QME Timelines & More Flashcards
A QME may seek reappointment by meeting the original requirements of appointment and by meeting additional requirements (after how long)
2 years
What are the requirements for QME renewal?
- compliance with all applicable regulations and evaluation guidelines adopted by the Administrative Director
- completion of at least 12 hours of continuing education in impairment evaluation or workers’ compensation-related medical dispute evaluation approved by the Administrative Director in the previous 24 months before reappointment
- no more than five evaluations rejected by a workers’ compensation judge (WCJ) while serving as a QME
- no termination, suspension, or probation by any licensing board. (Lab. Code, § 139.2(d).)
A claims administrator may not submit the QME form 10516 (i.e., request a QME panel) “unless the employee has not submitted the form within _________ after the employer has furnished the form to the employee and requested the employee to submit the form.”
10 days
If the request for a panel is not issued within __________ in an unrepresented case the employee shall have the right to obtain an evaluation from any QME within a reasonable geographic area. (Lab. Code, § 139.2(h)(4).)
20 working days
Within __________ after the panel is issued the injured worker is required to select a physician from the panel, make an appointment for the examination and inform the claims administrator of the selection and the appointment. (Lab. Code, § 4062.1(c).)
10 days
The party filing the QME request must wait to file the form 106 “[n]o earlier than (a) __________ that is at least (b) __________ after the date of mailing of a request for a medical evaluation pursuant to Section 4060 or the first working day that is at least (c) __________ after the date of mailing of an objection pursuant to Sections 4061 or 4062, …” (Lab. Code, § 4062.2(b).)
a. the first working day
b. 10 days
c. 10 days
After the assignment of the QME panel by the Medical Director, each party may strike one name from the panel for __________. (Lab. Code, § 4062.2(c).)
a ten (10) day period
After the issuance of a panel and selection of a QME as described in the preceding chapter, the selected QME must schedule an appointment to see the employee within __________ of a request for an appointment.
60 days
An appointment may be scheduled beyond (a)______ of a request for an appointment if the party who has the right to schedule the appointment is willing to accept an appointment up to (b) __________ from the date of the request. (Cal. Code Regs., tit. 8, § 33(e).)
a. 60 days
b. 90 days
When an appointment has been made the QME must submit the QME Appointment Notification form (Form 110) within __________ of making the appointment.
5 business days
Once scheduled, an appointment may not be cancelled by the QME evaluator, or by any party, less than __________ prior to the appointment date, except for good cause.
six (6) business days
Whenever an evaluator cancels a scheduled appointment, the evaluator must advise the parties in writing of the reason for the cancellation, and must reschedule the appointment to a date within __________ of the date of cancellation.
thirty (30) calendar days
The re-scheduled appointment date may not be more than __________ from the date of the initial request for an appointment, unless the parties agree in writing to accept the date beyond the aforementioned limit.
sixty (60) calendar days
An oral cancellation must be followed with a written confirming letter that is faxed or mailed by first class U.S. mail within __________ of the verbal cancellation.
twenty four hours
The Appeals Board has jurisdiction to resolve disputes among the parties regarding whether an appointment cancellation less than __________ prior to the appointment date was for good cause, and the Administrative Director has jurisdiction to take appropriate disciplinary action against any Agreed Panel QME or QME for violations of the regulations on this issue. (Cal. Code Regs., tit. 8, § 34, subds. (d), (e), (h).)
six (6) days
Any party may provide to the QME selected from a panel any of the following information:
A letter outlining the medical determination of the primary treating physician or the compensability issue that the evaluator is requested to address in the evaluation, which shall be served on the opposing party no less than __________ in advance of the evaluation;
20 days
Information that a party proposes to provide to the QME selected from a panel should be served on the opposing party __________ before the information is provided to the evaluator.
20 days
If the opposing party objects to sending non-medical records (such as a video tape) within __________ of receipt of the objection, the records shall not be provided to the evaluator.
10 days
If the party fails to provide relevant medical records within (a) __________ after the date of the evaluation, and the evaluator is unable to obtain the records, the evaluator shall complete and serve the report within (b)__________ of the evaluation to comply with the statutory time frames under section 38 of title 8 of the California Code of Regulations.19
a. 10 days
b. 30 days
The evaluator shall note in the report that the records were not received within __________ after the date of the evaluation.
10 days
The time frame for submission of a comprehensive medical-legal report is __________.
(Cal. Code Regs., tit. 8, § 38 (a).)
30 days
The time frame for submission of the supplemental medical-legal report is __________.
(Cal. Code Reg., tit. 8, § 38 (h).)
60 days
An evaluator who discovers a conflict of interest should disclose the nature of the conflict in writing to the parties __________ of becoming aware of the conflict. (Cal. Code Regs., tit. 8, § 41.5(f).)
within 5 business days
A QME shall advise an injured worker of their rights (when?) ________.
Before the examination or at the time of the actual evaluation
True or False?
An injured worker is entitled to ask the evaluator and the evaluator shall promptly answer questions about any matter concerning the evaluation process in which the QME and the injured worker are involved.
True
True or False?
The injured worker may NOT discontinue the evaluation based on good cause.
False. The injured worker may discontinue the evaluation based on good cause.
__________ includes:
(A) discriminatory conduct by the evaluator towards the worker based on race, sex, national origin, religion, or sexual preference,
(B) abusive, hostile or rude behavior including behavior that clearly demonstrates a bias against injured workers, and
(C) instances where the evaluator requests the worker to submit to an unnecessary exam or procedure.
Good cause (for an injured worker to discontinue the evaluation)
True or False?
When required as a condition of probation by the Administrative Director or his/her licensing authority, the QME shall disclose his/her probationary status. The QME shall be entitled to explain any circumstances surrounding the probation. If at that time, the injured worker declines to proceed with the evaluation, such termination shall be considered by the Administrative Director to have occurred for good cause.
True
True or False?
If the injured worker declines to ask any questions relating to the evaluation procedure, as set forth in section 40, and does not otherwise object on the grounds of good cause to the exam proceedings during the exam itself, the injured worker shall have the right to object to the QME comprehensive medical-legal evaluation based on a violation of this section. (Cal. Code Regs., tit. 8, § 40(c).)
False.
If the injured worker declines to ask any questions relating to the evaluation procedure, as set forth in section 40, and does not otherwise object on the grounds of good cause to the exam proceedings during the exam itself, the injured worker shall have NO right to object to the QME comprehensive medical-legal evaluation based on a violation of this section. (Cal. Code Regs., tit. 8, § 40(c).)
True or False?
If the injured worker terminates the examination process based on an alleged violation of section 40 of title 8 of the California Code of Regulations and the Appeals Board later determines that good cause did not exist for the termination, the cost of the evaluation shall be deducted from the injured worker’s award.
(Cal. Code Regs., tit. 8, § 41(g).)
True
True or False?
A violation of section 40 (of title 8 of the California Code of Regulations) by the evaluator shall NOT constitute good cause for purposes of an Appeals Board determination.
False.
A violation of section 40 by the evaluator shall constitute good cause for purposes of an Appeals Board determination.
(Cal. Code Regs., tit. 8, § 41(g)).
True or False?
No party shall be liable for any cost for medical reports or medical services delivered as a result of an exam terminated for good cause. (Cal. Code Regs., tit. 8, § 41(g)).
True.
The minimal face to face time for neuromusculoskeletal evaluations (whether a specific or cumulative injury is involved) by a QME is:
Twenty (20) minutes. This is the minimum allowable face to face time for an uncomplicated evaluation. (Cal. Code Regs., tit. 8, § 49.9).)
Cardiovascular evaluations (whether a specific or cumulative injury) minimal face to face evaluation time by a QME is:
Thirty (30) minutes. This is the minimum allowable face to face time for an uncomplicated evaluation. (Cal. Code Regs., tit. 8, § 49.9).)
The minimal face to face time for Pulmonary evaluations (whether a specific or cumulative injury) by a QME is:
Thirty (30) minutes. This is the minimum allowable face to face time for an uncomplicated evaluation. (Cal. Code Regs., tit. 8, § 49.9).)
The minimal face to face time Psychiatric evaluations (whether a specific or cumulative injury) by a QME is:
Sixty (60) minutes. This is the minimum allowable face to face time for an uncomplicated evaluation. (Cal. Code Regs., tit. 8, § 49.9).)
The minimal face to face time for an evaluation for any type of unjustly except for Neuromusculoskeletal, Cardiovascular, Pulmonary, and Psychiatric evaluations (whether a specific or cumulative injury) by a QME is:
Thirty (30) minutes is the minimum allowable face to face time for an uncomplicated evaluation. (Cal. Code Regs., tit. 8, § 49.9).)
A QME who will be unavailable to schedule or perform comprehensive medical evaluations as a Panel QME for a period of (a) __________ or up to a maximum of (b) __________ during a calendar period, for any reason shall notify the Medical Director at least (c) __________ before the period of unavailability is to begin. (Notice of Qualified Medical Evaluator Unavailability, QME Form 109.)
a. 14 days
b. 90 days
c. 30 days
If a QME fails to notify the Medical Director, by submitting the Notice of Qualified Medical Evaluator Unavailability of his or her unavailability at a medical office at least (a) __________ prior to the period the evaluator becomes unavailable, the Medical Director may designate the QME to be unavailable at that location for (b) __________ from the date the Medical Director learns of the unavailability.
a. 30 days
b. 30 days
If the Medical Director does not receive a response within __________ of the date the certified letter is mailed, then the QME will be made unavailable at that location.
fifteen (15) days
The time a QME is placed on unavailable status by the Medical Director counts towards the ___________ limit of unavailability during a calendar year.
ninety (90) day
A QME who has filed notifications for unavailability totaling more than __________ during the QME calendar year without good cause may be denied reappointment.
ninety (90) days
The time frame for an initial or a follow-up comprehensive medical-legal evaluation report to be prepared and submitted shall not exceed __________ after the QME, Agreed Panel QME or AME has seen the employee or otherwise commenced the comprehensive medical-legal evaluation procedure. (Cal. Code Regs., tit. 8, § 38(a).)
thirty (30) days
If there has been a failure to prepare and serve the initial or follow-up comprehensive medical-legal evaluation report within __________ and the evaluator has failed to obtain approval from the Medical Director for an extension of time, the employee or the employer may request a QME replacement.
thirty (30) days
Supplemental reports shall be completed and served no more than __________ from the date of a written or electronically transmitted request to the physician by a party
Sixty (60) days
An extension of the (a) __________ time frame for completing the supplemental report, of no more than (b) __________, may be agreed to by the parties without the need to request an extension from the Medical Director.
a. Sixty (60) day
b. Thirty (30) days
If the injured worker files the Request for Factual Correction of an Unrepresented Panel QME Report (QME form 37), the panel QME shall have __________ after service of the request to review the corrections requested in the form and determine if factual corrections are necessary to ensure the factual accuracy of the comprehensive medical-legal report.
Ten (10) days
If the request for factual correction is filed by the claims administrator or by both parties, the time to review the request for correction shall be extended to __________ after the service of the request for correction.
Fifteen (15) days
If the evaluation will not be completed on the original due date, the evaluator may request an extension from the Medical Director, not to exceed an additional __________.
Thirty (30) days
QMEs shall retain a copy of all comprehensive medical-legal reports completed by the QME for a period of __________ from the date of each evaluation report.
Five (5) years
With regards to temporary disability benefits, for most injuries, payments may not exceed (a) __________ within (b) from the date of injury.
a. 104 weeks
b. Five (5) years
An injured worker could lose their right to benefits if they employer does not learn of their injury within __________.
30 days
The employer must give the worker a DWC 1 claim form __________ after learning about the injury or illness.
within one working day
The employer must authorize treatment __________ of receiving the returned and completed DWC 1 claim form.
within one working day
Bonus info: The employee must complete the employee portion, sign and give it back to their employer. Their employer will then file the claim with the claims administrator.
If the injury is from repeated exposures, the injured worked has __________ from when they realized the injury was job related to file a claim.
One year
The claims administrator has up to __________ to decide whether to accept or deny an injured worker’s claim.
Ninety (90) days
The primary treating physician may be an employer chosen doctor, so they may have treatment responsibility __________ of injury if the employer does not have an medical provider network (MPN)
During the first 30 days
The primary treating physician may be the doctor of the injured worker’s choosing, __________ if the employer does not have an medical provider network (MPN).
After the first 30 days
With some exceptions, state law does not allow a chiropractor to continue as your treating physician after __________ visits. Once you have received __________ chiropractic visits, if you still require medical treatment, you will have to select a new physician who is not a chiropractor.
Twenty-four (24)
All __________ DWC offices throughout the state provide information and assistance on rights, benefits and obligations under California’s workers’ compensation laws.
24
Time employer has to get a PTP (primary treating physician) from their medical provider network (MPN) once they learn of employee injury.
24 hours
In case of a suspected or diagnosed pesticide poisoning, the treating physician must contact the local health officer within __________ and send a copy of the DFR to the address indicated on the Pesticide-Related Illness form.
24 hours
QMEs have to complete (a) ______ of CEs in (b) ______. Passing QME competency course counts for (c) ___ of the (d) _____.
a. 12 hours
b. 2 years
c & d. 6 hour of the 12
Employers must immediately report to OSHA serious injury in more than __________ of hospitalization for something other than observation, loss of a body part, or any serious degree of disfigurement.
24 hours
Decisions to approve a physician’s request for authorization prior to, or concurrent with, the provision of medical services to the injured worker must be communicated to the requesting physician within __________ of the decision.
24 hours
For Represented worker, the party filing the QME request must wait to file form 106 “no earlier than the first working day that is at least (a) ______ after the date of mailing of a request for a medical evaluation pursuant to Section 4060 or (b) __________ that is at least (c) __________ after the date of mailing of an objection pursuant to Sections 4061 or 4062.
a. 10 days
b. The first working day
c. 10 days
The employer must furnish the employee with an Employee’s Claim for Workers’ Compensation Benefits (DWC 1) claim form within ________ of learning of the injury (from any source). The employee must complete and return the form to the employer. A dated copy must be provided to the employee.
One working day
Decisions for expedited Utilization Review must be made in _________ after the receipt of the written information reasonably necessary to make the determination.
72 hours (3 days)
True or false?
Expedited review is when the injured worker’s condition is such that the injured worker faces an imminent and serious threat to his or her health so a normal timeframe is detrimental to worker health.
True
Temporary disability is not paid to injured workers for the first (a) ________ of missed work unless they are hospitalized or miss more than (b) ______ of work.
A. Three (3) days
B. 14 days
Employee may request change in PTP, this should be done by employer within __________.
5 days
When an appointment has been made the QME must submit the QME
Appointment Notification form (Form 110) within __________ of making the appointment.
5 business days
The failure by the QME to serve the appointment notification form within ________ is cause for the issuance of a replacement panel.
5 days
Within __________ of receipt of objection to spinal surgery, the AD (Administrative Director) shall provide a Spine physician randomly selected and located within 30 miles of employee’s address to provide a second opinion.
5 days
The PTP has ______ to get the first report of injury to the employer.
5 days
Employers must complete an Employer’s Report of Occupational Injury or Illness (“Employer’s First Report” Form 5020), within ________ of being notified by the employee of an occupational injury or illness
5 days
The DFR must be filed with the employer’s workers’ compensation insurer or directly with employers if they are self-insured, within _______________ of an injured worker’s first visit to the insurer or self-insured employer.
5 working days
A concurrent or prospective Utilization Review request requires an
affirmative or negative decision no later than _____________ after it is received by an adjuster
5 working days
A concurrent or prospective Utilization Review request requires an
affirmative or negative decision no later than ____________ after it is received by an adjuster. The treating doctor must be informed by phone or fax within _______ of a decision
5 working days
24 hours
Once scheduled, an appointment may not be cancelled by the QME evaluator, or by any party, less than ______________ prior to the appointment date, except for good cause.
six (6) business days
Temporary Disability Benefits Payments must begin within ______ of the employer’s knowledge of the claim and disability, unless the employer contests the claim.
14 days
The employer has ______ from the notification of the injury to contest the claim. If they do not contest it, it is considered compensable.
90 days
If unavailable to schedule or perform comprehensive medical evaluations as a Panel QME for a period of ___ days or up to a maximum of ___ days during a calendar period, for any reason shall notify the Medical Director at least ___ days before the period of unavailability is to begin.
14 days; 90 days; 30 days
If the party fails to provide relevant medical records within ___ days after the date of the evaluation, the evaluator shall complete and serve the report within ___ days of the evaluation to comply with the statutory time frames.
10 days
30 days
If the records were not received within ___ days after the date of the evaluation the evaluator shall note this in the report.
10 days
A dispute about spinal surgery is not handled by a QME or AME, but by a special procedure. If the employer disagrees with the recommendation that the worker needs spinal surgery, the insurer has ___ days from the receipt of the report to object. the worker is represented, the two attorneys can agree to a board certified or board-eligible orthopedic surgeon or neurosurgeon. If they can’t agree in ____ days or the injured worker does not have an attorney, the spinal surgery second opinion procedure is employed. The Administrative Director has a list of eligible surgeons, and the AD selects one randomly to give the opinion within ____ days. The assigned surgeon is not supposed to have any conflict of interests for that particular case. If the spinal surgeon says that the injured worker needs surgery, the insurer has to provide the surgery. Otherwise, the insurer can take the issue to court.
10 days; 10 days; 5 days
If the opposing party objects to sending non-medical records (such as a video tape) within ____ days thereafter, the records shall not be provided to the evaluator.
10 days
Am unrepresented IW has ___ days to choose his QME after the QME panel has been randomly generated.
10 days
If IW does not make the choice for a QME in ____ days then the insured will have to select the QME for the IW, also has ____ days to do so.
10 days; 10 days
A represented worker has ___ days to select an AME. There is a ___ day extension if agreed upon.
10 days; 20 days
If no AME agreed upon a QME panel will be given. The represented worker has ___ days to make a selection.
10 days
If no QME selection is made by the represented worker in ___ days, each party may strike one name from the list. If a party does not strike a name in ___ days, the other party may make the selection of the evaluator. The party submitting the request shall determine the specialty of the QME.
10 days; 3 days
Represented IW has ____ days to make an appointment with QME. If they don’t, the employer may arrange the appointment and tell the IW what the date/time are.
10 days
In the case of a represented employee with an objection to the PTP’s findings, the employer and the employee must wait at least the ___ day waiting period, plus ___ days for mailing an objection before DWC can assign a QME.
10 day; 5 days
____ days after the QME panel is issued the injured worker is required to: select a physician from the panel, make an appointment for the examination, & inform the claims administrator of the selection and the appointment.
10 days
10 days after the QME panel is issued the injured worker is required to
A. select a physician from the panel
B. make an appointment for the examination
C. inform the claims administrator of the selection and the appointment.
D.All of the above
E. Only A & B
F. Only A & C
G. Only B & C
D. All of the above
10 days after the QME panel is issued the injured worker is required to:
A. select a physician from the panel
B. make an appointment for the examination
C. inform the claims administrator of the selection and the appointment.
If the injured worker files the Request for Factual Correction of an Unrepresented Panel QME Report (QME form 37), the panel QME shall have ____ days after service of the request to review the corrections requested in the form and determine if factual corrections are necessary.
10 days
If the request for factual correction is filed by the claims administrator or by both parties, the time to review the request for correction shall be extended to ____ days after the service of the request for correction.
15 days
UR decision must then be made within _____ of the Request for Authorization - RFA. If such additional information is not received within ____, the request will be denied
14 calendar days from the date of first receipt
14 days from the date of submission
