Amended IN Assembly April 10, 2025 Amended IN Assembly March 24, 2025 CALIFORNIA LEGISLATURE 20252026 REGULAR SESSION Assembly Bill No. 1048Introduced by Assembly Member ChenFebruary 20, 2025 An act to amend Section 4603.6 of the Labor Code, relating to workers compensation. LEGISLATIVE COUNSEL'S DIGESTAB 1048, as amended, Chen. Workers compensation.Existing law establishes a workers compensation system, administered by the Administrative Director of the Division of Workers Compensation, within the Department of Industrial Relations, to compensate an employee for injuries sustained in the course of their employment. Among other things, the workers compensation system provides for medical and hospital treatment, disability payments, and death benefits, as specified. Existing law requires the administrative director to contract with one or more independent bill review organizations to conduct reviews of medical providers in accordance with specified criteria. Existing law authorizes a provider under certain circumstances, including when the amount of payment is in dispute, to request an independent bill review within a specified timeframe. Existing law requires that the medical provider pay to the administrative director a fee to cover the reasonable estimated cost of the independent bill review and the administration of the independent bill review program. Existing law requires the administrative director to adopt and revise periodically an official medical fee schedule establishing reasonable maximum fees paid for medical services other than physician services, drugs and pharmacy services, health care facility fees, home health care, and all other treatment, care, services, and goods.This bill would define a payment dispute to include a contract dispute involving any discount or reduction from the official medical fee schedule. The bill would also require, if the dispute only involves a percentage discount or reduction that results in the independent bill review upholding the decision, the independent review organization to provide a written decision to the medical provider and include the medical provider contract relied upon to uphold the decision.Digest Key Vote: MAJORITY Appropriation: NO Fiscal Committee: YES Local Program: NO Bill TextThe people of the State of California do enact as follows:SECTION 1. Section 4603.6 of the Labor Code is amended to read:4603.6. (a) (1) If the only dispute is the amount of payment and the provider has received a second review that did not resolve the dispute, the provider may request an independent bill review within 30 calendar days of service of the second review pursuant to Section 4603.2 or 4622. If the provider fails to request an independent bill review within 30 days, the bill shall be deemed satisfied, and neither the employer nor the employee shall be liable for any further payment. If the employer has contested liability for any issue other than the reasonable amount payable for services, that issue shall be resolved prior to filing a request for independent bill review, and the time limit for requesting independent bill review shall not begin to run until the resolution of that issue becomes final, except as provided for in Section 4622.(2) For the purposes of this section, a payment dispute includes a contract dispute involving a discount or reduction from the official medical fee schedule promulgated by the administrative director pursuant to Section 5307.1, that was applied to a medical treatment bill.(b) A request for independent review shall be made on a form prescribed by the administrative director, and shall include copies of the original billing itemization, any supporting documents that were furnished with the original billing, the explanation of review, the request for second review together with any supporting documentation submitted with that request, and the final explanation of the second review. The administrative director may require that requests for independent bill review be submitted electronically. A copy of the request, together with all required documents, shall be served on the employer. Only the request form and the proof of payment of the fee required by subdivision (c) shall be filed with the administrative director. Upon notice of assignment of the independent bill reviewer, the requesting party shall submit the documents listed in this subdivision to the independent bill reviewer within 10 days.(c) The provider shall pay to the administrative director a fee determined by the administrative director to cover no more than the reasonable estimated cost of independent bill review and administration of the independent bill review program. The administrative director may prescribe different fees depending on the number of items in the bill or other criteria determined by regulation adopted by the administrative director. If any additional payment is found owing from the employer to the medical provider, the employer shall reimburse the provider for the fee in addition to the amount found owing.(d) Upon receipt of a request for independent bill review and the required fee, the administrative director or the administrative directors designee shall assign the request to an independent bill reviewer within 30 days and notify the medical provider and employer of the independent reviewer assigned.(e) The independent bill reviewer shall review the materials submitted by the parties and make a written determination of any additional amounts to be paid to the medical provider and state the reasons for the determination. If the independent bill reviewer deems necessary, the independent bill reviewer may request additional documents from the medical provider or employer. The employer shall have no obligation to serve medical reports on the provider unless the reports are requested by the independent bill reviewer. If additional documents are requested, the parties shall respond with the documents requested within 30 days and shall provide the other party with copies of any documents submitted to the independent reviewer, and the independent reviewer shall make a written determination of any additional amounts to be paid to the medical provider and state the reasons for the determination within 60 days of the receipt of the administrative directors assignment. The written determination of the independent bill reviewer shall be sent to the administrative director and provided to both the medical provider and the employer.(f) (1) If the dispute only involves a percentage discount or reduction that results in independent bill review upholding the discount or reduction, independent bill review shall provide the rationale for that ruling in a written decision to the medical provider and include the medical provider contract or contracts relied upon to uphold the discount or reduction. If the payer cannot produce a valid medical provider contract or contracts justifying the discount or reduction, the independent bill review organization shall award the medical provider payment for the disputed medical treatment bill that is consistent with the official medical fee schedule.(2) This subdivision does not require the independent bill review organization to provide the medical provider with a contract to which the medical provider is not a party.(g) The determination of the independent bill reviewer shall be deemed a determination and order of the administrative director. The determination is final and binding on all parties unless an aggrieved party files with the appeals board a verified appeal from the medical bill review determination of the administrative director within 20 days of the service of the determination. The medical bill review determination of the administrative director shall be presumed to be correct and shall be set aside only upon clear and convincing evidence of one or more of the following grounds for appeal:(1) The administrative director acted without or in excess of their powers.(2) The determination of the administrative director was procured by fraud.(3) The independent bill reviewer was subject to a material conflict of interest that is in violation of Section 139.5.(4) The determination was the result of bias on the basis of race, national origin, ethnic group identification, religion, age, sex, sexual orientation, color, or disability.(5) The determination was the result of a plainly erroneous express or implied finding of fact, provided that the mistake of fact is a matter of ordinary knowledge based on the information submitted for review and not a matter that is subject to expert opinion.(h) If the determination of the administrative director is reversed, the dispute shall be remanded to the administrative director to submit the dispute to independent bill review by a different independent review organization. In the event that a different independent bill review organization is not available after remand, the administrative director shall submit the dispute to the original bill review organization for review by a different reviewer within the organization. The appeals board or any higher court shall not make a determination of ultimate fact contrary to the determination of the bill review organization.(i) Once the independent bill reviewer has made a determination regarding additional amounts to be paid to the medical provider, the employer shall pay the additional amounts per the timely payment requirements set forth in Sections 4603.2 and 4603.4.
Amended IN Assembly April 10, 2025 Amended IN Assembly March 24, 2025 CALIFORNIA LEGISLATURE 20252026 REGULAR SESSION Assembly Bill No. 1048Introduced by Assembly Member ChenFebruary 20, 2025 An act to amend Section 4603.6 of the Labor Code, relating to workers compensation. LEGISLATIVE COUNSEL'S DIGESTAB 1048, as amended, Chen. Workers compensation.Existing law establishes a workers compensation system, administered by the Administrative Director of the Division of Workers Compensation, within the Department of Industrial Relations, to compensate an employee for injuries sustained in the course of their employment. Among other things, the workers compensation system provides for medical and hospital treatment, disability payments, and death benefits, as specified. Existing law requires the administrative director to contract with one or more independent bill review organizations to conduct reviews of medical providers in accordance with specified criteria. Existing law authorizes a provider under certain circumstances, including when the amount of payment is in dispute, to request an independent bill review within a specified timeframe. Existing law requires that the medical provider pay to the administrative director a fee to cover the reasonable estimated cost of the independent bill review and the administration of the independent bill review program. Existing law requires the administrative director to adopt and revise periodically an official medical fee schedule establishing reasonable maximum fees paid for medical services other than physician services, drugs and pharmacy services, health care facility fees, home health care, and all other treatment, care, services, and goods.This bill would define a payment dispute to include a contract dispute involving any discount or reduction from the official medical fee schedule. The bill would also require, if the dispute only involves a percentage discount or reduction that results in the independent bill review upholding the decision, the independent review organization to provide a written decision to the medical provider and include the medical provider contract relied upon to uphold the decision.Digest Key Vote: MAJORITY Appropriation: NO Fiscal Committee: YES Local Program: NO
Amended IN Assembly April 10, 2025 Amended IN Assembly March 24, 2025
Amended IN Assembly April 10, 2025
Amended IN Assembly March 24, 2025
CALIFORNIA LEGISLATURE 20252026 REGULAR SESSION
Assembly Bill
No. 1048
Introduced by Assembly Member ChenFebruary 20, 2025
Introduced by Assembly Member Chen
February 20, 2025
An act to amend Section 4603.6 of the Labor Code, relating to workers compensation.
LEGISLATIVE COUNSEL'S DIGEST
## LEGISLATIVE COUNSEL'S DIGEST
AB 1048, as amended, Chen. Workers compensation.
Existing law establishes a workers compensation system, administered by the Administrative Director of the Division of Workers Compensation, within the Department of Industrial Relations, to compensate an employee for injuries sustained in the course of their employment. Among other things, the workers compensation system provides for medical and hospital treatment, disability payments, and death benefits, as specified. Existing law requires the administrative director to contract with one or more independent bill review organizations to conduct reviews of medical providers in accordance with specified criteria. Existing law authorizes a provider under certain circumstances, including when the amount of payment is in dispute, to request an independent bill review within a specified timeframe. Existing law requires that the medical provider pay to the administrative director a fee to cover the reasonable estimated cost of the independent bill review and the administration of the independent bill review program. Existing law requires the administrative director to adopt and revise periodically an official medical fee schedule establishing reasonable maximum fees paid for medical services other than physician services, drugs and pharmacy services, health care facility fees, home health care, and all other treatment, care, services, and goods.This bill would define a payment dispute to include a contract dispute involving any discount or reduction from the official medical fee schedule. The bill would also require, if the dispute only involves a percentage discount or reduction that results in the independent bill review upholding the decision, the independent review organization to provide a written decision to the medical provider and include the medical provider contract relied upon to uphold the decision.
Existing law establishes a workers compensation system, administered by the Administrative Director of the Division of Workers Compensation, within the Department of Industrial Relations, to compensate an employee for injuries sustained in the course of their employment. Among other things, the workers compensation system provides for medical and hospital treatment, disability payments, and death benefits, as specified.
Existing law requires the administrative director to contract with one or more independent bill review organizations to conduct reviews of medical providers in accordance with specified criteria. Existing law authorizes a provider under certain circumstances, including when the amount of payment is in dispute, to request an independent bill review within a specified timeframe. Existing law requires that the medical provider pay to the administrative director a fee to cover the reasonable estimated cost of the independent bill review and the administration of the independent bill review program. Existing law requires the administrative director to adopt and revise periodically an official medical fee schedule establishing reasonable maximum fees paid for medical services other than physician services, drugs and pharmacy services, health care facility fees, home health care, and all other treatment, care, services, and goods.
This bill would define a payment dispute to include a contract dispute involving any discount or reduction from the official medical fee schedule. The bill would also require, if the dispute only involves a percentage discount or reduction that results in the independent bill review upholding the decision, the independent review organization to provide a written decision to the medical provider and include the medical provider contract relied upon to uphold the decision.
## Digest Key
## Bill Text
The people of the State of California do enact as follows:SECTION 1. Section 4603.6 of the Labor Code is amended to read:4603.6. (a) (1) If the only dispute is the amount of payment and the provider has received a second review that did not resolve the dispute, the provider may request an independent bill review within 30 calendar days of service of the second review pursuant to Section 4603.2 or 4622. If the provider fails to request an independent bill review within 30 days, the bill shall be deemed satisfied, and neither the employer nor the employee shall be liable for any further payment. If the employer has contested liability for any issue other than the reasonable amount payable for services, that issue shall be resolved prior to filing a request for independent bill review, and the time limit for requesting independent bill review shall not begin to run until the resolution of that issue becomes final, except as provided for in Section 4622.(2) For the purposes of this section, a payment dispute includes a contract dispute involving a discount or reduction from the official medical fee schedule promulgated by the administrative director pursuant to Section 5307.1, that was applied to a medical treatment bill.(b) A request for independent review shall be made on a form prescribed by the administrative director, and shall include copies of the original billing itemization, any supporting documents that were furnished with the original billing, the explanation of review, the request for second review together with any supporting documentation submitted with that request, and the final explanation of the second review. The administrative director may require that requests for independent bill review be submitted electronically. A copy of the request, together with all required documents, shall be served on the employer. Only the request form and the proof of payment of the fee required by subdivision (c) shall be filed with the administrative director. Upon notice of assignment of the independent bill reviewer, the requesting party shall submit the documents listed in this subdivision to the independent bill reviewer within 10 days.(c) The provider shall pay to the administrative director a fee determined by the administrative director to cover no more than the reasonable estimated cost of independent bill review and administration of the independent bill review program. The administrative director may prescribe different fees depending on the number of items in the bill or other criteria determined by regulation adopted by the administrative director. If any additional payment is found owing from the employer to the medical provider, the employer shall reimburse the provider for the fee in addition to the amount found owing.(d) Upon receipt of a request for independent bill review and the required fee, the administrative director or the administrative directors designee shall assign the request to an independent bill reviewer within 30 days and notify the medical provider and employer of the independent reviewer assigned.(e) The independent bill reviewer shall review the materials submitted by the parties and make a written determination of any additional amounts to be paid to the medical provider and state the reasons for the determination. If the independent bill reviewer deems necessary, the independent bill reviewer may request additional documents from the medical provider or employer. The employer shall have no obligation to serve medical reports on the provider unless the reports are requested by the independent bill reviewer. If additional documents are requested, the parties shall respond with the documents requested within 30 days and shall provide the other party with copies of any documents submitted to the independent reviewer, and the independent reviewer shall make a written determination of any additional amounts to be paid to the medical provider and state the reasons for the determination within 60 days of the receipt of the administrative directors assignment. The written determination of the independent bill reviewer shall be sent to the administrative director and provided to both the medical provider and the employer.(f) (1) If the dispute only involves a percentage discount or reduction that results in independent bill review upholding the discount or reduction, independent bill review shall provide the rationale for that ruling in a written decision to the medical provider and include the medical provider contract or contracts relied upon to uphold the discount or reduction. If the payer cannot produce a valid medical provider contract or contracts justifying the discount or reduction, the independent bill review organization shall award the medical provider payment for the disputed medical treatment bill that is consistent with the official medical fee schedule.(2) This subdivision does not require the independent bill review organization to provide the medical provider with a contract to which the medical provider is not a party.(g) The determination of the independent bill reviewer shall be deemed a determination and order of the administrative director. The determination is final and binding on all parties unless an aggrieved party files with the appeals board a verified appeal from the medical bill review determination of the administrative director within 20 days of the service of the determination. The medical bill review determination of the administrative director shall be presumed to be correct and shall be set aside only upon clear and convincing evidence of one or more of the following grounds for appeal:(1) The administrative director acted without or in excess of their powers.(2) The determination of the administrative director was procured by fraud.(3) The independent bill reviewer was subject to a material conflict of interest that is in violation of Section 139.5.(4) The determination was the result of bias on the basis of race, national origin, ethnic group identification, religion, age, sex, sexual orientation, color, or disability.(5) The determination was the result of a plainly erroneous express or implied finding of fact, provided that the mistake of fact is a matter of ordinary knowledge based on the information submitted for review and not a matter that is subject to expert opinion.(h) If the determination of the administrative director is reversed, the dispute shall be remanded to the administrative director to submit the dispute to independent bill review by a different independent review organization. In the event that a different independent bill review organization is not available after remand, the administrative director shall submit the dispute to the original bill review organization for review by a different reviewer within the organization. The appeals board or any higher court shall not make a determination of ultimate fact contrary to the determination of the bill review organization.(i) Once the independent bill reviewer has made a determination regarding additional amounts to be paid to the medical provider, the employer shall pay the additional amounts per the timely payment requirements set forth in Sections 4603.2 and 4603.4.
The people of the State of California do enact as follows:
## The people of the State of California do enact as follows:
SECTION 1. Section 4603.6 of the Labor Code is amended to read:4603.6. (a) (1) If the only dispute is the amount of payment and the provider has received a second review that did not resolve the dispute, the provider may request an independent bill review within 30 calendar days of service of the second review pursuant to Section 4603.2 or 4622. If the provider fails to request an independent bill review within 30 days, the bill shall be deemed satisfied, and neither the employer nor the employee shall be liable for any further payment. If the employer has contested liability for any issue other than the reasonable amount payable for services, that issue shall be resolved prior to filing a request for independent bill review, and the time limit for requesting independent bill review shall not begin to run until the resolution of that issue becomes final, except as provided for in Section 4622.(2) For the purposes of this section, a payment dispute includes a contract dispute involving a discount or reduction from the official medical fee schedule promulgated by the administrative director pursuant to Section 5307.1, that was applied to a medical treatment bill.(b) A request for independent review shall be made on a form prescribed by the administrative director, and shall include copies of the original billing itemization, any supporting documents that were furnished with the original billing, the explanation of review, the request for second review together with any supporting documentation submitted with that request, and the final explanation of the second review. The administrative director may require that requests for independent bill review be submitted electronically. A copy of the request, together with all required documents, shall be served on the employer. Only the request form and the proof of payment of the fee required by subdivision (c) shall be filed with the administrative director. Upon notice of assignment of the independent bill reviewer, the requesting party shall submit the documents listed in this subdivision to the independent bill reviewer within 10 days.(c) The provider shall pay to the administrative director a fee determined by the administrative director to cover no more than the reasonable estimated cost of independent bill review and administration of the independent bill review program. The administrative director may prescribe different fees depending on the number of items in the bill or other criteria determined by regulation adopted by the administrative director. If any additional payment is found owing from the employer to the medical provider, the employer shall reimburse the provider for the fee in addition to the amount found owing.(d) Upon receipt of a request for independent bill review and the required fee, the administrative director or the administrative directors designee shall assign the request to an independent bill reviewer within 30 days and notify the medical provider and employer of the independent reviewer assigned.(e) The independent bill reviewer shall review the materials submitted by the parties and make a written determination of any additional amounts to be paid to the medical provider and state the reasons for the determination. If the independent bill reviewer deems necessary, the independent bill reviewer may request additional documents from the medical provider or employer. The employer shall have no obligation to serve medical reports on the provider unless the reports are requested by the independent bill reviewer. If additional documents are requested, the parties shall respond with the documents requested within 30 days and shall provide the other party with copies of any documents submitted to the independent reviewer, and the independent reviewer shall make a written determination of any additional amounts to be paid to the medical provider and state the reasons for the determination within 60 days of the receipt of the administrative directors assignment. The written determination of the independent bill reviewer shall be sent to the administrative director and provided to both the medical provider and the employer.(f) (1) If the dispute only involves a percentage discount or reduction that results in independent bill review upholding the discount or reduction, independent bill review shall provide the rationale for that ruling in a written decision to the medical provider and include the medical provider contract or contracts relied upon to uphold the discount or reduction. If the payer cannot produce a valid medical provider contract or contracts justifying the discount or reduction, the independent bill review organization shall award the medical provider payment for the disputed medical treatment bill that is consistent with the official medical fee schedule.(2) This subdivision does not require the independent bill review organization to provide the medical provider with a contract to which the medical provider is not a party.(g) The determination of the independent bill reviewer shall be deemed a determination and order of the administrative director. The determination is final and binding on all parties unless an aggrieved party files with the appeals board a verified appeal from the medical bill review determination of the administrative director within 20 days of the service of the determination. The medical bill review determination of the administrative director shall be presumed to be correct and shall be set aside only upon clear and convincing evidence of one or more of the following grounds for appeal:(1) The administrative director acted without or in excess of their powers.(2) The determination of the administrative director was procured by fraud.(3) The independent bill reviewer was subject to a material conflict of interest that is in violation of Section 139.5.(4) The determination was the result of bias on the basis of race, national origin, ethnic group identification, religion, age, sex, sexual orientation, color, or disability.(5) The determination was the result of a plainly erroneous express or implied finding of fact, provided that the mistake of fact is a matter of ordinary knowledge based on the information submitted for review and not a matter that is subject to expert opinion.(h) If the determination of the administrative director is reversed, the dispute shall be remanded to the administrative director to submit the dispute to independent bill review by a different independent review organization. In the event that a different independent bill review organization is not available after remand, the administrative director shall submit the dispute to the original bill review organization for review by a different reviewer within the organization. The appeals board or any higher court shall not make a determination of ultimate fact contrary to the determination of the bill review organization.(i) Once the independent bill reviewer has made a determination regarding additional amounts to be paid to the medical provider, the employer shall pay the additional amounts per the timely payment requirements set forth in Sections 4603.2 and 4603.4.
SECTION 1. Section 4603.6 of the Labor Code is amended to read:
### SECTION 1.
4603.6. (a) (1) If the only dispute is the amount of payment and the provider has received a second review that did not resolve the dispute, the provider may request an independent bill review within 30 calendar days of service of the second review pursuant to Section 4603.2 or 4622. If the provider fails to request an independent bill review within 30 days, the bill shall be deemed satisfied, and neither the employer nor the employee shall be liable for any further payment. If the employer has contested liability for any issue other than the reasonable amount payable for services, that issue shall be resolved prior to filing a request for independent bill review, and the time limit for requesting independent bill review shall not begin to run until the resolution of that issue becomes final, except as provided for in Section 4622.(2) For the purposes of this section, a payment dispute includes a contract dispute involving a discount or reduction from the official medical fee schedule promulgated by the administrative director pursuant to Section 5307.1, that was applied to a medical treatment bill.(b) A request for independent review shall be made on a form prescribed by the administrative director, and shall include copies of the original billing itemization, any supporting documents that were furnished with the original billing, the explanation of review, the request for second review together with any supporting documentation submitted with that request, and the final explanation of the second review. The administrative director may require that requests for independent bill review be submitted electronically. A copy of the request, together with all required documents, shall be served on the employer. Only the request form and the proof of payment of the fee required by subdivision (c) shall be filed with the administrative director. Upon notice of assignment of the independent bill reviewer, the requesting party shall submit the documents listed in this subdivision to the independent bill reviewer within 10 days.(c) The provider shall pay to the administrative director a fee determined by the administrative director to cover no more than the reasonable estimated cost of independent bill review and administration of the independent bill review program. The administrative director may prescribe different fees depending on the number of items in the bill or other criteria determined by regulation adopted by the administrative director. If any additional payment is found owing from the employer to the medical provider, the employer shall reimburse the provider for the fee in addition to the amount found owing.(d) Upon receipt of a request for independent bill review and the required fee, the administrative director or the administrative directors designee shall assign the request to an independent bill reviewer within 30 days and notify the medical provider and employer of the independent reviewer assigned.(e) The independent bill reviewer shall review the materials submitted by the parties and make a written determination of any additional amounts to be paid to the medical provider and state the reasons for the determination. If the independent bill reviewer deems necessary, the independent bill reviewer may request additional documents from the medical provider or employer. The employer shall have no obligation to serve medical reports on the provider unless the reports are requested by the independent bill reviewer. If additional documents are requested, the parties shall respond with the documents requested within 30 days and shall provide the other party with copies of any documents submitted to the independent reviewer, and the independent reviewer shall make a written determination of any additional amounts to be paid to the medical provider and state the reasons for the determination within 60 days of the receipt of the administrative directors assignment. The written determination of the independent bill reviewer shall be sent to the administrative director and provided to both the medical provider and the employer.(f) (1) If the dispute only involves a percentage discount or reduction that results in independent bill review upholding the discount or reduction, independent bill review shall provide the rationale for that ruling in a written decision to the medical provider and include the medical provider contract or contracts relied upon to uphold the discount or reduction. If the payer cannot produce a valid medical provider contract or contracts justifying the discount or reduction, the independent bill review organization shall award the medical provider payment for the disputed medical treatment bill that is consistent with the official medical fee schedule.(2) This subdivision does not require the independent bill review organization to provide the medical provider with a contract to which the medical provider is not a party.(g) The determination of the independent bill reviewer shall be deemed a determination and order of the administrative director. The determination is final and binding on all parties unless an aggrieved party files with the appeals board a verified appeal from the medical bill review determination of the administrative director within 20 days of the service of the determination. The medical bill review determination of the administrative director shall be presumed to be correct and shall be set aside only upon clear and convincing evidence of one or more of the following grounds for appeal:(1) The administrative director acted without or in excess of their powers.(2) The determination of the administrative director was procured by fraud.(3) The independent bill reviewer was subject to a material conflict of interest that is in violation of Section 139.5.(4) The determination was the result of bias on the basis of race, national origin, ethnic group identification, religion, age, sex, sexual orientation, color, or disability.(5) The determination was the result of a plainly erroneous express or implied finding of fact, provided that the mistake of fact is a matter of ordinary knowledge based on the information submitted for review and not a matter that is subject to expert opinion.(h) If the determination of the administrative director is reversed, the dispute shall be remanded to the administrative director to submit the dispute to independent bill review by a different independent review organization. In the event that a different independent bill review organization is not available after remand, the administrative director shall submit the dispute to the original bill review organization for review by a different reviewer within the organization. The appeals board or any higher court shall not make a determination of ultimate fact contrary to the determination of the bill review organization.(i) Once the independent bill reviewer has made a determination regarding additional amounts to be paid to the medical provider, the employer shall pay the additional amounts per the timely payment requirements set forth in Sections 4603.2 and 4603.4.
4603.6. (a) (1) If the only dispute is the amount of payment and the provider has received a second review that did not resolve the dispute, the provider may request an independent bill review within 30 calendar days of service of the second review pursuant to Section 4603.2 or 4622. If the provider fails to request an independent bill review within 30 days, the bill shall be deemed satisfied, and neither the employer nor the employee shall be liable for any further payment. If the employer has contested liability for any issue other than the reasonable amount payable for services, that issue shall be resolved prior to filing a request for independent bill review, and the time limit for requesting independent bill review shall not begin to run until the resolution of that issue becomes final, except as provided for in Section 4622.(2) For the purposes of this section, a payment dispute includes a contract dispute involving a discount or reduction from the official medical fee schedule promulgated by the administrative director pursuant to Section 5307.1, that was applied to a medical treatment bill.(b) A request for independent review shall be made on a form prescribed by the administrative director, and shall include copies of the original billing itemization, any supporting documents that were furnished with the original billing, the explanation of review, the request for second review together with any supporting documentation submitted with that request, and the final explanation of the second review. The administrative director may require that requests for independent bill review be submitted electronically. A copy of the request, together with all required documents, shall be served on the employer. Only the request form and the proof of payment of the fee required by subdivision (c) shall be filed with the administrative director. Upon notice of assignment of the independent bill reviewer, the requesting party shall submit the documents listed in this subdivision to the independent bill reviewer within 10 days.(c) The provider shall pay to the administrative director a fee determined by the administrative director to cover no more than the reasonable estimated cost of independent bill review and administration of the independent bill review program. The administrative director may prescribe different fees depending on the number of items in the bill or other criteria determined by regulation adopted by the administrative director. If any additional payment is found owing from the employer to the medical provider, the employer shall reimburse the provider for the fee in addition to the amount found owing.(d) Upon receipt of a request for independent bill review and the required fee, the administrative director or the administrative directors designee shall assign the request to an independent bill reviewer within 30 days and notify the medical provider and employer of the independent reviewer assigned.(e) The independent bill reviewer shall review the materials submitted by the parties and make a written determination of any additional amounts to be paid to the medical provider and state the reasons for the determination. If the independent bill reviewer deems necessary, the independent bill reviewer may request additional documents from the medical provider or employer. The employer shall have no obligation to serve medical reports on the provider unless the reports are requested by the independent bill reviewer. If additional documents are requested, the parties shall respond with the documents requested within 30 days and shall provide the other party with copies of any documents submitted to the independent reviewer, and the independent reviewer shall make a written determination of any additional amounts to be paid to the medical provider and state the reasons for the determination within 60 days of the receipt of the administrative directors assignment. The written determination of the independent bill reviewer shall be sent to the administrative director and provided to both the medical provider and the employer.(f) (1) If the dispute only involves a percentage discount or reduction that results in independent bill review upholding the discount or reduction, independent bill review shall provide the rationale for that ruling in a written decision to the medical provider and include the medical provider contract or contracts relied upon to uphold the discount or reduction. If the payer cannot produce a valid medical provider contract or contracts justifying the discount or reduction, the independent bill review organization shall award the medical provider payment for the disputed medical treatment bill that is consistent with the official medical fee schedule.(2) This subdivision does not require the independent bill review organization to provide the medical provider with a contract to which the medical provider is not a party.(g) The determination of the independent bill reviewer shall be deemed a determination and order of the administrative director. The determination is final and binding on all parties unless an aggrieved party files with the appeals board a verified appeal from the medical bill review determination of the administrative director within 20 days of the service of the determination. The medical bill review determination of the administrative director shall be presumed to be correct and shall be set aside only upon clear and convincing evidence of one or more of the following grounds for appeal:(1) The administrative director acted without or in excess of their powers.(2) The determination of the administrative director was procured by fraud.(3) The independent bill reviewer was subject to a material conflict of interest that is in violation of Section 139.5.(4) The determination was the result of bias on the basis of race, national origin, ethnic group identification, religion, age, sex, sexual orientation, color, or disability.(5) The determination was the result of a plainly erroneous express or implied finding of fact, provided that the mistake of fact is a matter of ordinary knowledge based on the information submitted for review and not a matter that is subject to expert opinion.(h) If the determination of the administrative director is reversed, the dispute shall be remanded to the administrative director to submit the dispute to independent bill review by a different independent review organization. In the event that a different independent bill review organization is not available after remand, the administrative director shall submit the dispute to the original bill review organization for review by a different reviewer within the organization. The appeals board or any higher court shall not make a determination of ultimate fact contrary to the determination of the bill review organization.(i) Once the independent bill reviewer has made a determination regarding additional amounts to be paid to the medical provider, the employer shall pay the additional amounts per the timely payment requirements set forth in Sections 4603.2 and 4603.4.
4603.6. (a) (1) If the only dispute is the amount of payment and the provider has received a second review that did not resolve the dispute, the provider may request an independent bill review within 30 calendar days of service of the second review pursuant to Section 4603.2 or 4622. If the provider fails to request an independent bill review within 30 days, the bill shall be deemed satisfied, and neither the employer nor the employee shall be liable for any further payment. If the employer has contested liability for any issue other than the reasonable amount payable for services, that issue shall be resolved prior to filing a request for independent bill review, and the time limit for requesting independent bill review shall not begin to run until the resolution of that issue becomes final, except as provided for in Section 4622.(2) For the purposes of this section, a payment dispute includes a contract dispute involving a discount or reduction from the official medical fee schedule promulgated by the administrative director pursuant to Section 5307.1, that was applied to a medical treatment bill.(b) A request for independent review shall be made on a form prescribed by the administrative director, and shall include copies of the original billing itemization, any supporting documents that were furnished with the original billing, the explanation of review, the request for second review together with any supporting documentation submitted with that request, and the final explanation of the second review. The administrative director may require that requests for independent bill review be submitted electronically. A copy of the request, together with all required documents, shall be served on the employer. Only the request form and the proof of payment of the fee required by subdivision (c) shall be filed with the administrative director. Upon notice of assignment of the independent bill reviewer, the requesting party shall submit the documents listed in this subdivision to the independent bill reviewer within 10 days.(c) The provider shall pay to the administrative director a fee determined by the administrative director to cover no more than the reasonable estimated cost of independent bill review and administration of the independent bill review program. The administrative director may prescribe different fees depending on the number of items in the bill or other criteria determined by regulation adopted by the administrative director. If any additional payment is found owing from the employer to the medical provider, the employer shall reimburse the provider for the fee in addition to the amount found owing.(d) Upon receipt of a request for independent bill review and the required fee, the administrative director or the administrative directors designee shall assign the request to an independent bill reviewer within 30 days and notify the medical provider and employer of the independent reviewer assigned.(e) The independent bill reviewer shall review the materials submitted by the parties and make a written determination of any additional amounts to be paid to the medical provider and state the reasons for the determination. If the independent bill reviewer deems necessary, the independent bill reviewer may request additional documents from the medical provider or employer. The employer shall have no obligation to serve medical reports on the provider unless the reports are requested by the independent bill reviewer. If additional documents are requested, the parties shall respond with the documents requested within 30 days and shall provide the other party with copies of any documents submitted to the independent reviewer, and the independent reviewer shall make a written determination of any additional amounts to be paid to the medical provider and state the reasons for the determination within 60 days of the receipt of the administrative directors assignment. The written determination of the independent bill reviewer shall be sent to the administrative director and provided to both the medical provider and the employer.(f) (1) If the dispute only involves a percentage discount or reduction that results in independent bill review upholding the discount or reduction, independent bill review shall provide the rationale for that ruling in a written decision to the medical provider and include the medical provider contract or contracts relied upon to uphold the discount or reduction. If the payer cannot produce a valid medical provider contract or contracts justifying the discount or reduction, the independent bill review organization shall award the medical provider payment for the disputed medical treatment bill that is consistent with the official medical fee schedule.(2) This subdivision does not require the independent bill review organization to provide the medical provider with a contract to which the medical provider is not a party.(g) The determination of the independent bill reviewer shall be deemed a determination and order of the administrative director. The determination is final and binding on all parties unless an aggrieved party files with the appeals board a verified appeal from the medical bill review determination of the administrative director within 20 days of the service of the determination. The medical bill review determination of the administrative director shall be presumed to be correct and shall be set aside only upon clear and convincing evidence of one or more of the following grounds for appeal:(1) The administrative director acted without or in excess of their powers.(2) The determination of the administrative director was procured by fraud.(3) The independent bill reviewer was subject to a material conflict of interest that is in violation of Section 139.5.(4) The determination was the result of bias on the basis of race, national origin, ethnic group identification, religion, age, sex, sexual orientation, color, or disability.(5) The determination was the result of a plainly erroneous express or implied finding of fact, provided that the mistake of fact is a matter of ordinary knowledge based on the information submitted for review and not a matter that is subject to expert opinion.(h) If the determination of the administrative director is reversed, the dispute shall be remanded to the administrative director to submit the dispute to independent bill review by a different independent review organization. In the event that a different independent bill review organization is not available after remand, the administrative director shall submit the dispute to the original bill review organization for review by a different reviewer within the organization. The appeals board or any higher court shall not make a determination of ultimate fact contrary to the determination of the bill review organization.(i) Once the independent bill reviewer has made a determination regarding additional amounts to be paid to the medical provider, the employer shall pay the additional amounts per the timely payment requirements set forth in Sections 4603.2 and 4603.4.
4603.6. (a) (1) If the only dispute is the amount of payment and the provider has received a second review that did not resolve the dispute, the provider may request an independent bill review within 30 calendar days of service of the second review pursuant to Section 4603.2 or 4622. If the provider fails to request an independent bill review within 30 days, the bill shall be deemed satisfied, and neither the employer nor the employee shall be liable for any further payment. If the employer has contested liability for any issue other than the reasonable amount payable for services, that issue shall be resolved prior to filing a request for independent bill review, and the time limit for requesting independent bill review shall not begin to run until the resolution of that issue becomes final, except as provided for in Section 4622.
(2) For the purposes of this section, a payment dispute includes a contract dispute involving a discount or reduction from the official medical fee schedule promulgated by the administrative director pursuant to Section 5307.1, that was applied to a medical treatment bill.
(b) A request for independent review shall be made on a form prescribed by the administrative director, and shall include copies of the original billing itemization, any supporting documents that were furnished with the original billing, the explanation of review, the request for second review together with any supporting documentation submitted with that request, and the final explanation of the second review. The administrative director may require that requests for independent bill review be submitted electronically. A copy of the request, together with all required documents, shall be served on the employer. Only the request form and the proof of payment of the fee required by subdivision (c) shall be filed with the administrative director. Upon notice of assignment of the independent bill reviewer, the requesting party shall submit the documents listed in this subdivision to the independent bill reviewer within 10 days.
(c) The provider shall pay to the administrative director a fee determined by the administrative director to cover no more than the reasonable estimated cost of independent bill review and administration of the independent bill review program. The administrative director may prescribe different fees depending on the number of items in the bill or other criteria determined by regulation adopted by the administrative director. If any additional payment is found owing from the employer to the medical provider, the employer shall reimburse the provider for the fee in addition to the amount found owing.
(d) Upon receipt of a request for independent bill review and the required fee, the administrative director or the administrative directors designee shall assign the request to an independent bill reviewer within 30 days and notify the medical provider and employer of the independent reviewer assigned.
(e) The independent bill reviewer shall review the materials submitted by the parties and make a written determination of any additional amounts to be paid to the medical provider and state the reasons for the determination. If the independent bill reviewer deems necessary, the independent bill reviewer may request additional documents from the medical provider or employer. The employer shall have no obligation to serve medical reports on the provider unless the reports are requested by the independent bill reviewer. If additional documents are requested, the parties shall respond with the documents requested within 30 days and shall provide the other party with copies of any documents submitted to the independent reviewer, and the independent reviewer shall make a written determination of any additional amounts to be paid to the medical provider and state the reasons for the determination within 60 days of the receipt of the administrative directors assignment. The written determination of the independent bill reviewer shall be sent to the administrative director and provided to both the medical provider and the employer.
(f) (1) If the dispute only involves a percentage discount or reduction that results in independent bill review upholding the discount or reduction, independent bill review shall provide the rationale for that ruling in a written decision to the medical provider and include the medical provider contract or contracts relied upon to uphold the discount or reduction. If the payer cannot produce a valid medical provider contract or contracts justifying the discount or reduction, the independent bill review organization shall award the medical provider payment for the disputed medical treatment bill that is consistent with the official medical fee schedule.
(2) This subdivision does not require the independent bill review organization to provide the medical provider with a contract to which the medical provider is not a party.
(g) The determination of the independent bill reviewer shall be deemed a determination and order of the administrative director. The determination is final and binding on all parties unless an aggrieved party files with the appeals board a verified appeal from the medical bill review determination of the administrative director within 20 days of the service of the determination. The medical bill review determination of the administrative director shall be presumed to be correct and shall be set aside only upon clear and convincing evidence of one or more of the following grounds for appeal:
(1) The administrative director acted without or in excess of their powers.
(2) The determination of the administrative director was procured by fraud.
(3) The independent bill reviewer was subject to a material conflict of interest that is in violation of Section 139.5.
(4) The determination was the result of bias on the basis of race, national origin, ethnic group identification, religion, age, sex, sexual orientation, color, or disability.
(5) The determination was the result of a plainly erroneous express or implied finding of fact, provided that the mistake of fact is a matter of ordinary knowledge based on the information submitted for review and not a matter that is subject to expert opinion.
(h) If the determination of the administrative director is reversed, the dispute shall be remanded to the administrative director to submit the dispute to independent bill review by a different independent review organization. In the event that a different independent bill review organization is not available after remand, the administrative director shall submit the dispute to the original bill review organization for review by a different reviewer within the organization. The appeals board or any higher court shall not make a determination of ultimate fact contrary to the determination of the bill review organization.
(i) Once the independent bill reviewer has made a determination regarding additional amounts to be paid to the medical provider, the employer shall pay the additional amounts per the timely payment requirements set forth in Sections 4603.2 and 4603.4.