Answers to your questions about qualified medical evaluators and agreed medical evaluators
This fact sheet will help you understand your rights and responsibilities when requesting a qualified medical evaluator (QME) or agreed medical evaluator (AME) exam. QMEs are independent physicians certified by the state Division of Workers’ Compensation (DWC) Medical Unit to do medical evaluations. QMEs and AMEs examine injured workers to determine the benefits they will receive.
Q: Do I need to fill out the claim form (DWC 1) my employer gave me?
A: Yes, if you want to make sure you qualify for all benefits. Your employer must give you a DWC 1 claim form within one day of knowing you were injured. Filling out the claim form opens your workers’ comp case. State law also lays out benefits beyond the basics you may qualify for once you file the claim form with your employer. Those benefits include, but are not limited to:
A presumption that your injury or illness was caused by work if your claim is not accepted or denied within 90 days of giving the completed claim form to your employer
Up to $10,000 in treatment under medical treatment guidelines while the claims administrator considers your claim
An increase in your disability payments if they’re late
A way to resolve any disagreements that might come up between you and the claims administrator over whether your injury or illness happened on the job, the medical treatment you receive and whether you will receive permanent disability benefits.
If you do not file the claim form within a year of your injury you may not be able get benefits.
Q: What if my employer didn’t give me the DWC 1 claim form?
A: Ask your employer for the form or call the claims administrator to get it. The claims administrator is the person or entity handling your employer’s claims. The name, address and phone number of this person should be posted at your workplace in the same area where other workplace information, like the minimum wage, is posted. You can also get the form from the DWC Web site at www.dir.ca.gov/dwc/. Click on "forms."
Q: I’ve been to the doctor. Why do I need to see a QME?
A: You and/or the claims administrator might disagree with what the doctor says. There could be other disagreements over medical issues in your claim. A doctor has to address those disagreements. You might disagree over:
Whether or not your injury was caused by your work
Whether or not you need treatment for your injury
What type of treatment is appropriate
Whether or not you need to stay home from work to recover
A permanent disability rating
Q: What qualifications do QMEs have?
A: The DWC Medical Unit certifies QMEs in different medical specialties. A QME must be a physician licensed to practice in California. QMEs can be medical doctors, doctors of osteopathy, chiropractors, psychologists or acupuncturists.
Q: Who makes the decision about going to a QME?
A: Either you or your attorney (if you have one) or the claims administrator can request a QME exam. You might request a QME exam if:
1. Your claim is delayed or denied and you need a medical exam to find out if the claim is payable
2. You need to find out if you are permanently disabled in some way or if you’ll need future medical treatment
3. You disagree with what your doctor says about your medical condition
4. If you disagree with the results of utilization review.
The DWC Medical Unit will provide whoever makes the request with a list (called a panel) of three QMEs. One physician from the list is chosen to examine you and make a report on your condition. Each QME panel is randomly generated and the physicians listed are specialists of the type requested. Once a QME is chosen for your claim, all medical disputes must go to that QME. 2
Q: What’s the difference between a QME and an AME?
A: If you have an attorney, your attorney and the claims administrator may agree on a doctor without going through the state system used to pick a QME. The doctor your attorney and the claims administrator agree on is called an agreed medical evaluator (AME). A QME is picked from a list of state-certified doctors issued by the DWC Medical Unit. QME lists are generated randomly.
Q: How do I request a QME exam?
A: Complete the "Request for Qualified Medical Evaluator" form and submit it to the DWC Medical Unit. See Information & Assistance (I&A) guide 2 for help with this form.
If your employer says there’s a problem with your claim and sends you a "Request for Qualified Medical Evaluator" form, you have 10 days from when you get the form to complete and submit the form to the DWC Medical Unit. If you do not submit the form within 10 days, the claims administrator will do it for you and will get to choose the kind of doctor you’ll see.
Q: What difference does it make who submits the form to request the QME?
A: Whoever submits the request form picks the specialty of the doctor that does the exam. The DWC Medical Unit will issue a panel of three doctors in that specialty. The doctors are selected randomly and will be as close as possible to your home address. See I&A guide 2 for more information. When you receive the panel, you will also receive a letter that explains how to set up the QME appointment and how to provide the QME with important information about yourself.
Q: Is there anything I can do if I disagree with what the QME says?
A: Yes, but you have a limited amount of time to decide if you agree with the QME’s report or if you need more information. When you receive the report, read it right away and decide if you think it is accurate. If not, and you have an attorney, you should talk to him or her about your options.
If you don’t have an attorney, first call the claims administrator. If that doesn’t help, contact an I&A officer at your local Workers’ Compensation Appeals Board office. The I&A officer can help you figure out what’s best in your case. See below for contact information.
If you are in a union, you may be able to see an ombudsperson or mediator under the terms of your collective bargaining agreement or labor-management agreement.
Q: I’m in a medical provider network (MPN). Does this process apply to me?
A: There are two tracks for resolving a medical dispute if you’re in an MPN, depending on the situation. If your MPN doctor requests treatment that you agree with and that treatment gets denied under utilization review (UR), you have the right to be evaluated by a QME. The claims administrator must advise you of this right. However, if you disagree with your MPN doctor about your diagnosis or treatment, you do NOT go to a QME – you have other options. First, you can change to another physician on the MPN list. You can also ask for a 2nd and 3rd opinion from a different MPN doctor. If you still disagree, you can have an independent medical review (IMR) to resolve the dispute. See the information on your MPN provided by your employer.
Q: I still have questions. Who do I contact?
A: If you have questions about requesting a QME panel, contact the DWC Medical Unit. Reach them by phone at 1-800-794-6900 or by writing to:
Division of Workers’ Compensation Medical Unit
P O Box 71010
Oakland CA 94612
If you need an Information & Assistance (I&A) guide or other help, call an I&A office or attend a workshop for injured workers. The local I&A phone numbers are attached to this fact sheet. You can also get information on local workshops and download the guides from the Web at www.dir.ca.gov/dwc/.
The information contained in this fact sheet is general in nature and is not intended as a substitute for legal advice. Changes in the law or the specific facts of your case may result in legal interpretations different than those presented here.