Claims Kit

Release Number:2021-99

Date:October 4, 2021

DWC Emergency Regulations for Medical-Legal Evaluations and Reporting in Response to COVID-19 in Effect through January 11, 2022

The Division of Workers’ Compensation (DWC) announces itsemergency regulations36.7 and 46.2 for medical-legal evaluations and reporting, which became effective on May 14, 2020 and were set to expire in October 2021, have been extended until January 11, 2022.

The Office of Administrative Law (OAL) approved the emergency regulations on September 30. This is DWC’s second and final re-adoption in accordance with Government Code section 11346.1(h).

Alternative filing during COVID-19

• In light of the continued state of emergency in response to the novel coronavirus (COVID-19) and to facilitate other methods of filing in line with the newslines issued onApril 3andApril 28, and pursuant to the WCAB’sen bancorder issued on April 6, documents subject to a statutory time limit may be sent by e-mail directly to the district offices pursuant to AD Rule 10205.7(c) where the filing party could not otherwise e-file, JET file or file the document by mail. Refer to thedistrict office pagefor e-mail and other contact information.

COVID-19 Vaccine Reaction Claims Reporting

The Workers Compensation Insurance Organizations (WCIO) has updated the Injury Description Tables with a new Nature of Injury Code 38 (Adverse reaction to a vaccination or inoculation) to reflect specific coding for adverse reactions to vaccinations. The description for the Cause of Injury Code 82 (Absorption, Ingestion or Inhalation, NOC) has also been updated to “Not otherwise classified in any other code. Applies only to non-impact cases in which the injury resulted from inhalation, absorption (skin contact), ingestion of harmful substances, or vaccinations”.

These codes are being adopted by DWC for reporting COVID-19 vaccine reaction cases and other NON-COVID-19 vaccine reaction cases. The WCIS reporting system has been modified to accept the new Nature of Injury code 38.

To report adverse COVID-19 vaccine reaction claims, use the new code 38 for Nature of Injury Code (FROI DN35) together with code 83 (Pandemic) for the Cause of Injury Code (FROI DN37).

To report adverse vaccine reaction claims that are not related to COVID-19, use the new code 38 for Nature of Injury Code (FROI DN35) together with code 82 (Absorption, Ingestion or Inhalation, NOC) for the Cause of Injury Code (FROI DN37).

To report regular COVID-19 exposure or positive COVID-19 test claims, continue to use the Nature of Injury Code 83 (COVID-19) and the Cause of Injury Code 83 as detailed in WCIS eNews 147. The most recent versions of the Injury Description Code tables can be found on the WCIO website: www.wcio.org and the WCIS website: https://www.dir.ca.gov/dwc/WCIS.htm

March 10, 2021

DWC Emergency Regulations for Medical-Legal Evaluations and Reporting in Response to COVID-19 in Effect through October 12, 2021

The Division of Workers’ Compensation (DWC) announces its emergency regulations 36.7 and 46.2 for medical-legal evaluations and reporting, which became effective on May 14, 2020 and were set to expire in January 2021, have been extended until October 12, 2021. The new expiration date is in accordance with Executive Orders N-40-20 and N-71-20.

This is the first 210-day extension of these regulations. If the Executive Orders remain in effect the DWC may be entitled to a second 210-day extension. The text of the emergency regulations can be found on the DWC website.

These emergency regulations help injured workers and employers continue to move their workers’ compensation claims toward a resolution and avoid additional and undue delay by addressing how medical-legal evaluations may proceed during this emergency period and providing alternative means for service of required forms related to medical-legal evaluations and reports.

Release Number: 2020-101

December 10, 2020

DWC Advises of Delayed Processing Times During Regional Stay-at-Home Orders

The Division of Workers’ Compensation (DWC) has been working since the start of the COVID-19 crisis to provide critical services while keeping employees safe. To that end, DWC has implemented multiple options for virtual hearings, including a call-in option on April 3 and a video option for trials that are usually heard at DWC district offices on August 12. DWC has maintained a limited staff in its 24 district offices during this crisis and has not been accepting any walk-in requests or walk-in filings.

Increasing infection rates have resulted in the closure of many state offices throughout California. While DWC will continue to maintain all critical functions in its district offices, including holding all remote hearings and processing documents, it will have limited staff during the next three weeks to process documents. This might result in extended processing times for documents that are mailed to the district offices.

DWC strongly encourages all parties to e-file or JET file documents to reduce processing times. For documents that are subject to a statute of limitations and cannot be otherwise e-filed or JET filed the parties may file those documents via e-mail as instructed in the Newsline dated April 23 and the WCAB en banc order of April 6. DWC previously posted instructions on its website on how to file settlement documents in EAMS. Parties should review those instructions. If you are not already an e-filer and would like to become one please go to DWC’s EAMS page to learn how or send a request to EFORMS@dir.ca.gov for more information.

These recommendations also apply to the DWC Subsequent Injury Benefit Trust Fund Unit, which is also experiencing delay times for processing documents due to the reduction in staff during the COVID-19 crisis. Parties are strongly encouraged to file their documents electronically.

DWC Emergency Regulations for Medical-Legal Reporting in Response to COVID-19 are in Effect through March 12, 2021

The Division of Workers’ Compensation (DWC) announces itsemergency regulations36.7 and 46.2 for medical-legal evaluations, which became effective on May 14, 2020, will expire on March 12, 2021. The expiration date is in accordance with Executive Orders N-40-20 and N-66-20.

There are two possible 210-day extensions if those Executive Orders remain in effect.

These emergency regulations help injured workers and employers continue to move their workers’ compensation claims toward a resolution and avoid additional and undue delay. The regulations address how medical-legal evaluations may proceed during this emergency period. The regulations also provide alternative forms of service for required forms related to medical-legal evaluations and reports.

Senate Bill 1159

Effective 9/17/2020

This bill would define “injury” for an employee to include illness or death resulting from the 2019 novel coronavirus disease (COVID-19) under specified circumstances, until January 1, 2023. The bill would create a disputable presumption, as specified, that the injury arose out of and in the course of the employment and is compensable, for specified dates of injury. The bill would limit the applicability of the presumption under certain circumstances. The bill would require an employee to exhaust their paid sick leave benefits and meet specified certification requirements before receiving any temporary disability benefits or, for police officers, firefighters, and other specified employees, a leave of absence. The bill would also make a claim relating to a COVID-19 illness presumptively compensable, as described above, after 30 days or 45 days, rather than 90 days. Until January 1, 2023, the bill would allow for a presumption of injury for all employees whose fellow employees at their place of employment experience specified levels of positive testing, and whose employer has 5 or more employees.

3212.88 employees who test positive during an outbreak

When the employer knows or reasonably should know that an employee has tested positive for COVID-19, the employer will report to their claims administrator in writing via electronic mail or facsimile within three business days all of the following:

An employee has tested positive.

The date that the employee tests positive

The specific address or addresses of the employee’s specific place of employment during the 14-day period preceding the date of the employee’s positive test.

The highest number of employees who reported to work at the employee’s specific place of employment in the 45-day period preceding the last day the employee worked at each specific place of employment.

Any employer who is aware of an employee testing positive on or after July 6, 2020, and prior to Septemeber 17, 2020 mustreport to their claims administrator, in writing via electronic mail or facsimile, within 30 business days of the effective date of this section, all of the data required above. For the data requiredthe employer will instead report the highest number of employees who reported to work at each of the employee’s specific places of employment on any given work day between July 6, 2020, and September 17, 2020. The claims administrator willuse the information reported to determine if an outbreak has occurred from July 6, 2020, September 17, 2020 for the purpose of applying the presumption

An employer who fails to submitfalse or misleading information or fails to submit information when reportingis subject to a civil penalty in the amount of up to ten thousand dollars ($10,000) to be assessed by the Labor Commissioner.

This will remain in effect only until January 1, 2023, and as of that date is repealed.

Release Number: 2020-69

August 12, 2020

Continuing Filing Procedures

DWC will not accept walk-in filings, walk-through documents or in-person requests at this time. DWC will only accept electronic filing via EAMS and JET File, and paper filing by U.S. mail.

DWC will accept limited email filings pursuant to WCAB’s en banc decision dated April 6 and its newsline issued on April 23. Email filings are limited to documents that are subject to a statute of limitations that cannot otherwise be efiled, JET filed or filed by U.S. mail.

DWC will continue to accept an electronic signature on any settlement documents, applications, pleadings, petitions or motions that are sent to the district offices or filed in EAMS. For all e-forms, parties should utilize “S signature” as shown in the E-forms Filing Reference Guide and the JET File Business Rules.

Injured workers who are unable to file utilizing the available options or need assistance may contact DWC’s call center at 909-383-4522.

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.”