Cal. Code Regs. Tit. 8, § 10112.1 - Definitions
As used in this article:
(a) "Adjusting location" means the office
where claims are administered. Separate underwriting companies, employers that
are both self-administered and self-insured, and/or third-party administrators
operating at one location shall be combined as one adjusting location only if
claims are administered under the same management at that location. Where
claims are administered from an office that includes a satellite office at
another location, claims administered at the satellite office(s) will be
considered as part of the single adjusting location for investigation and
auditing purposes under this article when it is demonstrated that the claims
are under the same immediate management.
(b) "Administrative Director" means the
Administrative Director of the Division of Workers Compensation, including his
or her designee.
(c) "Claim" means
a request for compensation, or record of an occurrence in which compensation
reasonably would be expected to be payable for an injury arising out of and in
the course of employment.
(d)
"Claim file" means a record in paper or electronic form, or any combination,
containing all of the information specified in section
10101.1 of Title 8 of the
California Code of Regulations and all documents or entries related to the
provision, payment, delay, or denial of benefits or compensation under
Divisions 1, 4 or 4.5 of the Labor Code.
(e) "Claims administrator" means a
self-administered workers' compensation insurer; a self-administered
self-insured employer; a self-administered legally uninsured employer; a
self-administered joint powers authority; or a third-party claims administrator
for an insurer, a self-insured employer, a legally uninsured employer or a
joint powers authority.
(f)
"Compensation" means every benefit or payment, including vocational
rehabilitation, supplemental job displacement benefits, medical treatment,
medical and medical-legal expenses, conferred by Divisions 1 and 4 of the Labor
Code on an injured employee or the employee's dependents.
(g) "Compensation order" means any award,
order or decision issued by the Workers' Compensation Appeals Board or the
Division of Workers' Compensation vocational rehabilitation unit by which a
party is entitled to payment of compensation.
(h) "Concurrent medical treatment
authorization" means authorization requested or provided during an inpatient
stay.
(i) " Determination and
Order" means Determination and Order in re Labor Code §
5814.6
Administrative Penalties.
(j)
"Employee" means every person in the service of another, as defined under
Article 2 of Chapter 2 of Part 1 of Division 4 of the Labor Code (Sections
3350 et seq.), or in the case of
the employee's death, his or her dependent, as each is defined in Division 4 of
the Labor Code, or the employee's or dependent's agent or attorney.
(k) "Employer" shall have the same meaning as
the word 'employer' as defined in Division 4 of the Labor Code (sections
3300 et seq.).
(l) "General business practice" means a
pattern of violations of Labor Code section
5814 at a
single adjusting location that can be distinguished by a reasonable person from
an isolated event. The pattern of violations must occur in the handling of more
than one claim. The pattern of violations may consist of one type of act or
omission, or separate, discrete acts or omissions in the handling of more than
one claim. However, where a claim file with a violation of Labor Code section
5814 has been
adjusted at multiple adjusting locations, that claim file may be considered
when determining the general business practice of any of the adjusting
locations where the conduct that caused the violation occurred even if the file
has been transferred to a different adjusting location.
(m) "Indemnity" means payments made directly
to an eligible person as a result of a work injury and as required under
Division 4 of the Labor Code, including but not limited to temporary disability
indemnity, salary continuation in lieu of temporary disability indemnity,
permanent disability indemnity, vocational rehabilitation temporary disability
indemnity, vocational rehabilitation maintenance allowance, life pension and
death benefits.
(n) "Insurer" means
any company, group, or entity in, or which has been in, the business of
transacting workers' compensation insurance for one or more employers subject
to the workers' compensation laws of this state. The term insurer includes the
State Compensation Insurance Fund.
(o) "Investigation" means the process used by
the Administrative Director, or his or her designee, pursuant to Section
10112.2 and/or Government Code
sections
11180
through
11191, to
determine whether a violation of Labor Code section
5814.6 has
occurred, including but not limited to reviewing, evaluating, copying and
preserving electronic and paper records, files, accounts and other things, and
interviewing potential witnesses.
(p) "Joint powers authority" means any
county, city, city and county, municipal corporation, public district, public
agency, or political subdivision of the state, but not the state itself,
included in a pooling arrangement under a joint exercise of powers agreement
for the purpose of securing a certificate of consent to self-insure workers'
compensation claims under Labor Code Section
3700(c).
(q) "Knowingly" means acting with knowledge
of the facts of the conduct at issue. For the purposes of this article, a
corporation has knowledge of the facts an employee receives while acting within
the scope of his or her authority. A corporation has knowledge of information
contained in its records and of the actions of its employees performed in the
scope and course of employment. An employer or insurer has knowledge of
information contained in the records of its third-party administrator and of
the actions of the employees of the third-party administrator performed in the
scope and course of employment.
(r)
"Notice of Assessment" means Notice of Labor Code §
5814.6
Administrative Penalty Assessment.
(s) "Penalty award" means a final order or
final award by the Workers' Compensation Appeals Board to pay penalties due to
a violation of section
5814 of the
Labor Code.
(t) "Petition Appealing
Determination and Order" means Petition Appealing Determination and Order of
the Administrative Director in re Labor Code §
5814.6
Administrative Penalties.
(u)
"Proof of service" means an affidavit or declaration made under penalty of
perjury and filed with one or more documents required to be filed, setting out
a description of the document(s) being served, the names and addresses of all
persons served, whether service was made personally or by mail, the date of
service, and the place of service or the address to which mailing was
made.
(v) "Prospective medical
treatment authorization" means authorization requested or provided prior to the
delivery of the medical services.
(w) "Recommended Determination and Order"
means Recommended Determination and Order in re Labor Code §
5814.6
Administrative Penalties.
(x)
"Retrospective medical treatment authorization" means authorization requested
or provided after medical services have been provided and for which services
approval has not already been given.
(y) "Salary continuation" means payment made
to an injured employee as provided under Division 4 of the Labor
Code.
(z) "Serve" means to file or
deliver a document or to cause it to be delivered to the Administrative
Director or his or her designee, or to such other person as is required under
this article.
(aa) "Stipulated
Order" means a Notice of Assessment that was timely paid.
(bb) "Supplemental job displacement benefits"
means benefits as described under Labor Code section
4658.5 and
sections 10133.50-10133.59 of Title 8 of the
California Code of Regulations.
(cc) "Third-party administrator" means an
agent under contract to administer the workers' compensation claims of an
insurer, a self-insured employer, a legally uninsured employer, a self-insured
joint powers authority or on behalf of the California Insurance Guarantee
Association. The term third-party administrator includes the State Compensation
Insurance Fund for locations that administer claims for legally uninsured and
self-insured employers, and also includes managing general agents.
(dd) "Utilization review files" means those
files, documents or records, whether paper or electronic, containing
information that documents an employer or insurer utilization review process
required under Division 4 of the Labor Code.
(ee) "Workers' Compensation Appeals Board"
means the Appeals Board, commissioners, deputy commissioners, presiding
workers' compensation judges and workers' compensation administrative law
judges.
Notes
Note: Authority cited: Sections 133, 5307.3 and 5814.6, Labor Code. Reference: Sections 129.5, 139.48, 5814 and 5814.6, Labor Code.
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