California Workers' Comp Compliance Requirements

Overview

CareHub must comply with California workers' compensation regulations for psychiatric injury claims. This document outlines specific compliance requirements and how CareHub addresses them.

Regulatory Framework

Key Statutes

Labor Code 3208.3 - Psychiatric injury claims
Labor Code 4660 - Permanent disability ratings
Labor Code 4062.2 - Medical-legal evaluations
8 CCR 9785 - Medical treatment utilization schedule

Key Concepts

Industrial Causation - Work must be at least 51% responsible
Rolda Analysis - Personnel actions exempt from causation
MMI - Maximum Medical Improvement
GAF - Global Assessment of Functioning
WPI - Whole Person Impairment

Claim Type Requirements

Physical-Mental (Compensable Consequence)

Definition: Psychological condition arising from a compensable physical injury.

Requirements:

Documented compensable physical injury
Psychological symptoms linked to physical injury
No 6-month employment requirement
Lower burden of proof for causation

CareHub Implementation:

Case type field: "Physical-Mental"
Link to original physical injury
Document psychological consequences

Mental-Mental (Pure Psyche)

Definition: Psychological injury from workplace stress without physical injury.

Requirements:

6-Month Employment Rule
- Must have been employed 6+ months
- Exceptions: sudden/extraordinary events
Predominantly Caused (51%+)
- Industrial factors must be predominant cause
- Must exceed 50% of total causation
Rolda Exception
- Personnel actions (discipline, termination) excluded from causation
- Unless actions were taken in violation of law
Good Faith Personnel Action Defense
- Employer defense if actions were lawful
- Member must prove actions were pretextual

CareHub Implementation:

Track employment start date
Calculate tenure automatically
Separate personnel action causation
Document Rolda analysis

Mental-Physical

Definition: Psychological condition causing physical symptoms.

Requirements:

Same as Mental-Mental
Document physical manifestations

Causation Analysis

Required Documentation

The treating clinician must document:

Pre-existing Impairment (%)
- Prior psychiatric conditions
- Prior treatment history
- Pre-injury functioning
Non-Industrial Factors (%)
- Personal stressors
- Family issues
- Financial problems
- Medical conditions
Personnel Actions (%)
- Discipline
- Termination
- Performance reviews
- Demotion/role changes
Work Exposure (%)
- Work stress
- Work conditions
- Work relationships
- Work demands

Total must equal 100%

Industrial Determination

If (Work Exposure %) > 50% = INDUSTRIAL
If (Work Exposure %) <= 50% = NON-INDUSTRIAL

Note: Personnel Action % is calculated separately
but excluded from industrial determination per Rolda

CareHub Causation Form

CAUSATION ANALYSIS FORM
=======================

Case: CH-2025-00001
Member: John Smith
Evaluating Clinician: Dr. Chen
Date: January 15, 2025

CLAIM TYPE: [ ] Physical-Mental  [X] Mental-Mental  [ ] Mental-Physical

EMPLOYMENT TENURE:
- Start Date: March 15, 2024
- Tenure: 10 months
- Meets 6-month requirement: [X] Yes  [ ] No

CAUSATION BREAKDOWN:

1. Pre-existing Impairment: 15%
   Narrative: Member has history of anxiety disorder diagnosed
   in 2019, treated with medication. Baseline GAF ~75.

2. Non-Industrial Factors: 20%
   Narrative: Member reports financial stress related to divorce
   proceedings and caring for elderly parent.

3. Personnel Actions: 10%
   Narrative: Member received performance warning in October 2024.
   Per Rolda, excluded from industrial causation calculation.

4. Work Exposure: 55%
   Narrative: Member reports excessive workload, hostile
   supervisor, denied reasonable accommodations for physical
   injury. Multiple documented incidents.

TOTAL: 100%

INDUSTRIAL CALCULATION (excluding Personnel Actions):
Pre-existing: 15% + Non-Industrial: 20% + Work: 55% = 90%
Work Exposure as % of relevant factors: 55/90 = 61%

INDUSTRIAL DETERMINATION:
[X] Industrial (Work >50%)  [ ] Non-Industrial  [ ] Pending

CLINICAL RATIONALE:
Based on comprehensive evaluation, it is my clinical opinion
that the member's current psychiatric condition is predominantly
caused by industrial factors. The work exposure, including
documented harassment and excessive demands, constitutes 61%
of the non-personnel-action causation...

GAF SCORES:
- Pre-injury: 75
- Initial: 52
- Current: 55

Clinician Signature: _______________  Date: _______________

GAF Scoring

Scale Reference

Score	Description	Level
91-100	Superior functioning in wide range	Absent symptoms
81-90	Good functioning, minimal symptoms	Minimal
71-80	Slight impairment, transient symptoms	Slight
61-70	Mild symptoms or difficulty	Mild
51-60	Moderate symptoms or difficulty	Moderate
41-50	Serious symptoms or impairment	Serious
31-40	Major impairment in multiple areas	Major
21-30	Influenced by delusions/hallucinations	Severe
11-20	Some danger to self/others	Critical
1-10	Persistent danger	Emergency

Required Documentation

Pre-injury GAF: Estimated baseline functioning
Initial GAF: At first evaluation
Current GAF: Updated regularly
Final GAF: At MMI/discharge
Rationale: Clinical justification for each score

MMI Documentation

Definition

Maximum Medical Improvement (MMI): The point at which the member's condition has plateaued and further treatment is not expected to produce significant improvement.

Required Elements

MMI Status
- Not yet at MMI
- Approaching MMI
- At MMI
MMI Date (when applicable)
Permanent Impairment
- Yes/No
- If Yes: WPI percentage
- Rating methodology
Work Restrictions
- None (Full Duty)
- Temporary restrictions
- Permanent restrictions
- Unable to work
RTW Status
- Returned Full Duty
- Returned Modified
- Unable to Return
- Pending
Future Medical
- Is ongoing treatment needed?
- Frequency estimate
- Duration estimate
- Clinical justification

Apportionment at MMI

When permanent impairment exists, clinician must apportion:

Industrial causation %
Non-industrial %
Pre-existing %

Required Documents

Per Session: PR-2 (Progress Report)

Contents:

Session date and duration
Treatment provided
Member response
Progress toward goals
Work status
Next steps

For Extensions: RFA (Request for Authorization)

Contents:

Current sessions used/authorized
Sessions requested
Justification
Progress summary
Goals remaining
Expected outcomes

At Discharge: Treatment Conclusion Report

Contents:

Treatment summary
Sessions completed
Goals achieved
Final diagnosis
Causation analysis
MMI status
Final GAF
Work status
Future medical needs
Apportionment (if PD)

Intake Data Requirements

For Causation Analysis

CareHub intake collects:

Employment History
- Employer name
- Job title
- Start date
- End date (if terminated)
- Termination date (if applicable)
- Current status
Non-Industrial Stressors
- Financial stress
- Relationship issues
- Family caregiving
- Personal health issues
- Legal matters
- Recent loss
- Other stressors
Personnel Actions
- Discipline received
- Performance reviews
- Demotion
- Termination notice
- Hours/pay reduced
- Timing relative to symptoms
Prior Mental Health
- Previous treatment
- Hospitalizations
- Medications
- Pre-injury functioning

Compliance Reporting

Causation Report

Generated for claims adjusters containing:

Member demographics
Claim type
Diagnosis
Full causation breakdown with narratives
Industrial determination
GAF scores
Clinician credentials and signature

Treatment Conclusion Report

Generated at discharge containing:

Complete treatment summary
All compliance elements
Final determinations
Clinician attestation

Audit Trail Requirements

CareHub maintains audit logs for:

All case modifications
Staff assignments
Document generation
AI analysis triggers
User access
Report generation

Retention: Minimum 5 years per CA requirements

Implementation Checklist

Intake Form

Employment history fields
Employment tenure calculation
Non-industrial stressor section
Personnel action section
Prior mental health history
Comprehensive safety assessment

Cases Table

Claim type field
All causation fields
GAF scoring fields
MMI tracking fields
Future medical fields
Apportionment fields

Psychologist Portal

Causation analysis form
Percentage validation (sum = 100%)
Industrial determination logic
GAF reference display
MMI/Discharge form

Reports

Causation Report template
Treatment Conclusion Report template
All required fields populated
PDF generation
Digital signature capability

Workflows

Causation reminder at session 3
MMI assessment prompts
Report generation triggers
Audit logging