If you’re involved with workers’ compensation in California, you’ve probably heard and/or worried about the various regulatory updates going into effect on April 1, 2026. It’s no joke–they could open up new risks of liability for the unprepared. It doesn’t help that the communication from the DWC has been spotty and unclear in some cases.

So if you’re in the Utilization Review trenches, you may need to think about some stuff that has been taken for granted for a while.

Here are some of the significant changes:

  • Specific Language: For drug requests, “exempt” and “generic substitute” phrases are now mandatory on URDs. This of course means you need to be aware when a request is exempt or a generic substitute. (§9792.9.4(a))
  • Precision in Denials: Specific and concise reasoning for denials must be provided, and if an expert reviewer was consulted, you have to list their specialty. (§9792.9.5(e))
  • The 5-Day “Incomplete” Clock: If an RFA is missing info, you have a strict 5 business day window to tell the provider exactly what’s wrong, or you’re stuck processing it as-is. (§9792.9.1(b))
  • Updated IMR Form: Speaking of specialties, the requesting provider specialty now must appear on IMR forms, along with a wider variety of determination possibilities. This new form is required for all URDs sent out starting on April 1st, despite the glaring typo and other omissions. (§9792.10.2Excerpt of new IMR form highlighting the misspelling of the word 'Completing.'

How we at DataCare are assisting our partners:

Compliance doesn’t have to mean more manual labor. DataCare’s systems are built to be the guardrails for your workflow so you can focus on outcomes, not an endless checklist of quality assurance items.

  • Exemption and Formulary Detection: We can identify when requested items are likely to be exempt–whether they’re eligible treatments in the first 30 days, or they appear on the MTUS drug list–and then put appropriate language on your reports.

  • Automated IMR Generation: When an adverse URD is produced in California, we automatically build the updated IMR form that needs to be included.

  • RFI Tracking: When information is needed, our guided Request For Information workflow ensures that the letter you send includes the specifics you need to justify a due date extension.

The goal is faster, fairer care and fewer IMR disputes. Let’s make April 1 the day your workflow gets easier, not harder.