Claims Kit

Physician Selection Cal. Lab. Code 4600(d) 4600.3 , Rules 9780.1, 9781 9782 9783

Workers with health care coverage for conditions unrelated to work are allowed to predesignate their personal physician or a medical group before injury.

If there is a medical provider network (MPN), in most cases the employee will first be treated in the MPN after the injury, unless they predesignated.

If there is a health care organization (HCO), the employer or insurer that has a contract with an HCO must give employees a form prepared by the state Division of Workers’ Compensation, DWC Form 1194, to allow them to choose whether to enroll in the HCO. This form must be given to new employees within 30 days after date of hire and to current employees at least once a year.

If the employer or the insurer has a contract with an HCO, in most cases the employee will first be treated in the HCO after the injury, unless they predesignated.

If the employer or the insurer does not have an MPN and does not have a contract with an HCO, in most cases the claims administrator can choose the doctor who first treats the employee after the injury, unless they predesignated.

When a self-insured employer, group of self-insured employers, or the insurer of an employer contracts with a health care organization certified pursuant to Section 4600.5 for health care services required for the injured employees, those employees who are subject to the contract will receive medical services in the manner prescribed in the contract, providing that the employee may choose to be treated by a personal physician, personal chiropractor, or personal acupuncturist that they have designated prior to the injury, in which case the employee will not be treated by the health care organization. Every employee must be given an affirmative choice at the time of employment and at least annually thereafter to designate or change the designation of a health care organization or a personal physician, personal chiropractor, or personal acupuncturist. The choice shall be memorialized in writing and maintained in the employee’s personnel records. The employee who has designated a personal physician, personal chiropractor, or personal acupuncturist may change their designated caregiver at any time prior to the injury. Any employee who fails to designate a personal physician, personal chiropractor, or personal acupuncturist shall be treated by the health care organization selected by the employer. If the health care organization offered by the employer is the workers’ compensation insurer that covers the employee or is an entity that controls or is controlled by that insurer, as defined by Section 1215 of the Insurance Code, this information shall be included in the notice of contract with a health care organization.

DWC- 9783 Predesignation Of Personal Physician (Spanish)

DWC-9783.1 Notice Of Personal Chiropractor Or Personal Acupuncturist (Spanish)

Change of Physician

Choices depend on whether the employee is being treated in a medical provider network (MPN) or a health care organization (HCO) and whether they predesignated their personal physician.

• If being treated in an MPN, after the first medical examination, the employee may switch to another doctor within the MPN, and may switch again whenever it is reasonable to do so. The employer or the insurer must give written information on how to do this and, starting January 1, 2014, offer services to help the employee find an available doctor. In most cases, the employee is not allowed to switch to a doctor outside the MPN.
• If being treated in an HCO, the employee may switch at least one time to another doctor within the HCO. The HCO must give a choice of physicians within 5 days after the request to change. If covered by employer-provided health insurance, then 180 days after the injury or illness is reported to the employer, the employee may switch to a doctor outside the HCO. If not covered by employer-provided health insurance, then 90 days after the injury or illness is reported to the employer, the employee may switch to a doctor outside the HCO. When switching to a doctor outside the HCO, the new doctor can be a medical doctor, osteopath, psychologist, acupuncturist, optometrist, dentist, podiatrist, or chiropractor*. The employee may switch again whenever it is reasonable to do so.
• If not being treated in an MPN or HCO and the employee did not predesignate, the employee may switch to a new doctor one time during the first 30 days after the injury or illness is reported to the employer. However, the claims administrator is usually allowed to choose the new doctor. If the employee gave the name of their personal chiropractor or acupuncturist in writing before the injury, they may switch to their chiropractor* or acupuncturist upon request, after they first see a doctor chosen by the claims administrator. .
• After 30 days, the employee may switch to a doctor of their choice if they still need medical care and the employer or the insurer still has not created an MPN. The new doctor can be a medical doctor, osteopath, psychologist, acupuncturist, optometrist, dentist, podiatrist, or chiropractor*.

*A chiropractor may not be the treating physician after the employee has received the maximum number of chiropractic visits. (If the date of injury is in 2004 or later, the employee is limited to 24 chiropractic visits, 24 physical therapy visits, and 24 occupational therapy visits for the injury (except for visits under the post-surgical treatment guidelines above), unless the claims administrator authorizes additional visits in writing. Cal. Lab. Code 4604.5(c))

Penalties for Late Reporting  6409.1 (b)    

In all cases involving a serious injury illness, or death,and in addition to the Employer's Report of Occupational Injury, a report must be made immediately by the employer to the Division of Occupational Safety and Health by telephone or email. An employer who violates this may be assessed a civil penalty of no less than $5,000
 

Reporting of Claim by Employer  6409.1 14001, 10140

Within 1 working day of receipt of a claim form DWC-1, the employer must date the claim form and provide a dated copy of the form to the employee and the employer's claims administrator.

California state law requires that the employer submit Form 5020, Employer's Report of Occupational Injury or Illness within 5 days to report every employee industrial injury or occupational illness that results in lost time beyond the date of injury or that results in medical treatment other than First Aid. 

First aid treatment is included as medical care that all employers must provide for their injured employees. In conjunction with the California Department of Insurance (CDI), the Department of Industrial Relations (DIR), Division of Workers' Compensation, wants to remind all employers, physicians, insurance carriers and self- insurers of the need to comply with section 6409(a) of the California Labor Code.

Section 6409(a) requires a physician who treats an injured employee to file a "Doctor's First Report of Injury" (DFR) with the claims administrator for every work illness or injury, even first aid cases where there is no lost time from work. Although the Labor Code contains "first aid" exceptions for the "Employers' Report" (form 5020) and the "Employee Claim Form" (DWC-1), there is no such exception for the DFR. The insurance carrier (or the employer if the employer is self-insured) must forward these DFRs to the Department of Industrial Relations, Division of Labor Statistics and Research (the address is listed at the top of the form). There is no "first aid" exception to this statute.

Employers are required to report costs incurred for any and all medical related care, including the cost of “first aid” treatment, even when employers do not ask their workers’ compensation carrier (“insurer”) to cover or reimburse the medical related costs incurred.  These costs must be reported to their insurer.

California Labor Code Section 5401 defines “first aid” as “any one-time treatment, and any follow-up visit for the purpose of observation of minor scratches, cuts, burns, splinters, or other minor industrial injury, which do not ordinarily require medical care. This one-time treatment, and follow-up visit, is considered first aid even though provided by a physician or registered professional personnel.”  

Workers’ compensation carriers are required to report these medical costs to the WCIRB of California. 

Posting Requirements  9881 3550

On July 15, Gov. Gavin Newsom signed Assembly Bill 1870 

This bill would require the notice to include information concerning an injured employee’s ability to consult a licensed attorney to advise them of their rights under workers’ compensations laws, as specified. The bill would also make technical, nonsubstantive changes to these provisions. The requirement is effective January 1, 2025

Every employer subject to the compensation provisions of this division must post and keep posted in a conspicuous location frequented by employees, and where the notice may be easily read by employees during the hours of the workday, a notice that states the name of the current compensation insurance carrier of the employer, or when appropriate, that the employer is self-insured, and who is responsible for claims adjustment.

 Failure to keep any notice required by this section conspicuously posted shall constitute a misdemeanor, and shall be prima facie evidence of noninsurance.

DWC 7   This is the new poster for 2025 (Rev 10/24) - Poster must be printed on legal size (8 1/2 x 14) paper.

Newsline 2024-30

The Division of Workers’ Compensation (DWC) has posted an updated time of hire notice on its website. The time of hire notice was previously referred to as the time of hire pamphlet.

The notice, which is posted in English and Spanish versions, meets the requirements under Labor Code section 3551 to notify new employees about California workers’ compensation rights and benefits either at the time of hire or by the end of the first pay period. The time of hire notice was created in 2011 to help employers and claims administrators ensure that employees know what to do in case of workplace injury.

This notice can be customized as long as the text meets the “time of hire” legal requirements. Title 8, California Code of Regulations section 9883 allows insurers, employers or private enterprises to prepare and publish the notice upon prior approval of the form and content of the notice by the Administrative Director. A revised time of hire notice should be submitted via email to DWC for review, using the subject line “Time of Hire Notice Approval Request.”