Chapter 4.5. Division of Workers' Compensation
Subchapter 1. Administrative Director--Administrative Rules
Article 5.5.1. Utilization Review Standards

§9792.9.6. Utilization Review -- Extension of Timeframe for Decision.

(a)(1) The timeframes for decisions specified in section 9792.9.3 may only be extended under one or more of the following circumstances:

(A) The claims administrator or reviewer is not in receipt of all of the information reasonably necessary to make a determination.

(B) The reviewer has asked that an additional examination or test be performed upon the injured worker that is reasonable and consistent with professionally recognized standards of medical practice.

(C) The reviewer needs a specialized consultation and review of medical information by an expert reviewer.

(b)(1) If the circumstance under subdivision (a) (1)(A) applies, a reviewer or non-physician reviewer shall request the information from the treating physician within five (5) business days from the date of receipt of the request for authorization.

(2) If any of the circumstances set forth in subdivisions (a) (1)(B) or (C) are deemed to apply following the receipt of a complete or accepted request for authorization, the physician reviewer shall within five (5) business days from the date of receipt of the request for authorization notify the requesting physician, the injured worker, and if the injured worker is represented by counsel, the injured worker's attorney in writing, that the reviewer cannot make a decision within the required timeframe, and request, as applicable, the additional examinations or tests required, or indicate that a consultation by an expert reviewer is needed, in which case, the specialty of the expert reviewer to be consulted must be identified.

(c)(1) If the information reasonably necessary to make a determination under subdivision (a) (1)(A) that is requested by the reviewer or non-physician reviewer is not received within fourteen (14) days from receipt of the completed or accepted request for authorization for prospective or concurrent review, or within thirty (30) days of the request for retrospective review, a physician reviewer shall deny the request in accordance with applicable rules in section 9792.9.5(e).

(2) If the results of the additional examination or test required under subdivision (a) (1)(B), or the specialized consultation under subdivision (a) (1)(C), that is requested by the physician reviewer under this subdivision is not received within thirty (30) days from the date of the request for authorization, the reviewer shall deny the treating physician's request in accordance with the applicable requirements under section 9792.9.5(e).

(d)(1) Upon receipt of the information requested pursuant to subdivisions (a) (1)(A), (B), or (C), the claims administrator or reviewer, for prospective or concurrent review, shall make the decision to approve, modify, or deny the request for authorization within five (5) business days of receipt of the information in accordance with the applicable provisions of sections 9792.9.4 and 9792.9.5.

(2) Upon receipt of the information requested pursuant to subdivisions (a) (1)(A), (B), or (C), the claims administrator or reviewer, for prospective or concurrent decisions related to an expedited review, shall make the decision to approve, modify, or deny the request for authorization within 72 hours of receipt of the information in accordance with the applicable provisions of sections 9792.9.4 and 9792.9.5.

(3) Upon receipt of the information requested pursuant to subdivisions (a) (1)(A), (B), or (C), the claims administrator or reviewer, for retrospective review, shall make the decision to approve, modify or deny the request for authorization within thirty (30) calendar days of receipt of the information requested in accordance with the applicable provisions of sections 9792.9.4 and 9792.9.5.

Credits

Note: Authority cited: Sections 133, 4603.5 and 5307.3, Labor Code. Reference: Sections 4062, 4600, 4600.4, 4604.5, 4610 and 4610.5, Labor Code.

History

1. Redesignation and amendment of former section 9792.9.1(f)(1)-(f)(6) as new section 9792.9.6 filed 12-30-2025; operative 4-1-2026 (Register 2026, No. 1).