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State of California

Department of Insurance

45 Fremont Street

San Francisco, California 94105

CALIFORNIA CODE OF REGULATIONS, TITLE 10

CHAPTER 5, SUBCHAPTER 3

ADOPT ARTICLE 20 TO READ:

Article 20. Standards Applicable to Workers' Compensation Claims Adjusters and Medical Billing Entities and Certification of those Standards by Insurers.

Section 2592 Authority and Purpose

These regulations are promulgated pursuant to authority granted to the Insurance Commissioner under the provisions of Section 11761 of the California Insurance Code. The purpose of these regulations is to set forth the minimum standards of training, experience, and skill that workers' compensation claims adjusters, including adjusters working for medical billing entities, must possess to perform their duties with regard to workers' compensation claims and to specify how insurers must meet those standards.

NOTE: Authority and reference cited: Section 11761 of the Insurance Code

Section 2592.01 Definitions

For purposes of these regulations:

(a) "Certify" means a written statement made under penalty of perjury.

(b) "Claims adjuster" means a person who, on behalf of an insurer, is responsible for determining the validity of a workers' compensation claim, including a "medical only" claim. The adjuster may also establish a case reserve, approve and process indemnity and medical benefits, may hire investigators, attorneys or other professionals and may negotiate settlements of claims. "Claims adjuster " also means a person who is responsible for the immediate supervision of a claims adjuster but does not mean an attorney representing the insurer or a person whose primary function is clerical.

(c) "Classroom" means any space sufficiently designed so that the instructor and students can communicate with a high degree of privacy and relative freedom from outside interference. The instructor may be physically present or may communicate with students by means of an electronic device.

(d) "Course" means any program of instruction taken or given to satisfy the requirements of Insurance Code Section 11761.

(e) "Curriculum" means a course of study that satisfies the requirements of Insurance Code Section 11761. The curriculum must provide sufficient content, including time allocated to each subject area, to enable claims adjusters to meet minimum standards of training, experience, and skill to perform their duties with regard to workers' compensation claims.

(f) "Experienced claims adjuster" means a person who has had at least five years within the past eight years of on-the-job experience adjusting California workers' compensation claims and has been certified as an experienced claims adjuster by an insurer. A person who has successfully completed the written examination specified by Title 8, Section 15452 of the California Code of Regulations is an experienced claims adjuster, provided that he or she has either worked as a workers' compensation claims adjuster continuously since passing the examination; had at least five years of experience working with California workers' compensation within the past eight years; or has passed the examination within the previous five years.

(g) "Experienced medical-only claims adjuster" means a person who has had at least three years within the past five years of on-the-job experience adjusting California workers' compensation medical-only claims and has been designated as an experienced medical-only claims adjuster by an insurer or a person meeting the training requirements of this regulation and certified by an insurer.

(h) "Instructor" means a person who conveys curriculum content to students on behalf of an insurer, a training entity, or a medical billing entity. An instructor shall have at least eight (8) years of experience in the workers' compensation system in the previous 12 years, including at least four years of experience with California workers' compensation. Persons knowledgeable about specific workers' compensation issues may train students under the supervision of an instructor.

(i) "Insurer" means an insurance company admitted to transact workers' compensation insurance in California, the State Compensation Insurance Fund, an employer that has secured a certificate of consent to self-insure from the Department of Industrial Relations pursuant to Labor Code Section 3700(b) or (c) or a third party administrator that has a secured a certificate of consent pursuant to Labor Code Section 3702.1.

(j) "Medical billing entity" means an entity that is not an insurer as defined herein that reviews or adjusts workers' compensation medical bills for an insurer.

(k) "Post-certification training" means a course of study provided to trained and/or experienced workers' compensation claims adjusters. Post-certification training also includes seminars, workshops, or other informational meetings pertaining to California workers' compensation.

(l) "Student" means an individual taking a course that is required for that person in order to be a workers' compensation claims adjuster.

(m) "Training" means to provide a course of instruction that includes the topics specified in Sections 2592.04 and 2592.05.

NOTE: AUTHORITY and reference cited: Section 11761 of the Insurance Code

Section 2592.02 Training Required For Claims Adjusters

NOTE: AUTHORITY and reference cited: Section 11761 of the Insurance Code

Section 2592.03 Curriculum

(a) The course of study required by Section 2592.02 for claims adjusters who handle claims that include both medical and indemnity benefits shall include but not be limited to the following topics:

1. Historical overview of the workers' compensation system.

2. Organizational structure of the system.

3. The workers' compensation insurance policy, its forms and endorsements, insurance principles of compensation.

4. Concepts and terminology.

5. Benefit provisions.

6. Compensability.

7. Notice requirements.

8. Temporary disability.

9. Permanent disability, including evaluation and rating.

10. Death benefits.

11. Return to work and vocational rehabilitation.

12. Cumulative trauma.

13. Serious and willful misconduct.

14. WCAB procedures, forms, hearings, and penalties.

15. Investigation.

16. Fraud.

17. Medical terminology.

18. Knowledge and use of utilization guidelines (American College of Occupational and Environmental Medicine or other guidelines approved by the Administrative Director of the Division of Workers' Compensation.)

19. Medical evidence.

20. Fee schedules.

21. Liens.

22. Apportionment.

23. Subrogation.

24. Reserving.

25. Ethical issues.

(b) The course of study required for the training of claims adjusters who adjust only claims where medical benefits and not indemnity benefits are provided or at issue, shall include, at a minimum, topics relevant to workers' compensation medical care and benefits.

(c) The course of study required by Section 2592.02(d) shall include changes in the law that affect workers' compensation claims and other topics relevant to the work of a trained and/or experienced claims adjuster.

NOTE: AUTHORITY and reference cited: Section 11761 of the Insurance Code

Section 2592.04 Training Required for Medical Bill Reviewers


Entities that review medical bills on behalf of an insurer shall require all personnel employed as bill reviewers to be trained. The medical bill review entity shall require at least 40 hours of training for medical bill reviewers, at least 30 hours of which shall be conducted in a classroom by an instructor. No more than 10 hours of training may be on-the-job training.

NOTE: AUTHORITY and reference cited: Section 11761 of the Insurance Code

Section 2592.05 Accreditation

(a). A Certificate of Completion in the form and manner determined by the commissioner shall be provided by the insurer or medical billing entity to any person who successfully completes the adjuster training, including the curriculum subjects required by section 2592.03 herein or the medical bill review training required by Section 2592.04, respectively.

(b). An Experienced Claims Adjuster Certificate in the form and manner determined by the commissioner shall be provided by the insurer or training entity sponsored by the insurer to any person who has at least five years of on-the-job experience of handling workers' compensation claims in California within the past eight years and has successfully completed the post-certification training including the curriculum subjects required by section 2592.03.

(c) Upon request by a policyholder or an injured worker whose claim is being adjusted by a claims adjuster, the insurer employing the claims adjuster shall provide a copy of the claims adjuster's Certificate of Completion or Experienced Claims Adjuster Certificate to the requesting policyholder or injured worker.

NOTE: AUTHORITY and reference cited: Section 11761 of the Insurance Code

Section 2592.06 Maintenance of Records

(a) An insurer shall maintain records pertaining to the training of the adjusters in its employ for whom training has been provided or sponsored, or who were trained by another insurer, for eight (8) years after the adjuster has completed the training. If the trained claims adjuster is employed by an insurer other than the insurer providing the training, the insurer that provided the training shall send copies of the adjuster's records pertaining to training to the insurer employing the adjuster within 20 days after a request for the records has been sent. The records which shall be kept in the form and manner specified by the commissioner shall contain the following information:

(1). Name and address of adjuster.

(2). Date training completed.

(3). Name, address, and telephone number of training entity.

(b) All insurers shall maintain a record of all courses given to comply with this chapter. The record shall include:

Section 2592.07 Submission of Documents


NOTE: AUTHORITY and reference cited: Section 11761 of the Insurance Code

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Last Revised - August 25, 2004
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