Free Microsoft Word - QMEForm105 newAttachmenton112408 CLEAN - non-fillable - California

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Use QME Form 105 when there is a dispute over a medical decision or medical opinion of the primary treating physician or utilization review. Read these instructions to know what you must do and the time limits for making decisions. You must have given your employer or the claims administrator a claim form before you may get a QME or any benefits. Answer all of the questions on QME form 105, sign the form and mail it to the DWC Medical Unit. The DWC Medical Unit will use the information on the form to issue a "QME panel". A "QME panel" is a list of three physicians who are certified as Qualified Medical Evaluators ("QME"). One physician from the list must be selected. The QME selected will do a medical examination and write a report. This QME report provides an independent, second medical opinion on all of the disputed and unresolved issues in the case that need a medical opinion.

How to Get a QME Panel Send QME Form 105 to the DWC Medical Unit
You, the injured worker, will have the first opportunity to choose the specialty of physician to perform the exam. You must do so within ten (10) days of the date the claims administrator sent you the QME Form 105. Within the 10-day time limit, fill out the form, write in the three letter code for the specialty you have picked, sign the form and mail it to the DWC Medical Unit. If you do not return the form, the claims administrator may gain the legal right to select the specialty of the QME instead. All three physicians on the "QME panel" will have the same specialty. The names are selected randomly within the general geographic area of your home. Sometimes it is necessary to travel far to see a QME in the specialty you select. Your employer must pay all reasonable transportation expenses to attend the exam, including lodging if needed. If you and the claims administrator agree in writing for your convenience to have the panel issued in the area of your workplace, attach that written agreement including the street address and zip code of your workplace to the panel request form. If the DWC Medical Unit does not send you and the claims administrator a "QME panel" within fifteen (15) business days of receiving the request, you may select any QME to do the evaluation. If this happens, call your Information and Assistance Officer at 1-800-736-7401 or the Medical Unit at 1-800-794-6900. The QME database, listing all QMEs by specialty and location, can be found on the internet at

How to Complete the Form "Request Date": Write the date you sign this form. "Requesting Party": Check the box for the person who selects the QME specialty and signs the form at the bottom. Answer the questions, about whether any part of the claim has been accepted, whether the claim has been denied; and about the wording of the notice from the claims administrator to you about the need to get a QME report, by checking the box that answers each question. Selecting a Reason for Requesting the QME Panel Select " 4060 (compensability exam)" whenever: 1) during the 90 days since you gave the employer your claim form, the claims administrator says the employer requests a QME report to determine whether to accept your claim and asks you to complete the form and select the specialty for the QME; or 2) when the claim is denied altogether and the
Attachment to QME Form 105 Rev. February 2009

claims administrator has refused to provide or has stopped all benefits including medical treatment; or 3) if the treating physician writes that your injury was not caused by work and you disagree with that opinion. If the claims administrator has accepted any body part in the claim, select a different reason. If the notice from the claims examiner during the only says the employer has not accepted liability and you may request a panel, you are not required by law to send the panel request form to the Medical Unit. Call the Information and Assistance officer 1-800-736-7401 to discuss your options.

Select " 4061 (permanent impairment or disability dispute)" if there is a dispute about temporary disability or
whether you have any permanent impairment permanent disability, or you disagree over the amount or percentage of permanent impairment or permanent disability.

Select " 4062 (injured employee only - medical treatment or UR dispute or other 4062 reason)" if treatment, that your treating physician has recommended, has been denied, delayed or modified based on a decision by utilization review or the claims administrator; or, whenever there is a dispute over the amount or frequency or type of treatment that you need now or will need in the future. Select this reason also if the dispute is about `permanent and stationary' status. Select " 4062 (claims administrator only other non-treatment, non-UR reason under 4062)" if you are
the claims administrator who has objected to some other medical determination or issue under Labor Code 4062. However, the requesting claims administrator must state the reason on the line provided. Examples may include medical determinations on new and further disability, medical eligibility for vocational rehabilitation, the permanent and stationary date, MPN continuity of care or transfer of care, that a new body part needing treatment is causally connected to the claimed injury. If you are covered for medical treatment in an MPN and you disagree over the MPN physician's diagnosis or treatment you do not need a QME. Call the Information and Assistance officer 1-800-736-7401 to discuss how to get another MPN physician or an MPN second opinion. You may request a QME panel and select 4062 for disputes over a treating physician's opinion about whether you qualify for continuity of care (care by the same treating physician after your MPN physician left or is terminated by the MPN) or transfer of care (whether your condition or treatment qualifies for your claims administrator to transfer your care to an MPN physician).

Select " 4061 and 4062 issues" if currently there are disagreements about both permanent disability and medical
determinations. The claims administrator may not select this reason if the only disputes under 4062 are because of a denial, delay or modification of your medical treatment by a utilization review physician.

Prior QME Panel List or Examination
Answer the questions about any QME panel lists you have received in the past. This information is needed to avoid delays in issuing the QME panel list you are requesting now.

Select the Medical Specialty, Sign and Mail the Form
Use the list on the back of QME Form 105 to select a medical specialty. If necessary, request help from your treating physician to choose the specialty. Write the 3 letter code for the medical specialty you select on the front of Form 105. Also, sign the form and print your name below the signature.

What if I pick the wrong medical specialty and wish to change the medical specialty?
You may request a change of medical specialty if you have not had the QME evaluation yet and you and the claims administrator agree in writing to the change of medical specialty. Please include the QME panel number on your request.

What if there is a need for another QME report in a different specialty?
Attachment to Form 105 Rev. February 2009 Page 2

Sometimes, there may be a need for an additional examination and report by a QME in a different specialty. Generally this will occur only if the first QME states in the report that an exam by a physician in another specialty is necessary, or if a Workers' Compensation Judge orders the additional report, or if the parties meet with Information and Assistance Officer who determines that the conditions for obtaining an additional report are met.

Your rights to an attorney
You are entitled to be represented by an attorney at any stage of your workers' compensation claim. However, after you have had an evaluation by a QME, you are not entitled to a new QME evaluation. Should you decide to be represented by an attorney, you may or may not receive a larger award, but unless you are determined to be ineligible for an award, the attorney's fee will be deducted from any award you might receive for disability benefits. The decision to be represented by an attorney is yours to make, but it is voluntary and may not be necessary for you to receive your benefits.

Other questions?
For other questions about the QME process, please call the DWC Medical Unit at 1-800-794-6900. For general questions about your workers' compensation claim and benefits, please call the Information and Assistance Officer at the Division of Workers' Compensation 1-800-736-7401 or look on our website at

Attachment to QME Form 105 Rev. February 2009 Page 3