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MLFS Billing Tip: CA Med-Legal Deadlines Extended

MLFS Billing Tip: CA Med-Legal Deadlines Extended

As providers continue to grapple with COVID-19’s impact on healthcare systems, California Medical-Legal examiners (and workers’ comp claims administrators) are reminded: the 15-day extension to the deadline for submitting Medical-Legal evaluation reports remains in place.

Under normal circumstances, the doctor must submit the Medical-Legal evaluation report within 30 days of the injured worker’s evaluation. However, Section 46.2 of the California Code of Regulations (CCR), effective from March 14, 2020 to October 12, 2021, extends the deadline by an additional 15 days, to 45 days total.Once approved by the state Office of Administrative Law (OAL), the deadline extensions will remain in place for an additional 90 days, to January 11, 2022.*

Unfortunately for QMEs and AMEs, claims administrators (and the DWC) can fail to honor the extensions, as demonstrated by one dispute.

Have questions about Medical-Legal billing in California? Join us for a live Q&A with DaisyBill co-founder Sarah Moray. Sign up & submit questions here.

Med-Legal Reporting Deadlines for CA Workers’ Comp (pre-COVID)

The pre-Covid deadline for submitting a medical-legal evaluation report is found in California Code of Regulations (CCR) Section 38, which states:

The time frame for an initial or a follow-up comprehensive medical-legal evaluation report to be prepared and submitted shall not exceed thirty (30) days after the QME, Agreed Panel QME or AME has seen the employee or otherwise commenced the comprehensive medical-legal evaluation procedure. [emphasis added]

CCR §38 offers two exceptions to the 30-day time frame:

  1. Lack of test results or other information necessary to complete the evaluation, and
  2. “Good cause” as defined by California Labor Code Section 139.2(j)(1)(B)

In either of the above cases, the physician is responsible for submitting a written request to extend the deadline, using QME Form 112 (Agreed Medical Evaluators [AME] also use the same form to request a deadline extension). The physician must submit the form no less than 5 days before the initial 30-day deadline expires.

However, these deadlines represent the world as we knew it before COVID-19.

Med-Legal Reporting Deadline Extensions Since COVID

In April of 2020, the California DWC announced emergency regulations in response to the pandemic, which included a 15-day extension to the above-noted 30-day deadline.

Originally effective from May 14, 2020 to January 12, 2021, the emergency regulations are found in CCR § 46.2, which states in subsection (c):

During the time this regulation is in effect, all of the time periods enumerated in section 38 of title 8 of the California Code of Regulations are extended by a period of 15 days.

CCR §46.2 was twice extended by executive order of the Governor, first to March 12, 2021, and most recently to October 12, 2021. According to a recent Newsline, the DWC has re-adopted the deadline extension once again, pending approval by the OAL. The re-adoption will extend the emergency measures an additional 90 days.

Billing Tip: Include Emergency Extension Language in Bills and Appeals

To help avoid improper denials on the basis of “untimely” submission, we recommend including the following language when submitting the requested Medical-Legal report:

Per Governor Newsom’s stay-at-home order in response to COVID-19 issued on March 19, 2020, and the California Division of Workers’ Compensation’s emergency measures extending the deadline for submitting Medical-Legal reports found in California Code of Regulations Section 46.2(c), this Evaluation Report was delayed by 15 or fewer days in excess of the 30-day submission requirement.

Physicians must be prepared for claims administrators to improperly deny reimbursement by failing to recognize the emergency measures.

Claims administrators may do so in error, being unaware of the extension or its effective dates. It would also surprise precisely no one if some claims administrators simply disregarded the deadline extension, as with so many of the barely-enforced rules for payers in California.

In the event your practice is denied payment for a Medical-Legal report submitted within 45 days of the evaluation, promptly submit a Second Review appeal with the following language:

California Code of Regulations Section 46.2, QME Emergency Regulation in Response to COVID-19, effective from 5/14/2020 to 10/12/2021, states that “During the time this regulation is in effect, all of the time periods enumerated in section 38 of title 8 of the California Code of Regulations are extended by a period of 15 days.” The evaluation report in question was submitted within 45 days, as allowed by this emergency regulation.

Keep your eye on the blog — we’ll keep our readers updated in this space regarding any further extensions to Medical-Legal reporting deadlines. For further questions, sign up for our upcoming Medical-Legal billing Q&A webinar:


*A previous version of this post listed the deadline extension expiration as January 10, 2022.

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