1) For purposes of this section, the "nature of the physical
injury or disfigurement" shall incorporate the descriptions and
measurements of physical impairments and the corresponding
percentages of impairments published in the American Medical
Association (AMA) Guides to the Evaluation of Permanent Impairment
(5th Edition).
   (2) For purposes of this section, an employee's diminished future
earning capacity shall be a numeric formula based on empirical data
and findings that aggregate the average percentage of long-term loss
of income resulting from each type of injury for similarly situated
employees. The administrative director shall formulate the adjusted
rating schedule based on empirical data and findings from the
Evaluation of California's Permanent Disability Rating Schedule,
Interim Report (December 2003), prepared by the RAND Institute for
Civil Justice, and upon data from additional empirical studies.
   (c) The administrative director shall amend the schedule for the
determination of the percentage of permanent disability in accordance
with this section at least once every five years. This schedule
shall be available for public inspection and, without formal
introduction in evidence, shall be prima facie evidence of the
percentage of permanent disability to be attributed to each injury
covered by the schedule.
   (d) The schedule shall promote consistency, uniformity, and
objectivity. The schedule and any amendment thereto or revision
thereof shall apply prospectively and shall apply to and govern only
those permanent disabilities that result from compensable injuries
received or occurring on and after the effective date of the adoption
of the schedule, amendment or revision, as the fact may be. For
compensable claims arising before January 1, 2005, the schedule as
revised pursuant to changes made in legislation enacted during the
2003-04 Regular and Extraordinary Sessions shall apply to the
determination of permanent disabilities when there has been either no
comprehensive medical-legal report or no report by a treating
physician indicating the existence of permanent disability, or when
the employer is not required to provide the notice required by
Section 4061 to the injured worker.
   (e) On or before January 1, 2005, the administrative director
shall adopt regulations to implement the changes made to this section
by the act that added this subdivision.



4660.1.  This section shall apply to injuries occurring on or after
January 1, 2013.
   (a) In determining the percentages of permanent partial or
permanent total disability, account shall be taken of the nature of
the physical injury or disfigurement, the occupation of the injured
employee, and his or her age at the time of injury.
   (b) For purposes of this section, the "nature of the physical
injury or disfigurement" shall incorporate the descriptions and
measurements of physical impairments and the corresponding
percentages of impairments published in the American Medical
Association (AMA) Guides to the Evaluation of Permanent Impairment
(5th Edition) with the employee's whole person impairment, as
provided in the Guides, multiplied by an adjustment factor of 1.4.
   (c) (1) Except as provided in paragraph (2), there shall be no
increases in impairment ratings for sleep dysfunction, sexual
dysfunction, or psychiatric disorder, or any combination thereof,
arising out of a compensable physical injury. Nothing in this section
shall limit the ability of an injured employee to obtain treatment
for sleep dysfunction, sexual dysfunction, or psychiatric disorder,
if any, that are a consequence of an industrial injury.
   (2) An increased impairment rating for psychiatric disorder shall
not be subject to paragraph (1) if the compensable psychiatric injury
resulted from either of the following:
    (A) Being a victim of a violent act or direct exposure to a
significant violent act within the meaning of Section 3208.3.
   (B) A catastrophic injury, including, but not limited to, loss of
a limb, paralysis, severe burn, or severe head injury.
   (d) The administrative director may formulate a schedule of age
and occupational modifiers and may amend the schedule for the
determination of the age and occupational modifiers in accordance
with this section. The Schedule for Rating Permanent Disabilities
pursuant to the American Medical Association (AMA) Guides to the
Evaluation of Permanent Impairment (5th Edition) and the schedule of
age and occupational modifiers shall be available for public
inspection and, without formal introduction in evidence, shall be
prima facie evidence of the percentage of permanent disability to be
attributed to each injury covered by the schedule. Until the schedule
of age and occupational modifiers is amended, for injuries occurring
on or after January 1, 2013, permanent disabilities shall be rated
using the age and occupational modifiers in the permanent disability
rating schedule adopted as of January 1, 2005.
   (e) The schedule of age and occupational modifiers shall promote
consistency, uniformity, and objectivity.
   (f) The schedule of age and occupational modifiers and any
amendment thereto or revision thereof shall apply prospectively and
shall apply to and govern only those permanent disabilities that
result from compensable injuries received or occurring on and after
the effective date of the adoption of the schedule, amendment, or
revision, as the case may be.
   (g) Nothing in this section shall preclude a finding of permanent
total disability in accordance with Section 4662.
   (h) In enacting the act adding this section, it is not the intent
of the Legislature to overrule the holding in Milpitas Unified School
District v. Workers' Comp. Appeals Bd. (Guzman) (2010) 187
Cal.App.4th 808.
   (i) The Commission on Health and Safety and Workers' Compensation
shall conduct a study to compare average loss of earnings for
employees who sustained work-related injuries with permanent
disability ratings under the schedule, and shall report the results
of the study to the appropriate policy and fiscal committees of the
Legislature no later than January 1, 2016.



4661.  Where an injury causes both temporary and permanent
disability, the injured employee is entitled to compensation for any
permanent disability sustained by him in addition to any payment
received by such injured employee for temporary disability.
   Every computation made pursuant to this section shall be made only
with reference to disability resulting from an original injury
sustained after this section as amended during the 1949 Regular
Session of the Legislature becomes effective; provided, however, that
all rights presently existing under this section shall be continued
in force.



4661.5.  Notwithstanding any other provision of this division, when
any temporary total disability indemnity payment is made two years or
more from the date of injury, the amount of this payment shall be
computed in accordance with the temporary disability indemnity
average weekly earnings amount specified in Section 4453 in effect on
the date each temporary total disability payment is made unless
computing the payment on this basis produces a lower payment because
of a reduction in the minimum average weekly earnings applicable
under Section 4453.


4662.  Any of the following permanent disabilities shall be
conclusively presumed to be total in character:
   (a) Loss of both eyes or the sight thereof.
   (b) Loss of both hands or the use thereof.
   (c) An injury resulting in a practically total paralysis.
   (d) An injury to the brain resulting in incurable mental
incapacity or insanity.
   In all other cases, permanent total disability shall be determined
in accordance with the fact.



4663.  (a) Apportionment of permanent disability shall be based on
causation.
   (b) Any physician who prepares a report addressing the issue of
permanent disability due to a claimed industrial injury shall in that
report address the issue of causation of the permanent disability.
   (c) In order for a physician's report to be considered complete on
the issue of permanent disability, the report must include an
apportionment determination. A physician shall make an apportionment
determination by finding what approximate percentage of the permanent
disability was caused by the direct result of injury arising out of
and occurring in the course of employment and what approximate
percentage of the permanent disability was caused by other factors
both before and subsequent to the industrial injury, including prior
industrial injuries. If the physician is unable to include an
apportionment determination in his or her report, the physician shall
state the specific reasons why the physician could not make a
determination of the effect of that prior condition on the permanent
disability arising from the injury. The physician shall then consult
with other physicians or refer the employee to another physician from
whom the employee is authorized to seek treatment or evaluation in
accordance with this division in order to make the final
determination.
   (d) An employee who claims an industrial injury shall, upon
request, disclose all previous permanent disabilities or physical
impairments.
   (e) Subdivisions (a), (b), and (c) shall not apply to injuries or
illnesses covered under Sections 3212, 3212.1, 3212.2, 3212.3,
3212.4, 3212.5, 3212.6, 3212.7, 3212.8, 3212.85, 3212.9, 3212.10,
3212.11, 3212.12, 3213, and 3213.2.



4664.  (a) The employer shall only be liable for the percentage of
permanent disability directly caused by the injury arising out of and
occurring in the course of employment.
   (b) If the applicant has received a prior award of permanent
disability, it shall be conclusively presumed that the prior
permanent disability exists at the time of any subsequent industrial
injury. This presumption is a presumption affecting the burden of
proof.
   (c) (1) The accumulation of all permanent disability awards issued
with respect to any one region of the body in favor of one
individual employee shall not exceed 100 percent over the employee's
lifetime unless the employee's injury or illness is conclusively
presumed to be total in character pursuant to Section 4662. As used
in this section, the regions of the body are the following:
   (A) Hearing.
   (B) Vision.
   (C) Mental and behavioral disorders.
   (D) The spine.
   (E) The upper extremities, including the shoulders.
   (F) The lower extremities, including the hip joints.
   (G) The head, face, cardiovascular system, respiratory system, and
all other systems or regions of the body not listed in subparagraphs
(A) to (F), inclusive.
   (2) Nothing in this section shall be construed to permit the
permanent disability rating for each individual injury sustained by
an employee arising from the same industrial accident, when added
together, from exceeding 100 percent.

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4700.  The death of an injured employee does not affect the
liability of the employer under Articles 2 (commencing with Section
4600) and 3 (commencing with Section 4650). Neither temporary nor
permanent disability payments shall be made for any period of time
subsequent to the death of the employee. Any accrued and unpaid
compensation shall be paid to the dependents, or, if there are no
dependents, to the personal representative of the deceased employee
or heirs or other persons entitled thereto, without administration.



4701.  If an injury causes death, either with or without disability,
the employer shall be liable, in addition to any other benefits
provided by this division, for all of the following:
   (a) Reasonable expenses of the employee's burial, in accordance
with the following:
   (1) Up to two thousand dollars ($2,000) for injuries occurring
prior to January 1, 1991.
   (2) Up to five thousand dollars ($5,000) for injuries occurring on
or after January 1, 1991, and prior to January 1, 2013.
   (3) Up to ten thousand dollars ($10,000) for injuries occurring on
or after January 1, 2013.
   (b) A death benefit, to be allowed to the dependents when the
employee leaves any person dependent upon him or her for support.



4702.  (a) Except as otherwise provided in this section and Sections
4553, 4554, 4557, and 4558, and notwithstanding any amount of
compensation paid or otherwise owing to the surviving dependent,
personal representative, heir, or other person entitled to a deceased
employee's accrued and unpaid compensation, the death benefit in
cases of total dependency shall be as follows:
   (1) In the case of two total dependents and regardless of the
number of partial dependents, for injuries occurring before January
1, 1991, ninety-five thousand dollars ($95,000), for injuries
occurring on or after January 1, 1991, one hundred fifteen thousand
dollars ($115,000), for injuries occurring on or after July 1, 1994,
one hundred thirty-five thousand dollars ($135,000), for injuries
occurring on or after July 1, 1996, one hundred forty-five thousand
dollars ($145,000), and for injuries occurring on or after January 1,
2006, two hundred ninety thousand dollars ($290,000).
   (2) In the case of one total dependent and one or more partial
dependents, for injuries occurring before January 1, 1991, seventy
thousand dollars ($70,000), for injuries occurring on or after
January 1, 1991, ninety-five thousand dollars ($95,000), for injuries
occurring on or after July 1, 1994, one hundred fifteen thousand
dollars ($115,000), for injuries occurring on or after July 1, 1996,
one hundred twenty-five thousand dollars ($125,000), and for injuries
occurring on or after January 1, 2006, two hundred fifty thousand
dollars ($250,000), plus four times the amount annually devoted to
the support of the partial dependents, but not more than the
following: for injuries occurring before January 1, 1991, a total of
ninety-five thousand dollars ($95,000), for injuries occurring on or
after January 1, 1991, one hundred fifteen thousand dollars
($115,000), for injuries occurring on or after July 1, 1994, one
hundred twenty-five thousand dollars ($125,000), for injuries
occurring on or after July 1, 1996, one hundred forty-five thousand
dollars ($145,000), and for injuries occurring on or after January 1,
2006, two hundred ninety thousand dollars ($290,000).
   (3) In the case of one total dependent and no partial dependents,
for injuries occurring before January 1, 1991, seventy thousand
dollars ($70,000), for injuries occurring on or after January 1,
1991, ninety-five thousand dollars ($95,000), for injuries occurring
on or after July 1, 1994, one hundred fifteen thousand dollars
($115,000), for injuries occurring on or after July 1, 1996, one
hundred twenty-five thousand dollars ($125,000), and for injuries
occurring on or after January 1, 2006, two hundred fifty thousand
dollars ($250,000).
   (4) (A) In the case of no total dependents and one or more partial
dependents, for injuries occurring before January 1, 1991, four
times the amount annually devoted to the support of the partial
dependents, but not more than seventy thousand dollars ($70,000), for
injuries occurring on or after January 1, 1991, a total of
ninety-five thousand dollars ($95,000), for injuries occurring on or
after July 1, 1994, one hundred fifteen thousand dollars ($115,000),
and for injuries occurring on or after July 1, 1996, but before
January 1, 2006, one hundred twenty-five thousand dollars ($125,000).
   (B) In the case of no total dependents and one or more partial
dependents, eight times the amount annually devoted to the support of
the partial dependents, for injuries occurring on or after January
1, 2006, but not more than two hundred fifty thousand dollars
($250,000).
   (5) In the case of three or more total dependents and regardless
of the number of partial dependents, one hundred fifty thousand
dollars ($150,000), for injuries occurring on or after July 1, 1994,
one hundred sixty thousand dollars ($160,000), for injuries occurring
on or after July 1, 1996, and three hundred twenty thousand dollars
($320,000), for injuries occurring on or after January 1, 2006.
   (6) (A) In the case of a police officer who has no total
dependents and no partial dependents, for injuries occurring on or
after January 1, 2003, and prior to January 1, 2004, two hundred
fifty thousand dollars ($250,000) to the estate of the deceased
police officer.
   (B) For injuries occurring on or after January 1, 2004, in the
case of no total dependents and no partial dependents, two hundred
fifty thousand dollars ($250,000) to the estate of the deceased
employee.
   (b) A death benefit in all cases shall be paid in installments in
the same manner and amounts as temporary total disability indemnity
would have to be made to the employee, unless the appeals board
otherwise orders. However, no payment shall be made at a weekly rate
of less than two hundred twenty-four dollars ($224).
   (c) Disability indemnity shall not be deducted from the death
benefit and shall be paid in addition to the death benefit when the
injury resulting in death occurs after September 30, 1949.
   (d) All rights under this section existing prior to January 1,
1990, shall be continued in force.



4703.  Subject to the provisions of Section 4704, this section shall
determine the right to a death benefit.
   If there is any person wholly dependent for support upon a
deceased employee, that person shall receive a full death benefit as
set forth in Section 4702 for one total dependent, and any additional
partial dependents shall receive a death benefit as set forth in
subdivision (b) of Section 4702 to a maximum aggregate amount of
twenty-five thousand dollars ($25,000).
   If there are two or more persons wholly dependent for support upon
a deceased employee, those persons shall receive the death benefit
set forth in subdivision (a) of Section 4702, and any person
partially dependent shall receive no part thereof.
   If there is more than one person wholly dependent for support upon
a deceased employee, the death benefit shall be divided equally
among them.
   If there is more than one person partially dependent for support
upon a deceased employee, and no person wholly dependent for support,
the amount allowed as a death benefit shall be divided among the
persons so partially dependent in proportion to the relative extent
of their dependency.



4703.5.  (a) In the case of one or more totally dependent minor
children, as defined in Section 3501, after payment of the amount
specified in Section 4702, and notwithstanding the maximum
limitations specified in Sections 4702 and 4703, payment of death
benefits shall continue until the youngest child attains 18 years of
age, or until the death of a child physically or mentally
incapacitated from earning, in the same manner and amount as
temporary total disability indemnity would have been paid to the
employee, except that no payment shall be made at a weekly rate of
less than two hundred twenty-four dollars ($224).
   (b) (1) Notwithstanding the age limitation in subdivision (a), the
payment of death benefits shall continue until the youngest child
attains 19 years of age if the child is still attending high school
and is receiving the death benefits as a child of an active member of
a sheriff's office, active member of a police or fire department of
a city, county, city and county, district, or other public or
municipal corporation or political subdivision, individual described
in Chapter 4.5 (commencing with Section 830) of Title 3 of Part 2 of
the Penal Code who is primarily engaged in active law enforcement
activities, active firefighting member of the Department of Forestry
and Fire Protection, or an active member of any county forestry or
firefighting department or unit killed in the performance of duty.
   (2) Paragraph (1) shall not apply with respect to a child of a
person whose principal duties are clerical or otherwise do not
clearly fall within the scope of active law enforcement or active
firefighting services, such as stenographers, telephone operators,
and other office workers.



4703.6.  The provisions of Section 4703.5 shall also apply to a
totally dependent minor child of a local safety member as defined in
Article 4 (commencing with Section 20420) of Chapter 4 of Part 3 of
Division 5 of Title 2 of the Government Code, or a safety member as
defined in Section 31469.3 of the Government Code, other than a
member performing duties related to juvenile hall group counseling
and group supervision, or a safety member subject to any public
retirement system, or a patrol member as defined in Section 20390 of
the Government Code, if that member was killed in the line of duty
prior to January 1, 1990, and the totally dependent minor child is
otherwise entitled to benefits under Section 4703.5.




4704.  The appeals board may set apart or reassign the death benefit
to any one or more of the dependents in accordance with their
respective needs and in a just and equitable manner, and may order
payment to a dependent subsequent in right, or not otherwise entitled
thereto, upon good cause being shown therefor. The death benefit
shall be paid to such one or more of the dependents of the deceased
or to a trustee appointed by the appeals board for the benefit of the
person entitled thereto, as determined by the appeals board.



4705.  The person to whom the death benefit is paid for the use of
the several beneficiaries shall apply it in compliance with the
findings and directions of the appeals board.



4706.  (a) If a dependent beneficiary of any deceased employee dies
and there is no surviving dependent, the payments of the death
benefit accrued and payable at the time of the death of the sole
remaining dependent shall be paid upon the order of the appeals board
to the heirs of the dependent or, if none, to the heirs of the
deceased employee, without administration.
   (b) In the event there is no surviving dependent and no surviving
heir, the appeals board may order the burial expense of the deceased
employee, not to exceed the amount specified in Section 4701, paid to
the proper person, without administration.



4706.5.  (a) Whenever any fatal injury is suffered by an employee
under circumstances that would entitle the employee to compensation
benefits, but for his or her death, and the employee does not leave
surviving any person entitled to a dependency death benefit, the
employer shall pay a sum to the Department of Industrial Relations
equal to the total dependency death benefit that would be payable to
a surviving spouse with no dependent minor children.
   (b) When the deceased employee leaves no surviving dependent,
personal representative, heir, or other person entitled to the
accrued and unpaid compensation referred to in Section 4700, the
accrued and unpaid compensation shall be paid by the employer to the
Department of Industrial Relations.
   (c) The payments to be made to the Department of Industrial
Relations, as required by subdivisions (a) and (b), shall be
deposited in the General Fund and shall be credited, as a
reimbursement, to any appropriation to the Department of Industrial
Relations for payment of the additional compensation for subsequent
injury provided in Article 5 (commencing with Section 4751), in the
fiscal year in which the Controller's receipt is issued.
   (d) The payments to be made to the Department of Industrial
Relations, as required by subdivision (a), shall be paid to the
department in a lump sum in the manner provided in subdivision (b) of
Section 5101.
   (e) The Department of Industrial Relations shall keep a record of
all payments due the state under this section, and shall take any
steps as may be necessary to collect those amounts.
   (f) Each employer, or the employer's insurance carrier, shall
notify the administrative director, in any form as the administrative
director may prescribe, of each employee death, except when the
employer has actual knowledge or notice that the deceased employee
left a surviving dependent.
   (g) When, after a reasonable search, the employer concludes that
the deceased employee left no one surviving who is entitled to a
dependency death benefit, and concludes that the death was under
circumstances that would entitle the employee to compensation
benefits, the employer may voluntarily make the payment referred to
in subdivision (a). Payments so made shall be construed as payments
made pursuant to an appeals board findings and award. Thereafter, if
the appeals board finds that the deceased employee did in fact leave
a person surviving who is entitled to a dependency death benefit,
upon that finding, all payments referred to in subdivision (a) that
have been made shall be forthwith returned to the employer, or if
insured, to the employer's workers' compensation carrier that
indemnified the employer for the loss.
   (h) This section does not apply where there is no surviving person
entitled to a dependency death benefit or accrued and unpaid
compensation if a death benefit is paid to any person under paragraph
(6) of subdivision (a) of Section 4702.



4707.  (a) Except as provided in subdivision (b), no benefits,
except reasonable expenses of burial not exceeding one thousand
dollars ($1,000), shall be awarded under this division on account of
the death of an employee who is an active member of the Public
Employees' Retirement System unless it is determined that a special
death benefit, as defined in the Public Employees' Retirement Law, or
the benefit provided in lieu of the special death benefit in
Sections 21547 and 21548 of the Government Code, will not be paid by
the Public Employees' Retirement System to the surviving spouse or
children under 18 years of age, of the deceased, on account of the
death, but if the total death allowance paid to the surviving spouse
and children is less than the benefit otherwise payable under this
division the surviving spouse and children are entitled, under this
division, to the difference.
   The amendments to this section during the 1977-78 Regular Session
shall be applied retroactively to July 1, 1976.
   (b) The limitation prescribed by subdivision (a) shall not apply
to local safety members, or patrol members, as defined in Section
20390 of the Government Code, of the Public Employees' Retirement
System. This subdivision shall be applied retroactively.



4708.  Upon application of any party in interest for a death benefit
provided by this division on the death of an employee member of the
Public Employees' Retirement System, the latter shall be joined as a
defendant, and the appeals board shall determine whether the death
resulted from injury or illness arising out of and in the course of
his employment, for the purpose of enabling the appeals board to
apply the provision of this division and the board of administration
to apply the provisions of the Public Employees' Retirement Law.



4709.  (a) Notwithstanding any other law, a dependent of a peace
officer, as defined in Section 830.1, 830.2, 830.3, 830.31, 830.32,
830.33, 830.34, 830.35, 830.36, 830.37, 830.38, 830.39, 830.4, 830.5,
or 830.6 of the Penal Code, or a Sheriff's Special Officer of the
County of Orange, who is killed in the performance of duty or who
dies or is totally disabled as a result of an accident or an injury
caused by external violence or physical force, incurred in the
performance of duty, when the death, accident, or injury is
compensable under this division or Division 4.5 (commencing with
Section 6100) shall be entitled to a scholarship at any qualifying
institution described in subdivision (l) of Section 69432.7 of the
Education Code. The scholarship shall be in an amount equal to the
amount provided a student who has been awarded a Cal Grant
scholarship as specified in Chapter 1.7 (commencing with Section
69430) of Part 42 of Division 5 of Title 3 of the Education Code.
   (b) A dependent of an officer or employee of the Department of
Corrections and Rehabilitation or the Department of Corrections and
Rehabilitation, Division of Juvenile Justice, described in Section
20403 of the Government Code who is killed in the performance of
duty, or who dies or is totally disabled as a result of an accident
or an injury incurred in the performance of duty, when the death,
accident, or injury is caused by the direct action of an inmate, and
is compensable under this division or Division 4.5 (commencing with
Section 6100), shall also be entitled to a scholarship specified in
this section.
   (c) Notwithstanding any other law, a dependent of a firefighter
employed by a county, city, city and county, district, or other
political subdivision of the state, who is killed in the performance
of duty or who dies or is totally disabled as a result of an accident
or injury incurred in the performance of duty, when the death,
accident, or injury is compensable under this division or Division
4.5 (commencing with Section 6100), shall also be entitled to a
scholarship specified in this section.
   (d) Nothing in this section shall be interpreted to allow the
admittance of the dependent into a college or university unless the
dependent is otherwise qualified to gain admittance to the college or
university.
   (e) The scholarship provided for by this section shall be paid out
of funds annually appropriated in the Budget Act to the Student Aid
Commission established by Article 2 (commencing with Section 69510)
of Chapter 2 of Part 42 of Division 5 of Title 3 of the Education
Code.
   (f) The receipt of a scholarship provided for by this section
shall not preclude a dependent from receiving a Cal Grant award
pursuant to Chapter 1.7 (commencing with Section 69430) of Part 42 of
Division 5 of Title 3 of the Education Code, any other grant, or any
fee waivers that may be provided by an institution of higher
education. The receipt of a Cal Grant award pursuant to Chapter 1.7
(commencing with Section 69430) of Part 42 of Division 5 of Title 3
of the Education Code, any other grant, or any fee waivers that may
be provided by an institution of higher education shall not preclude
a dependent from receiving a scholarship provided for by this
section.
   (g) As used in this section, "dependent" means the children
(natural or adopted) or spouse, at the time of the death or injury,
of the peace officer, law enforcement officer, or firefighter.
   (h) Eligibility for a scholarship under this section shall be
limited to a person who demonstrates financial need as determined by
the Student Aid Commission pursuant to Article 1.5 (commencing with
Section 69503) of Chapter 2 of Part 42 of Division 5 of Title 3 of
the Education Code. For purposes of determining financial need, the
proceeds of death benefits received by the dependent, including, but
not limited to, a continuation of income received from the Public
Employees' Retirement System, the proceeds from the federal Public
Safety Officers' Benefits Act, life insurance policies, proceeds from
Sections 4702 and 4703.5, any private scholarship where receipt is
predicated upon the recipient being the survivor of a deceased public
safety officer, the scholarship awarded pursuant to Section 68120 of
the Education Code, and any interest received from these benefits,
shall not be considered.

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4720.  As used in this article:
   (a) "Elected public official" means any person other than the
President or Vice President of the United States who holds any
federal, state, local, or special district elective office as a
result of winning election in California to such office or being
appointed to fill a vacancy in such office.
   (b) "Assassination" means the killing of an elected public
official as a direct result of an intentional act perpetrated by an
individual or individuals acting to prevent, or retaliate for, the
performance of official duties, acting because of the public position
held by the official, or acting because of pathological reasons.




4721.  The surviving spouse or dependent minor children of an
elected public official who is killed by assassination shall be
entitled to a special death benefit which shall be in addition to any
other benefits provided for by this division or Division 4.5
(commencing with Section 6100).



4722.  If the deceased elected public official is survived by a
spouse with or without dependent minor children, such special death
benefit shall be payable to the surviving spouse. If the deceased
elected public official leaves no surviving spouse but one or more
dependent minor children, benefits shall be paid to a guardian ad
litem and trustee for such child or children appointed by the Workers'
Compensation Appeals Board. In the absence of a surviving spouse and
dependent minor children, the benefit shall be payable to any
legally recognized dependent parent of the deceased elected public
official.


4723.  The person or persons to whom the special death benefit is
payable pursuant to Section 4722 shall, within one year of the date
of death of the elected public official, choose either of the
following benefits:
   (a) An annual benefit equal to one-half of the average annual
salary paid to the elected public official in his or her elected
capacity, less credit for any other death benefit provided for under
existing law or by public funds, except benefits payable pursuant to
this division or Division 4.5 (commencing with Section 6100).
Payments shall be paid not less frequently than monthly, and shall be
paid from the date of death until the spouse dies or remarries, or
until the youngest minor dependent child reaches the age of 18 years,
whichever occurs last. If payments are being made to a dependent
parent or parents they shall continue during dependency.
   (b) A lump-sum benefit of one hundred fifty thousand dollars
($150,000), less any other death benefit provided for under existing
law or by public funds, except benefits payable pursuant to this
division or Division 4.5 (commencing with Section 6100).




4724.  The person or persons to whom the special death benefit is
payable pursuant to Section 4722 shall file a claim therefor with the
State Board of Control, which shall be processed pursuant to the
provisions of Chapter 3 (commencing with Section 900) of Part 2 of
Division 3.6 of Title 1 of the Government Code.



4725.  The State Compensation Insurance Fund shall be the disbursing
agent for payments made pursuant to this article and shall receive a
fee for its services to be negotiated by the State Board of Control.
Unless otherwise provided herein, payments shall be made in
accordance with the provisions of this division.



4726.  The State Board of Control and the Administrative Director of
the Division of Workers' Compensation shall jointly adopt rules and
regulations as may be necessary to carry out the provisions of this
article.


4727.  Any person who is convicted of any crime in connection with
the assassination of an elected public official shall not be eligible
for any benefits pursuant to this article.



4728.  (a) A dependent of an elected public official, who was
intentionally killed while holding office, in retaliation for, or to
prevent the performance of, an official duty, shall be entitled to a
scholarship at any institution described in subdivision (k) of
Section 69535 of the Education Code. The scholarship shall be in an
amount equal to the amount provided a student who has been awarded a
Cal Grant scholarship as specified in Article 3 (commencing with
Section 69530) of Chapter 2 of Part 42 of the Education Code.
Eligibility for a scholarship under this section shall be limited to
a person who demonstrates financial need as determined by the Student
Aid Commission pursuant to Article 1.5 (commencing with Section
69503) of Chapter 2 of Part 42 of the Education Code.
   (b) The scholarship provided for by this section shall be paid out
of funds annually appropriated in the Budget Act to the Student Aid
Commission established by Article 2 (commencing with Section 69510)
of Chapter 2 of Part 42 of the Education Code.
   (c) The receipt of a scholarship provided for by this section
shall not preclude a dependent from receiving a Cal Grant award
pursuant to Article 3 (commencing with Section 69530) of Chapter 2 of
Part 42 of the Education Code, any other grant, or any fee waivers
that may be provided by an institution of higher education. The
receipt of a Cal Grant award pursuant to Article 3 (commencing with
Section 69530) of Chapter 2 of Part 42 of the Education Code, any
other grant, or any fee waivers that may be provided by an
institution of higher education shall not preclude a dependent from
receiving a scholarship provided for by this section.
   (d) This section shall apply to a student receiving a scholarship
on the effective date of the section unless that application would
result in the student receiving a scholarship on less favorable terms
or in a lesser amount, in which case the student shall continue to
receive the scholarship on the same terms and conditions in effect
prior to the effective date of this section.
   (e) As used in this section, "dependent" means the children
(natural or adopted) or spouse, at the time of the death or injury,
of the elected public official.

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4751.  If an employee who is permanently partially disabled receives
a subsequent compensable injury resulting in additional permanent
partial disability so that the degree of disability caused by the
combination of both disabilities is greater than that which would
have resulted from the subsequent injury alone, and the combined
effect of the last injury and the previous disability or impairment
is a permanent disability equal to 70 percent or more of total, he
shall be paid in addition to the compensation due under this code for
the permanent partial disability caused by the last injury
compensation for the remainder of the combined permanent disability
existing after the last injury as provided in this article; provided,
that either (a) the previous disability or impairment affected a
hand, an arm, a foot, a leg, or an eye, and the permanent disability
resulting from the subsequent injury affects the opposite and
corresponding member, and such latter permanent disability, when
considered alone and without regard to, or adjustment for, the
occupation or age of the employee, is equal to 5 percent or more of
total, or (b) the permanent disability resulting from the subsequent
injury, when considered alone and without regard to or adjustment for
the occupation or the age of the employee, is equal to 35 percent or
more of total.


4753.  Such additional compensation is not in addition to but shall
be reduced to the extent of any monetary payments received by the
employee, from any source whatsoever, for or on account of such
preexisting disability or impairment, except as to payments being
made to the employee or to which he is entitled as a pension or other
compensation for disability incurred in service in the armed forces
of the United States, and except as to payments being made to him or
to which he is entitled as assistance under the provisions of Chapter
2 (commencing with Section 11200), Chapter 3 (commencing with
Section 12000), Chapter 4 (commencing with Section 12500), Chapter 5
(commencing with Section 13000), or Chapter 6 (commencing with
Section 13500) of Part 3, or Part 5 (commencing with Section 17000),
of Division 9 of the Welfare and Institutions Code, and excluding
from such monetary payments received by the employee for or on
account of such preexisting disability or impairment a sum equal to
all sums reasonably and necessarily expended by the employee for or
on account of attorney's fees, costs and expenses incidental to the
recovery of such monetary payments.
   All cases under this section and under Section 4751 shall be
governed by the terms of this section and Section 4751 as in effect
on the date of the particular subsequent injury.



4753.5.  In any hearing, investigation, or proceeding, the state
shall be represented by the Attorney General, or the attorneys of the
Department of Industrial Relations, as appointed by the director.
Expenses incident to representation, including costs for
investigation, medical examinations, other expert reports, fees for
witnesses, and other necessary and proper expenses, but excluding the
salary of any of the Attorney General's deputies, shall be
reimbursed from the Workers' Compensation Administration Revolving
Fund. No witness fees or fees for medical services shall exceed those
fees prescribed by the appeals board for the same services in those
cases where the appeals board, by rule, has prescribed fees.
Reimbursement pursuant to this section shall be in addition to, and
in augmentation of, any other appropriations made or funds available
for the use or support of the legal representation.



4754.  The appeals board shall fix and award the amounts of special
additional compensation to be paid under this article, and shall
direct the State Compensation Insurance Fund to pay the additional
compensation so awarded. Such additional compensation may be paid
only from funds appropriated for such purpose. Out of any such
appropriation the fund may reimburse itself for the cost of service
rendered in payment of compensation awards pursuant to this article
and maintenance of accounts and records pertaining thereto, which
cost shall not exceed 5 percent of the amount of award paid.



4754.5.  Nothing in this article shall impair the right of the
Attorney General or the Department of Industrial Relations to release
by compromise any claims brought under the provisions of this
article. No such compromise and release agreement is valid unless it
is approved by the appeals board; however, the provisions of Sections
5000 to 5004, inclusive, of this code, shall not apply to such
compromise and release agreements.



4755.  (a) The State Compensation Insurance Fund may draw from the
State Treasury out of the Subsequent Injuries Benefits Trust Fund for
the purposes specified in Section 4751, without at the time
presenting vouchers and itemized statements, a sum not to exceed in
the aggregate fifty thousand dollars ($50,000), to be used as a cash
revolving fund. The revolving fund shall be deposited in any banks
and under any conditions as the Department of Finance determines. The
Controller shall draw his or her warrants in favor of the State
Compensation Insurance Fund for the amounts so withdrawn and the
Treasurer shall pay these warrants.
   (b) Expenditures made from the revolving fund in payments on
claims for any additional compensation and for adjusting services are
exempted from the operation of Section 16003 of the Government Code.
Reimbursement of the revolving fund for these expenditures shall be
made upon presentation to the Controller of an abstract or statement
of the expenditures. The abstract or statement shall be in any form
as the Controller requires.
   (c) The director shall assign claims adjustment services and legal
representation services respecting matters concerning subsequent
injuries. The director or his or her representative may make these
service assignments within the department, or he or she may contract
for these services with the State Compensation Insurance Fund, for a
fee in addition to that authorized by Section 4754, except insofar as
these matters might conflict with the interests of the State
Compensation Insurance Fund. The administrative costs associated with
these services shall be reimbursed from the Workers' Compensation
Administration Revolving Fund, except when a budget impasse requires
advances as provided in subdivision (d) of Section 62.5. To the
extent permitted by state law, the director may contract for audits
or reports of services under this section.

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4800.  (a) Whenever any member of the Department of Justice falling
within the "state peace officer/firefighter" class is disabled by
injury arising out of and in the course of his or her duties, he or
she shall become entitled, regardless of his or her period of service
with the Department of Justice to leave of absence while so disabled
without loss of salary, in lieu of disability payments under this
chapter, for a period of not exceeding one year. This section shall
apply only to members of the Department of Justice whose principal
duties consist of active law enforcement and shall not apply to
persons employed in the Department of Justice whose principal duties
are those of telephone operator, clerk, stenographer, machinist,
mechanic or otherwise clearly not falling within the scope of active
law enforcement service, even though this person is subject to
occasional call or is occasionally called upon to perform duties
within the scope of active law enforcement service.
   (b) This section shall apply to law enforcement officers employed
by the Department of Fish and Wildlife who are described in
subdivision (e) of Section 830.2 of the Penal Code.
   (c) This section shall apply to harbor police officers employed by
the San Francisco Port Commission who are described in Section 20402
of the Government Code.
   (d) This section shall not apply to periods of disability which
occur subsequent to termination of employment by resignation,
retirement or dismissal. When this section does not apply, the
employee shall be eligible for those benefits which would apply if
this section had not been enacted.



4800.5.  (a) Whenever any sworn member of the Department of the
California Highway Patrol is disabled by a single injury, excluding
disabilities that are the result of cumulative trauma or cumulative
injuries, arising out of and in the course of his or her duties, he
or she shall become entitled, regardless of his or her period of
service with the patrol, to leave of absence while so disabled
without loss of salary, in lieu of disability payments under this
chapter, for a period of not exceeding one year. This section shall
apply only to members of the Department of the California Highway
Patrol whose principal duties consist of active law enforcement and
shall not apply to persons employed in the Department of the
California Highway Patrol whose principal duties are those of
telephone operator, clerk, stenographer, machinist, mechanic, or
otherwise clearly not falling within the scope of active law
enforcement service, even though this person is subject to occasional
call or is occasionally called upon to perform the duties of active
law enforcement service.
   (b) Benefits payable for eligible sworn members of the Department
of the California Highway Patrol whose disability is solely the
result of cumulative trauma or injury shall be limited to the actual
period of temporary disability or entitlement to maintenance
allowance, or for one year, whichever is less.
   (c) This section shall not apply to periods of disability that
occur subsequent to termination of employment by resignation,
retirement, or dismissal. When this section does not apply, the
employee shall be eligible for those benefits that would apply had
this section not been enacted.
   (d) The appeals board may determine, upon request of any party,
whether or not the disability referred to in this section arose out
of and in the course of duty. In any action in which a dispute exists
regarding the nature of the injury or the period of temporary
disability or entitlement to maintenance allowance, or both, and upon
the request of any party thereto, the appeals board shall determine
when the disability commenced and ceased, and the amount of benefits
provided by this division to which the employee is entitled during
the period of this disability. The appeals board shall have the
jurisdiction to award and enforce payment of these benefits, subject
to subdivision (a) or (b), pursuant to Part 4 (commencing with
Section 5300). A decision issued by the appeals board under this
section is final and binding upon the parties subject to the rights
of appeal contained in Chapter 7 (commencing with Section 5900) of
Part 4.
   (e) Except as provided in subdivision (g), this section shall
apply for periods of disability commencing on or after January 1,
1995.
   (f) This section does not apply to peace officers designated under
subdivision (a) of Section 2250.1 of the Vehicle Code.
   (g) Peace officers of the California State Police Division who
become sworn members of the Department of the California Highway
Patrol as a result of the Governor's Reorganization Plan No. 1 of
1995, other than those officers described in subdivision (f), shall
be eligible for injury benefits accruing to sworn members of the
Department of the California Highway Patrol under this division only
for injuries occurring on or after July 12, 1995.



4801.  It shall be the duty of the appeals board to determine in the
case of members of the California Highway Patrol, upon request of
the Department of the California Highway Patrol or Department of
Justice, and, in the case of the harbor policemen, upon the request
of the San Francisco Port Commission, whether or not the disability
referred to in Section 4800 arose out of and in the course of duty.
The appeals board shall, also, in any disputed case, determine when
such disability ceases.



4802.  Any such member of the California Highway Patrol or
Department of Justice, or any such harbor policeman, so disabled is
entitled from the date of injury and regardless of retirement under
the Public Employees' Retirement System, to the medical, surgical and
hospital benefits prescribed by this division as part of the
compensation for persons injured in the course of and arising out of
their employment, at the expense of the Department of the California
Highway Patrol, the Department of Justice, or the San Francisco Port
Commission, as the case may be, and such expense shall be charged
upon the fund out of which the compensation of the member is paid.




4803.  Whenever such disability of such member of the California
Highway Patrol, or Department of Justice, or of such harbor
policeman, continues for a period beyond one year, such member or
harbor policeman shall thereafter be subject, as to disability
indemnity, to the provisions of this division other than Section
4800, which refers to temporary disability only, during the remainder
of the disability, except that such compensation shall be paid out
of funds available for the support of the Department of the
California Highway Patrol, the Department of Justice, or the San
Francisco Port Commission, as the case may be, and the leave of
absence shall continue.



4804.  No disability indemnity shall be paid to said member of the
California Highway Patrol or harbor policeman as temporary disability
concurrently with wages or salary payments.



4804.1.  Whenever any member of a University of California fire
department specified in Section 3212.4 falling within the active
"firefighting and prevention service" class is disabled by injury
arising out of and in the course of his duties, he shall become
entitled, regardless of his period of service with a University of
California fire department, to leave of absence while so disabled
without loss of salary, in lieu of disability payments under this
chapter, for a period of not exceeding one year. This section shall
apply only to members of a University of California fire department
whose principal duties consist of active firefighting and prevention
service and shall not apply to persons employed in a University of
California fire department whose principal duties are those of
telephone operator, clerk, stenographer, machinist, mechanic, or
otherwise clearly not falling within the scope of active firefighting
and prevention service, even though such person is subject to
occasional call or is occasionally called upon to perform duties
within the scope of active firefighting and prevention service.



4804.2.  It shall be the duty of the appeals board to determine in
the case of members of a University of California fire department
specified in Section 4804. 1, upon request of the Regents of the
University of California, whether or not the disability referred to
in Section 4804.1 arose out of and in the course of duty. The appeals
board shall, also in any disputed case, determine when such
disability ceases.



4804.3.  Any such member of a University of California fire
department specified in Section 4804.1, so disabled is entitled from
the date of injury and regardless of retirement under the Public
Employees' Retirement System, or other retirement system, to the
medical, surgical, and hospital benefits prescribed by this division
as part of the compensation for persons injured in the course of and
arising out of their employment, at the expense of the Regents of the
University of California, and such expense shall be charged upon the
fund out of which the compensation of the member is paid.



4804.4.  Whenever such disability of such member of a University of
California fire department, specified in Section 4804.1, continues
for a period beyond one year, such member shall thereafter be
subject, as to disability indemnity, to the provisions of this
division other than Section 4804.1, which refers to temporary
disability only, during the remainder of the disability, except that
such compensation shall be paid out of funds available for the
support of the Regents of the University of California, and the leave
of absence shall continue.


4804.5.  No disability indemnity shall be paid to said member of a
University of California fire department, specified in Section
4804.1, as temporary disability concurrently with wages or salary
payments.


4806.  Whenever any member of the University of California Police
Department falling within the "law enforcement" class is disabled by
injury arising out of and in the course of his duties, he shall
become entitled, regardless of his period of service with the police
department, to leave of absence while so disabled without loss of
salary, in lieu of disability payments under this chapter, for a
period of not exceeding one year. This section shall apply only to
members of the University of California Police Department whose
principal duties consist of active law enforcement, and shall not
apply to persons employed in the University of California Police
Department whose principal duties are those of telephone operator,
clerk, stenographer, machinist, mechanic or otherwise clearly not
falling within the scope of active law enforcement service, even
though such person is subject to occasional call or is occasionally
called upon to perform duties within the scope of active law
enforcement service.
   This section shall apply only to those members of the University
of California Police Department specified in Section 3213.




4807.  It shall be the duty of the appeals board to determine, in
the case of members of the University of California Police
Department, upon the request of the Regents of the University of
California, whether or not the disability referred to in Section 4806
arose out of and in the course of duty. The appeals board shall,
also in any disputed case, determine when such disability ceases.



4808.  Any such member of the University of California Police
Department so disabled is entitled from the date of injury, and
regardless of retirement under either the University of California
Retirement System or Public Employees' Retirement System, to the
medical, surgical, and hospital benefits prescribed by this division
as part of the compensation for persons injured in the course of and
arising out of their employment, at the expense of the Regents of the
University of California, and such expense shall be charged upon the
fund out of which the compensation of the member is paid.



4809.  Whenever such disability of such member of the University of
California Police Department continues for a period beyond one year,
such member shall thereafter be subject, as to disability indemnity,
to the provisions of this division other than Section 4806, which
refers to temporary disability only, during the remainder of the
disability, except that such compensation shall be paid out of funds
available for the support of the Regents of the University of
California and the leave of absence shall continue.



4810.  No disability indemnity shall be paid to such member of the
University of California Police Department as temporary disability
concurrently with wages or salary payments.



4816.  Pursuant to a collective bargaining agreement applicable to
members of the California State University Police Department,
whenever any member of that police department falling within the "law
enforcement" class is disabled by injury or illness arising out of
and in the course of his or her duties, he or she shall become
entitled, regardless of his or her period of service with the police
department, to enhanced industrial disability leave equivalent to the
injured employee's net take home salary on the date of occurrence of
the injury. For the purposes of this section, "net take home salary"
means the amount of salary received after federal income tax, state
income tax, and the employee's retirement contribution has been
deducted from the employee's gross salary, in lieu of disability
payments under this chapter, for a period of not exceeding one year.
No benefits shall be paid under this section for any psychiatric
disability or any physical disability arising from a psychiatric
injury.
   This section shall apply only to members of the California State
University Police Department whose principal duties consist of active
law enforcement, and shall not apply to persons employed in the
California State University Police Department whose principal duties
are those of telephone operator, clerk, stenographer, machinist,
mechanic, or otherwise clearly not falling within the scope of active
law enforcement service, even though the person is subject to
occasional call or is occasionally called upon to perform duties
within the scope of active law enforcement service.



4817.  It shall be the duty of the appeals board to determine, in
the case of members of the California State University Police
Department, upon the request of the Board of Trustees of the
California State University, whether or not the disability referred
to in Section 4816 arose out of and in the course of duty. The
appeals board shall, also in any disputed case, determine when such
disability ceases.



4819.  Whenever the disability of a member of the California State
University Police Department continues for a period beyond one year,
that member shall thereafter be subject, as to disability indemnity,
to the provisions of this division other than Section 4816, which
refers to temporary disability only, during the remainder of the
disability.



4820.  No disability indemnity shall be paid to a member of the
California State University Police Department as temporary disability
concurrently with wages or salary payments.

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4850.  (a) Whenever any person listed in subdivision (b), who is
employed on a regular, full-time basis, and is disabled, whether
temporarily or permanently, by injury or illness arising out of and
in the course of his or her duties, he or she shall become entitled,
regardless of his or her period of service with the city, county, or
district, to a leave of absence while so disabled without loss of
salary in lieu of temporary disability payments or maintenance
allowance payments under Section 139.5, if any, that would be payable
under this chapter, for the period of the disability, but not
exceeding one year, or until that earlier date as he or she is
retired on permanent disability pension, and is actually receiving
disability pension payments, or advanced disability pension payments
pursuant to Section 4850.3.
   (b) The persons eligible under subdivision (a) include all of the
following:
   (1) City police officers.
   (2) City, county, or district firefighters.
   (3) Sheriffs.
   (4) Officers or employees of any sheriff's offices.
   (5) Inspectors, investigators, detectives, or personnel with
comparable titles in any district attorney's office.
   (6) County probation officers, group counselors, or juvenile
services officers.
   (7) Officers or employees of a probation office.
   (8) Peace officers under Section 830.31 of the Penal Code employed
on a regular, full-time basis by a county of the first class.
   (9) Lifeguards employed year round on a regular, full-time basis
by a county of the first class.
   (10) Airport law enforcement officers under subdivision (d) of
Section 830.33 of the Penal Code.
   (11) Harbor or port police officers, wardens, or special officers
of a harbor or port district or city or county harbor department
under subdivision (a) of Section 830.1 or subdivision (b) of Section
830.33 of the Penal Code.
   (12) Police officers of the Los Angeles Unified School District.
   (c) This section shall apply only to persons listed in subdivision
(b) who meet the requirements of subdivision (a), and shall not
include any of the following:
   (1) Employees of a police department whose principal duties are
those of a telephone operator, clerk, stenographer, machinist,
mechanic, or otherwise, and whose functions do not clearly fall
within the scope of active law enforcement service.
   (2) Employees of a county sheriff's office whose principal duties
are those of a telephone operator, clerk, stenographer, machinist,
mechanic, or otherwise, and whose functions do not clearly come
within the scope of active law enforcement service.
   (3) Employees of a county probation office whose principal duties
are those of a telephone operator, clerk, stenographer, machinist,
mechanic, or otherwise, and whose functions do not clearly come
within the scope of active law enforcement service.
   (4) Employees of a city fire department, county fire department,
or fire district whose principal duties are those of a telephone
operator, clerk, stenographer, machinist, mechanic, or otherwise, and
whose functions do not clearly fall within the scope of active
firefighting and prevention service.
   (d) If the employer is insured, the payments that, except for this
section, the insurer would be obligated to make as disability
indemnity to the injured, the insurer may pay to the insured.
   (e) No leave of absence taken pursuant to this section by a peace
officer, as defined by Chapter 4.5 (commencing with Section 830) of
Title 3 of Part 2 of the Penal Code, or by a city, county, or
district firefighter, shall be deemed to constitute family care and
medical leave, as defined in Section 12945.2 of the Government Code,
or to reduce the time authorized for family care and medical leave by
Section 12945.2 of the Government Code.
   (f) This section shall not apply to any persons described in
paragraph (1) or (2) of subdivision (b) who are employees of the City
and County of San Francisco.
   (g) Amendments to subdivision (f) made by the act adding this
subdivision shall be applied retroactively to January 1, 2010.




4850.3.  A city, county, special district, or harbor district that
is a member of the Public Employees' Retirement System, is subject to
the County Employees Retirement Law of 1937, or is subject to the
Los Angeles City Employees' Retirement System, may make advanced
disability pension payments to any local safety officer who has
qualified for benefits under Section 4850 and is approved for a
disability allowance. The payments shall be no less than 50 percent
of the estimated highest average annual compensation earnable by the
local safety officer during the three consecutive years of employment
immediately preceding the effective date of his or her disability
retirement, unless the local safety officer chooses an optional
settlement in the permanent disability retirement application process
which would reduce the pension allowance below 50 percent. In the
case where the local safety officer's choice lowers the disability
pension allowance below 50 percent of average annual compensation as
calculated, the advanced pension payments shall be set at an amount
equal to the disability pension allowance. If a local agency has an
adopted policy of paying for any accumulated sick leave after the
safety officer is eligible for a disability allowance, the advanced
disability pension payments under this section may only be made when
the local safety officer has exhausted all sick leave payments.
Advanced disability pension payments shall not be considered a salary
under this or any other provision of law. All advanced disability
pension payments made by a local agency with membership in the Public
Employees' Retirement System shall be reimbursed by the Public
Employees' Retirement System pursuant to Section 21293.1 of the
Government Code.


4850.4.  (a) A city, county, special district, or harbor district
that is a member of the Public Employees' Retirement System, is
subject to the County Employees Retirement Law of 1937, or is subject
to the Los Angeles City Employees' Retirement Systems, shall make
advanced disability pension payments in accordance with Section
4850.3 unless any of the following is applicable:
   (1) After an examination of the employee by a physician, the
physician determines that there is no discernable injury to, or
illness of, the employee.
   (2) The employee was incontrovertibly outside the course of his or
her employment duties when the injury occurred.
   (3) There is proof of fraud associated with the filing of the
employee's claim.
   (b) Any employer described in subdivision (a) who is required to
make advanced disability pension payments, shall make the payments
commencing no later than 30 days from the date of issuance of the
last disbursed of the following:
   (1) The employee's last regular payment of wages or salary.
   (2) The employee's last payment of benefits under Section 4850.
   (3) The employee's last payment for sick leave.
   (c) The advanced disability payments shall continue until the
claimant is approved or disapproved for a disability allowance
pursuant to final adjudication as provided by law.
   (d) An employer described in subdivision (a) shall be required to
make advanced disability pension payments only if the employee does
all of the following:
   (1) Files an application for disability retirement at least 60
days prior to the payment of benefits pursuant to subdivision (a).
   (2) Fully cooperates in providing the employer with medical
information and in attending all statutorily required medical
examinations and evaluations set by the employer.
   (3) Fully cooperates with the evaluation process established by
the retirement plan.
   (e) The 30-day period for the commencement of payments pursuant to
subdivision (b) shall be tolled by whatever period of time is
directly related to the employee's failure to comply with the
provisions of subdivision (d).
   (f) After final adjudication, if an employee's disability
application is denied, the local agency and the employee shall
arrange for the employee to repay any advanced disability pension
payments received by the employee pursuant to this subdivision. The
repayment plan shall take into account the employee's ability to
repay the advanced disability payments received. Absent an agreement
on repayment, the matter shall be submitted for a local agency
administrative appeals remedy that includes an independent level of
resolution to determine a reasonable repayment plan. If repayment is
not made according to the repayment plan, the local agency may take
reasonable steps, including litigation, to recover the payments
advanced.


4850.5.  Any firefighter employed by the County of San Luis Obispo,
and the sheriff or any officer or employee of the sheriff's office of
the County of San Luis Obispo, and any county probation officer,
group counselor, or juvenile services officer, or any officer or
employee of a probation office, employed by the County of San Luis
Obispo, shall, upon the adoption of a resolution of the board of
supervisors so declaring, be entitled to the benefits of this
article, if otherwise entitled to these benefits, even though the
employee is not a member of the Public Employees' Retirement System
or subject to the County Employees Retirement Law of 1937 (Chapter 3
(commencing with Section 31450) of Part 3 of Division 4 of Title 3 of
the Government Code).



4850.7.  (a) Any firefighter employed by a dependent or independent
fire district may be entitled to the benefits of this article, if
otherwise entitled to these benefits, even though the employee is not
a member of the Public Employees' Retirement System or subject to
the County Employees Retirement Law of 1937 (Chapter 3 (commencing
with Section 31450) of Part 3 of Division 4 of Title 3 of the
Government Code).
   (b) The issue of whether the firefighters employed by a fire
district are entitled to the benefits of this article is subject to
Article 10 (commencing with Section 3500) of Chapter 3 of Division 4
of Title 1 of the Government Code.
   (c) If the governing body of the district agrees that the benefits
shall apply, it shall adopt a resolution to that effect.



4851.  The governing body of any city, county, or city and county,
in addition to anyone else properly entitled, including the Public
Employees' Retirement System, may request the appeals board to
determine in any case, and the appeals board shall determine, whether
or not the disability referred to in Section 4850 arose out of and
in the course of duty. The appeals board shall also, in any disputed
case, determine when the disability commenced and ceased, and the
amount of benefits provided by this division to which the employee is
entitled during the period of the disability. The appeals board
shall have jurisdiction to award and enforce payment of these
benefits pursuant to Part 4 (commencing with Section 5300).




4852.  The provisions of this article do not diminish or affect the
right of any such officer or employee to the medical, surgical, and
hospital benefits prescribed by this division.



4853.  Whenever such disability of any such officer or employee
continues for a period beyond one year, such member shall thereafter
be subject as to disability indemnity to the provisions of this
division other than Section 4850 during the remainder of the period
of said disability or until the effective date of his retirement
under the Public Employees' Retirement Act, and the leave of absence
shall continue.



4854.  No disability indemnity shall be paid to any such officer or
employee concurrently with wages or salary payments.



4855.  This article shall not be applicable to individuals who are
appointed as reserve public safety employees and are deemed to be
employees of a county, city, town or district for workmen's
compensation purposes pursuant to Section 3362.




4856.  (a) Whenever any local employee who is a firefighter, or
peace officer as described in Chapter 4.5 (commencing with Section
830) of Title 3 of Part 2 of the Penal Code, or a Sheriff's Special
Officer of the County of Orange, is killed in the performance of his
or her duty or dies as a result of an accident or injury caused by
external violence or physical force incurred in the performance of
his or her duty, the employer shall continue providing health
benefits to the deceased employee's spouse under the same terms and
conditions provided prior to the death, or prior to the accident or
injury that caused the death, of the employee unless the surviving
spouse elects to receive a lump-sum survivors benefit in lieu of
monthly benefits. Minor dependents shall continue to receive benefits
under the coverage provided the surviving spouse or, if there is no
surviving spouse, until the age of 21 years. However, pursuant to
Section 22822 of the Government Code, the surviving spouse may not
add the new spouse or stepchildren as family members under the
continued health benefits coverage of the surviving spouse.
   (b) Subdivision (a) also applies to the employer of any local
employee who is a firefighter, or peace officer as described in
Chapter 4.5 (commencing with Section 830) of Title 3 of Part 2 of the
Penal Code, who was killed in the performance of his or her duty or
who died as a result of an accident or injury caused by external
violence or physical force incurred in the performance of his or her
duty prior to September 30, 1996.