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DWC 15th Annual Educational Conference
Los Angeles Sheraton February 28-29, 2008 Oakland Marriot March 3-4, 2008
QME Update
Presenters
Sue Honor-Vangerov
QM
E R
egul
atio
ns U
pdat
eD
WC
Edu
catio
nal C
onfe
renc
e 20
08
Suz
anne
Hon
or
Wor
kers
’Com
pens
atio
n M
anag
er, D
WC
Med
ical
Uni
t
Suz
anne
Mar
riaIn
dust
rial R
elat
ions
Cou
nsel
III,
DW
C L
egal
Uni
t
QM
E R
egul
atio
n R
ulem
akin
g•
Sta
rted
Nov
embe
r 200
7•
Cov
ers
all Q
ME
regu
latio
ns a
nd fo
rms
(§§
1 –
159,
Titl
e 8
Cal
iforn
ia C
ode
of R
egul
atio
ns [8
CC
R]
•H
ad 4
5 da
y pu
blic
com
men
t per
iod
and
publ
ic h
earin
gs•
DW
C is
revi
ewin
g th
e co
mm
ents
now
•W
ill p
ublic
ly re
leas
e an
d po
st re
visi
ons
for a
dditi
onal
15
day
publ
ic w
ritte
n co
mm
ent p
erio
d•
Pro
pose
d re
gula
tions
at
http
://w
ww
.dir.
ca.g
ov/d
wc/
DW
CP
ropR
egs/
qme_
regu
latio
ns/q
me_
regu
latio
ns.h
tm•
Ann
ounc
emen
ts o
f pub
lic c
omm
ent p
erio
ds a
t ht
tp://
ww
w.d
ir.ca
.gov
/dw
c/dw
cRul
emak
ing.
htm
Hig
hlig
hts
of W
hat’s
New
•S
ome,
not
all
chan
ges
•D
efin
ition
s•
Pan
el P
roce
ss a
nd P
anel
Req
uest
For
ms
•Q
ME
Spe
cifie
d Fi
nanc
ial I
nter
ests
•Q
ME
Con
flict
s of
Inte
rest
dis
clos
ure
•G
roun
ds fo
r Rep
laci
ng a
Pan
el Q
ME
•Q
ME
Min
imum
Ava
ilabi
lity
for P
anel
s•
Lim
it on
QM
E o
ffice
loca
tions
list
ed w
ith
DW
C
Sco
pe o
f Reg
ulat
ion
Cha
nges
•U
pdat
e pe
r ref
orm
s by
SB
228
/AB
227
& S
B 8
99–
Aut
horit
y fo
r QM
Es
trans
ferre
d to
A.D
.–
Cha
nges
to L
C 4
060,
406
1 an
d 40
62•
Whe
n em
ploy
er m
ay re
ques
t QM
E p
anel
in u
nrep
rese
nted
cas
e(L
C 4
062.
1(b)
; LC
406
0(d)
)–
LC 4
062.
1 –
QM
E p
anel
pro
cess
for u
nrep
rese
nted
Inju
red
Wor
ker
(IW)
–LC
406
2.2
–A
ME
or Q
ME
pan
el p
roce
ss fo
r rep
rese
nted
cas
es w
ith
date
of i
njur
y (D
OI)
on/a
fter 1
/1/2
005
–LC
406
2.3
-Inf
orm
atio
n ex
chan
ge: E
x pa
rte c
omm
unic
atio
n w
ith
AM
E o
r QM
E–
Sec
tion
47 o
f SB
899
–m
ade
chan
ges
in S
B 8
99 a
pply
‘p
rosp
ectiv
ely’
from
4/1
9/04
to a
ll ca
ses
‘rega
rdle
ss o
f the
dat
e of
in
jury
, unl
ess
othe
rwis
e sp
ecifi
ed…
’•
Upd
ate
to c
onfo
rm to
cas
e la
w fr
om W
CA
B a
nd c
ourts
–P
rece
dent
val
ue:
–C
A S
upre
me
Cou
rt>C
ourt
of A
ppea
l>W
CA
B e
n ba
nc >
Sig
nific
ant
Pan
el d
ecis
ions
>WC
AB
pan
el d
ecis
ion
–W
CA
B e
n ba
nc d
ecis
ion
are
bind
ing
on a
ll W
CA
B p
anel
s an
d W
CA
LJs
(Sim
mon
s v.
WC
AB
)
New
or C
hang
ed D
efin
ition
s P
ropo
sed
•A
OE/
CO
E(§
1(f))
–Fo
r pur
pose
s of
QM
E re
gula
tions
and
form
s–
Dis
pute
ove
r com
pens
abili
ty n
eedi
ng m
edic
al o
pini
on–
See
sec
tion
30(d
) and
pan
el re
ques
t for
ms
in s
ectio
ns 1
05
and
106
•C
laim
s ad
min
istr
ator
(§1(
j))–
Add
s U
EB
TF a
fter p
rope
r ser
vice
and
join
der
•Em
ploy
er(§
1(r)
)–
Add
s in
sure
d em
ploy
er, s
elf i
nsur
ed e
mpl
oyer
, law
fully
un
insu
red
empl
oyer
to U
EB
TF a
fter p
rope
r ser
vice
and
jo
inde
r
Def
initi
ons
–co
nt.
•Fo
llow
up
and
Supp
lem
enta
lcom
preh
ensi
ve
med
ical
/lega
l rep
orts
–Fo
llow
Up
(§1(
t)):
in-p
erso
n ex
amin
atio
n –
Sup
plem
enta
l (§
1(ee
)):
only
revi
ew o
f med
ical
test
re
sults
or r
ecor
ds
•Sp
ecifi
ed F
inan
cial
Inte
rest
(§1(
dd))
diff
eren
t tha
n ‘S
igni
fican
t Fin
anci
al In
tere
st o
r Affi
liatio
n H
eld
by
Facu
lty’
(§1
(cc)
) of c
ontin
uing
edu
catio
n pr
ovid
er•
Prim
ary
prac
tice
loca
tion
(§1
(x))
•A
CO
EM, A
MA
Gui
des,
Med
ical
Tre
atm
ent U
tiliz
atio
n Sc
hedu
le (M
TUS)
all d
efin
ed•
QM
E C
ompe
tenc
y Ex
am fo
r Acu
punc
turis
ts –
see
§§
1(aa
) and
11(
f)
QM
E P
anel
Pro
cess
Thro
ugh
the
Look
ing
Gla
ss•
Whe
n C
an Y
ou R
eque
st a
Pan
el?
•W
ho C
an R
eque
st a
Pan
el?
•W
hich
Tra
ck –
Rep
rese
nted
or
Unr
epre
sent
ed?
•W
hat D
o Y
ou S
end
the
Med
ical
Uni
t?•
Why
the
Med
ical
Uni
t Ask
s fo
r Mor
e In
fo?
•R
epla
cem
ent Q
ME
sor
QM
E P
anel
s•
Late
Rep
orts
Whe
n C
an a
QM
E P
anel
Be
Req
uest
ed?
•Fo
r com
pens
abili
tydu
ring
90 d
ay p
erio
d af
ter
clai
m fo
rm fi
led
(e.g
. bef
ore
clai
mde
nied
)–
Rep
rese
nted
IW c
ase
Mus
t fol
low
AM
E/Q
ME
pro
cess
in L
C 4
062.
2 (L
C
4060
(c))
–U
nrep
rese
nted
IW c
ase
Mus
t fol
low
LC
406
0(d)
and
406
2.1
•E
mpl
oyer
/cla
ims
adm
inis
trato
r mus
t not
ify
unre
pres
ente
d in
jure
d w
orke
r eith
er:
–E
mpl
oyer
is re
ques
ting
an e
valu
atio
n to
det
erm
ine
com
pens
abili
ty, o
r–
Em
ploy
er h
as n
ot a
ccep
ted
liabi
lity
and
the
IW e
mpl
oyee
m
ay re
ques
t a Q
ME
pan
el to
det
erm
ine
com
pens
abili
ty•
Obt
ain
QM
E p
anel
onl
y th
roug
h pr
oces
s in
LC
40
62.1
•A
ftera
dis
pute
exi
sts
–D
ispu
te o
n m
edic
al tr
eatm
ent o
pini
ons
by
PTP
(LC
406
2) o
r dis
pute
per
man
ent
impa
irmen
t or d
isab
ility
opi
nion
(LC
406
1)–
Inju
red
wor
ker m
ay d
ispu
te U
R d
enia
l, de
lay
or m
odifi
catio
n (L
C 4
062)
–If
any
body
par
t acc
epte
d, L
C 4
060
does
not
ap
ply
(see
, LC
406
0(a)
). T
here
fore
onc
e em
ploy
er/c
laim
s ad
min
istra
tor a
ccep
ts a
ny
part
of c
laim
Whe
n C
an a
QM
E P
anel
Be
Req
uest
ed –
cont
.?
Who
Can
Req
uest
a P
anel
? •
Inju
red
Wor
ker:
–A
fter t
he e
mpl
oyer
/cla
ims
adm
inis
trato
r de
nies
the
clai
men
tirel
y du
ring
the
first
90
days
(LC
406
0)–
Afte
r IW
mak
es ti
mel
y ob
ject
ion
to U
R
deci
sion
that
del
ays,
mod
ifies
or d
enie
s tre
atm
ent (
LC 4
062(
a))
–A
fter I
W m
akes
tim
ely
obje
ctio
n to
em
ploy
er/c
laim
s ad
min
istra
tor’s
not
ice
rega
rdin
g pe
rman
ent i
mpa
irmen
t or d
isab
ility
(L
C 4
061)
–W
hen
empl
oyer
/cla
ims
adm
inis
trato
r pro
vide
s th
e Q
ME
pan
el re
ques
t for
m w
ith a
requ
est t
o fil
e th
e fo
rm w
ithin
10
days
of r
ecei
pt d
ue to
em
ploy
er/c
laim
adm
inis
trato
r’s ti
mel
y
Who
Can
Req
uest
a P
anel
–co
nt.?
•E
mpl
oyer
/cla
ims
adm
inis
trato
r:–
Unr
epre
sent
ed IW
cas
e: O
nly
afte
r gi
ving
IW p
rope
r and
tim
ely
notic
es o
f na
ture
of o
bjec
tion/
disp
ute;
pro
vide
IW
with
a Q
ME
requ
est f
orm
, ins
truct
ions
an
d a
requ
est t
o fil
e it
with
the
Med
ical
U
nit w
ithin
10
days
; and
at l
east
10
days
ha
ve p
asse
d si
nce
it w
as fu
rnis
hed
to IW
(L
C 4
062.
1(b)
)–
Rep
rese
nted
cas
e [D
OI p
ost 1
/1/0
5]:
Onl
y af
ter c
ompl
ying
with
LC
406
2.2
AM
E/Q
ME
dan
ce re
quire
men
ts
Pan
el P
roce
ss –
Rep
rese
nted
IW•
DO
I on/
afte
r 1/1
/200
5:–
LC 4
062.
2 pr
oces
s–
Agr
ee o
n A
ME
per
LC
, or
–R
ace
to g
et p
anel
QM
E•
Med
ical
Uni
t will
pro
cess
firs
t com
plet
e an
d pr
oper
re
ques
t rec
eive
d (L
C 4
062.
2)•
Pro
pose
d §
31.1
: If
two
rece
ived
on
the
sam
e da
y re
ques
ting
diffe
rent
spe
cial
ties
in s
ame
case
, Med
ical
D
irect
or w
ill u
se s
ame
spec
ialty
as
treat
ing
phys
icia
n un
less
:–
Per
suad
ed b
y pa
rty e
vide
nce
supp
ortin
g re
ques
ted
spec
ialty
–N
eith
er p
arty
requ
ests
sam
e sp
ecia
lty a
s P
TP a
nd
Med
ical
Dire
ctor
det
erm
ines
ano
ther
spe
cial
ty
mor
e ap
prop
riate
•D
OI 1
/1/1
994
to 1
2/31
/04:
–E
ach
party
sel
ects
ow
n Q
ME
for a
ll di
sput
ed
inju
ries
(Sim
i v. S
ave-
Max
Foo
ds, I
nc. (
2005
) 70
Cal
. Cas
es 2
17
en b
anc)
–C
an’t
use
LC 4
050
or 4
064
to c
ircum
vent
LC
40
62.2
pro
cess
(N
unez
v. W
CA
B(2
006)
136
Cal
. App
. 4th
584,
71
Cal
. Com
p. C
as16
1; C
orte
z v.
WC
AB
(200
6) 1
36 C
al. A
pp. 4
th59
6, 7
1 C
al. C
omp.
C
as15
5; W
ard
v. C
ity o
f Des
ert H
ot S
prin
gs (2
006)
71
Cal
. Com
p.
Cas
1313
(sig
nific
ant p
anel
dec
isio
n))
–G
ener
ally
one
QM
E fo
r all
med
ical
issu
es, b
ut
appl
ican
t ent
itled
to a
s m
any
repo
rts a
s de
fens
e(G
ubbi
nsv
WC
AB
(199
7) 6
2 C
al. C
omp.
Cas
946)
•W
indo
w P
erio
d D
OI 1
/1/9
1 –
12/3
1/93
:–
Eac
h pa
rty s
elec
ts o
wn
QM
E fo
r eac
h ne
eded
Pan
el P
roce
ss –
Rep
rese
nted
IW co
nt.
Pan
el P
roce
ss –
Unr
epre
sent
ed IW
•A
ll D
OIs
•In
jure
d w
orke
r (IW
) mus
t:–
Sig
n pa
nel r
eque
st fo
rm;
–S
elec
t spe
cial
ty fo
r QM
E p
anel
; and
–S
elec
t a Q
ME
from
the
pane
l iss
ued
–S
ched
ule
an a
ppoi
ntm
ent w
ith Q
ME
•E
xcep
tem
ploy
er/c
laim
s ad
min
istra
tor m
ay re
ques
t pan
el
and
spec
ify s
peci
alty
:–
If em
ploy
er s
ent t
he IW
the
pane
l req
uest
form
(For
m 1
05 a
nd
Atta
chm
ent t
o 10
5), a
nd–
10 c
alen
dar d
ays
have
pas
sed
–IW
faile
d to
sen
d pa
nel r
eque
st to
Med
ical
Uni
t (LC
406
2.1(
b))
•A
lso
Em
ploy
er m
ay s
elec
t QM
E fr
om p
anel
list
–If
IW fa
ils to
sel
ect Q
ME
from
pan
el a
nd in
form
em
ploy
er o
f se
lect
ion
with
in 1
0 da
ys o
f iss
uanc
e of
QM
E p
anel
(LC
406
2.1(
c))
Unr
epre
sent
ed →
Rep
rese
nted
–If
unre
pres
ente
d IW
‘rec
eive
d’a
QM
E
eval
uatio
n an
d la
ter b
ecam
e re
pres
ente
d, n
ot e
ntitl
ed to
ano
ther
ev
alua
tion
(LC
406
2.1(
e); L
C
4062
.2(e
)).–
How
ever
, IW
has
“rec
eive
d”ev
alua
tion
only
afte
r IW
atte
nds
and
parti
cipa
tes
in
eval
uatio
n.(R
omer
o v.
Cos
tco
(200
7) 7
2 C
al. C
omp.
Cas
es
824)
Pan
el P
roce
ss
Wha
t to
Sen
d M
edic
al U
nit-
Rep
rese
nted
Cas
e•
Rep
rese
nted
DO
I on/
afte
r 1/1
/200
5–
Doc
umen
t sho
win
g w
hat i
s in
dis
pute
that
nee
ds m
edic
al o
pini
on to
re
solv
e
(LC
406
2.2(
a))
–W
ritte
nof
fer t
o ot
her p
arty
of A
ME
nam
ing
at le
ast o
ne p
hysi
cian
(LC
406
2.2(
b))
–N
o so
oner
than
10
days
afte
r the
firs
t writ
ten
AM
E pr
opos
al:
•Q
ME
pan
el re
ques
t for
m 1
06•
Form
com
plet
ed a
nd s
igne
d•
Iden
tify
date
of i
njur
y-
Sta
te Q
ME
spe
cial
ty re
ques
ted,
spe
cial
ty o
f tre
atin
g ph
ysic
ian
and
spec
ialty
pre
ferr
ed b
y ot
her p
arty
, if k
now
n (L
C 4
062.
2(b)
-P
roof
of S
ervi
ce o
n ot
her p
arty
-C
anno
t req
uest
QM
E pa
nel i
f is
obje
ctio
n to
spin
al s
urge
ry-
Par
ties
mus
t use
spi
nal s
urge
ry s
econ
d op
inio
n pr
oces
s un
der L
C
4062
(b) a
nd 8
CC
R §
§97
88.0
1 to
978
8.91
Pan
el P
roce
ssW
hat t
o S
end
Med
ical
Uni
t -U
nrep
rese
nted
C
ase
•R
eque
st fr
om IW
–Q
ME
pan
el re
ques
t for
m 1
05•
Form
com
plet
ed; d
ate
of in
jury
sta
ted
•S
igne
dby
IW
•R
eque
st fr
om e
mpl
oyer
/cla
ims
adm
inis
trat
or–
QM
E p
anel
requ
est f
orm
105
•Fo
rm c
ompl
eted
; dat
e of
inju
ry s
tate
d•
Sig
ned
by C
A–
Doc
umen
t sho
win
g tim
ely
obje
ctio
n by
CA
•In
jure
d w
orke
r (IW
) obj
ectio
n to
UR
dec
isio
n m
odify
ing,
del
ayin
gor
de
nyin
g m
edic
al tr
eatm
ent r
ecom
men
ded
by P
TP (L
C 4
062(
a))
–C
opy
of p
rope
r not
ices
to IW
abo
ut ri
ght t
o re
ques
t QM
E p
anel
, to
sele
ct
QM
E p
anel
spe
cial
ty, r
eque
st IW
to s
ubm
it th
e fo
rm a
nd ti
me
limit
for
send
ing
QM
E p
anel
form
to M
edic
al U
nit
•Po
stm
ark
mor
e th
an 1
0 da
ys a
fter f
orm
furn
ishe
d to
IW
Whe
n th
e M
edic
al U
nit A
sks
for
Info
rmat
ion
•R
easo
ns: i
ncom
plet
e in
form
atio
n fil
ed w
ith p
anel
re
ques
t•
Med
ical
Uni
t dat
abas
e sh
ows
a Q
ME
pan
el
alre
ady
was
issu
ed fo
r thi
s in
jure
d w
orke
r–
MU
nee
ds to
find
out
if p
anel
was
use
d an
d Q
ME
re
port
alre
ady
was
issu
ed o
n di
sput
ed is
sue
–LC
406
2.3(
i)–
LC 4
062.
3(j)
•E
xam
ples
–S
ame
inju
red
wor
ker;
diffe
rent
par
ties
–S
ame
inju
red
wor
ker;
diffe
rent
bod
y pa
rt–
Sam
e in
jure
d w
orke
r; di
ffere
nt d
ate
of in
jury
Pro
blem
Are
as
•S
pina
l Sur
gery
dis
pute
s•
MP
N d
ispu
tes
•U
R a
nd C
ausa
tion
Dis
pute
s•
Oth
er p
robl
ems
with
PTP
Spi
nal S
urge
ry d
ispu
tes
•V
ery
shor
t tim
elin
es to
obj
ect t
o P
TP re
com
men
datio
n fo
r sp
inal
sur
gery
und
er L
C 4
062(
b) a
nd p
roce
dure
s in
8 C
CR
§§
9788
.01
–97
88.9
1•
10 c
alen
dar d
ays
of re
ceip
t of P
TP re
port
reco
mm
endi
ng
spin
al s
urge
ry (L
C 4
062(
b))
•Fi
le D
WC
For
m 2
33 (8
CC
R §
9788
.1(a
))•
Em
ploy
er’s
opt
ions
, per
WC
AB
, whe
n P
TP re
com
men
ds
spin
al s
urge
ry:
–A
utho
rize
the
surg
ery;
or
–O
bjec
t und
er L
C 4
062
and
file
DW
C F
or 2
33 w
ith th
e M
edic
al U
nit
with
in 1
0 da
ys o
f rec
eipt
of t
he d
octo
r’s re
com
men
datio
n; o
r–
Sen
d th
e re
com
men
ded
treat
men
t thr
ough
util
izat
ion
revi
ew (U
R);
or–
Sim
ulta
neou
sly,
obj
ect u
nder
LC
406
2 by
filin
g D
WC
233
and
sen
d th
e re
com
men
datio
n th
roug
h U
R, o
r if s
till t
imel
y af
ter r
ecei
ve U
R
deni
al, t
hen
obje
ct a
nd fi
le D
WC
233
–B
rash
er v
. Nat
ionw
ide
Stu
dio
Fund
(200
6) 7
1 C
al. C
omp.
Cas
1282
(s
igni
fican
t pan
el d
ecis
ion)
•C
anno
task
for Q
ME
pan
el
MP
N D
ispu
tes
IW in
MP
N d
ispu
tes
PTP
opi
nion
on
diag
nosi
s or
tre
atm
ent:
•IW
mus
t sel
ect 2
ndop
inio
n fro
m a
phy
sici
an in
th
e M
PN
and
, if n
eede
d, a
3rd
opin
ion,
then
if IW
st
ill o
bjec
ts, r
eque
st in
depe
nden
t med
ical
revi
ew
(IMR
) (s
ee, 8
CC
R §
§97
67.7
, 976
8.9)
•
If IM
R p
hysi
cian
dis
agre
es w
ith 3
rdop
inio
n ph
ysic
ian,
IW m
ay s
elec
t any
phy
sici
an in
side
or
outs
ide
of M
PN
for t
reat
men
t or d
iagn
ostic
se
rvic
e ap
prov
ed b
y IM
R p
hysi
cian
(8 C
CR
§97
68.1
7)
With
MP
N, W
hen
AM
E/Q
ME
App
lies
•Fo
r UR
dis
pute
, IW
may
mak
e tim
ely
obje
ctio
n un
der L
C §
4062
and
get
AM
E o
r Q
ME
•Fo
r any
dis
pute
und
er L
C §
4061
or 4
062
eith
er p
arty
may
go
thro
ugh
the
AM
E/Q
ME
pr
oces
s as
app
ropr
iate
.
MP
N D
ispu
tes
•“N
o ad
ditio
nal e
xam
inat
ions
sha
ll be
or
dere
d by
the
appe
als
boar
d an
d no
oth
er
repo
rts s
hall
be a
dmis
sibl
e to
reso
lve
any
cont
rove
rsy
aris
ing
out o
f thi
s (M
PN
) ar
ticle
.”(L
C 4
616.
6)•
Onl
y W
CA
LJ c
an re
solv
e fa
ctua
l MP
N
cove
rage
dis
pute
s:–
Whe
ther
IW c
over
ed b
y M
PN
–W
heth
er p
rope
r not
ice
of M
PN
or p
rope
r tra
nsfe
r int
o M
PN
giv
en to
IW–
Whe
ther
MP
N h
as s
peci
alis
t com
pete
nt to
trea
t in
jury
UR
Cau
satio
n D
ispu
tes
•W
hen
empl
oyer
/cla
ims
adm
inis
trato
r firs
t le
arns
from
UR
revi
ewin
g ph
ysic
ian
that
th
e cl
aim
ed in
jury
may
not
aris
e ou
t of o
r ha
ve o
ccur
red
in th
e co
urse
of
empl
oym
ent,
mus
t fol
low
pro
cedu
re in
S
imm
ons
v W
CA
Bto
avo
id U
R p
enal
ties
and
to g
et a
dmis
sibl
e m
edic
al/le
gal r
epor
t
Med
ical
ly N
eces
sary
But
Cau
sal
Link
Que
stio
ned
•Tw
o st
ep d
ecis
ion
proc
ess
avoi
ds p
robl
em•
Is re
ques
ted
treat
men
t med
ical
ly n
eces
sary
?–
If no
, den
y on
med
ical
nec
essi
ty a
lone
–If
yes,
sta
te m
edic
ally
nec
essa
ry, a
dd c
linic
al re
ason
ing
that
su
ppor
ts m
edic
al o
pini
on re
gard
ing
whe
ther
nee
d fo
r tre
atm
ent
aris
es fr
om c
laim
ed in
jury
and
sen
d re
port
to a
djus
ter
•Le
t adj
uste
r iss
ue U
R d
enia
l in
relia
nce
on a
ttach
ed U
R
phys
icia
n re
port
and
issu
e ob
ject
ion
unde
r LC
406
2;•
Den
ial b
ased
on
caus
atio
n w
ithou
t med
ical
nec
essi
ty
dete
rmin
atio
n fro
m U
R p
hysi
cian
to re
ques
tor–
viol
ates
8
CC
R 9
792.
6(s)
, 979
2.9(
j) an
d S
imm
ons
en b
anc
WC
AB
de
cisi
on•
Den
ial b
y ad
just
er o
r RN
cas
e m
anag
er w
ithou
t UR
ph
ysic
ian
repo
rt on
med
ical
nec
essi
ty a
ttach
ed v
iola
tes
LC 4
610(
e), L
C 4
610(
a), 8
CC
R 9
792.
6(s)
and
Sim
mon
s
Med
ical
ly N
eces
sary
But
…co
n’t.
•“W
hen
a U
R p
hysi
cian
find
s th
at re
ques
ted
treat
men
t is
med
ical
ly n
eces
sary
but
que
stio
ns
whe
ther
the
need
for t
hat t
reat
men
t is
caus
ally
re
late
d to
the
indu
stria
l inj
ury,
the
defe
ndan
tmus
t ei
ther
: (a)
aut
horiz
e th
e tre
atm
ent;
or (b
) tim
ely
deny
aut
horiz
atio
n ba
sed
on c
ausa
tion’
with
in th
e de
adlin
es in
LC
461
0(g)
(3)(
A) a
nd ‘t
imel
y in
itiat
e th
e A
ME
/QM
E p
roce
ss’w
ithin
the
spec
ified
tim
e lim
its u
nder
LC
406
2(a)
.’‘If
def
enda
nt d
ecid
es to
de
ny a
utho
rizat
ion
for c
oncu
rren
t or p
rosp
ectiv
e tre
atm
ent b
ased
on
a qu
estio
n ar
isin
g in
util
izat
ion
revi
ew re
gard
ing
the
treat
men
t’s c
ausa
l co
nnec
tion
to th
e in
jury
then
the
defe
ndan
t mus
t re
ach
this
dec
isio
n to
den
y w
ithin
the
time
dead
lines
est
ablis
hed
by s
ectio
n 46
10.’
(Sim
mon
s v
Sta
teof
Cal
iforn
iaS
CIF
(200
5)W
CA
Ben
banc
Oth
er P
TP P
robl
ems
•P
TP w
ill n
ot is
sue
P&
S re
port:
–N
on M
PN
phy
sici
an: P
etiti
on fo
r Cha
nge
of T
reat
ing
Phy
sici
an (s
ee, L
C §
4603
, 8 C
CR
§§
9786
, 978
6.1,
97
87)
–M
PN
phy
sici
an:
Obj
ect u
nder
LC
§40
62 a
nd 8
CC
R §
9767
.10(
d)(3
))•
PTP
dis
cuss
ion
on p
erm
anen
t im
pairm
ent a
nd
disa
bilit
y no
t com
plia
nt w
ith A
MA
gui
des
•D
ispu
te o
ver d
eter
min
atio
n ov
er IW
ent
itlem
ent t
o co
ntin
uity
of c
are
with
non
-MN
P o
r ter
min
ated
MP
N
PTP:
–O
bjec
t und
er L
C §
4062
and
8 C
CR
§97
67.1
0(d)
(3))
Wha
t’s N
ew a
bout
Pan
el
Req
uest
s in
QM
E R
egs?
•P
anel
Req
uest
For
ms
–Fo
rm 1
05 –
Unr
epre
sent
ed c
ases
–Fo
rm 1
06 –
Rep
rese
nted
cas
es•
Onc
e en
tire
clai
m is
den
ied
durin
g 90
day
per
iod,
onl
y th
e in
jure
d w
orke
r or h
is/h
er re
pres
enta
tive
may
re
ques
t pan
el u
nder
LC
406
0 to
det
erm
ine
com
pens
abili
ty (p
ropo
sed
8 C
CR
§30
(d)(
3))
Wha
t’s N
ew a
bout
Pan
el R
eque
sts
in Q
ME
Reg
s–
cont
.?•
If ne
ed Q
ME
eva
luat
ion
to d
eter
min
e co
mpe
nsab
ility
afte
r cla
im a
ccep
ted
or ‘f
or g
ood
caus
e’af
ter p
resu
mpt
ion
of c
ompe
nsab
ility
in L
C
5402
(b):
–E
ither
get
‘fol
low
up’
or ‘s
uppl
emen
tal’
eval
uatio
n fro
m
the
AM
E o
r QM
E w
ho a
lread
y re
porte
d in
the
case
; or
–If
no p
rior e
valu
atio
n, if
prio
r eva
luat
or is
una
vaila
ble
or n
ot m
edic
ally
qua
lifie
d to
add
ress
, mus
t pro
vide
su
ppor
ting
evid
ence
suc
h as
a d
escr
iptio
n of
new
ly
disc
over
ed e
vide
nce
not a
vaila
ble
durin
g 90
day
s or
ex
plan
atio
n of
the
reas
on fo
r a c
ompe
nsab
ility
ev
alua
tion
at th
is ti
me
(pro
pose
d 8
CC
R §
30(d
)(4)
)•
Mus
t be
5 ac
tive
QM
Es
in s
peci
alty
requ
este
d to
issu
e pa
nel o
r Med
ical
Dire
ctor
will
ask
re
ques
tort
ose
lect
anot
hers
peci
alty
(pro
pose
d
Look
at F
orm
s 10
5 an
d 10
6
QM
E D
iscl
osur
e of
Spe
cifie
d Fi
nanc
ial I
nter
ests
•P
ropo
sed:
QM
Es
will
be
requ
ired
to d
iscl
ose
‘spe
cifie
d fin
anci
al in
tere
sts’
and
upda
te th
e di
sclo
sure
form
ann
ually
(p
ropo
sed
8 C
CR
§29
)•
Gen
eral
ly in
volv
es o
wne
rshi
p or
fina
ncia
l in
tere
sts
of 5
% o
f mor
e of
spe
cifie
d bu
sine
sses
•A
D w
ill u
se in
form
atio
n to
atte
mpt
to a
void
as
sign
ing
two
phys
icia
ns w
ith a
sha
red
finan
cial
in
tere
st to
the
sam
e Q
ME
pan
el•
Par
ty c
an re
ques
t a re
plac
emen
t for
QM
Es
who
ha
ve s
hare
d fin
anci
al in
tere
sts
and
appe
ar o
n th
e sa
me
pane
l
QM
E C
onfli
cts
of In
tere
st•
Cur
rent
: 8
CC
R §
§41
(c)(1
) and
41(
c)(4
)•
Pro
pose
d pe
r LC
139
.2(o
):–
8 C
CR
§41
.5 p
rohi
bits
eva
luat
ors
from
re
ques
ting
or a
ccep
ting
any
com
pens
atio
n or
ot
her t
hing
of v
alue
from
any
sou
rce
that
doe
s or
cou
ld c
reat
e a
conf
lict w
ith th
e du
ties
as a
n ev
alua
tor
–C
onfli
ct w
ith th
e du
ties
of a
n ev
alua
tor i
s de
fined
as
havi
ng a
‘dis
qual
ifyin
g’co
nflic
t of
inte
rest
with
one
or m
ore
pers
ons
or e
ntiti
es
invo
lved
in th
e ca
se a
nd fa
iling
to d
iscl
ose
the
conf
lict (
prop
osed
§41
.5(b
))–
‘Dis
qual
ifyin
g’co
nflic
ts d
efin
ed b
y sp
ecifi
c fa
mili
al, b
usin
ess,
pro
fess
iona
l or o
ther
re
latio
nshi
ps
QM
E C
onfli
cts
of In
tere
st –
cont
.•
Pro
cedu
res
prop
osed
–
AM
E o
r QM
E m
ay s
elf d
isqu
alify
due
to c
onfli
ct
of in
tere
st–
Par
ties
may
obj
ect t
o A
ME
or Q
ME
due
to
alle
ged
conf
lict
–O
nce
conf
lict d
iscl
osed
or r
aise
d, p
roce
dure
for
each
par
ty to
sta
te w
heth
er th
e pa
rty w
ill w
aive
th
e co
nflic
t or o
bjec
t to
the
eval
uato
r–
Dis
pute
s ov
er w
heth
er c
onfli
ct e
xist
s to
be
reso
lved
by
a W
CA
LJ•
AM
Es
and
QM
Es
will
not b
e al
low
ed to
ac
cept
gift
s ha
ving
a fa
ir m
arke
t val
ue o
ver $
36
0 fro
m a
ny s
ingl
e so
urce
in a
ny 1
2 m
onth
pe
riod
(pro
pose
d§
417)
Gro
unds
for R
epla
cing
a P
anel
Q
ME
•E
xist
ing
reas
ons
in §
31.5
with
som
e m
odifi
catio
ns•
Obj
ectio
ns e
xpan
ded
to ‘p
arty
hol
ding
le
gal r
ight
to re
ques
t the
pan
el’
•P
rimar
y or
sec
onda
ry P
TP s
tatu
s ad
ded
•Fa
ilure
to is
sue
repo
rt w
ithin
dea
dlin
es in
LC
406
2.5
and
prop
osed
8 C
CC
§38
Gro
unds
for R
epla
cing
a
Pan
el Q
ME
–co
nt.
•D
isqu
alify
ing
conf
lict o
f int
eres
t per
41.
5•
Ord
er b
y A
.D. f
or a
dditi
onal
QM
E•
Upo
n sh
owin
g of
goo
d ca
use
that
an
addi
tiona
l Q
ME
in a
diff
eren
t spe
cial
ty is
nee
ded
(see
pro
pose
d §
31.5
(b))
–B
y or
der o
f WC
ALJ
–W
hen
AM
E o
r QM
E s
tatu
es n
eed
for i
ssue
s ou
tsid
e ow
n sp
ecia
lty–
Par
ties
in re
pres
ente
d ca
se a
gree
nee
d bu
t fai
l to
agre
e on
AM
E–
In u
nrep
rese
nted
cas
e, w
hen
parti
es m
eet w
ith I
& A
of
ficer
and
all
agre
e ad
ditio
nal Q
ME
of d
iffer
ent
spec
ialty
nee
ded
QM
E M
inim
um A
vaila
bilit
y fo
r P
anel
s•
To h
elp
parti
es g
et Q
ME
app
oint
men
ts•
Pro
pose
d se
ctio
n §
32.7
•Q
ME
mus
t sch
edul
e, if
requ
este
d, o
n av
erag
e du
ring
a 90
-day
per
iod,
3x
the
appl
icab
le n
umbe
r of p
anel
app
oint
men
ts
per m
onth
per
cha
rt•
1 pa
nel c
ase
if do
es 1
-10
eval
uatio
ns/y
r•
2 pa
nel c
ases
if d
oes
11-2
4 ev
alua
tions
/yr
•3
pane
l cas
es if
doe
s ov
er 2
5/yr
Lim
it on
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pan
el re
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Med
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Uni
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700
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10, O
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4612
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QME Form 105 (rev. Aug. 2007) Page 1
State of California DIVISION OF WORKERS’ COMPENSATION - MEDICAL UNIT
REQUEST FOR QME PANEL UNDER LABOR CODE § 4062.1
UNREPRESENTED (Please Complete Form/Type or Print)
Request Date:______________________ The Party Making the Panel Request (Check one)
Unrepresented injured employee Employer/Claims Administrator
Please specify the reason for your request for a medical/legal examination by a QME. (See attachment on How to Request a Qualified Medical Evaluator for help in completing this section.) (Check one)
§ 4060 (causation exam) § 4061 (permanent disability dispute) § 4062 (medical treatment dispute) Check this box if your claim was denied altogether by the employer or insurer
EMPLOYEE INFORMATION Date of injury: Name: Address: City: State: Zip: Day time phone No.: (_____) If currently residing out of state, city and zip code at the time of injury: Representative (if any): Phone: (___) Address: City: State: Zip:
NOTE: If you are currently residing out of state, the panel will be issued using the California city and zip code where you were residing at the time of the injury. The claims administrator and injured worker may agree to another city and zip code instead of the city where you were residing in California. However, the DWC-Medical Unit needs a copy of your agreement with signatures from each (the injured employee and the employer/insurer). The city and zip code agreed upon must be in California.
EMPLOYER/INSURER or CLAIMS ADMINSTRATOR INFORMATION
Employer Name: W.C. Insurer/TPA: Claim No.: Address: City: State: Zip: Claims Adjuster (if known): Phone: (___) Attorney/Representative: Phone: (___) Address: City: State: Zip:
MEDICAL SPECIALITY REQUESTED
Please list ONLY ONE (insert three letter code from the list on the back of this page)
Specialty Requested: Signature of Requestor: Requestor name (print):
(Note: Any employer/claims administrator using this form to request a QME panel must attach a copy of correspondence sent to the injured employee furnishing the form and advising the employee how to request a QME.)
Send the completed form to: Division of Workers’ Compensation – Medical Unit
P.O. Box 71010, Oakland, CA 94612 (510) 286-3700 or (800) 794-6900
QME Form 105 (rev. Aug 2007) Page 2
For Use with the QME Panel Request Form 105
MD/DO SPECIALTY CODES NON-MD/DO SPECIALTY CODES
MAI Allergy and Immunology ACA Acupuncture MDE Dermatology DCH Chiropractic MEM Emergency Medicine DEN Dentistry MTT Emergency Medicine - Toxicology OPT Optometry MFP Family Practice POD Podiatry MPM General Preventive Medicine PSY Psychology MHH Hand – Orthopaedic Surgery PSN Psychology - Clinical Neuropsychology MMM Internal Medicine MMV Internal Medicine - Cardiovascular Disease MME Internal Medicine – Endocrinology Diabetes and
Metabolism MMG Internal Medicine - Gastroenterology MMH Internal Medicine - Hematology
MMI Internal Medicine - Infectious Disease MMN Internal Medicine - Nephrology MMP Internal Medicine - Pulmonary Disease MMR Internal Medicine - Rheumatology MNB Spine – Orthopaedic Surgery and Neurological
Surgery MPN Neurology MNS Neurological Surgery MOG Obstetrics and Gynecology MPO Occupational Medicine MMO Orthopaedic Surgery – Oncology, Internal
Medicine – Oncology, Radiology - Oncology MOP Ophthalmology MOS Orthopaedic Surgery MTO Otolaryngology MPA Pain Medicine MHA Pathology MEP Pediatrics MPR Physical Medicine & Rehabilitation MPS Plastic Surgery MPD Psychiatry MSY Surgery MHH Surgery - Hand MSG Surgery - General Vascular MTS Thoracic Surgery MUU Urology
STATE OF CALIFORNIA DEPARTMENT OF INDUSTRIAL RELATIONS DIVISION OF WORKERS’ COMPENSATION MEDICAL UNIT MAILING ADDRESS: P.O. Box 71010 Oakland, CA 94612 (510) 286-3700 or (800) 794-6900
Over…
HOW TO REQUEST A QUALIFIED MEDICAL EVALUATOR IF YOU DO NOT HAVE AN ATTORNEY
(Attachment to Form 105) Since you do not have an attorney and there is a disagreement over some of the opinions of your treating physician, you need to complete QME Form 105 to obtain a panel of three Qualified Medical Evaluators (QMEs). The purpose of the QME examination is to obtain a second medical opinion to help resolve the disputed medical issues in your workers’ compensation claim(s). The QME report must discuss all of the disputed and unresolved issues in your claim that need a medical opinion. You, the injured worker, have the first opportunity to choose the type of physician to perform the exam. Complete this form to request a QME panel, write the medical specialty you prefer for the QME and return it to the DWC Medical Unit. Send a copy of your completed form to the employer/insurer as well. If you do not request a panel within ten (10) days of being asked to do so by the employer/insurer, then the employer/insurer has the right to request the panel and choose the medical specialty. The employer/insurer may not submit this form until ten (10) days have passed after the form was given to the injured worker with the instruction to send the completed form to the DWC Medical Unit. After you receive the panel list of three QME names, you must select a doctor and make an appointment. If you do not select a QME from the panel, schedule an appointment with the QME and inform the employer/insurer of your choice within 10 days of the date the Medical Unit issued the panel, you may lose the right to choose the QME and the exam date. You must tell the employer/insurer the time and date of your appointment. If the Medical Unit does not issue a panel within fifteen (15) working days of its receipt of a request for a QME panel in an unrepresented case, the employee may select any QME of his or her choice to do the evaluation. Selecting the reason for your request for a QME panel: Select § 4060 if your claim is “on delay” or if the insurance company disputes that your injury was caused by work (i.e. compensability) or denies your claim or if you disagree with the treating physician’s opinion that work was not a medical cause of your claimed injury or illness. If the employer/insurer has accepted any body part as compensable for this date of injury, this reason may not apply. The QME evaluation will be used to determine whether the employer is liable for this injury. Select § 4061 if permanent disability is in dispute. The dispute may be about the amount or percentage of permanent disability or whether there is any permanent disability. Either party may request the QME panel. Select § 4062 if medical treatment is in dispute. The dispute may be over whether any treatment is needed, whether further treatment is needed, the form or type of treatment or the frequency of treatment recommended by the treating physician. Either party may request the panel. Selecting the medical specialty: If necessary, request help from your treating physician in choosing the appropriate medical specialty for the QME. Use the list on the back of the panel request form to select a specialty. Enter the 3 letter code for the medical specialty you select on the front of the form.
Where will the QMEs be located?
Attachment to Form 105 (rev. Aug. 2007)
The DWC-Medical Unit uses a random selection program to name three QMEs to the panel. If there are too few QMEs of the specialty you request in your geographic area, then the system will pick QMEs from other geographic areas and the employer shall pay all reasonable and necessary travel expenses. What if I pick the wrong medical specialty and wish to change the medical specialty? You may request a change of medical specialty if you have not had the QME evaluation yet. When requesting the change in medical specialty, the injured worker and claims administrator must agree in writing to the change of medical specialty. Please refer to the QME panel number if you request another medical specialty. Insufficient information or incomplete form:
• If the panel request form is not fully completed then it will be returned to you.
• If we do not have sufficient QMEs in the medical specialty you chose, then the request will be returned to you asking that you pick a different medical specialty.
• If a QME panel was previously issued for this injured worker, then the new panel request will be returned by the Medical Unit with a request that you provide us with more information about the status of the claim for which the earlier QME panel was issued.
How long will it take to have the examination and to get the QME’s report? QMEs must be able to schedule and do your exam within 60 days of your call for an appointment. If a QME on the panel cannot, you are entitled to a replacement QME. You are entitled to the written QME report within 30 days of the date the QME starts the physical exam. At times, the QME may request the Medical Unit to extend the time for writing the report. The QME must notify you, the employer/insurer and the Medical Unit in order to get an extension approval. You will be notified of the Medical Unit’s decision. If the QME selected does not complete the evaluation report within 30 days of starting the examination or within the extension of time approved by the Medical Director, you have a choice. You may request that the Medical Unit replace the QME and start over, or instead you may agree in writing to wait until the QME report is completed, by using QME form 113 or 116. Even if you are willing to wait, if the employer or insurer chooses not to wait, a new QME or QME panel may be issued. In that case a QME or QME panel in the same specialty will be issued. What if there is a need for another QME report in a different specialty? Under very limited circumstances, there may be a need for an additional examination and report by a QME in a different specialty. Generally this will only occur if a Workers’ Compensation Judge orders the additional report, if the QME states in the report that an examination by a physician in another specialty is necessary or when the parties meet with an Information and Assistance Officer who determines the conditions for obtaining an additional report under section 31.5(b)(4) of Title 8 of the California Code of Regulations are met. Other questions? If you have any other questions about the QME process, please call the Division of Workers’ Compensation Medical Unit at 1-800-794-6900. If you have other general questions about your workers’ compensation claim, please call the Information and Assistance officer at the Division of Workers’ Compensation listed in your phone book, or look on our website at http://www.dir.ca.gov/dwc.
QME Form 106 (rev. May 2007) Page 1
State of California DIVISION OF WORKERS’ COMPENSATION MEDICAL UNIT
REQUEST FOR QME PANEL UNDER LABOR CODE §4062.2
REPRESENTED (Please Complete Form/Type or Print)
Request Date: The Party Making the Panel Request (Check one)
Applicant’s attorney (or injured employee) Defense attorney (or employer/claims adjuster)
Please specify the reason for your request for a medical/legal examination by a QME. (See instruction sheet attached regarding use of this form.) (Check one)
§ 4060 (causation exam) § 4061 (permanent disability dispute) § 4062 (medical treatment) Check here if claim was denied
EMPLOYEE INFORMATION
Date of injury: Name: Address: City: State: Zip: Day time phone No.: (_____) If currently residing out of state, city and zip code at the time of injury: Attorney/Representative: Phone: (___) Address: City: State: Zip:
EMPLOYER/INSURER or CLAIMS ADMINSTRATOR INFORMATION
Employer Name: W.C. Insurer/TPA: Claim No.: Address: City: State: Zip: Claims Adjuster (if known): Phone: (___) Attorney/Representative: Phone: (___) Address: City: State: Zip:
MEDICAL SPECIALITY REQUESTED
Please list ONLY ONE (insert three letter code from the list on the reverse side of form)
Specialty Requested: Signature of Requestor: Requestor name (print): Treating Physician Specialty: Specialty Preferred by other party (if known):
(NOTE: YOU MUST ATTACH A COPY OF YOUR WRITTEN PROPOSAL NAMING ONE OR MORE AMEs)
Send the completed form and copy of your written AME proposal to:
Division of Workers’ Compensation – Medical Unit P.O. Box 71010, Oakland, CA 94612
(510) 286-3700 or (800) 794-6900
QME Form 106 (rev. Aug 2007) Page 2
For Use with the QME Panel Request Form 106
MD/DO SPECIALTY CODES NON-MD/DO SPECIALTY CODES
MAI Allergy and Immunology ACA Acupuncture MDE Dermatology DCH Chiropractic MEM Emergency Medicine DEN Dentistry MTT Emergency Medicine - Toxicology OPT Optometry MFP Family Practice POD Podiatry MPM General Preventive Medicine PSY Psychology MHH Hand – Orthopaedic Surgery PSN Psychology - Clinical Neuropsychology MMM Internal Medicine MMV Internal Medicine - Cardiovascular Disease MME Internal Medicine – Endocrinology Diabetes and
Metabolism MMG Internal Medicine - Gastroenterology MMH Internal Medicine - Hematology
MMI Internal Medicine - Infectious Disease MMN Internal Medicine - Nephrology MMP Internal Medicine - Pulmonary Disease MMR Internal Medicine - Rheumatology MNB Spine – Orthopaedic Surgery and Neurological
Surgery MPN Neurology MNS Neurological Surgery MOG Obstetrics and Gynecology MPO Occupational Medicine MMO Orthopaedic Surgery – Oncology, Internal
Medicine – Oncology, Radiology - Oncology MOP Ophthalmology MOS Orthopaedic Surgery MTO Otolaryngology MPA Pain Medicine MHA Pathology MEP Pediatrics MPR Physical Medicine & Rehabilitation MPS Plastic Surgery MPD Psychiatry MSY Surgery MHH Surgery - Hand MSG Surgery - General Vascular MTS Thoracic Surgery MUU Urology
STATE OF CALIFORNIA DEPARTMENT OF INDUSTRIAL RELATIONS
DIVISION OF WORKERS’ COMPENSATION – MEDICAL UNIT MAILING ADDRESS: P. O. Box 71010 Oakland, CA 94612 (510) 286-3700 or (800) 794-6900
Over…
HOW TO REQUEST A QUALIFIED MEDICAL EVALUATOR IN A REPRESENTED CASE
(Attachment to Form 106)
To request a panel of three QMEs for a represented case, please complete QME Form 106, attached to these instructions. When you have completed the form, return it to the Division of Workers’ Compensation-Medical Unit (DWC-MU) with a copy of your written proposal naming one or more physicians to be Agreed Medical Evaluators attached. You must send a copy of your completed form to the other party. If represented parties have been unable to agree on an Agreed Medical Evaluator within the time limits specified in the Labor Code, a medical evaluator must be selected from the names provided on the QME panel letter. The DWC-MU uses a random selection program to assign three QMEs to the panel. If there are too few QMEs of the specialty requested in the geographic area of the injured worker’s residence, the system will pick QMEs from other geographic areas and the employer is responsible for paying for necessary travel costs incurred. The non-requesting party will receive a copy of the panel letter when it is issued. If the Medical Unit does not issue a panel within thirty (30) working days of receiving the request for a QME panel, either party may seek an order from a Workers’ Compensation Administrative Law Judge that a QME panel be issued. Selecting the reason for your request for a QME panel: § 4060 applies if the claim is “on delay” or if the employer/insurer disputes that the injury is compensable. If the employer/insurer has accepted any body part as compensable for this date of injury, this reason may not apply. The claim form must have been filed with the employer. (Labor Code § 4060(c)). Either party in a represented case may request a QME panel to resolve the issue of compensability under § 4060. (Labor Code § 4062.2(b)). § 4061 applies if permanent disability is in dispute. The dispute may be about the amount or percentage of permanent disability or whether there is any permanent disability. Either party may request the QME panel. § 4062 applies if medical treatment is in dispute. The dispute may be over whether any treatment is needed, whether further treatment is needed, the form or type of treatment or the frequency of treatment recommended by the treating physician. Either party may request the panel. Selecting the medical specialty: Enter the 3 letter code from the reverse side of QME Form 106 for the medical specialty you select on the front of the form. If known, also state the medical specialty of the treating physician and the specialty preferred by the opposing party. Insufficient information or incomplete form:
• If the panel request form is not fully completed then it will be returned to you.
• If we do not have sufficient QMEs in the medical specialty you chose, then the request will be returned to you asking that you pick a different medical specialty.
Attachment to Form 106 (rev. Mar. 2007) 2
• If a QME panel was previously issued for this injured worker, the new panel request will be returned by the Medical Unit with a request that you provide us with more information about the status of the claim for which the earlier QME panel was issued.
The AME or QME selection process in represented cases: After the panel is issued, represented parties have ten (10) days to communicate and to agree on one QME from the list to serve as an Agreed Medical Evaluator. If the parties have not agreed on an AME by the 10th day after assignment of the panel, each party may then strike one name from the panel. The remaining QME shall serve as the medical evaluator. If a represented party fails to exercise the right to strike a name from the panel within three working days of gaining the right to do so, the other party may select any QME who remains on the panel to serve as the medical evaluator. (Labor Code §4062.2(c)). Scheduling the evaluation appointment: The represented employee is responsible for arranging the appointment for the examination. Upon his or her failure to inform the employer/insurer of the appointment within 10 days after the medical evaluator has been selected, the employer/insurer may arrange the appointment and notify the employee of the arrangements.
How long will it take to have the examination and to get the QME’s report? The QME must be able to schedule the exam within 60 days of the call for an appointment. If the QME cannot, you are entitled to a replacement. You also are entitled to an evaluation report within 30 days of the commencement of the exam by a panel-selected AME or QME. At times, an AME or QME may request the Medical Unit to extend the deadline for completing the report because the evaluator has not received test results or a consulting physician’s report or for legal ‘good cause’. The evaluator must notify the DWC-Medical Unit and you of the request for approval of an extension of time to complete the report. You will be notified of the Medical Unit’s decision. If the physician you choose cannot complete the report within 30 days or the extension of time approved by the Medical Director, you have a choice. The parties may both agree in writing (on QME form 113 or 116) to wait until the physician can complete the report, or either party may request a replacement panel of physicians. If this occurs, you must go through the selection process again. Obtaining a QME in a different specialty: Under the circumstances listed in section 31.5(b) of Title 8 of the California Code of Regulations, parties in a represented case may obtain an additional QME panel in a different specialty. All requests for an additional QME panel in a different specialty must be written with supporting information or documentation showing how one of the conditions in section 31.5(b) are being met. Other questions? If you have any questions about the QME process, please call the DWC-MU at 1-800-794-6900. Other questions about the workers’ compensation claim and dispute resolution process should be directed to an Information and Assistance officer at the Division of Workers’ Compensation office listed in your phone book, or look on our website at http://www.dir.ca.gov/dwc.
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