On April 1, 2026, California’s Division of Workers’ Compensation put a comprehensive new set of utilization review (UR) and independent medical review (IMR) regulations into effect — approved by the Office of Administrative Law on December 30, 2025. For treating providers, three things matter most: the regulations finally build working machinery around the Labor Code §4610(b) rule that lets you treat an accepted injury without prospective UR for the first 30 days; every UR plan that modifies or denies treatment must now hold URAC accreditation and be identified on the denial; and the IMR request deadline remains a hard 30 days — miss it and the denial stands. Here is what changed, what didn’t, and how to run your authorization calendar under the new rules.
What changed on April 1, 2026 — and what didn’t
The statutes themselves aren’t new. Senate Bill 1160 wrote the 30-day UR exemption into Labor Code §4610 for injuries on or after January 1, 2018, and Assembly Bill 1124 created the MTUS drug formulary whose exempt drugs skip prospective review. What was missing for years was the implementing regulation — the administrative detail that tells providers, claims administrators, and UR vendors how the exemption actually operates day to day.
That’s what the 2026 rulemaking delivers. Per the DWC’s announcement and analyses by Sullivan on Comp (defense-side) and Enlyte (payer-side), the new rules:
- Spell out the 30-day exemption’s mechanics in 8 CCR §9792.9.7 — who qualifies, what paperwork keeps you qualified, and which services are carved out.
- Enforce the URAC accreditation requirement: a UR plan that modifies or denies treatment must show proof of URAC Workers’ Compensation Utilization Management accreditation, and the accredited entity liable for the decision must be identified (§9792.9.5) and approved by the DWC.
- Put UR plans themselves under active DWC review: the Division reviews filed plans on a 60-day clock, may extend 60 more days, and a plan is provisionally approved if the DWC takes no action within 120 days; a disapproval can be appealed within 25 days (§9792.7).
- Tighten drug-dispute timelines: formulary-drug UR decisions in 5 business days with no extension, and drug-only IMR requests compressed to a 10-day filing window.
- Keep the rule that a non-physician reviewer may approve, but may not modify or deny, a treatment request.
The 30-day no-prior-auth window: how to actually qualify
The exemption is real, but it is conditional, and the conditions are exactly where clinics lose it. Under LC §4610(b) and §9792.9.7, treatment in the first 30 days after injury is authorized without prospective UR when all of the following hold:
- The body part or condition is accepted as compensable. A disputed or delayed claim gets no exemption.
- You’re an eligible physician — an MPN or HCO member, a predesignated physician, or one selected by the employer.
- The care follows the MTUS. The exemption covers guideline-concordant treatment, not whatever gets scheduled.
- The paperwork goes in within 5 days of the initial visit: the Doctor’s First Report plus a complete RFA listing the anticipated treatment. Skip the filing and you’re back in ordinary prospective UR.
The carve-outs matter just as much. Even inside the 30 days, prospective review still applies to: pharmaceuticals not exempted by the formulary, non-emergency surgery, psychological treatment, home health, imaging other than X-rays, durable medical equipment over $250, electrodiagnostic testing (EMG/NCV) — and, added by the new regulations, spinal injections. For a pain-management practice, that last carve-out means the highest-value procedures stay squarely in UR; the exemption mostly accelerates evaluation and conservative care. (More on pain-practice operations on our pain management page.)
One more reason to stay guideline-clean: the exemption is revocable. Claims administrators may run retrospective review, and a documented pattern of MTUS-inconsistent care — per Sullivan’s analysis, roughly 20 separate services across 10 or more injured workers in three months, or 8 services involving 2 or fewer workers in one month — supports a petition to strip a physician of the exemption.
The deadlines that now run your UR/IMR calendar
| Event | Deadline / rule | Source |
|---|---|---|
| Treatment without prospective UR | First 30 days post-injury, accepted condition, MTUS-aligned | LC §4610(b); §9792.9.7 |
| DFR + complete RFA to keep the exemption | Within 5 days of the initial visit | LC §4610(b) |
| Standard prospective UR decision | 5 working days from RFA receipt; never more than 14 days when information is outstanding | LC §4610(i) |
| Formulary-drug UR decision | 5 business days, no extension | §9792.9.8(b) |
| IMR request — standard denial | 30 days from service of the UR determination (hard deadline) | §9792.10.1 |
| IMR request — drug-formulary-only denial | 10 days | §9792.10.1 |
| Median IMR decision time | ~32 days from application to decision letter (2024) | CWCI |
| DWC review of a filed UR plan | 60 days + 60-day extension; provisional approval at 120 days; 25 days to appeal a disapproval | §9792.7 |
When the denial lands anyway
Nothing in the overhaul suggests fewer denials. CWCI’s data shows IMR volume — which only exists because a UR physician modified or denied a request — rising again after years of decline: up 2.9% in 2023, 8.2% in 2024, and 38,393 decision letters in the first quarter of 2025 alone. Applicant-side firms report UR getting stricter in practice under the new regime. Plan for the denial, not the exception.
Three operational moves follow directly from the new rules:
Check the denial letter itself. An adverse determination must now identify the URAC-accredited entity liable for the decision, and only a physician reviewer can modify or deny. A denial that fails these requirements is a denial worth challenging on procedure as well as merits.
Calendar the IMR clock the day the determination is served. Thirty days is a hard deadline, and the median IMR takes about 32 more days to decide — so a missed window costs the patient two months, minimum. Drug-only denials give you ten days.
Front-load the appeal paperwork. Most California denials trace to the same predictable causes — body part not accepted, request outrunning the MTUS, thin medical-necessity documentation. We walk those in the 12 predictable reasons RFAs get denied, and our free workers’ comp appeal letter generator drafts a structured appeal letter in the browser, no signup required.
Where an agent helps
Every rule above is a tracking problem: a 5-day filing window on every new injury, a carve-out list to check before assuming the exemption, a 30-day IMR fuse on every adverse determination, an accreditation line to verify on every denial notice. That is mechanical, deadline-driven work — exactly what clinics miss when it lives in someone’s head.
Kaira’s workers’-comp automation is designed to help here: drafting UR appeal letters, letters of medical necessity, and peer-to-peer prep for staff review, flagging denial risk before an RFA goes out, and tracking each authorization through its lifecycle so filing windows and IMR deadlines don’t slip. Your team reviews and approves everything; the agent keeps the clock. See the platform overview for how that fits the rest of the practice.
State regulations change and individual claims differ — this guide summarizes the new rules with links to the primary sources, but it isn’t legal advice. Confirm specifics with the DWC’s utilization review resources or qualified counsel. The providers who come out ahead under the 2026 rules will be the ones who treat these deadlines as operational defaults, not surprises.