Rule 16 Changes Document 2009 to 2010

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, 2010 2009.  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.
16-3      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  apply its own internal guidelines or other standards for medical determination.   treatment if they conflict with Rule 17 and its exhibits.  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
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.
All providers are required to report services in accordance with codes and standards in Rule 18 Medical Fee Schedule.  The medical fee schedule sets the maximum allowable payment but the fee schedule does not limit the billing charges.  
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:
(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:
(3)	Athletic Trainers (ATC) – certified by the Board of Certification, Inc. (BOC);
(5)        Licensed Clinical Social Worker (LCSW) – licensed by the Colorado State Board of Social Work Examiners;
 (7)	Massage Therapist (RMT) – registered as a massage therapist by the Colorado Department of Regulatory Agencies;
(8)        Occupational Therapist (OTR) – registered certified by the Colorado Department of Regulatory Agencies  as an occupational therapist certified by the  National Board for Certification of Occupational Therapy Occupational Therapy Certification Board;
(14)       Licensed Practical Nurse (LPN) – licensed by the Colorado State Board of Nursing;
(15)      Licensed Professional Counselor (LPC) – licensed by the Colorado State Board of Professional Counselor Examiners;
(5)        Rule 18 Medical Fee Schedule (medical fee schedule) applies to authorized services provided in relation to a specific workers’ compensation case.
16-6      HANDLING, PROCESSING AND PAYMENT OF MEDICAL BILLS 
(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.
(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 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 designated 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 2)     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 3)     The provider shall submit to the payer the completed WC164 form as specified in Rule 16-7(E), no later than fourteen (14) days from the date of service.
(2 4)      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.
(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.
16-10    CONTEST OF A REQUEST FOR PRIOR AUTHORIZATION
(A)        If the payer contests a request for prior authorization for non-medical reasons as defined under Rule 16-11(B)(1), the payer shall notify the provider and parties, in writing, of the basis for the contest within seven (7) business days from receipt of the provider’s completed request as defined in Rule 16-9(E).  A certificate of mailing of the written contest must be sent to the provider and parties. 
            If an ATP requests prior authorization and indicates in writing,  including their reasoning and relevant documentation, that they believe the requested treatment is related to the admitted workers’ compensation (WC) claim, the insurer cannot deny based solely on relatedness without a medical review as under Rule 16-10(B).  
16-11    PAYMENT OF MEDICAL BENEFITS (the entire text of Rule 16-11 has been stricken and replaced with the following)
(A)        Payer Requirements for Processing Medical Service Bills
(1)	For every medical service bill submitted by a provider, the payer shall reply with a written notice or explanation of benefits.   In those instances where the payer reimburses the exact billed amount, identification of the patient’s name, the payer, the paid bill, the amount paid and the dates of service are required.  If any adjustments are made then the payer’s written notice shall include: 
	(a)        Name of the injured worker or patient;
(b)        Specific identifying information coordinating the notice with any payment instrument associated with the bill;
(c)	Date(s) of service(s), if date(s) was(were) submitted on the bill;
(d)        Payer’s claim number and/or Division’s workers’ compensation claim number, if one has been created; 
(e)        Reference to the bill and each item of the bill;
(f)         Notice that the billing party may resubmit the bill or corrected bill within sixty (60) days;
(g) 	For compensable services for a work-related injury or occupational disease the payer shall notify the billing provider that the injured worker shall not be balance-billed for services related to the  work-related injury or occupational disease;
(h)	Name of insurer with admitted, ordered or contested liability for the workers’ compensation claim, when known;  
(i)	name, address, e-mail (if any), phone number and fax of a person who has responsibility and authority to discuss and resolve disputes on the bill;
 (j)	If applicable, a statement that the payment is being held in abeyance because a relevant issue is being brought to hearing.
(2)        The payer shall send the billing party written notice that complies with 16-11(A)(1) within thirty (30) days of receipt of the bill.  Any notice that fails to include the required information set forth in 16-11(A)(1) is defective and does not satisfy the payer’s 30-day notice requirements set forth in this section.   
(3)	Unless the payer provides timely and proper reasons as set forth by the provisions outlined in 16-11(B) - (D), all bills submitted by a provider are due and payable in accordance with the Medical Fee Schedule within thirty (30) days after receipt of the bill by the payer.  
(4)	If the payer discounts a bill and the provider requests clarification in writing, the payer shall furnish to the requester the specifics of the discount within 30 days including a copy of any contract relied on for the discount.  If no response is forthcoming within 30 days, the payer must pay the maximum fee schedule allowance or the billed charges, whichever is less.
(5)	Date of receipt of the bill may be established by the payer’s date stamp or electronic acknowledgement date; otherwise, receipt is presumed to occur three (3) business days after the date the bill was mailed to the payer’s correct address.   
(6)	Unreasonable delay in processing payment or denial of payment of medical service bills, as determined by the Director or an administrative law judge, may subject the payer to penalties under the Workers’ Compensation Act.
(7)	If the payer fails to make timely payment of uncontested billed services, the billing party may report the incident to the Division’s Carrier Practices Unit who may use it during an audit.
 (B)    	Process for Contesting Payment of Billed Services Based on Non-Medical Reasons
 (1)       Non-medical reasons are administrative issues.  Examples of non-medical reasons for contesting payment include the following:  no claim has been filed with the payer; compensability has not been established; the billed services are not related to the admitted injury; the provider is not authorized to treat; the insurance coverage is at issue; typographic, gender or date errors are in the bill; failure to submit any medical documentation at all; unrecognized CPT® code.
(2)        If an ATP bills for medical services and indicates in writing, including their reasoning and relevant documentation, that they believe the medical services are related to the admitted WC claim, the payer cannot deny based solely on relatedness without a medical review as under Rule 16-11(C).  
(3)        In all cases where a billed service is contested for non-medical reasons, the payer shall send the billing party written notice of the contest within 30 days of receipt of the bill.  The written notice shall include all of the notice requirements set forth in 16-11(A)(1) and shall also include:
(a)        Date(s) of service(s) being contested, if date(s)  was(were) submitted on the bill;
(b)        If applicable, acknowledgement of specific uncontested and paid items submitted on the same bill as contested services;
(c)        Reference to the bill and each item of the bill being contested; and
(d)        Clear and persuasive reasons for contesting the payment of any item specific to that bill including the citing of appropriate statutes, rules and/or documents supporting the payer’s reasons for contesting payment.
Any notice that fails to include the required information set forth in this section is defective and does not satisfy the notice requirement set forth in this section.  Such defective notice shall not satisfy the payer’s 30 day notice requirement set forth in this section.
(4)        Prior to modifying a billed code, the payer must contact the billing provider and determine if the modified code is accurate.
(a)        If the billing provider agrees with the payer, then the payer shall process the service with the agreed upon code and shall document on their explanation of benefits (EOB) the agreement with the provider.  The EOB shall include the name of the person at the provider’s office who made the agreement.
(b)        If the provider is in disagreement, then the payer shall proceed according to Rule 16-11(B) or 16-11(C), as appropriate.
(5)        If the payer agrees a service or procedure was reasonable and necessary, the provider’s lack of prior authorization for payment does not warrant denial of liability for payment.
(C)     Process for Contesting Payment of Billed Services Based on Medical Reasons
When contesting payment of billed services based on medical reasons, the payer shall:
(1)        Have the bill and all supporting medical documentation under Rule 16-7(E) reviewed by a physician or other health care professional as defined in Rule 16-5(A)(1)(a), who holds a license and is in the same or similar specialty as would typically manage the medical condition, procedures, or treatment under review.  After reviewing the supporting medical documentation, the reviewing provider may call the billing provider to expedite communication and timely processing of the contested or paid medical bill.  
(2)        In all cases where a billed service is contested for medical reasons, the payer shall send the provider and the parties written notice of the contest within thirty (30) days of receipt of the bill.  The written notice shall include all of the notice requirements set forth in 16-11(A)(1) and shall also include:
(a)        Date(s) of service(s) being contested, if date(s) was(were) submitted on the bill;
(b)        If applicable, acknowledgement of specific uncontested and paid items submitted on the same bill as contested services;
(c)        Reference to the bill and each item of the bill being contested;
(d)        An explanation of the clear and persuasive  medical reasons for the decision, including the name and professional credentials of the person performing the medical review and a copy of the medical reviewer's opinion;
(e)        The specific cite from the Division’s Medical Treatment Guidelines exhibits to Rule 17, when applicable; and 
(f)        Identification of the information deemed most likely to influence the reconsideration of the contest, when applicable.
Any notice that fails to include the required information set forth in this section is defective and does not satisfy the notice requirement set forth in this section.  Such defective notice shall not satisfy the payer’s 30-day notice requirement set forth in this section. 
(D)	Process for Ongoing Contest of Billed Services 
(1)        The billing party shall have sixty (60) days to respond to the payer’s written notice under 16-11(A) – (C).  The billing party’s timely response must include:
(a)	A copy of the original or corrected bill;
(b)	A copy of the written notice or EOB received;
(c)	A statement of the specific item(s) contested;
(d)	Clear and persuasive supporting documentation or clear and persuasive reasons for the appeal; and 
(e)	Any available additional information requested in the payer’s written notice.
(2)	If the billing party responds timely and in compliance with Rule 16-11(D)(1), the payer shall:
(a) 	When contesting for medical reasons, have the bill and all supporting medical documentation and reasoning under 16-7(E) and, if applicable, 16-11(D)(1) reviewed by a physician or other health care professional as defined in Rule 16-5(A)(1)(a), who holds a license and is in the same or similar specialty as would typically manage the medical condition, procedures, or treatment under review.  After reviewing the provider’s documentation and response, the reviewing provider may call the billing provider to expedite communication and timely processing of the contested or paid medical bill. 
(b)	When contesting for non-medical reasons, have the bill and all supporting medical documentation and reasoning under 16-7(E) and, if applicable, 16-11(D)(1) reviewed by a person who has knowledge of the bill.  After reviewing the provider’s documentation and response, the reviewing person may call the billing provider to expedite communication and timely processing of the contested or paid medical bill. 
(3)	If before or after conducting a review pursuant to 16-11(D)(2), the payer agrees with the billing party’s response, the billed service is due and payable in accordance with the Medical Fee Schedule within thirty (30) days after receipt of the billing party’s response.  Date of receipt may be established by the payer’s date stamp or electronic acknowledgement date; otherwise, receipt is presumed to occur three (3) business days after the date the response was mailed to the payer’s correct address.  
(4)        After conducting a review pursuant to 16-11(D)(2), if there is still a dispute regarding the billed services, the payer shall send the billing party written notice of contest within thirty (30) days of receipt of the response.  The written notice shall include all of the notice requirements set forth in 16-11(A)(1) and shall also include:
(a)        Date(s) of service(s) being contested, if date(s) was(were) submitted by the provider;
(b)        If applicable, acknowledgement of specific uncontested and paid items submitted on the same bill as contested services;
(c)        Reference to the bill and each item of the bill being contested;
(d)        An explanation of the clear and persuasive medical or non-medical reasons for the decision, including the name and professional credentials of the person performing the medical or non-medical review and a copy of the medical reviewer's opinion when the contest is over a medical reason; and 
(e)        The explanation shall include the citing of appropriate statutes, rules and/or documents supporting the payer’s reasons for contesting payment.
	Any notice that fails to include the required information set forth in this section is defective and does not satisfy the notice requirement set forth in this section.  Such defective notice shall not satisfy the payer’s 30-day notice requirement set forth in this section.
(5)        In the event of continued disagreement, the parties should follow dispute resolution and adjudication procedures available through the Division or Office of Administrative Courts.
(E)        When seeking clarification or dispute resolution from the Division’s Medical Policy Unit (MPU), the requesting party must provide:
(1)        A copy of the bill with the contested codes and dates of services in dispute;
(2)        A copy of the payer’s explanation as to why the billed services are being contested; and
(3)        A copy of any applicable medical record documentation.
The MPU will try to provide a written analysis and opinion to the parties regarding the appropriate application of the Medical Fee Schedule within thirty (30) days of receipt of the complete documentation and the written request for assistance; or as soon thereafter as possible.
(F)	Retroactive review of Medical Bills
(1)        All medical bills paid by a payer shall be considered final at twelve months after the date of the original explanation of benefits unless:
(a)	a hearing is requested within the twelve month period, and
(b)	the requesting provider is notified that the payment is being contested and the matter is going to hearing.
 (2)        If the payer conducts a retroactive review to recover overpayments from a provider based on medical reasons, the payer shall have the bill and all supporting documentation reviewed by a physician or other health care professional as defined in Rule 16-5(A)(1)(a), who holds a license and is in the same or similar specialty as would typically manage the medical condition, procedures, or treatment under review.  The payer shall send the billing party written notice that shall include all of the notice requirements set forth in 16-11(A)(1) and shall also include:
(a)	Reference to each item of the bill where payer seeks to recover overpayments; and
(b)	Clear and persuasive medical reason(s) for seeking recovery of overpayment(s).  The explanation shall include the citing of appropriate statutes, rules, and/or other documents supporting the payer’s reason for seeking to recover overpayment.
 (c)	Evidence that these payments were in fact made to the provider.
(3)	If the payer conducts a retroactive review to recover overpayments from a provider based on non-medical reasons, the payer shall send the billing party written notice that shall include all of the notice requirements set forth in 16-11(A)(1) and shall also include:
(a)	Reference to each item of the bill where payer seeks to recover overpayments; and
(b)	Clear and persuasive reason(s) for seeking recovery of overpayment(s).  The explanation shall include the citing of appropriate statutes, rules, and/or other documents supporting the payer’s reason for seeking to recover overpayment.
(c)	Evidence that these payments were in fact made to the provider.
 (4)	In the event of continued disagreement, the parties should follow dispute resolution and adjudication procedures available through the Division or Office of Administrative Courts.
(G)        An injured worker shall never be required to directly pay for admitted or ordered medical benefits covered under the Workers’ Compensation Act.  In the event the injured worker has directly paid for medical services that are then admitted or ordered as covered under the Workers’ Compensation Act , the payer shall reimburse the injured worker for the amounts actually paid for authorized services within thirty (30) days after receipt of the bill.  If the actual costs exceed the maximum fee allowed by the medical fee schedule, the payer may seek a refund from the medical provider for the difference between the amount charged to the injured worker and the maximum fee.  Each request for a refund shall indicate the service provided and the date of service(s) involved.
(H)        To the extent not otherwise precluded by the laws of this state, contracts between providers, payers and any agents acting on behalf of providers or payers shall comply with Rule 16-11.  
16-12    ONSITE REVIEW OF HOSPITAL OR OTHER MEDICAL CHARGES
(C)        The hospital or other medical facility shall comply with the following procedures:
(4)        Provide a written response to each of the preliminary review findings within ten (10) business days of receipt of those findings; and
(D)        The reviewer shall comply with the following procedures:
(4)        Establish the schedule for the review which shall include, at a minimum, the dates for the delivery of preliminary findings to the hospital or other medical facility, a 10 business day response period for the hospital or other medical facility, and the delivery of an itemized listing of discrepancies at an exit conference upon the completion of the review; and
(5)        Provide the payer and hospital or other medical facility with a written summary of the review within twenty (20) business working days of the exit conference.