Workers’ Compensation Claims Adjuster Regulations

Insurance Code Section 11761 and Title 10, California Code of

Regulations Section 2592, et seq., effective February 22, 2006

Insurance Code Section 11761Insurance Code Section 11761

(a)(a) The commissioner shall adopt regulations setting The commissioner shall adopt regulations setting forth the minimum standards of training, forth the minimum standards of training, experience, and skill that workers' compensation experience, and skill that workers' compensation claims adjusters must possess to perform their claims adjusters must possess to perform their duties with regard to workers' compensation duties with regard to workers' compensation claims. The regulations adopted pursuant to this claims. The regulations adopted pursuant to this section shall, to the greatest extent possible, section shall, to the greatest extent possible, encourage the use of existing private and public encourage the use of existing private and public education, training, and certification programs.education, training, and certification programs.

(b)(b) Every insurer shall certify to the commissioner that Every insurer shall certify to the commissioner that the personnel employed by the insurer to adjust the personnel employed by the insurer to adjust workers' compensation claims, or employed for workers' compensation claims, or employed for that purpose by any medical billing entity with that purpose by any medical billing entity with which the insurer contracts, meet the minimum which the insurer contracts, meet the minimum standards adopted by the commissioner pursuant standards adopted by the commissioner pursuant to subdivision (a). to subdivision (a).

Insurance Code Section 11761 Insurance Code Section 11761 (continued)(continued)

(c)(c) For the purposes of this section, "medical billing For the purposes of this section, "medical billing entity" means a third party that reviews or entity" means a third party that reviews or adjusts workers' compensation medical bills for adjusts workers' compensation medical bills for insurers.insurers.

(d)(d) For the purposes of this section, "insurer" means For the purposes of this section, "insurer" means an insurer admitted to transact workers' an insurer admitted to transact workers' compensation insurance in this state, the State compensation insurance in this state, the State Compensation Insurance Fund, an employer that Compensation Insurance Fund, an employer that has secured a certificate of consent to self-insure has secured a certificate of consent to self-insure pursuant to subdivision (b) or (c) of Section 3700 pursuant to subdivision (b) or (c) of Section 3700 of the Labor Code, or a third-party administrator of the Labor Code, or a third-party administrator that has secured a certificate of consent pursuant that has secured a certificate of consent pursuant to Section 3702.1 of the Labor Code. to Section 3702.1 of the Labor Code.

Who is an Insurer?Who is an Insurer?

Insurer Admitted to write workers’ Insurer Admitted to write workers’ compensation in Californiacompensation in CaliforniaSCIFSCIFSelf-Insured EmployerSelf-Insured EmployerThird-Party Administrator per Labor Code Third-Party Administrator per Labor Code Section 3702.1 [for self-insured employer]Section 3702.1 [for self-insured employer]

Insurer defined in Subdivision (d) of Insurer defined in Subdivision (d) of Insurance Code Section 11761Insurance Code Section 11761

Who is NOT an Insurer?Who is NOT an Insurer?

Medical Billing EntityMedical Billing Entity Third-Party Administrator for Third-Party Administrator for

Admitted InsurerAdmitted Insurer

Certification to theCertification to theInsurance CommissionerInsurance Commissioner

• Each Insurer shall certify to the Insurance Commissioner annually on or before July 1 that they have complied with the requirements established by these regulations.

• Only Insurers are to certify; not medical billing entities.

• Certification format contained in regulations.• Two Certifications: Claims Adjusters and

Medical Bill Reviewers.

Training and/or ExperienceTraining and/or ExperienceClaims Adjusters and Medical Bill Claims Adjusters and Medical Bill

Reviewers can either meet training or Reviewers can either meet training or experience requirements to be Designated experience requirements to be Designated by an Insurer to adjust California Workers’ by an Insurer to adjust California Workers’ Compensation Claims.Compensation Claims.A person can adjust or review medical bills A person can adjust or review medical bills for up to 12 consecutive months during for up to 12 consecutive months during training while under the supervision of an training while under the supervision of an instructor or experienced claims adjuster.instructor or experienced claims adjuster.

Training RequirementsTraining RequirementsClaims Adjusters: 160 hours of training Claims Adjusters: 160 hours of training with 120 hours conducted in classroom with 120 hours conducted in classroom with an instructor.with an instructor.

Medical-Only Claims Adjuster: 80 hours of Medical-Only Claims Adjuster: 80 hours of training with 50 hours conducted in training with 50 hours conducted in classroom with an instructor.classroom with an instructor.

Medical Bill Reviewer: 40 hours of Medical Bill Reviewer: 40 hours of training with 30 hours conducted in training with 30 hours conducted in classroom with an instructor.classroom with an instructor.

Training RequirementsTraining Requirements

Training must be completed within 12 Training must be completed within 12 consecutive months, with certain consecutive months, with certain exceptions.exceptions.

Classes taken 3 years prior to the Classes taken 3 years prior to the effective date of these Regulations effective date of these Regulations can apply to the hourly requirements can apply to the hourly requirements upon verification of the Insurer.upon verification of the Insurer.

Instructors and ClassroomsInstructors and Classrooms

► Instructors must qualify as Experienced Instructors must qualify as Experienced Claims Adjusters or have 8 years in the last Claims Adjusters or have 8 years in the last 12 years of experience in California workers’ 12 years of experience in California workers’ compensation.compensation.

► Classroom means a place where there is Classroom means a place where there is privacy and little outside interference so that privacy and little outside interference so that students and the instructor can communicate.students and the instructor can communicate.

► Classroom also includes the use of electronic Classroom also includes the use of electronic medium, such as audio, video, computer, or medium, such as audio, video, computer, or Internet.Internet.

Curriculum Topics for Claims Adjusters

(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) Workers’ Compensation Appeals Board 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) Medical dispute resolution (Qualified

Medical Examiners, spinal surgery second opinions, pre-designation of physicians, independent medical reviewers, utilization review.)

(21) Fee schedules.(22) Liens.(23) Apportionment.(24) Subrogation.(25) Reserving.(26) Ethical issues.

Curriculum Topics for Medical-Only Claims

AdjustersSame as for Claims Adjusters, except

(8) Temporary disability.(9) Permanent disability, including evaluation

and rating.(10) Death benefits.(11) Return to work and vocational

rehabilitation.(13) Serious and willful misconduct.(23) Apportionment.

Curriculum Topics for Medical Bill Reviewers

(1) The correct use of billing codes and detection of improper use of billing codes. (2) All fee schedules applicable in California to workers' compensation medical care, including statutes and regulations authorizing the fee schedules. (3) Workers' compensation benefit provisions. (4) Fraud. (5) Medical terminology. (6) Utilization guidelines (American College of Occupational and Environmental Medicine or other guidelines approved by the Administrative Director of the Division of Workers' Compensation.) (7) Medical evidence. (8) Liens. (9) Ethical issues.

ExperienceExperience

A person may handle workers’ compensation A person may handle workers’ compensation claims based upon experience only and without claims based upon experience only and without

initial traininginitial training Experienced Claims Adjuster: 5 years in the last Experienced Claims Adjuster: 5 years in the last

8 years of on-the-job experience adjusting or 8 years of on-the-job experience adjusting or supervising California WC Claims; or Complete supervising California WC Claims; or Complete the Self-Insurance Exam and (1) worked as the Self-Insurance Exam and (1) worked as claims adjuster or supervisor continuously since claims adjuster or supervisor continuously since the exam or (2) passed the exam within the last the exam or (2) passed the exam within the last 5 years.5 years.

ExperienceExperience(continued)(continued)

Experienced Medical-Only Claims Experienced Medical-Only Claims Adjuster: 3 years in the past 5 years of Adjuster: 3 years in the past 5 years of on-the-job experience adjusting California on-the-job experience adjusting California workers’ compensation medical-only workers’ compensation medical-only claims.claims.

Experienced Medical Bill Reviewer: 3 Experienced Medical Bill Reviewer: 3 years in the past 5 years of on-the-job years in the past 5 years of on-the-job experience adjusting California workers’ experience adjusting California workers’ compensation medical bills.compensation medical bills.

DesignationsDesignations• An Insurer will Designate their claims adjusters, An Insurer will Designate their claims adjusters,

medical-only claims adjusters, and medical bill medical-only claims adjusters, and medical bill reviewers to handle workers’ compensation claims reviewers to handle workers’ compensation claims based upon completion of training or experience.based upon completion of training or experience.

• Designations can be transferred from one insurer Designations can be transferred from one insurer to another insurer with proper documentation.to another insurer with proper documentation.

• Records of Designations can be obtained by Records of Designations can be obtained by claims adjusters or bill reviewers from previous claims adjusters or bill reviewers from previous insurers employing or using theminsurers employing or using them

• Copies of Designations are available to employers Copies of Designations are available to employers or claimants to verify the qualifications of claims or claimants to verify the qualifications of claims adjusters or medical bill reviewers.adjusters or medical bill reviewers.

Post-Designation TrainingPost-Designation TrainingFollowing Designation by an Insurer, a claims adjuster, medical-only Following Designation by an Insurer, a claims adjuster, medical-only claims adjuster, or bill reviewers must maintain required continuing claims adjuster, or bill reviewers must maintain required continuing

education every 2 years and receive a Post-Designation Training education every 2 years and receive a Post-Designation Training FormForm

Claims Adjusters must complete 30 hours every two years.Claims Adjusters must complete 30 hours every two years.Medical-Only Claims Adjusters must complete 20 hours every two Medical-Only Claims Adjusters must complete 20 hours every two years.years.Medical Bill Reviewers must complete 16 hours every two years.Medical Bill Reviewers must complete 16 hours every two years.

Post-Designation Training should cover curriculum topics and current Post-Designation Training should cover curriculum topics and current changes to the law.changes to the law.

Post-Designation Training can be obtained through classes, seminars, Post-Designation Training can be obtained through classes, seminars, workshops, etc., and does not have to be done in a classroom with workshops, etc., and does not have to be done in a classroom with

an instructor.an instructor.The 3 year retrospective for Designation training courses does not The 3 year retrospective for Designation training courses does not

apply to Post-Designation Training.apply to Post-Designation Training.

Do I Need Post-Designation Do I Need Post-Designation Training?Training?

Failure of a Claims Adjuster, Medical-Only Failure of a Claims Adjuster, Medical-Only Claims Adjuster, or Medical Bill Reviewer Claims Adjuster, or Medical Bill Reviewer to maintain the required hours of Post-to maintain the required hours of Post-Designation Training shall result in that Designation Training shall result in that

person being no longer considered person being no longer considered Designated. That person shall not be Designated. That person shall not be authorized to adjust claims or medical authorized to adjust claims or medical bills until the requisite number of hours bills until the requisite number of hours

of Post-Designation Training is of Post-Designation Training is completed. completed.

Maintenance of RecordsMaintenance of Records

Insurers are required to maintain copies of Insurers are required to maintain copies of Designation and Post-Designation Training Forms Designation and Post-Designation Training Forms for all claims adjusters and medical bill reviewers for all claims adjusters and medical bill reviewers employed or working on their behalf.employed or working on their behalf.

Insurers are required to maintain training course Insurers are required to maintain training course records for both Designation and Post-Designation records for both Designation and Post-Designation training.training.

Designation and training records are to be made Designation and training records are to be made available to claims adjusters and medical bill available to claims adjusters and medical bill reviewers and other insurers employing them.reviewers and other insurers employing them.

Records are to be maintained during the period that Records are to be maintained during the period that the claims adjuster or medical bill reviewer is the claims adjuster or medical bill reviewer is employed or utilized by the insurer and for 5 years employed or utilized by the insurer and for 5 years thereafter.thereafter.

Maintenance of RecordsMaintenance of Records

DO NOT SEND TRAINING OR DO NOT SEND TRAINING OR DESIGNATION RECORDS TO THE DESIGNATION RECORDS TO THE INSURANCE COMMISSIONER.INSURANCE COMMISSIONER.

ONLY SEND Certification Forms to:ONLY SEND Certification Forms to:

California Department of Insurance, California Department of Insurance, Producer Licensing Bureau Producer Licensing Bureau

Education Unit, 320 Capitol Mall, 1Education Unit, 320 Capitol Mall, 1stst Floor, Sacramento, CA 95814; Floor, Sacramento, CA 95814;

Telephone (916) 492-3064.Telephone (916) 492-3064.

Remaining Issues and Remaining Issues and ThoughtsThoughtsInsurers Insurers DODO include Property and Casualty include Property and Casualty Insurers that write workers’ compensation for Insurers that write workers’ compensation for domestic workers per Insurance Code Section domestic workers per Insurance Code Section 108.1 and Labor Code Section 3351(d).108.1 and Labor Code Section 3351(d).Insurers will be self-administering their own Insurers will be self-administering their own training and post-designation programs training and post-designation programs according to the regulations training, according to the regulations training, curriculum, and topic requirements. Records curriculum, and topic requirements. Records are to be maintained for audit by CDI or DWC.are to be maintained for audit by CDI or DWC.Insurers, as defined, are responsible for Insurers, as defined, are responsible for certifying to the Insurance Commissioner and certifying to the Insurance Commissioner and maintaining proper records to support those maintaining proper records to support those certifications and cannot rely upon third parties.certifications and cannot rely upon third parties.

Remaining Issues and Remaining Issues and ThoughtsThoughts(continued)(continued)Only Certifications shall be sent to Only Certifications shall be sent to the Insurance Commissioner and the Insurance Commissioner and NOTNOT the supporting documentation. the supporting documentation.Claims Adjusters and Medical Bill Claims Adjusters and Medical Bill Reviewers should maintain their Reviewers should maintain their own documentation of Training, own documentation of Training, Designation, Post-Designation Designation, Post-Designation Training for future reference.Training for future reference.

Questions ?Questions ?

Contacts at Department of Insurance

Christopher Citko, Senior Staff Counsel (916) 492-3187;

citkoc@insurance.ca.gov

Brian Bugsch, Policy Office Manager (916) 492-3506;

bugschb@insurance.ca.gov