Notes

employees have to predesignate a doctor (primarily before hiring) to see that doctor not in the MPN
- doctor has to agree to work with workers comp
psych injuries are more complex
- send to a more experienced claims adjuster
- possibility to be indemnity
claims adjuster (me) must determine whether claim is accepted or denied
- must also let workers know within this 14 days
Delay:
- cant reach anyone, hard to determine
- adjuster has 90 days starting when the employer was made aware to determine
- also have to send delay w/in 14 days if not, generally accepted

MEDICAL CARE:
- "reasonable and necessary" claims adjuster does not have to determine what this is, separate dept. for utilization review (UR)
- limits:
- ex. chiropractic (usually sessions of 6)
if after 30 sessions, no improvement, its not "reasonable or necessary" anymore
- if worker disagrees about UR, they can get an IMR, through state (3rd party)
- IMR tells us their determination
- may take up to 40 days, worker should not get that care within this window
- if they get this treatment and IMR determines that we are right, we will not pay for the treatment (or negotiate)

Employers are not entitled to full medical records. Do not disclose.
- they will instead get a 1 page overview from provider (work status report(?)) : w/ work restrictions, etc.

We are not entitled to medical reports before injury, employee needs to sign disclosure
- CA Workers Comp Claim Board, petition for reports to be released if absolutely necessary

QME:
- medical LEGAL evaluators
- immediately indemnity

First 3 days, claims is not responsible for benefits
- if they miss more than 14 days or get hospitalized, we retroactively pay for 3 days