Workers’ compensation rules of procedure




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DEPARTMENT OF LABOR AND EMPLOYMENT

Division of Workers’ Compensation

7 CCR 1101-3

WORKERS’ COMPENSATION RULES OF PROCEDURE

Rule 16           UTILIZATION STANDARDS

 

16-1      STATEMENT OF PURPOSE

            In an effort to comply with its legislative charge to assure appropriate and timely medical care at a reasonable cost, the Director (Director) of the Division of Workers' Compensation (Division) has promulgated these utilization standards, effective January 1, 2013 2012. This rule defines the standard terminology, administrative procedures and dispute resolution procedures required to implement the Division's Medical Treatment Guidelines and Medical Fee Schedule.  With respect to any matter arising under the Colorado Workers' Compensation Act and/or the Workers' Compensation Rules of Procedure and to the extent not otherwise precluded by the laws of this state, all providers and payers shall use and comply with the provisions of the "Medical Treatment Guidelines," Rule 17, and the "Medical Fee Schedule," Rule 18, as incorporated and defined in the Workers' Compensation Rules of Procedure, 7 CCR 1101-3.

16-2      STANDARD TERMINOLOGY FOR RULES 16 AND 18

(A)        Ambulatory Surgical Center (ASC) – licensed as an ambulatory surgery center by the Colorado Department of Public Health and Environment.

(B)        Authorized Treating Provider (ATP) – may be any of the following:

(1)        The treating physician designated by the employer and selected by the injured worker;

(2)        A health care provider to whom an authorized treating physician refers the injured worker for treatment, consultation, or impairment rating;

(3)        A physician health care provider selected by the injured worker when the injured worker has the right to select a provider;

(4)        A health care physician provider authorized by the employer when the employer has the right or obligation to make such an authorization;

(5)        A health care provider determined by the director or an administrative law judge to be an ATP;

(6)        A provider who is designated by the agreement of the injured worker and the payer.

(C)        Billed Service(s) – any billed service, procedure, equipment or supply provided to an injured worker by a provider.

(D)        Billing Party – a service provider or an injured worker who has incurred authorized medical costs.

(E)        Certificate of Mailing – a signed and dated statement containing the names and mailing addresses of all persons receiving copies of attached or referenced document(s), certifying the documents were placed in the U.S. Mail, postage pre-paid, to those persons.

(F)        Children’s Hospital – as identified and Medicare certified by the Colorado Department of Public Health and Environment.

(G)        Convalescent Center – as licensed by the Colorado Department of Public Health and Environment.

(H)        Critical Access Hospital (CAH) – as identified and Medicare certified by the Colorado Department of Public Health and Environment.

(I)         Dispute Resolution -- Division review of materials for compliance with the Rules prior to any pre-hearing or hearing before the Director or an Administrative Law Judge (ALJ).

(I J) Day – defined as a calendar day unless otherwise noted.

(K J)     Hospital – as identified and licensed by the Colorado Department of Public Health and Environment.

(L K)     Long-Term Care Facility – as identified and Medicare certified by the Colorado Department of Public Health and Environment

(M L)     Medical Fee Schedule – Division's Rule 18, its Exhibits, and the documents incorporated by reference in that rule.

(N M)    Medical Treatment Guidelines – the medical treatment guidelines as incorporated into Rule 17, "Medical Treatment Guidelines."

(O N)    Payer – an insurer, employer, or their designated agent(s) who is responsible for payment of medical expenses.

(P O)     Prior Authorization – guarantee that appropriate reimbursement for a specific treatment will be paid.

(O Q) Private Psychiatric Facilities – Licensed as a psychiatric hospital by the Colorado Department of Public Health and Environment.

(P R)     Provider – a person or entity providing authorized health care service, whether involving treatment or not, to a worker in connection with work-related injury or occupational disease.

(Q S)    Rehabilitation Facilities – licensed as a rehabilitation hospital by the Colorado Department of Public Health and Environment.

(R T)     Rural Health Facility – as identified and Medicare certified by the Colorado Department of Public Health and Environment.

(S U) Skilled Nursing Facility (SNF) – licensed as a skilled nursing facility by the Colorado Department of Public Health and Environment

(T V)     State Psychiatric Hospitals and State Mental Health Institutions – licensed as a psychiatric facility and operated by the state.

(U W)     “Supply et al.” – any single supply, durable medical equipment (DME), orthotic, prosthesis, biologic item, or single drug dose, for which the billed amount exceeds $500.00 and all implants.

(V X)      Veterans’ Administration Medical Facilities – all medical facilities overseen by the Federal Veterans’ Administration.

16-3      REQUIRED USE OF THE MEDICAL TREATMENT GUIDELINES AND PAYMENT FOR SERVICE

            When an injury or occupational disease falls within the purview of Rule 17 "Medical Treatment Guidelines" and the date of injury occurs on or after July 1, 1991, providers and payers shall use the medical treatment guidelines, in effect at the time of service, to prepare or review their treatment plan(s) for the injured worker. A payer may not dictate the type or duration of medical treatment. Nor may a payer rely solely on its own internal guidelines or other standards for medical determination. When treatment exceeds or is outside of the Medical Treatment Guidelines, prior authorization is required. In all instances of contest appropriate processes to deny are required. Refer to applicable sections of Rule 16-9, 16-10 and/or 16-11.

16-4      REQUIRED USE OF THE MEDICAL FEE SCHEDULE

(A) When services provided to an injured worker fall within the purview of the medical fee schedule, all payers shall use the fee schedule to determine maximum allowable fees.

(B) All providers are required to report services in accordance with codes, modifiers (both CPT and Level II HCPCS/National Modifiers as listed in RVP Introduction and or in Appendix A of CPT) and standards in Rule 18 Medical Fee Schedule that accurately represent the services provided. The medical fee schedule sets the maximum allowable payment but the fee schedule does not limit the billing charges.

(C) The provider may be subject to penalties under the Workers’ Compensation Act for inaccurate billing when the provider knew or should have known that the services billed were inaccurate, as determined by the Director or an administrative law judge.

16-5      RECOGNIZED HEALTH CARE PROVIDERS

(A)        Physician and Non-Physician Providers

(1)        For the purpose of this rule, recognized health care providers are divided into the major categories of "physician" and "non-physician".  Recognized providers are defined as follows:

(a)        "Physician providers" are those individuals who are licensed by the State of Colorado through one of the following state boards:

(1)        Colorado State Board of Medical Examiners;

(2)        Colorado State Board of Chiropractic Examiners;

(3)        Colorado Podiatry Board; or

(4)        Colorado State Board of Dental Examiners.

(b)        "Non-physician providers" are those individuals who are registered or licensed by the State of Colorado Department of Regulatory Agencies, or certified by a national entity recognized by the State of Colorado as follows:

(1)        Acupuncturist (LAc) – licensed by the Office of Acupuncturist Registration, Colorado Department of Regulatory Agencies;

(2)        Advanced Practice Nurse – licensed by the Colorado State Board of Nursing; Advanced Practice Nurse Registry;

(3) Athletic Trainers (ATC) – certified by the Board of Certification, Inc.;

(4) Audiologist (AU.D. CCC-A) – certified by the American Speech Language-Hearing Association or board certified in audiology from the American Board of Audiology;

(5)        Clinical Social Worker (LCSW) – licensed by the Colorado State Board of Social Work Examiners;

(6)        Marriage and Family Therapist (LMFT) – licensed by the Colorado State Board of Marriage and Family Therapist Examiners;

(7) Massage Therapist (RMT) – registered as a massage therapist by the Colorado Department of Regulatory Agencies;

(8)        Occupational Therapist (OTR) – registered by the Colorado Department of Regulatory Agencies as an occupational therapist certified by the National Board for Certification of Occupational Therapy;

(9)        Optometrist (OD) – licensed by the Colorado State Board of Optometric Examiners;

(10)      Orthopedic Technologist (OTC) – certified by the Board for Certification of Orthopedic Technologists, National Association of Orthopedic Technologists;

(11) Pharmacist – licensed by the Colorado State Board of Pharmacy;

(12)      Physical Therapist (LPT) – licensed by the Colorado State Board of Physical Therapy;

(13)      Physician Assistant (PA) – licensed by the Colorado State Board of Medical Examiners;

(14)      Practical Nurse (LPN) – licensed by the Colorado State Board of Nursing;

(15)      Professional Counselor (LPC) – licensed by the Colorado State Board of Professional Counselor Examiners;

(16)      Psychologist (PsyD, PhD, EdD) – licensed by the Colorado State Board of Psychologist Examiners;

(17)      Registered Nurse (RN) – licensed by the Colorado State Board of Nursing;

(18)      Respiratory Therapist (RTL) – certified by the National Board of Respiratory Care and licensed by the Colorado Department of Regulatory Agencies;

(19)       Speech Language Pathologist (CCC-SLP) – certified by the American Speech Language-Hearing Association; and

(20)       Surgical Technologist (CST) – certified under direction of the Association of Surgical Technologists.

(2)        Upon request, health care providers must provide copies of license, registration, certification or evidence of health care training for billed services.

(3) Any provider not listed in Rule 16-5(A)(1)(a) or (b) must comply with Rule 16-9, Prior Authorization when providing all services.

(4) Referrals:

(a) A payer or employer shall not redirect or alter the scope of an authorized treating provider’s referral to another provider for treatment or evaluation of a compensable injury. Any party who has concerns regarding a referral or its scope shall advise the other parties and providers involved.

(b) All non-physician providers must have a referral from an authorized treating physician.  An authorized treating physician making the referral to any listed or unlisted non-physician provider is required to clarify any questions concerning the scope of the referral, prescription, or the reasonableness or necessity of the care.

(c) Any listed or non-listed non-physician provider is required to clarify any questions concerning the scope of the referral, prescription, or the reasonableness or necessity of the care with the referring authorized treating physician.

(5)        Rule 18 Medical Fee Schedule applies to authorized services provided in relation to a specific workers’ compensation case.

(B)        Out-of-State Provider

(1)        Injured Worker Relocated

(a)        Upon receipt of the "Employer's First Report of Injury" or the "Worker's Claim for Compensation” form, the payer shall notify the injured worker that the procedures for change-of-provider, should s/he relocate out-of-state, can be obtained from the payer.

(b)        A change of provider must be made:

(1)        Through referral by the injured worker's authorized treating physician provider; or

(2)        In accordance with § 8-43-404 (5)(a), C.R.S.

(2)        Injured Worker Referred

In the event an injured worker has not relocated out-of-state but is referred to an out-of-state provider for treatment or services not available within Colorado, the referring provider shall obtain prior authorization from the payer as set forth in Rule 16-9, Prior Authorization, and 16-10, Contest of a Request for Prior Authorization.  The referring provider's written request for out-of-state treatment shall include the following information:

(a)        Medical justification prepared by the referring provider;

(b)        Written explanation as to why the requested treatment/services cannot be obtained within Colorado;

(c)        Name, complete mailing address and telephone number of the out-of-state provider;

(d)        Description of the treatment/services requested, including the estimated length of time and frequency of the treatment/service, and all associated medical expenses; and

(e)        Out-of-state provider’s qualifications to provide the requested treatment or services.

(3)        The Colorado fee schedule should govern reimbursement for out-of-state providers.

16-6      HANDLING, PROCESSING AND PAYMENT OF MEDICAL BILLS

(A)       Use of agents, including but not limited to  Preferred Provider Organizations (PPO) networks, bill review companies, third party administrators (TPAs) and case management companies, shall not relieve the employer or insurer from their legal responsibilities for compliance with these rules. 

(B)        Payment for billed services identified in the fee schedule shall not exceed those scheduled rates and fees, or the provider's actual billed charges, whichever is less.

(C)       Payment for billed services not identified or identified but without established value, by report (BR) and relativity not established (RNE), in the fee schedule shall require prior authorization from the payer as set forth in Rule 16-9 Prior Authorization, except when the billed nonestablished valued service or procedure is an emergency or a payment mechanism under Rule 18 is identifiable, but not explicit. Examples of the prior authorization request exception(s) include, ambulance bills or supply bills that are covered under Rule18-6(H) with an identified payment mechanism of either CO Medicare HCPCS Level II values or cost of the supply plus 20%. and Rule 16-10 Contest of a Request for Prior Authorization.  The payer and provider shall negotiate a payment amount using a reasonable method that identifies a similar existing code with established RVUs and that justifies the difference in value.

The similar established code from the Medical Fee Schedule and recommended by the requesting physician shall govern maximum fee value payment from the payer.

If no established RVUs are reasonably similar, then the payer and provider may agree to the amount to be paid.

If no established similar CPT© exists and no agreement between the provider and payer exists, then the payer shall pay the billed amount.

(D) Any payer contesting a provider’s treatment shall follow the procedures as outlined under Rule 16-10 Contest of a Request for Prior Authorization, or Rule 16-11 Payment of Medical Benefits.

(E) The payer should note that ICD-9 Supplementary Classification of External Causes of Injury and Poisoning codes (E-codes), when submitted, shall not be used to establish the work relatedness of an injury or treatment.

16-7      REQUIRED BILLING FORMS AND ACCOMPANYING DOCUMENTATION

(A)        Providers may use electronic reproductions of any required form(s) referenced in this section; however, any such reproduction shall be an exact duplication of such form(s) in content and appearance. With the agreement of the payer, identifying information may be placed in the margin of the form.

(B)        Required Billing Forms

All health care providers shall use only the following billing forms or electronically produced formats when billing for services:

(1)        CMS (Centers for Medicare & Medicaid Services) 1500 (08-05) - shall be used by all providers billing for professional services, durable medical equipment (DME) and ambulance services with the exception of those providers billing for dental services or procedures; hospitals are required to use the CMS 1500 (08-05) when billing for professional services.  Health care providers shall provide their name and credentials in an appropriate box of the CMS 1500 (08-05).

(2)        UB-04 - shall be used by all hospitals, hospital-based ambulance/air services, Children’s Hospitals, CAHs, Veterans’ Administration Facilities, home health and facilities meeting the definitions found in Rule 16-2 when billing for hospital services or any facility fees billed by any other provider, such as ASCs, except for urgent care which may use the CMS 1500 (08-05).

(3)        American Dental Association’s Dental Claim Form, Version 2006 shall be used by all providers billing for dental services or procedures.

(4)        With the agreement of the payer, the ANSI ASC X12 (American National Standards Institute Accredited Standards Committee) or NCPDP (National Council For Prescription Drug Programs) electronic billing transaction containing the same information as in  (1), (2) or (3) in this subsection may be used.

(C)        Required Billing Codes

             All billed services shall be itemized on the appropriate billing form as set forth in Rule 16-7(A) and (B), and shall include applicable billing codes and modifiers from the fee schedule. National provider identification (NPI) numbers are required for workers’ compensation bills; providers who cannot obtain NPI numbers are exempt from this requirement When billing on a CMS 1500 (08-05), the NPI should be that of the rendering provider at the line level whenever possible.

(D)        Inaccurate Billing Forms or Codes

Payment for any services not billed on the forms identified and/or not itemized as instructed in Rule 16-7(B) and (C), may be contested until the provider complies.  However, when payment is contested, the payer shall comply with the applicable provisions set forth in Rule 16-11 Payment of Medical Benefits.

(E)        Accompanying Documentation

(1)        Authorized treating physicians sign (or countersign) and submit to the payer, with their initial and final visit billings, a completed “Physician’s Report of Workers’ Compensation Injury” (Form WC164) specifying: 

(a)        The report type as “initial” when the injured worker has their initial visit with the authorized treating physician managing the total workers’ compensation claim of the patient. Generally, this will be the designated or selected authorized treating physician. When applicable, the emergency room or urgent care authorized treating physician for this workers’ compensation injury may also create a WC 164 initial report.  Unless requested or prior authorized by the payer in a specific workers’ compensation claim, no other authorized physician should complete and bill for the initial WC 164 form. This form shall include completion of items 1-7 and 10.  Note that certain information in item 2 (such as Insurer Claim #) may be omitted if not known by the provider.

(b)        The report type as “closing” when the authorized treating physician (generally the designated or selected physician) managing the total workers’ compensation claim of the patient determines the injured worker has reached maximum medical improvement (MMI) for all injuries or diseases covered under this workers’ compensation claim, with or without a permanent impairment.  The form requires the completion of items 1-5, 6.B, C, 7, 8 and 10.  If the injured worker has sustained a permanent impairment, then item 9 must also be completed also and the following additional information shall be attached to the bill at the time MMI is determined:

(1)        All necessary permanent impairment rating reports when the authorized treating physician (generally the designated or selected physician) managing the total workers’ compensation claim of the patient is Level II Accredited; or

(2)        Referral to a Level II Accredited physician requested to perform the permanent impairment rating when a rating is necessary and the authorized treating physician (generally the designated or selected physician) managing the total workers’ compensation claim of the patient is not determining the permanent impairment rating.

(c)     At no charge, the physician shall supply the injured worker with one legible copy of all completed “Physician’s Report of Workers’ Compensation Injury” (WC164) forms at the time the form is completed.

(d)     The provider shall submit to the payer the completed WC 164 form as specified in Rule 16-7(E), no later than fourteen (14) days from the date of service.

(2)      Providers, other than hospitals, shall provide the payer with all supporting documentation at the time of submission of the bill unless other agreements have been made between the payer and provider.  This shall include copies of the examination, surgical, and/or treatment records.

(3)      Hospital documentation shall be available to the payer upon request.  Payers shall specify what portion of a hospital record is being requested.  (For example, only the emergency room (ER) chart notes, in-patient physician orders and chart notes, x-rays, pathology reports, etc.)

(4)      In accordance with Rule 16-11, the payer may contest payment for billed services until the provider completes and submits the relevant required accompanying documentation as specified by Rule 16-7(E).

(F) Providers shall submit their bills for services rendered within one hundred twenty (120) days of the date of service or the bill may be denied unless extenuating circumstances exist.  Extenuating circumstances may include but are not limited to delays in compensability being decided or the provider has not been informed where to send the bill.

16-8      REQUIRED MEDICAL RECORD DOCUMENTATION

(A)        A treating provider shall maintain medical records for each injured worker when the provider intends to bill for the provided services.

(B)        All medical records shall contain legible documentation substantiating the services billed.  The documentation shall itemize each contact with the injured worker and shall detail at least the following information per contact or, at a minimum for cases where contact occurs more than once a week, be summarized once per week:

(1)        Patient's name;

(2)        Date of contact, office visit or treatment;

(3)        Name and professional designation of person providing the billed service;

(4)        Assessment or diagnosis of current condition with appropriate objective findings;

(5)        Treatment status or patient’s functional response to current treatment;

(6)        Treatment plan including specific therapy with time limits and measurable goals and detail of referrals;

(7)       Pain diagrams, where applicable;

(8 7) If being completed by an authorized treating physician, all pertinent changes to work and/or activity restrictions which reflect lifting, standing, stooping, kneeling, hot or cold environment, repetitive motion or other appropriate physical considerations; and

(9 8)      All prior authorization(s) for payment received from the payer (i.e., who approved the prior authorization for payment, services authorized, dollar amount, length of time, etc.).

16-9      PRIOR AUTHORIZATION

(A)        Granting of prior authorization is a guarantee of payment for those services/procedures requested by the provider per Rule 16-9 (F).

(B A) Prior authorization for payment shall be requested by the provider when:

(1)        A prescribed service exceeds the recommended limitations set forth in the medical treatment guidelines;

(2)        The medical treatment guidelines otherwise require prior authorization for that specific service;

(3)        A prescribed service is identified within the medical fee schedule as requiring prior authorization for payment; or

(4)        A prescribed service is not identified in the fee schedule as referenced in Rule 16-6(C).

(C B)     All p Prior authorization for a prescribed service or procedure may be granted immediately and without medical review.  However, the payer shall respond to all providers requesting prior authorization within seven (7) business days from receipt of the provider’s completed request as defined in Rule 16-9(F E).  The duty to respond to a provider's written request applies without regard for who transmitted the request.

(D C)     The payer, upon receipt of the "Employer's First Report of Injury" or a "Worker's Claim for Compensation,” shall give written notice to the injured worker stating that the requirements for obtaining prior authorization for payment are available from the payer.

(E D)     The payer, unless they have previously notified said provider, shall give notice to the provider of these procedures for obtaining prior authorization for payment upon receipt of the initial bill from that provider.

(F E)     To complete a prior authorization request, the provider shall concurrently explain reasonableness and the medical necessity of the services requested and provide relevant supporting medical documentation.  Supporting medical documentation is defined as documents used in the provider’s decision-making process to substantiate the need for the requested service or procedure. and include:

(1) When the indicators of the Treatment Guidelines are met, no prior authorization is required. If the provider requests prior authorization for payment the following documentation is recommended:


(a) An adequate definition or description of the nature, extent, and need for the procedure;

(b) Identify the appropriate Medical Treatment Guideline application to the requested service;

(c) Document that the indicators in the guidelines have been met.

(d) Final diagnosis;


(2) When the service/procedure does not fall within the treatment guidelines and/or past treatment failed functional goals or if the requested procedure is not identified in the Medical Fee Schedule or does not have an established value under the Medical Fee Schedule, such as any unlisted procedure/service with a BR value or an RNE value listed in the RVP© authorization requests shall be made using Division form # WC ____.
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