What Is 8 CCR §9792.10.6: IMR Standards and Timeframes?

The final determination issued by the independent review organization shall be deemed to be the determination of the Administrative Director and shall be binding on all parties.

What is 8 CCR §9792.10.6?

Section 9792.10.6 is the Title 8 rule that tells the IRO how to review your case and exactly how many days it has to decide.

When a claims administrator's utilization review denies or changes your doctor's requested treatment, you have the right to request an independent medical review, called IMR for short. That gets your case a fresh look from an outside reviewer. This site's Labor Code 4610.5 card covers the right to request that review. Section 9792.10.6 picks up once your case is assigned to an IRO. It governs what the reviewer looks at, how many reviewers can be used, and the clock each type of case is decided on. It applies to every IMR assigned under the Labor Code, whether the dispute is about surgery, physical therapy, a diagnostic test, or a prescription drug.

How does the IRO reach a decision?

A medical reviewer examines your submitted records and decides, in plain language where possible, whether the treatment is medically necessary.

Once your case is assigned, the IRO picks a medical reviewer. That reviewer examines the documents filed under the related records rule and decides whether the treatment is medically necessary, using the standard set out in Labor Code section 4610.5. Say the claims administrator does not send the records it owes. The reviewer can still decide, using the utilization review decision's own summary plus whatever you or your physician submitted. But the rule will not let a reviewer decide based only on that utilization review decision. For an unusually complex case, the IRO may use more than one reviewer, with the Administrative Director's written approval. If those reviewers split evenly on whether to provide the treatment, the regulation resolves the tie in favor of providing it.

How many days does the review take?

Thirty days for a regular dispute, 5 business days for a drug-formulary-only dispute, and 3 days for an urgent case where treatment has not started.

These periods come from the regulation and from its parent statute, Labor Code section 4610.6. That statute sets the same 30-day, working-day, and 3-day periods, and the same extension for extraordinary circumstances or good cause. This card covers that statute and the limited WCAB petition that follows a final decision. If two or more disputes about the same treatment get consolidated, the clock restarts from the last application filed.

What happens once the decision is made?

The decision is deemed to be the Administrative Director's own determination, and it binds the claims administrator, you, and your provider.

The IRO sends its final determination, the reviewer's qualifications, and the reasons for the decision to the Administrative Director, the claims administrator, you, your attorney if you are represented, and your treating provider. Under subdivision (h), that determination is deemed to be the Administrative Director's own decision. It binds every party once issued. This site's IMR appeal guide covers the separate, narrow process for challenging a final determination at the WCAB, which is not a fresh medical review.

What if the claims administrator will not cooperate?

The Administrative Director can order a claims administrator to show cause and assess a penalty for not meeting the independent medical review requirements.

Say the Administrative Director receives credible information that a claims administrator failed to meet its independent medical review duties under Labor Code section 4610.5 or the related regulations. The director can then issue an order to show cause and assess an administrative penalty, separate from the medical decision itself. This site's treatment-denied guide covers what to do at each stage of a denial, including this one.

What should you do about a pending or finished IMR?

Keep a copy of your IMR application, every record you or your doctor sent in, and the date you sent it. If the deadlines above have passed with no decision, or you disagree with a final determination, call (661) 273-1780 or use the contact form. Yazdchi Law P.C. reviews each workers' compensation matter on its own facts before deciding whether to take it on, from its office in Palmdale. A workers' compensation judge must approve any attorney's fee in a California claim, under Labor Code section 4906, and the usual request is 15% to 18% of the amount recovered. The attorney cost guide explains how that approval works.