Section 4603.6 Of Article 2. Medical And Hospital Treatment From California Labor Code >> Division 4. >> Part 2. >> Chapter 2. >> Article 2.
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.