https://www.dir.ca.gov/dwc/FactSheets/FactSheet_E.pdf

Qualified medical evaluators (QMEs) or agreed medical evaluators (AMEs) examine injured workers to determine the benefits they will receive if there is a disagreement over the treating physician’s opinions. QMEs are physicians licensed to practice in California as medical doctors, osteopaths, chiropractors, psychologists, dentists, optometrists, podiatrists or acupuncturists and are certified by the Division of Workers’ Compensation Medical Unit to perform medical/legal evaluations. AMEs are physicians selected by agreement between the defense and applicant’s attorneys to perform medical/legal evaluations in a workers’ compensation case. AMEs are only used if the injured worker is represented by an attorney. 

What’s the difference between a QME and an AME? 

If you have an attorney, your attorney and the claims administrator may agree on a doctor without using the state system for getting a QME. The doctor they agree on is called an AME. If they cannot agree, they must ask for a QME. 

Why do I need to see a QME? 

You and/or the claims administrator might disagree with what the treating doctor says. There could also be other disagreements over medical issues in your claim. A different doctor -- an AME or QME -- has to address these disagreements, which might include: 

• Whether or not your injury was caused by your work 

• Whether or not you need treatment for your injury (only if date of injury is before Jan. 1, 2013) 

• Whether or not you need to stay home from work to recover 

• Whether your condition is permanent and stationary 

• Whether you have new and further disability 

• A permanent disability rating. 

Who makes the decision about going to a QME? 

You, your attorney or the claims administrator can request a QME exam. The DWC Medical Unit will provide whomever makes the request with a list (called a panel) of three QMEs. Each QME panel is randomly generated and the physicians listed are specialists of the type requested. One physician from the list is chosen to examine you and make a report on your condition. Once a QME is chosen for your claim, most disputes must go to that QME. 

How do I request a QME exam? 

Complete the “Request for QME panel” form and submit it to the DWC Medical Unit. See Information & Assistance (I&A) guide 2 for help with this form. NOTE: If your employer or claims administrator says there’s a problem with your claim and sends you a “Request for QME panel” form, you have 10 days to complete the form, select the QME medical specialty and send the form to the DWC Medical Unit. If you do not submit the form within 10 days, the claims administrator will do it and will get to choose the kind of doctor you’ll see. 

What difference does it make who submits the form to request the QME? 

Whoever submits the request form picks the specialty of the doctor for the exam. 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. Within 10 days of the date on the list, you must pick a QME from the list, make an appointment and tell the claims administrator. If you do not do this, the claims administrator may select the doctor and make the appointment for you. 

Is there anything I can do if I disagree with what the QME says? 

Yes, you have 30 days from the receipt of the report 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 (WCAB) district office. The I&A officer can help you figure out what’s best in your case. 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. 

I’m in a medical provider network (MPN). Does the QME process apply to me? 

Yes, the QME process may still be utilized if you are part of a MPN. 

I still have questions. Who do I contact? 

If you have questions about requesting a QME panel, contact the DWC Medical Unit by phone at 1-800- 794-6900 or by writing to: DWC Medical Unit, P O Box 71010, Oakland, CA 94612. For more information, call 1-800-736-7401 or visit the DWC Web site at www.dwc.ca.gov to find a local I&A office. You may also download I&A guides and get information on workshops for injured workers. 

Notice to Injured Worker regarding QME Exam

The list of Qualified Medical Evaluators (QMEs) enclosed with this letter is being sent to you because either you or your claims administrator requested a QME panel (list of QMEs). If you have an attorney, contact your attorney. If you do not have an attorney, please take the following steps: 

1) Select a QME physician from the list within ten (10) days of the date the list was issued (shown at the top of the panel list). 

Your claims administrator should not select the QME or try to influence your decision. You may ask your treating physician for assistance, they cannot act as the QME. You have the right to consult with an Information and Assistance Officer at DWC Information and Assistance Unit https://www.dir.ca.gov/dwc/IandA.html#IandAoffices or 1-800-736-7401. 

2) Call the QME’s office, listed on the panel form, within ten (10) days of the date the QME list was issued by the Medical Unit and make an appointment for an examination. 

Tell the office staff for the QME that you are calling for a “QME exam”. If you will need an interpreter, tell the QME’s office. The staff will ask you for information that you will find at the top of the QME panel list. The examination can occur by agreement at an office location listed with the medical director or by a remote health evaluation in accordance with regulation section 46.3. If the QME you call is unable to schedule an appointment within ninety (90) days of the date of your call, the QME’s office may not suggest another physician in that office to do the QME evaluation. You may: 

a) agree to wait as long as the QME you selected is able to schedule your appointment within one-hundred twenty (120) days of the date of your first call for an appointment; or 

b) select a different QME on the panel list. 

If you decide to ask for a replacement QME from the Medical Unit, tell the claims administrator to avoid having duplicate requests for replacement QME’s. To obtain a replacement panel you will need to complete Replacement Panel Request Form 31.5 and mail your request to the Medical Unit with a copy to your claims examiner. This Form can be found on the DWC website at: https://www.dir.ca.gov/dwc/FORMS/QMEForms/QMEForm31_5.pdf. If you need assistance requesting a replacement panel contact an Information and Assistance Officer. 

3) If the Medical Unit returns the panel request form to ask for additional information, the time limits for selecting a QME and scheduling the appointment are tolled (delayed). (See, 8 Cal. Code Regs.§ 30(h)). 

4) Call the Claim Administrator in your case within ten (10) days of the date the QME list was issued by the Medical Unit. Tell the claims administrator the time, date and location of your appointment with the QME. 

5) Review all of the medical records and other non-medical records sent by the claims administrator. 

Once you have scheduled an appointment with a QME, the claims administrator must send you, at least twenty (20) days before the information is sent to the QME, copies of all medical and nonmedical records (videos, photos, interview transcripts, non-medical paperwork) the administrator plans to send to the QME in your case. If you believe some of the non-medical records or materials should not go to the QME, you must notify the claims administrator within ten (10) days that you object and the reasons for your objection. QME Form 108 (rev. February 2023) Page 2 You also must send to the claims administrator copies of any medical records and other materials you plan to send to the QME at least 20 days before sending it to the QME, and the claims administrator also may object within 10 days to non-medical records by notifying you in writing. Once you or the claims administrator object, the non-medical records objected to should not be sent to the QME until or unless a Workers’ Compensation Judge makes an order. You may call the Information and Assistance Officer for information about this process. 

6) Communication with the QME before and after your examination must be in writing. 

You may send the QME a letter listing the disputed medical issues you believe the evaluator should address in your claim. If you wish, or the claims administrator wishes, to send a letter to the QME about your case before the examination, it must be written and mailed to the QME and the other party at least twenty (20) days before the exam. After the examination, a copy of any letter to the QME must be mailed to the other party the same day it is sent to the QME. If the QME contacts you, you may answer questions. 

7) Your employer will pay for the QME exam, an interpreter if required and reasonable transportation including lodging costs if necessary. 

There is no charge to you and no co-payment for a QME exam or interpreter fees. The claims administrator will either send you a check in advance or reimburse you for any reasonable transportation costs. If you must miss work to attend the QME exam, you are entitled to temporary disability benefits for any lost wages that day. 

8) If you are not represented by an attorney and do not receive a QME panel list that was assigned within 20 business days after we receive the request for a panel, you may choose any QME (with the proper specialty) to do your examination from the QMEdatabase which is available at https://www.dir.ca.gov/databases/dwc/qmestartnew.asp. The panel is assigned and mailed on the same date, which is shown as the “Date Issued” at the top of the QME panel list, QME Form 107 (See, 8 Cal. Code Regs. § 107). 

9) A QME may not offer to treat you or solicit to become your treating physician. However, you have the right to request the QME to become your treating physician. If you are covered by a Medical Provider Network (“MPN”), you may choose to treat with the QME if the QME is an MPN physician for your employer. If the QME is not in the MPN, you will need authorization from your claims administrator to treat with the QME. In addition, you may need to have another QME examination by a different QME. You may wish to consult with an Information and Assistance Officer before you make this decision. 

10) If the QME does not send you a copy of the report within 30 calendar days after your examination, or within the extension of time approved by the Medical Director of DWC, contact the Medical Unit at 1- 800-794-6900. 

11) If your claim eventually goes to court, the Workers’ Compensation Administrative Law Judge will consider the evaluation prepared by the QME you select to decide your claim. 

12) For more information call the nearest Information and Assistance Office to request pamphlets, fact sheets and guides for injured workers, including “Guide Book for Injured Workers”. These publications are free. To get copies, call the nearest Information and Assistance Officer at the number listed in your local phone book, or look up the number by computer on the internet at DWC Information and Assistance Unit https://www.dir.ca.gov/dwc/IandA.html#IandAoffices. 

To download a free copy of the publications regarding Fact Sheets and Guides for Injured Workers from the internet, go to: http://www.dir.ca.gov/dwc/iwguides.html, or the DWC Home Page at http://www.dir.ca.gov/DWC/dwc_home_page.htm or Commission on Health and Safety and Workers’ Compensation Educational Materials at http://www.dir.ca.gov/chswc/EduMaterials.html

https://www.dir.ca.gov/dwc/FORMS/QMEForms/QMEForm105.pdf

https://www.dir.ca.gov/dwc/DWCForm1.pdf