Claims Kit

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 shall 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 five thousand dollars ($5,000).
 

Reporting of Claim by Employer  6409.1 14001, 10140

Within one working day of receipt of a claim form DWC-1, the employer shall 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. (see note below)

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.

NOTE: The Insurance Commissioner recently approved amendments to the California Workers’ Compensation Uniform Statistical Reporting Plan—1995 (USRP) effective January 1, 2017, to clarify the reporting requirements for small medical only or “first aid” claims.

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.”  Employers are referred to the WCIRB Bulletin (Nov. 10, 2016).

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

Posting Requirements  9881

You must post the "Notice to Employees" poster in a conspicuous place at the work site. This poster provides employees with information on your workers' compensation coverage and where to get medical care for work injuries. Specific requirements are contained in sections 3550-3553 of the California Labor Code. Failure to post this notice is a misdemeanor that can result in a civil penalty of up to $7,000 per violation. You must also provide newly hired employees with a workers’ compensation pamphlet explaining their rights and responsibilities. (spanish version here)

Physician Selection Cal. Lab. Code 4600(d), 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.

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))