Section 2592.09 - Insurer Annual Certification Form-Medical Bill ReviewersANNUAL CERTIFICATION OF MEDICAL BILL REVIEWERS
To the Insurance Commissioner of the State of California Pursuant to California Insurance Code Section 11761 and California
Code of Regulations, Title 10, Sections 2592.04 and 2592.07
As the person or officer responsible for the claims operation of:
______________________________
(Name of Insurer)
[] Insurance Company | [] Self-Insured Employer |
[] Third-Party Administrator |
(Check One) |
I hereby certify the following regarding California workers' compensation claims:
1. The total number of medical bill reviewers reviewing medical bills on this insurer's behalf is: __________.2. The total number of experienced or trained medical bill reviewers reviewing medical bills on this insurer's behalf is: __________.3. The percentage of experienced or trained medical bill reviewers reviewing medical bills on this insurer's behalf is: __________%4. All persons reviewing medical bills on behalf of this insurer are designated to do so or are in training.5. The course of instruction provided for training of all medical bill reviewers of this insurer and of medical billing entities used by this insurer meets all requirements set forth in Article 20 (commencing with section 2592) of Subchapter 3, Chapter 5, Title 10, California Code of Regulations, and that all medical bill reviewers of this insurer and of medical billing entities used by this insurer have attended training for the required number of hours to be qualified to perform medical bill review. I certify under the penalty of perjury under the laws of the State of California that the foregoing is true and correct:
| ___________________________ | | ___________________________ |
| (Date and Place) | | (Signature) |
Name of person certifying (print or type):
Title of person certifying:
Business address:
Cal. Code Regs. Tit. 10, § 2592.09
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).