Section 2592.04 - Training Required for Medical Bill Reviewers(a) Every insurer shall require all medical bill reviewers, other than those defined in section 2592.01(h), including employees and agents of medical billing entities used by the insurer, to be trained. The insurer shall require at least 40 hours of training for medical bill reviewers, at least 30 hours of which shall be conducted in a classroom by an instructor. No more than ten (10) hours of training may be done on the job.(b) The training required by this section shall be completed within a twelve (12) month period, during which time a medical bill review trainee may review bills under the supervision of an instructor, experienced medical bill reviewer, or experienced claims adjuster. No individual may review medical bills on behalf of one or more insurers for a combined total of more than twelve (12) months unless the individual has been trained pursuant to this article.(c) Any classes or courses taken within one (1) year before the effective date of these regulations that satisfy the curriculum requirement of subdivision (h) below may be used to meet the hourly requirements upon verification by the student to the insurer or medical billing entity of the type of course taken, the course of study, the date or dates taken, the person or organization providing the class or course, and the number of hours taken.(d) Upon the effective date of these regulations, every insurer shall require a minimum of 16 hours every two (2) years of post-designation training for all medical bill reviewers and shall include in the post-designation training changes in the law affecting medical bill reviewers and topics as specified in subdivision (h) below.(e) Failure of a medical bill reviewer designated pursuant to subdivisions (a) or (c) of section 2592.05 to fulfill the requirements for post-designation training every two years pursuant to subdivision (d) above shall result in that person being no longer considered a designated medical bill reviewer. That person shall not be authorized to review medical bills until the requisite number of hours of post-designation training is completed.(f) The insurer may provide the designation training directly or by sending its employees or agents to be trained by a training entity for the entire designation curriculum. The insurer shall require all medical billing entities that review or adjust medical billings on its behalf to have the medical billing entities' employees or agents trained directly by the medical billing entity, the insurer, or by a training entity for the entire designation curriculum. The insurer shall certify, in the manner provided for in sections 2592.07 and 2592.09, that the course of instruction provided or that is provided by its medical billing entities meets all the requirements set forth in this article and that all medical bill reviewers of the insurer and its medical billing entities have actually attended the training for the required number of hours.(g) A medical bill reviewer who has received a Designation as having completed the training required by this article shall not be required to be re-trained and re-designated in order to review medical bills for a different insurer.(h) The curriculum for the training of medical bill reviewers shall include, but not be limited to, the following topics:(1) The correct use of billing codes and detection of improper use of billing codes.(2) All fee schedules applicable in California to workers' compensation medical care, including statutes and regulations authorizing the fee schedules.(3) Workers' compensation benefit provisions.(6) Utilization guidelines (American College of Occupational and Environmental Medicine or other guidelines approved by the Administrative Director of the Division of Workers' Compensation.)(i) An insurer may not authorize an individual to act in the capacity of a medical bill reviewer who has not been trained pursuant to this article or who is not an experienced medical bill reviewer, except that an individual who is undergoing training may review medical bills under the direct supervision of an instructor, experienced medical bill reviewer or experienced claims adjuster.Cal. Code Regs. Tit. 10, § 2592.04
1. New section filed 1-23-2006; operative 2-22-2006 (Register 2006, No. 4). Note: Authority cited: Section 11761, Insurance Code. Reference: Section 11761, Insurance Code.
1. New section filed 1-23-2006; operative 2-22-2006 (Register 2006, No. 4).