The California Division of Workers’ Compensation (CA DWC) will enact new regulations to (theoretically) streamline authorization for injured workers’ care, effective April 1, 2026.

Unfortunately, the regulations will be virtually meaningless in practice and will fail to improve injured workers’ access to care in California.

In 2016, California legislators passed Senate Bill 1160, which updated Labor Code (LAB) Section 4610 by, theoretically, exempting many treatments from prospective Utilization Review (UR) in the first 30 days after a work-related injury (UR is the process by which payers decide whether to approve the care an injured worker’s recommended in a physician’s Request for Authorization).

Eight years after LAB § 4610 took effect in 2018, the CA DWC under recently retired Administrative Director (AD) George Parisotto promulgated California Code of Regulations (CCR) Section 9792.9.7 to implement LAB § 4610. Sadly, the regulatory loopholes are big enough to drive an ambulance through:

1. Providers can only bypass UR when the payer deems the body part or condition compensable. Since payers have up to 90 days to determine compensability, providers have no way to easily ascertain an injury’s status in the first 30 days.
2. The provider must be a member of the applicable Medical Provider Network (MPN). It is often difficult or impossible to determine which MPN applies (if any) to an injured worker or whether the provider is a member.
3. The UR exemption does not apply to a substantial list of specific treatments.

Even more ridiculous, despite the alleged “UR exemption,” the provider must:

• Submit a Request for Authorization (RFA) for all recommended treatment proposed during the first 30 days, along with the Doctor’s First Report of Occupational Injury or Illness (DFR/Form 5021), within 5 days of treatment.
• Submit a bill within 30 days of treatment, as compared to 365 days for all other workers’ comp bills.

Finally, these regulations fail to address the fact that payers routinely deny payment when the provider does not include proof of authorization with the bill. In reality, providers who attempt to exercise the UR exemption risk having their reimbursement denied.

For the inevitably denied bills, providers will have to submit Second Review appeals and (somehow) prove that the injury was compensable, the provider was in the applicable MPN, the treatment qualified for the exemption, and the bill was submitted within 30 days of treatment. Good luck.

Like its statutory counterpart, CCR § 9792.9.7 is riddled with exceptions and caveats that undermine the legislature’s attempt to streamline access to care. California will continue to delay care by forcing physicians to submit RFAs and wait for UR decisions for all treatment. Ultimately, employers will pay the price.

Bypassing Prospective UR? Not Exactly.

Under LAB § 4610(b), in the first 30 days after an injury, a physician does not have to wait for UR approval for care that meets state treatment guidelines…unless:

• The payer doesn’t accept the injured body part or condition as compensable.
• The physician isn’t in the employer or insurer’s MPN.
• The treatment is one of several exceptions under § 4610(c).

As LAB § 4610(b) states (emphases ours):

“...medical treatment rendered for a body part or condition that is accepted as compensable by the employer and is addressed by the medical treatment utilization schedule adopted pursuant to Section 5307.27, by a member of the medical provider network or health care organization, or by a physician predesignated pursuant to subdivision (d) of Section 4600, within the 30 days following the initial date of injury, shall be authorized without prospective utilization review, except as provided in subdivision (c).”

In other words, there are huge asterisks to the supposed exemptions from prospective UR.

Between compensability, MPNs, and treatment exceptions, the caveats pile up so high that, in reality, a treating doctor may have no reasonable way to know whether or not they can render care without waiting for a UR decision.

The New CCR § 9792.9.7: A Mirage of Treatment Access

Apparently in no hurry to implement SB 1160’s revamped LAB § 4610, the CA DWC will enact CCR § 9792.9.7 on April 1, 2026, ten years after SB 1160 passed and eight years after LAB § 4610 took effect.

CCR § 9792.9.7, originally promulgated under former AD Parisotto, reiterates the alleged UR exemptions of LAB § 4610, but only for treating physicians "specified in Labor Code section 4610(b).” This means that, again, the physician can only bypass prospective UR if they’re in the employer or insurer’s MPN.

As daisyNews has reported in great detail, MPN applicability and provider membership are often a black hole of an abyss of a mystery to both patients and providers. Regardless, CCR § 9792.9.7 states (emphases ours):

“...a treating physician specified in Labor Code section 4610(b), may render medically necessary treatment or services to an injured worker without prospective utilization review for the first thirty (30) days after the date of injury…”

CCR § 9792.9.7 goes on to note other caveats, including:

1. The payer must have accepted the body part/condition as compensable.
2. The treatment must follow the Medical Treatment Utilization Schedule.
3. The physician must submit the DFR/Form 5021 “timely” as required under CCR Section 9785; i.e., within five days.
4. The physician must include an RFA for all treatment anticipated to be provided in the first 30 days “concurrent with” the DFR/Form 5021; i.e, within five days.
5. The physician must bill for the treatment within 30 days of the date of service.
6. Further details on the treatments that still require prospective UR as noted in LAB § 4610(c).

At its annual conference this March, the CA DWC presented a slide deck on CCR § 9792.9.7. Notably, in the slide below, the CA DWC reminds providers when the exemption to prospective UR applies…but fails to mention that the provider must be an MPN member.

The CA DWC also offered instructions for how payers can punish physicians they suspect of a “pattern and practice” of abusing the UR exemption. Consequences include filing a change of Primary Treating Physician and terminating the physician from the MPN. Physicians who fail to submit Form 5021 promptly can lose the “privilege” of UR exemptions for the remainder of the 30-day period.

The regulations, of course, do not impose punishments when a payer improperly denies reimbursement for failure to submit a prospective RFA, even when the UR exemption applies.

The CA DWC’s new UR regulations are the culmination of a legislative effort that started with SB 1160 in 2016. While on the surface, this appears to improve access to care for workers and lighten providers’ administrative burden, the regulation is too compromised to be effective.

We’ve seen too many instances of payers denying reimbursement based on physician non-membership in unspecified or non-existent MPNs, and witnessed too many battles over liability and compensability, to believe that providers can actually treat without prospective UR (without risking their reimbursement).

CCR § 9792.9.7 is just another example of the CA DWC performing, rather than executing, its role in protecting providers and ensuring workers’ access to care.

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