Workers' Compensation Claims Adjuster and Medical Bill Reviewer Training

The insurers listed on this Web page, which include insurance companies, self-insured employers, and third-party administrators, certified to the Insurance Commissioner that all claims adjusters, medical-only claims adjusters and medical bill reviewers met the requisite initial training or experience requirements and subsequent training requirements for handling workers' compensation claims in California. Each insurer must certify this annually to the Commissioner, on or before July 1st. These requirements are outlined in the regulations promulgated by the Commissioner in accordance with Section 11761 of the California Insurance Code.

Insurer, Third Party Administrator (TPA) and Self Insured Employer Certification Summaries

Certification Forms

NOTE: Certification Forms are the ONLY forms that should be submitted by the insurer to the Department of Insurance. DO NOT submit Designation Forms to the Department of Insurance. Designation Forms are provided for the insurer's convenience to use in issuing required designations to employees.

Designation Forms

Initial Training or Experience Requirements and Subsequent Training Requirements

Claims Adjuster Training

To handle workers' compensation claims, each claims adjuster shall receive a Claims Adjuster Designation Form that verifies that he or she has completed a minimum of 160 hours of training, with at least 120 hours of training being conducted in a classroom with an instructor or has met the requisite experience requirements as set forth in the regulations (Section 2592.01(f)). Subsequent to the initial designation, all claims adjusters shall receive a Post-Designation Training Form that demonstrates he or she has met the required 30 hours of post-designation training every two years.

Medical-only Claims Adjuster Training

To handle claims involving only medical benefits, each medical-only claims adjuster shall receive a Medical-Only Claims Adjuster Designation Form that verifies he or she has completed at least 80 hours of training, with at least 50 hours of training being conducted in a classroom with an instructor or has met the requisite experience requirements as set forth in the regulations (Section 2592.01(g)). Subsequent to the initial designation, all designated medical-only claims adjusters shall receive a Post-Designation Training Form that demonstrates he or she has met the required 20 hours of post-designation training every two years.

Medical-only Claims Adjuster Curriculum Training Requirement

Medical Bill Reviewer Training

To handle medical bill review for an insurer or medical billing entity, each medical bill reviewer shall receive a Medical Bill Reviewer Designation Form that verifies he or she has completed at least 40 hours of training with at least 30 hours of training being conducted in a classroom by an instructor or has met the requisite experience requirements as set forth in the regulations (Section 2592.01(h)). Subsequent to the initial designation, all designated medical bill reviewers shall receive a Post-Designation Training Form that demonstrates they have met the required 16 hours of post-designation training every two years.

Medical Bill Review Curriculum Training Requirement

Curriculum

Required curriculum topics for each are listed below. All on-the-job training shall be done under the supervision of an instructor or an experienced claims adjuster.

Claims Adjuster Curriculum

All workers' compensation claims adjuster training programs in California shall include but not be limited to the following topics:

1. Historical overview of the workers' compensation system. 
2. Organizational structure of the system. 
3. The workers' compensation insurance policy, its forms and endorsements, insurance principles of compensation. 
4. Concepts and terminology. 
5. Benefit provisions. 
6. Compensability. 
7. Notice requirements. 
8. Temporary disability. 
9. Permanent disability, including evaluation and rating. 
10. Death benefits. 
11. Return to work and vocational rehabilitation. 
12. Cumulative trauma. 
13. Serious and willful misconduct. 
14. Workers' Compensation Appeals Board procedures, forms, hearings, and penalties. 
15. Investigation. 
16. Fraud. 
17. Medical terminology. 
18. Knowledge and use of utilization guidelines (American College of Occupational and Environmental Medicine or other guidelines approved by the Administrative Director of the Division of Workers' Compensation.)
19. Medical evidence.
20. Medical dispute resolution (Qualified Medical Examiners, spinal surgery second opinions, pre-designation of physicians, independent medical reviewers, utilization review.)
    
21. Fee schedules.
22. Liens. 
23. Apportionment. 
24. Subrogation. 
25. Reserving. 
26. Ethical issues.

Training for medical-only claims adjusters shall, at a minimum, include all the topics specified above in the claims adjuster training, with the exception of topics 8, 9, 10, 11, 13, and 23, which may, but are not required to, be included.

Training for 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. 
4. Fraud. 
5. Medical terminology. 
6. Utilization guidelines (American College of Occupational and Environmental Medicine or other guidelines approved by the Administrative Director of the Division of Workers' Compensation).
7. Medical evidence. 
8. Liens. 
9. Ethical issues.

If you need further assistance, please call CDI's Education Unit at (916) 492-3064. Please be sure to include your name, telephone number, license number and e-mail address in all correspondence with the California Department of Insurance.