Module 1 – Workers’ Compensation System (Cards 106 – 150)

Question 2

Define Independent Medical Review (IMR).

Answer 2

State-run process to review utilization review (UR) denials of medical care.

Question 3

Timeline to request IMR after UR denial?

Answer 3

30 days from denial letter.

Question 4

Mnemonic

Answer 4

“IMR in 30.”

Question 5

Who issues IMR decisions?

Answer 5

Maximus Federal Services (CA DWC contractor).

Question 6

IMR decision timeline?

Answer 6

Usually 30 days (urgent: 3 days).

Question 7

What is a Primary Treating Physician (PTP)?

Answer 7

Main doctor managing WC case, issues work status & MMI opinions.

Question 8

PTP report frequency?

Answer 8

Every 45 days or at key milestones.

Question 9

Mnemonic

Answer 9

“PTP = 45-day check-ins.”

Question 10

What’s a PR-2 form?

Answer 10

Progress report by PTP updating treatment/TD/RTW status.

Question 11

Define MMI.

Answer 11

Maximum Medical Improvement — condition is stable; no further functional change expected.

Question 12

Who determines MMI?

Answer 12

Treating doctor, QME, or AME.

Question 13

Mnemonic

Answer 13

“MMI = Medically plateaued.”

Question 14

Difference TD vs PD?

Answer 14

TD = wage replacement during healing; PD = lasting impairment after MMI.

Question 15

Temporary Partial Disability (TPD)?

Answer 15

Partial wage loss when working modified duty at reduced pay.

Question 16

Temporary Total Disability (TTD)?

Answer 16

No work ability; pays 2/3 AWW (up to cap).

Question 17

Mnemonic

Answer 17

“TTD = Totally out; TPD = Partly out.”

Question 18

PD rating source?

Answer 18

AMA Guides (5th Ed.) + DWC rating schedule.

Question 19

What’s an FEC adjustment?

Answer 19

Future Earning Capacity modifier adjusting WPI % to PD %.

Question 20

Mnemonic

Answer 20

“FEC = Future Earning Correction.”

Question 21

When is LC 4658(d) supplement due?

Answer 21

For workers with <70% PD — extra weeks if employer lacks suitable work.

Question 22

Define Return-to-Work Supplement Program.

Answer 22

$5,000 one-time payment for injured workers with SJDB voucher.

Question 23

Statute of limitations for WC claim?

Answer 23

1 year from date of injury (with tolling exceptions).

Question 24

What’s cumulative trauma (CT)?

Answer 24

Injury from repeated microtrauma/exposure over time.

Question 25

Mnemonic

Answer 25

**“CT = Constant Trauma.”**

Question 26

What is a **Date of Injury (DOI)** for CT?

Answer 26

When employee first knew injury was work-related and caused disability.

Question 27

Serious & Willful claim filing time?

Answer 27

**1 year** from injury or employer knowledge.

Question 28

Define **Third-Party Action.**

Answer 28

Worker sues non-employer whose negligence contributed to injury; employer may get lien.

Question 29

What’s **subrogation** in WC?

Answer 29

Employer/insurer recovers WC costs from liable 3rd party.

Question 30

Mnemonic

Answer 30

**“Subro = payback from third party.”**

Question 31

What is **LC 5405**?

Answer 31

Sets **1-year filing deadline** for WC benefits.

Question 32

Define **apportionment.**

Answer 32

Splitting PD % between work and **non-industrial** causes.

Question 33

Who can rebut apportionment?

Answer 33

Opposing med-legal expert with valid evidence.

Question 34

Mnemonic

Answer 34

**“Apportion = Portion out.”**

Question 35

Define **injury AOE/COE.**

Answer 35

**Arising Out of & in Course of Employment** — must prove both for compensability.

Question 36

What’s the **Going/Coming Rule**?

Answer 36

Normal commute **not COE** (unless exceptions like special mission).

Question 37

Define **Special Mission exception.**

Answer 37

Commute counts if **employer-directed special task/errand.**

Question 38

Mnemonic

Answer 38

**“Special mission = COE trip.”**

Question 39

What is **LC 3600**?

Answer 39

Establishes WC as **exclusive remedy** for work injuries.

Question 40

Who administers WC system?

Answer 40

**DWC (Division of Workers’ Compensation)** under DIR.

Question 41

Define **WCAB panel QME process.**

Answer 41

DWC issues 3-name list; parties strike until 1 remains.

Question 42

Time to request panel after dispute?

Answer 42

**10 days** if rep / **15 days** if unrep after objection.

Question 43

What is **Labor Code 5813**?

Answer 43

Allows WCAB to sanction bad-faith or frivolous tactics (fees/penalties).

Question 44

Mnemonic

Answer 44

**“5813 = Stop games, pay fees.”**

Question 45

Employer’s duty under LC 5401?

Answer 45

Provide claim form **within 1 day** of injury notice.

Question 46

LC 5402 presumption?

Answer 46

If no denial in **90 days**, claim presumed accepted.

Question 47

Mnemonic

Answer 47

**“5402 = 90-day accept.”**

Question 48

Define **EAMS.**

Answer 48

**Electronic Adjudication Management System** — WCAB’s case tracking portal.

Question 49

What is an **RU-91 form**?

Answer 49

Used to request **SJDB voucher**.

Question 50

Who sets medical fee schedule?

Answer 50

**DWC Administrative Director.**

Question 51

Define **MTUS.**

Answer 51

**Medical Treatment Utilization Schedule** — CA evidence-based treatment guidelines.

Question 52

Mnemonic

Answer 52

**“MTUS = Med rules to use safely.”**

Question 53

What is **LC 4663**?

Answer 53

Governs **apportionment** — physicians must assign % to non-industrial factors.

Question 54

LC 4660 factors?

Answer 54

**Age & occupation** adjustments for PD.

Question 55

What is a **QME panel strike process**?

Answer 55

Each side strikes one name; remaining doctor evaluates.

Question 56

Define **DEU**.

Answer 56

**Disability Evaluation Unit** — calculates official PD rating.

Question 57

Who controls WC medical network?

Answer 57

Employers may use **MPN (Medical Provider Network)** if compliant.

Question 58

Mnemonic

Answer 58

**“MPN = My Provided Network.”**

Question 59

Define **post-termination defense.**

Answer 59

If worker files after termination (w/ some exceptions), employer may deny.

Question 60

What is **LC 5401 form**?

Answer 60

DWC-1 — Employee claim form for WC.

Question 61

How many days employer to respond DWC-1?

Answer 61

**1 working day** to give claim form & benefits notice.

Question 62

Who pays QME mileage?

Answer 62

**Requesting party** reimburses per state mileage rate.

Question 63

Define **RTW (Return to Work) offer.**

Answer 63

Modified/regular job within **60 days** of MMI.

Question 64

Mnemonic

Answer 64

**“RTW in 60.”**

Question 65

Failure to offer RTW triggers?

Answer 65

**Supplemental Job Displacement Benefit voucher** & $5k supplement.

Question 66

What is **SIBTF**?

Answer 66

**Subsequent Injuries Benefit Trust Fund** — extra PD $$ if prior + current injuries combine ≥70%.

Question 67

Define **Voc Rehab voucher (SJDB).**

Answer 67

Up to **$6,000** for training if no suitable work offered.

Question 68

Mnemonic

Answer 68

**“SJDB = Study Job, Don’t Backslide.”**

Question 69

Employer coverage requirement in CA?

Answer 69

Mandatory **WC insurance or self-insurance**.

Question 70

What’s the penalty for no WC coverage?

Answer 70

**Stop order + $1,500 per employee** & possible criminal charges.

Question 71

Purpose of DWC Information & Assistance Unit?

Answer 71

Helps **injured workers** navigate WC without lawyers.

Question 72

Who certifies self-insured employers?

Answer 72

**DIR Office of Self-Insurance Plans (OSIP).**

Question 73

Define **TTD max duration.**

Answer 73

Generally **104 weeks** within 5 years of DOI (exceptions: severe injuries).

Question 74

Mnemonic

Answer 74

**“TTD = 104 in 5.”**

Question 75

What is LC 4650 penalty?

Answer 75

10% self-imposed penalty if TD/PD late (plus 5814 if unreasonable).

Question 76

Employer’s posting requirement?

Answer 76

Must display **WC coverage & claim info** at worksite.

Question 77

DWC audit unit function?

Answer 77

Ensures carriers/employers pay correct, timely benefits.

Question 78

What’s an **Application for Adjudication of Claim**?

Answer 78

Formal filing to open a WCAB case number (ADJ).

Question 79

Mnemonic

Answer 79

**“App = Activate WCAB case.”**