QME forms, proof of service and e-billing
Short version: a QME files QME 110 for every appointment, QME 112 for any extension, and QME 122 or QME 111 with every report, plus a DEU packet in unrepresented permanent disability cases. QME Companion says it autofills 110, 111, 112 and 122; SimpleExam says it fills DWC forms and the CMS 1500 and mails with a proof of service. No software signs a declaration for you.
Limits: We read each vendor's own pages and the DWC regulations on 2026-11-12 and did not test any product with real records. Prices change, and nothing here is legal or billing advice.
The QME forms, when they're due and who fills them
Form names and numbers from the DWC forms page; timing from the regulation cited in each row. All read 2026-11-12.
| Form | What it is | When | Rule | Software that says it fills it |
|---|---|---|---|---|
| QME 110 | Appointment notification | Within 5 business days of making the appointment, by mail or fax | 8 CCR 34(a) | QME Companion; SimpleExam (DWC forms generally) |
| QME 109 | Notice of unavailability | As the form directs | DWC forms page | None stated |
| QME 112 | Report time frame extension request | No later than 5 days before day 30 | 8 CCR 38(d) | QME Companion; SimpleExam (generally) |
| QME 113, 116 | Denial of extension; late report notice | Sent by the Medical Director, returned by the parties | 8 CCR 38(e), (f) | Not the QME's form |
| QME 122 | AME or QME declaration of service of medical-legal report | With every report in a represented case | 8 CCR 36(a) | QME Companion; SimpleExam (generally) |
| QME 111 | QME findings summary, unrepresented cases only, with its own declaration of service | With every report in an unrepresented case | 8 CCR 36(b) | QME Companion; SimpleExam (generally) |
| DWC-AD 100 and 101 (DEU) | Employee's disability questionnaire; request for summary rating | With the report and QME 111, served on the local DEU, when an unrepresented worker has impairment, disability or apportionment findings | 8 CCR 36(c) | None stated by name |
| DWC-CA 10232.1 and 10232.2 | Document cover sheet; separator sheets | With the DEU packet | 8 CCR 36(c) | None stated by name |
| DWC-AD 10133.36 | Physician's report of P&S status and work capacity | With the report when P&S with permanent partial disability | 8 CCR 35.5(c)(2) | None stated by name |
| QME 120, 121 | Alternate service directive and declaration for psych injury reports | Disputed injury to the psyche | 8 CCR 36, 36.5 | None stated |
| QME 123 | Conflict of interest disclosure, objection or waiver | When a conflict applies | DWC forms page | None stated |
| CMS 1500 | Claim form used for many med-legal bills | With the bill | No DWC rule names the form for med-legal bills (see below) | SimpleExam |
"Generally" means the vendor says it fills DWC forms without naming this one. Ask for a printout of each form from a test case and compare it with the blank PDF on the DWC site, field by field.
How a QME report is served
Software can build the service list from the case's representation status and print the declaration, but a person still signs it. Software can't confirm the list is right for this case; check for attorney substitutions before each service.
Mail or electronic? 8 CCR 36 names the forms and the recipients, not the delivery method. 8 CCR 34 lets the QME 110 go by mail or fax. SimpleExam sells "electronic-to-print" mailing that creates a proof of service each time; QME Companion charges for legal mailing separately. Confirm what each party accepts before you stop mailing paper.
How QME bills go out, and what the payer owes
A medical-legal bill needs the "reports and documents required by the administrative director": an itemized bill, a copy of the report, the parties' correspondence and any verification under 9795, such as the page count (8 CCR 9793). From receipt of those, the claims administrator has 60 days to pay, or to pay the uncontested part and send an explanation of review (8 CCR 9794). A disputed amount goes to second review, requested within 90 days of the EOR (8 CCR 9792.5.5), then to independent bill review.
Paper or e-bill? daisyBill pointed out in 2017 that DWC regulations set no billing form or submission method for medical-legal bills, and described a payer that denied a med-legal e-bill and then reversed (daisyBill, 2017-12-08). We found no newer DWC rule on the point in the sections we read. Today SimpleExam says it submits and tracks bills via EDI. Ask each vendor which claims administrators accept its med-legal e-bills, and keep the proof of each submission.
What software automates, and what it doesn't
| Task | Software can | Stays with you |
|---|---|---|
| QME 110 | Fill names, claim number, office and interpreter fields; count 5 business days | Check the office matches the panel form |
| Extension (QME 112) | Alert on day 25; fill the form | Decide whether you qualify, and send it |
| Service declarations | Build the list from representation status; print QME 122 or 111 | Confirm the list and sign |
| DEU packet | Assemble the documents and sheets in order | Decide the findings that trigger it |
| P&S form 10133.36 | Carry over claimant and claim details | Every clinical field |
| Page-count verification | Count pages in the files received | Verify the pages you reviewed, under penalty of perjury |
| Bill | Code, modifiers, CMS 1500, EDI, status tracking | Choose the code and modifiers |
| Second review | 90-day timer, packet, submission | Decide to dispute |
EAMS and the QME
EAMS, the Electronic Adjudication Management System, is the DWC's case system for workers' comp cases. 8 CCR 36 describes service of the report on the parties and, in some cases, the DEU; it doesn't mention EAMS. Of the vendors we read, only SimpleExam mentions EAMS, listing "expedited intake via DWC EAMS". Represented parties request panels through the online QME Form 106 on the DWC site.
Questions about QME forms and service
Which form serves a QME report in a represented case?
QME Form 122, the AME or QME declaration of service of medical-legal report, attached to the report and served on the worker, the attorney and the claims administrator under 8 CCR 36(a).
What extra goes to the DEU with an unrepresented QME report?
When the report finds permanent impairment, disability or apportionment, the QME serves the local DEU with the report, QME 111, DWC-AD 100 and DWC-AD 101, each with a separator sheet, and a cover sheet, at the same time as the parties.
Can medical-legal bills be sent electronically in California?
SimpleExam says it sends medical-legal bills via EDI, and daisyBill has noted that DWC rules set no required form or method for them. Confirm acceptance with each claims administrator and keep proof of submission.