Jurisdiction in WC Cases

Division 4, Part 4, Chapter 1 deals with jurisdiction in workers’ compensation cases in California.

Section 5300 provides that all of the six specified proceedings must be instituted before the appeals board and not elsewhere, except as otherwise provided.

Section 5301 explains that the appeals board is vested with full power, authority and jurisdiction to try and determine finally all the matters specified in law subject only to the review by the courts.

Section 5302 requires all orders, rules, findings, decisions, and awards of the appeals board to be prima facie lawful and conclusively presumed to be reasonable and lawful.

Section 5303 provides that there is one cause of action for each injury coming within the provisions of this division. All claims brought for medical expense, disability payments, death benefits, burial expense, liens, or any other matter arising out of such injury may, in the discretion of the appeals board, be joined in the same proceeding at any time.

Section 5304 explains that the appeals board has jurisdiction over any controversy, unless an express agreement fixing the amounts to be paid for medical, surgical or hospital treatment as the treatment is described in those sections has been made between the persons or institutions rendering treatment and the employer or insurer.

Section 5305 provides that the Division of Workers’ Compensation and the appeals board have jurisdiction over all controversies arising out of injuries suffered outside the territorial limits of this state in those cases where the injured employee is a resident of this state at the time of the injury and the contract of hire was made in this state.

Section 5306 states that the death of an employer subsequent to the sustaining of an injury by an employee cannot impair the right of the employee to proceed before the appeals board against the estate of the employer, and the failure of the employee or his dependents to cause the claim to be presented to the executor or administrator of the estate cannot in any way bar or suspend the right.

Section 5307 allows the appeals board, by an order signed by four members, to do four specified actions.

Section 5307.1 requires the administrative director, after public hearings, to adopt and revise periodically an official medical fee schedule that establishes 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. Except for physician services, all fees must be in accordance with the fee-related structure and rules of the relevant Medicare and Medi-Cal payment systems, with exceptions.

Section 5301.11 allows a health care provider or health facility, and a contracting agent, employer, or carrier to contract for reimbursement rates different from those in the fee schedule adopted and revised. When a health care provider or health facility, and a contracting agent, employer, or carrier contract for reimbursement rates different from those in the fee schedule, the medical fee schedule for that health care provider or health facility does not apply to the contracted reimbursement rates.

Section 5307.12 requires the official medical fee schedule to establish maximum reimbursement rates for all medical services for injuries subject to this division provided by a health care provider or health care facility other than those specified in contracts subject to this section.

Section 5307.2 requires the administrative director to contract with an independent consulting firm, to the extent permitted by state law, to perform an annual study of access to medical treatment for injured workers. The study must analyze specified items. If the administrative director determines, based on this study, that there is insufficient access to quality health care or products for injured workers, the administrative director may make appropriate adjustments to medical, prescription drugs and pharmacy services, and facilities’ fees.

When there has been a determination that substantial access problems exist, the administrative director may, in accordance with the notification and hearing requirements, adopt fees in excess of 120 percent of the applicable Medicare payment system fee, or in excess of 100 percent of the fees prescribed in the relevant Medi-Cal payment system, for the applicable services or products.

Section 5307.27 requires the administrative director, in consultation with the Commission on Health and Safety and Workers’ Compensation, to adopt, after public hearings, a medical treatment utilization schedule, that incorporates the evidence-based, peer-reviewed, nationally recognized standards of care, and that address specified treatment procedures and modalities commonly performed in workers’ compensation cases.

Evidence-based updates to the utilization schedule must be made through an order, but the administrative director must allow at least a 30-day period for public comment and a public hearing. The administrative director is also required to provide responses to submitted comments prior to the effective date of the updates. All orders issued pursuant to this subdivision must be published on the Internet Web site of the Division of Workers’ Compensation.

Section 5307.28 requires the administrative director to meet and consult regarding the establishment of a formulary with stakeholders, including employers, insurers, private sector employee representatives, public sector employee representatives, treating physicians actively practicing medicine, pharmacists, pharmacy benefit managers, attorneys who represent applicants, and injured workers.

Section 5307.29 requires the administrative director to make provision for no less than quarterly updates to the drug formulary to allow for the provision of all appropriate medications, including those new to the market. Changes made to the list of drugs in the drug formulary are required to be made through an order informing the public of the changes and their effective date. All orders issued pursuant to this subdivision must be published on the Internet Web site of the Division of Workers’ Compensation.

The administrative director is required to establish an independent pharmacy and therapeutics committee to review and consult with the administrative director on available evidence of the relative safety, efficacy, and effectiveness of drugs within a class of drugs in the updating of an evidence-based drug formulary.

Section 5307.4 explains that public hearings required are subject to the provisions of this section, except to the extent that there is involved a matter relating to the management, or to personnel, or to public property, loans, grants, benefits, or to contracts, of the appeals board or the administrative director.

After notice required by this section, the appeals board or the administrative director are required to give interested persons the opportunity to participate in the rulemaking through submission of written data, views, or arguments, with opportunity for oral presentation. If, after consideration of the relevant matter presented, the appeals board or the administrative director adopts a rule, it or he is required to publish a concise, general statement of reasons for the adoption of the rule. The rule and statement of reasons is given to the same individuals and organizations who have requested notice of hearings. The notice required under this section must be made not less than 30 days prior to the public hearing date.

Section 5307.5 allows the appeals board or a workers’ compensation judge to do two specified activities.

Section 5307.6 requires the administrative director to adopt and revise a fee schedule for medical-legal expenses which is prima facie evidence of the reasonableness of fees charged for medical-legal expenses at the same time he or she adopts and revises the medical fee schedule.

A provider is prohibited from being paid fees in excess of those set forth in the fee schedule established under this section unless the provider provides an itemization and explanation of the fee that shows that it is both a reasonable fee and that extraordinary circumstances relating to the medical condition being evaluated justify a higher fee. However, in no event is a provider permitted to charge in excess of his or her usual fee. The employer and employee have standing to contest fees in excess of those set forth in the fee schedule.

Section 5307.8 requires the administrative director to adopt, after public hearings, a schedule for payment of home health care services that are not covered by a Medicare fee schedule and are not otherwise covered by the official medical fee schedule adopted. The schedule is required to set forth fees and requirements for service providers, and may be based upon two specified topics.

Section 5308 explains that the appeals board has jurisdiction to determine controversies arising out of insurance policies issued to self-employing persons, conferring benefits identical with those prescribed by this division. The appeals board may try and determine matters referred to it by the parties with respect to controversies arising out of insurance issued to self-employing persons under the provisions of this division. These controversies may be submitted to it by the signed agreement of the parties, or by the application of one party and the submission of the other to its jurisdiction, with or without an express request for arbitration.

Section 5309 allows the appeals board, in accordance with rules of practice and procedure which it must adopt and upon the agreement of the parties, on the application of either, or of its own motion, and with or without notice, direct and order a workers’ compensation judge to perform three specified tasks.

Section 5310 authorizes the appeals board to appoint one or more workers’ compensation administrative law judges in any proceeding, as it may deem necessary or advisable, and may refer, remove to itself, or transfer to a workers’ compensation administrative law judge the proceedings on any claim.

In addition, the administrative director may appoint workers’ compensation administrative law judges. Any workers’ compensation administrative law judge appointed by the administrative director has the powers, jurisdiction, and authority granted by law, by the order of appointment, and by the rules of the appeals board.

Section 5311 provides that any party to the proceeding may object to the reference of the proceeding to a particular workers’ compensation judge upon any one or more of the grounds and the objection must be heard and disposed of by the appeals board.

Section 5311.5 requires the administrative director to ensure that all workers’ compensation administrative law judges to participate in continuing education to further their abilities as workers’ compensation administrative law judges, including courses in ethics and conflict of interest.

Section 5317 states that, before entering upon his or her duties, the workers’ compensation judge is to be sworn, faithfully and fairly to hear and determine the matters and issues referred to him or her, to make just findings and to report according to his or her understanding.

Section 5313 requires the appeals board or the workers’ compensation judge to makes and file findings, within 30 days after the case is submitted, upon all facts involved in the controversy and an award, order, or decision stating the determination as to the rights of the parties. Together with the findings, decision, order or award there must be served upon all the parties to the proceedings a summary of the evidence received and relied upon and the reasons or grounds upon which the determination was made.

Section 5315 provides that, within 60 days after the filing of the findings, decision, order or award, the appeals board may confirm, adopt, modify or set aside the findings, order, decision, or award of a workers’ compensation judge.

Section 5316 states that any notice, order, or decision required by this division to be served upon any person either before, during, or after the institution of any proceeding before the appeals board, may be served in the manner provided by law, unless otherwise directed by the appeals board. 

Section 5317 provides that any notice, order or decision affecting the State or any county, city, school district, or public corporation, must be served upon the person upon whom the service of similar notices, orders, or decisions is authorized by law.