2 Timelines (2 hrs.) Flashcards
Master the timelines rules for QME events
New Injury
How much time does an employer have to provide the employee with a DWC1 form for a new claim?
1 business day
What is the timeframe for an employee to file a WC claim to receive benefits?
within 30 days of DOI
By when must an objection to a medical determination by a treating physician be made?
within 20 days of PTP report receipt if represented, 30 days if unrepresented
When can a claims admin submit a QME form 105?
if employee has not submitted the form within 10 days after the form was given to him/her by the employee
If the request for a panel QME is not issued within ____ working days in an unrepresented case the employee can obtain an evaluation from any QME in the area.
20
How many days does the unrepresented worker have to select a physician and make an appointment after the panel is issued before the claims administrator can do so?
10
How many days do the claims administrator/represented worker have to strike a name from a panel?
10
Within how many days must a QME make an appointment with an employee?
Within 90days of initial request, can be extended to 120 days with written request. If not scheduled within 90 days, a new QME Dr. panel can be requested.
How many days does the QME have to submit the QME appointment notification form (form 110)? What info must it include?
5 business days; if an interpreter is needed
Once scheduled, A QME appointment cannot be cancelled less than _____ days by any party without good cause.
6 business days
What is the process for sending records to a QME?
records must first be served to the opposing party 20 days before it is provided to the QME; if the opposing party objects to sending non-medical records within 10 days of its receipt, it will not be provided to the QME
How long do parties have after an appointment to get requested records to QME before QME is allowed to finish report without them? How long does QME have to finish report, regardless of records received?
10 days; 30 days
How long does a QME have to identify a conflict of interest?
5 days from becoming aware of the conflict. For example the person was a former patient, family member, etc.
What is the minimum allowable facetime for a QME exam for a neuromusculoskeleton evaluation?
20 minutes
For how long can a QME be unavailable? When does that QME need to notify the Medical Director of that fact?
14-120 days/year; 30 days prior
How long does a QME have to complete supplemental reports?
60 days from written notice
After employers knowledge of the claim (unless the employer contests the claim), temporary disability payments must be made within…
14 days
How long does a PTP have to file a doctors first report
5 days
How long does a physician have to contact a local health officer for suspected or diagnosed pesticide poisoning?
24 hours
How many days does an employer have to contest a work comp claim?
90
When a QME receives a request to schedule an evaluation, the QME must issue a QME Appointment Notification Form to all parties within
5 working days
A QME must retain QME reports for how many years?
5
Temporary disability benefits/payments from 2005 forward can last for:
104 weeks
When an IW contacts a QME to make an appointment, the QME must set the appointment within how many days of the contact?
90 days
Within how many days, does the PTP have to send the Doctor’s First Report of Occupational Illness or Injury to the involved parties?
5 days of the initial examination
The ‘QME Appointment Notification Form’ should be sent:
Within 5 business days after scheduling the patient for the evaluation
A PQME or Agreed PQME who cancels a scheduled appointment shall:
Reschedule the appointment within 60 calendar days
QME has to schedule a deposition within .. days.
120 days. It takes place w/in 20 miles where IW’s eval took place.
Temporary disability may last up to… week within … years from the DOI for injuries from 1/1/2008
2 years (104 weeks) , 5 years
Employers who contract with HCO can direct tx of IW up to … days.
90 or 180 days following an injury.
The boss (insurer) has … days to accept or deny IW’s claim. In the meantime, IW may receive $….. worth of treatment.
90 days
$10,000
QME may be denied reappointment if she was made unavailable for more than… days during a calendar year, WITHOUT good cause.
90 days
QME can apply for an extension on a 30 day after appointment report deadline in cases of good cause (medical emergency, natural disaster etc) - how long is the extension?
15 days
Employee has … years to use Supplemental Job Displacement Benefit (SJDB) or within … years of DOI.
2 years or 5 years.
Employer has … days to give return to work date after the Return To Work (RTW) and voucher report.
60 days.
Supplemental reports must be completed and served no later than…. days since the request.
60 days from the request.
Supplemental report deadline may have extended for no more than… days.
You have 60 days to issed a supplemental report. Request for an extention of 30 days if agreed by both parties.
The re-scheduled appointment date may not be more than … calendar days from the date of the CANCELLATION request (unless parties agree in writing).
60 days
In how many days after the PTP’s report, shall 2nd opinion spine report be served to all partied?
45 days
IMR decision must be provided to all parties in layterms within how many days of the receipt of the request for review?
30 days and 72 hrs for expedited request
To get the money, IW has to tell the boss about the injury within … days of injury.
30 days
When UR is RETROSPECTIVE, decisions must be communicated to PTP who requested med. services and IW/his lawyer within… days.
30 days
If employer doesn’t provide a new PTP within … days, then IW can choose one himself.
30 days
* normally within 5 days boss should provide a new PTP if IW requests.
Unrep IW. If request for QME panel is not issued within … working days, then IW can have eval from any QME within reasonable geographic area.
20 days
Either party may object PTP’s med. determination by notifying the other party in writing in how many days?
rep vs unrep IW
represented IW- 20 days
unrepresented- 30 days
PTP says IW is P&S. PTP must report within how many days from the date of exam all info about perm. impairment & any need for med. Tx?
20 days unless good cause
Before 1 party can give any info to the QME/AME they must send it (give the heads up) to the other party within… days before info is sent to QME.
20 days
PTP must report results of consults, results of other Drs reports or changes in IW condition in … days after receiving them.
20 days
Within …. days of the Request for Authorization, the UR decision must be made.
14 days. If no additional info submitted within 14 days from the date of submission, then request will be denied.
IW files Request for Factual Correction of QME report, the QME panel has:
… days after request to review corrections and determine if factual corrections are necessary for unrep IW and
….days for both parties or claims admin.
10 days for unrep and 15 days for rep IW or if the request was filed by the both parties or the claims admin.
Represented IW. If IW & boss disagree w/PTP’s findings, they must wait…. waiting period and… for mailing an objection before DWC can assign a QME.
10 days waiting period
5 days for mailing an objection
Represented IW. If no AME agreed upon, then IW has …days to choose a QME.
10 days
A represented IW has…. days to select an AME.
This can be extended if agreed upon for… days.
10 days
20 days
If unrepresented IW doesn’t make a choice of his QME in … days then the insured can make this choice for him in ….days.
10 days and 10 days
If the opposing party objects to sending non-medical records (video tape etc), they need to object how fast so that QME will not be provided the tape?
Within 10 days
Dispute about spinal surgery is NOT handled by QME/AME but a special procedure.
If boss disagrees with needing a sx, insurer (IW) has …. days from the report to disagree. (with the boss)
Both lawyers can agree on a surgeon for a 2nd opinion. If they can’t agree in … days, then AD will provide randomly selected surgeon for a 2nd opinion in … days. If boss/insurer disagrees w/ 2nd opinion–> go to court.
10 days
10 days
5 days
How much in advance should QME notify medical director of being unavailable to perform or schedule an eval?
30 days before the period of unavailability
QME has to let MD (medical director) know of being unavailable to schedule or perform medical eval if QME is unavailable for how long?
14-120 days max
Employer has …. days from the notification of the injury to contest the claim. If he doesn’t, the injury is compensable.
90 days
Temporary Disability Benefits payments must begin within…. days of the employer’s knowledge of the claim
14 days (unless the employer contests (objects) the claim.
Once scheduled, an appointment can not be canceled by QME or any party in ….day, except for good cause.
6 biz. days
A concurrent or prospective Utilization Review REQUEST must get a yes or no decision in… how many days after being received by an adjuster?
5 working days
PTP must be informed by phone/fax in 24 hrs
After employer learns of an injury, how soon should they complete “Employer’s First Report” Employer’s Report of Occupational Injury or Illness?
5 days
Decisions for expedited Utilization Review are made in…
72 hrs (after the receipt of written information reasonably necessary to make a decision)
After employer learns about an injury (from any source), he must provide IW Employee’s Claim for WCB claim (DWC1) within…
1 working day. It must be dated. IW fills it out & returns to boss
PTP must be notified that his request for authorization prior or concurrent with provision of med care is approve is..
24 hrs
Employer must immediately report to OSHA a serious injury in more than ….hrs of hospitalization except obs, loss of body part or disfigurement
24 hrs
How many hrs/days does the employer have to get a PTP from their MPN once they learn of an employee injury?
24 hrs
Labor Code 5402(b)(1) states, “If liability is not rejected within __ days after the date the claim form is filed under Section 5401, the injury shall be presumed compensable under this division.”
90 DAYS
