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Additionally, your doctor's treatment plan may be reviewed by a third party hired by the claims administrator. This process is called utilization review (UR). All claims administrators are required by law to have a UR program. They use UR to decide whether or not to approve treatment recommended by your doctor.




Doctor Who Am I


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A. UR is the program claims administrators use to make sure the treatment you receive is medically necessary. All claims administrators are required by law to have a utilization review program. This program will be used to decide whether or not to approve medical treatment recommended by your doctor.


A. A medical provider network (MPN) is a group of health care providers set up by your employer's insurance company and approved by DWC's administrative director to treat workers injured on the job. Each MPN includes a mix of doctors specializing in work-related injuries and doctors with expertise in general areas of medicine. If your employer is in an MPN your workers' compensation medical needs will be taken care of by doctors in the network unless you were eligible to predesignate your personal doctor and did so before your injury happened.


A. This is a process you can use to tell your employer you want your personal physician to treat you for a work injury. You can predesignate your personal doctor of medicine (M.D.) or doctor of osteopathy (D.O.) only if the following conditions are met:


A. If your employer or your employer's insurer does not have a MPN, you may be able to change your treating physician to your personal chiropractor or acupuncturist following a work-related injury or illness. In order to be eligible to make this change, you must give your employer the name and business address of a personal chiropractor or acupuncturist in writing prior to the injury or illness. There is a form you can use called the notice of personal chiropractor or personal acupuncturist. After your claims administrator has initiated your treatment with another doctor during the first 30 day period, you may then, upon request, have your treatment transferred to your personal chiropractor or acupuncturist.


A. If you disagree with your MPN doctor about your treatment, you can change to another physician on the MPN list. You can also ask for a 2nd and 3rd opinion from different MPN doctors. If you still disagree, you can have an IMR to resolve the dispute. See the information on your MPN provided by your employer.


You, your treating doctor, your employer and your attorney (if you have one) should review your job description and discuss the changes needed in your job. For example, your employer might give you a reduced work schedule or have you spend less time on certain tasks.


If you are represented, your attorney and the claims administrator may agree on a doctor to examine you. To receive a list of QMEs to choose from, complete the panel request form (QME 105) and mail it to the DWC Medical Unit. Ask your treating physician to help if you don't know what kind of doctor should look at your injury.


You have 10 days from the date the list is printed and mailed to select a QME from the list, make an appointment and tell the insurance company which doctor you picked and the date of your appointment. If you don't do this within 10 days, the insurance company will have the right to pick the doctor you'll see and make the appointment.


A. You might need to see a QME if the insurance company disagrees with something in your claim. In that case, the insurance company will give you the form to request a QME. When this happens, you have 10 days to request a QME list by sending the form to the DWC Medical Unit. If you don't send the form within 10 days of receiving it, the insurance company will have the right to request the QME list and select the kind of doctor you'll see.


You have 10 days from the date the list is printed and mailed to select a QME from the list, make an appointment and tell the insurance company which doctor you picked, and the date of your appointment. If you don't do this within 10 days, the insurance company will have the right to pick the doctor you'll see and make the appointment.


A. The DWC Medical Unit certifies QMEs in different medical specialties. A QME must be a physician licensed to practice in California. QMEs can be medical doctors, doctors of osteopathy, chiropractors, psychologists, dentists, optometrists, podiatrists or acupuncturists.


A. If you have an attorney, your attorney and the claims administrator may agree on a doctor without using the state system for getting a QME. The doctor they agree on is called an agreed medical evaluator (AME). If they cannot agree, they must ask for a QME panel list.


A. You and/or the claims administrator might disagree with what the treating doctor says. There could be other disagreements over medical issues in your claim. A doctor has to address those disagreements. You might disagree over:


A. TD payments begin when your doctor says you can't do your usual work for more than three days or you get hospitalized overnight. Payments must be made every two weeks. Generally, TD stops when you return to work, or when the doctor releases you for work, or says your injury has improved as much as it's going to. If you were injured after Apr. 19, 2004, your TD payments won't last more than 104 weeks within a period of 2 years from the first payment for most injuries. If you were injured after Jan. 1, 2008, your TD payments won't last more than 104 weeks within a period of 5 years from the date of your injury. Payments for a few long-term injuries such as severe burns or chronic lung disease can go longer than 104 weeks. TD payments for these injuries can continue for up to 240 weeks of payment within a five-year period.


A. A doctor determines if your injury or illness caused PD. After your doctor decides your injury or illness has stabilized and no change is likely, PD is evaluated. At that time, your condition has become permanent and stationary (P&S). Your doctor might use the term maximal medical improvement (MMI) instead of P&S.


Once you are P&S or have reached MMI, your doctor will send a report to the claims administrator telling them you have PD. The doctor also determines if any of your disability was caused by something other than your work injury. For example, a previous injury or other condition. Assigning a percentage of your disability to factors other than your work injury is called apportionment.


A. If you or the claims administrator disagrees with your doctor's findings you can be seen by a doctor called a QME. You request a QME list (called a panel) from the DWC Medical Unit. The claims administrator will send you the forms to request a QME. Your employer will pay for the cost of the QME exam. You have 10 days from the date the claims administrator tells you to begin the QME process to submit your request form to the DWC Medical Unit. If you do not submit the form within 10 days, the claims administrator will do it for you and will get to choose the kind of doctor you'll see.


When you receive the list of QMEs from the DWC Medical Unit you have to select a doctor, set up an exam and tell the claims administrator about your appointment. If you do not make the appointment within 10 days, the claims administrator may pick the doctor and make the appointment for you.


If you have an attorney, he or she can help you pick a QME or you can be evaluated by AME. An AME is the doctor your attorney and the claims administrator agree on to do your medical examination. In this case you should discuss your options with your attorney.


A. After your examination the doctor will write a medical report about your impairment. Impairment means how your injury affects your ability to do normal life activities. The report includes whether any portion of your disability was caused by something other than your work injury. The doctor's report ends with an impairment number.


A. PD benefits are normally paid when TD benefits end and your doctor indicates you have some permanent effects from your injury. The claims administrator must begin paying your PD payments within 14 days after TD ends. The claims administrator picks which day to pay you and will continue to make payments every two weeks until a reasonable estimate of your disability amount has been paid.


A. After the amount of PD in a claim is determined, there is usually a settlement or award for benefits. This award must be approved by a workers' compensation administrative law judge. If you have an attorney, your attorney should help you obtain this award. If you don't have an attorney, the claims administrator should help you obtain the award. You can also get help from the I&A officer at the local DWC district office. If your doctor said further medical treatment for your injury or illness might be necessary, the award may provide future medical care.


In all of these situations your PD payments will likely begin before the final decision about the amount of your PD is reached. That's because, once your doctor says you have permanent disability, the claims administrator will estimate how much you should receive and begin making payments to you before the final percentage of disability has been calculated.


A. Injured workers who return to the job as soon as medically possible have the best outcomes. They recover from their injuries faster and suffer less wage loss. Your decision about returning to work will be influenced by your doctor, your employer and the claims administrator. Communicate honestly and frequently with them for the best results.


Sometimes doctors and claims administrators do not fully understand your job or other jobs that could be assigned to you. That's why it is important that everyone stay in close contact throughout the process. You (and your attorney if you have one) should actively communicate with your treating doctor, your employer and the claims administrator about: 041b061a72


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