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QME > TIME AND TIMELINES > Flashcards

TIME AND TIMELINES Flashcards

1
Q

How many hrs/days does the employer have to get a PTP from their MPN once they learn of an employee injury?

A

24 hrs

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2
Q

Pesticide poisoning, PTP must inform local health center & send a copy of DFR within…

A

24 hrs

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3
Q

CME for QME is ….. hrs in …years

A

12 hrs in 2 years. Passing QME is 6 hrs

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4
Q

Employer must immediately report to OSHA a serious injury in more than ….hrs of hospitalization except obs, loss of body part or disfigurement

A

24 hrs

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5
Q

PTP must be notified that his request for authorization prior or concurrent with provision of med care is approve is..

A

24 hrs

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6
Q

For represented worker, the party filing QME request must wait to file 106 form no earlier than…

A

the first working day that is at least 10 days after the mailing of a request (4060)/objection (4061-62) for med eval

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7
Q

After employer learns about an injury (from any source), he must provide IW Employee’s Claim for WCB claim (DWC1) within…

A

1 working day. It must be dated. IW fills it out & returns to boss

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8
Q

Decisions for expedited Utilization Review are made in…

A

72 hrs (after the receipt of written information reasonably necessary to make a decision)

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9
Q

Temporary disability is not paid for IW for …. (hrs/days) unless they are hospitalized/miss work for more than 14 days

A

3 days

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10
Q

If employee requests a change in PTP, in how many days should employer do that?

A

5 days

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11
Q

An app is made, QME must submit Appointment Notification form (110) within..

A

5 days

If QME doesn’t do it, a replacement QME panel may be issued

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12
Q

In how many days of spinal surgery rejection (receipt of objection) should AD find a 2nd opinion?

A

5 days

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13
Q

How soon should PTP get DFR to employer?

A

5 days

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14
Q

After employer learns of an injury, how soon should he complete “Employer’s First Report” (form 5020)/ Employer’s Report of Occupational Injury or Illness?

A

5 days

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15
Q

PTP has to file DFR in…

A

5 days for ANY suspected work-related injury. Within 5 days of IW’s 1st visit

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16
Q

A concurrent or prospective Utilization Review REQUEST must get a yes or no decision in… how many days after being received by an adjuster?

A

5 working days

PTP must be informed by phone/fax in 24 hrs

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17
Q

Once scheduled, an appointment can not be canceled by QME or any party in ….day, except for good cause.

A

6 biz. days

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18
Q

Temporary Disability Benefits payments must begin within…. days of the employer’s knowledge of the claim

A

14 days (unless the employer contests (objects) the claim.

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19
Q

Employer has …. days from the notification of the injury to contest the claim. If he doesn’t, the injury is compensable.

A

90 days

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20
Q

QME has to let MD (medical director) know of being unavailable to schedule or perform medical eval if QME is unavailable for how long?

A

14-90 days max

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21
Q

How much in advance should QME notify medical director of being unavailable to perform or schedule an eval?

A

30 days before the period of unavailability

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22
Q

If the party fails to provide necessary medical records within 10 days of QME eval, QME should still complete her report within..

A

30 days of eval and note in the report that records were not received within 10 days of eval.

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23
Q

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.

A

10 days
10 days
5 days

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24
Q

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?

A

Within 10 days

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25
Q

Unrepresented IW has …. days to choose his QME after panel has been randomly generated.

A

10 days

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26
Q

If unrepresented IW doesn’t make a choice of his QME in … days then the insured can make this choice for him in ….days.

A

10 days and 10 days

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27
Q

A represented IW has…. days to select an AME.

This can be extended if agreed upon for… days.

A

10 days

20 days

28
Q

Represented IW. If no AME agreed upon, then IW has …days to choose a QME.

A

10 days

29
Q

How many days for each party to strike out 1 QME name from the panel?
If they don’t, then another party choses a QME.

A

3 days

30
Q

The party that submitted the request for QME shall determine his/her…?

A

Specialty of the QME

31
Q

Represented IW. After QME is selected, IW has … days to make an appointment with QME. If they don’t, the boss will arrange it.

A

10 days

32
Q

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.

A

10 days waiting period

5 days for mailing an objection

33
Q

…. days after a QME panel is issued, an IW must:

  • select a physician (QME)
  • make an app w/ QME for an exam
  • let claims admin know about QME name & exam date
A

10 days

34
Q

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.

A

10 days for unrep and 15 days for rep IW or if the request was filed by the both parties or the claims admin.

35
Q

Within …. days of the Request for Authorization, the UR decision must be made.

A

14 days. If no additional info submitted within 14 days from the date of submission, then request will be denied.

36
Q

PTP must report results of consults, results of other Drs reports or changes in IW condition in … days after receiving them.

A

20 days

37
Q

AD shall calculate PD (perm disability) rating and serve it on the boss & IW within…. days of the receipt of a med. eval.

A

20 days

38
Q

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.

A

20 days

39
Q

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?

A

20 days unless good cause

40
Q

Either party may object PTP’s med. determination by notifying the other party in writing in how many days?
rep vs unrep IW

A

represented IW- 20 days

unrepresented- 30 days

41
Q

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.

A

20 days

42
Q

If employer doesn’t provide a new PTP within … days, then IW can choose one himself.

A

30 days

* normally within 5 days boss should provide a new PTP if IW requests.

43
Q

If the employer doesn’t have an MPN & didn’t provide a new PTP within 30 days, then IW can chose their…

A

personal chiro or acupuncturist if they are pre-designated. . Otherwise boss has control over 1st 30 days of who the PTP is.

44
Q

IF QME has to cancel scheduled app, she must tell the parties in writing the reason and reschedule within ….days of cancelation.

A

30 days

45
Q

When UR is RETROSPECTIVE, decisions must be communicated to PTP who requested med. services and IW/his lawyer within… days.

A

30 days

46
Q

To get the money, IW has to tell the boss about the injury within … days of injury.

A

30 days

47
Q

3 reasons for ineligibility for IMR:

A
  • didn’t submit IMR application within 30 days of adverse UR determination
  • didn’t sign IMR application
  • dispute reg. liability
48
Q

IMR decision must be provided to all parties in layterms within how many days of the receipt of the request for review?

A

30 days and 72 hrs for expedited request

49
Q

How to appeal IMR and in what time frame?

A

Filing a petition before a WCAB judge within 30 days of the mailing of the final determination.

50
Q

If you file a petition to appeal IMR, what can WCAB judge do?

A

He can not make a finding of medical necessity contrary to the final determination of IMR but judge can order a repeat IMR decision to be performed by different Drs.

51
Q

PTP must report on IW’s condition every… days.

A

45 days

52
Q

In how many days after the PTP’s report, shall 2nd opinion spine report be served to all partied?

A

45 days

53
Q

PTP progress report are submitted within every … days and … days if any exam occurs.

A

45 days and 20 days.

54
Q

QME has to provide an appointment no later than … days from the request.

A

60 days

* it can be extended up to 90 days from the request if the requesting party is OK with that.

55
Q

The re-scheduled appointment date may not be more than … calendar days from the date of the INITIAL request (unless parties agree in writing).

A

60 days

56
Q

Supplemental reports must be completed and served no later than…. days since the request.

A

60 days from the request.

57
Q

Supplemental report deadline may have extended for no more than… days.

A

30 days if agreed by both parties.

58
Q

Employer has … days to give return to work dater after the RTW and voucher report.

A

60 days.

59
Q

If employer doesn’t provide a return to work DATE 60 days after the RTW and voucher report, then what kicks in?

A

SJBD.

6K. 1K towards computer. The rest is resume, job search, exam fees etc.

60
Q

Employee has … years to use SJDB or within … years of DOI.

A

2 years or 5 years.

61
Q

In how many days must QME hand in her report after an exam/appointment ?

A

30 days

62
Q

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?

A

15 days

63
Q

QME may be denied reappointment if she was made unavailable for more than… days during a calendar year.

A

90 days

64
Q

The boss (insurer) has … days to accept or deny IW’s claim. In the meantime, IW may receive $….. worth of treatment.

A

90 days

$10,000

65
Q

Employers who contract with HCO can direct tx of IW up to … days.

A

90 or 180 days following an injury.

66
Q

QME has to schedule a deposition within .. days.

A

120 days. It takes place w/in 20 miles where IW’s eval took place.

67
Q

Temporary disability may last up to… week within … years from the DOI for injuries from 1/1/2008.

A

2 years (104 weeks) , 5 years

QME (2 decks)

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