department of labor and employment
Division of Workers’ Compensation
7 ccr 1101-3
workers’ compensation rules of procedure
           Rule 11	Division Independent Medical Examination
These rules apply to parties and physicians participating in the workers’ compensation IME program pursuant to the authority of the Workers’ Compensation Act. 
11-3 	Requests for an IME
(F)	Requests for Summary Disclosure: 
	(1) Within five (5) business days of issuance of the three-physician list by the Division, a party may request the physicians on the list provide a summary disclosure concerning any business, financial, employment or advisory relationship with the insurer, self-insured employer or the claimant.  Such request shall be submitted, in writing, to the Division IME Unit with a copy to the other party.  If a request is submitted, the requirement to strike a name from the list as described in paragraph (G) below shall be held in abeyance until the disclosure process is completed.  
			(a)  No requests for any other information regarding a physician’s business, financial, employment or advisory relationships shall be granted under this rule.
                                       (b)  The parties may use the information provided on the summary disclosure forms to assist in the decision to strike a physician from the list as described in paragraph (G) below.  The information shall not be used as a basis for the Division to remove a physician from the three-physician panel.    
	(2)  In response to requests for summary disclosure concerning relationships with the insurer or self-insured employer, the physicians shall submit a completed Form WC 179 to the Division IME Unit within seven (7) business days of notice from the Division.
	(a)  A physician may choose to pre-submit a disclosure Form WC 179 to the Division IME Unit to be kept on file.  If the form is on file the physician shall update the form within thirty (30) days of a material change and at least once a year.  
(b)  The Division IME Unit shall provide the completed forms to all parties. 
	(c) If a physician has not provided the required form to be kept on file and fails to provide the required form in a timely manner, the physician shall be removed from the three-physician list and a substitute physician selected by the Division IME Unit. The substitute physician shall be notified of the request for a summary disclosure and the same seven (7) business day time period described in paragraph (2) above shall apply.  
	(3) In response to requests for summary disclosure concerning relationships with a claimant who is a party to the claim, the physicians shall submit a completed Form WC 180 to the Division IME Unit within seven (7) business days of notice from the Division.
	(a)  The Division notice will include the name of the claimant and a blank copy of Form WC 180.  
(b)  The Division IME Unit shall provide the completed forms to all parties.
	(c)  If a physician fails to provide the required form in a timely manner, the physician shall be removed from the three-physician list and a substitute physician selected by the Division IME Unit.  The substitute physician shall be notified of the request for a summary disclosure and the same seven (7) business day time period described in paragraph (3) above shall apply.  	 
(4)  Nothing in this section prohibits an insurer, self-insured employer or a claimant from disclosing any business, employment, financial or advisory relationship they may have with any or all of the physicians on the list.  
(5)  Physicians who are “agreed-upon” to perform Division IMEs pursuant to the Notice & Proposal Process described in section 8-42-107.2(3)(a), are not required to comply with the provisions in this section (F). 
(G) 	If no request for a summary disclosure as set out in paragraph (F) above is made, within seven (7) business days of issuance of the three-physician list by the Division the requesting party shall strike one name and inform the other party and the Division.  If a request for a summary disclosure as set out in paragraph (F) above is made, within five (5) business days of the Division’s issuance to the parties of the WC 179 and/or the WC 180 forms by the Division IME Unit, the requesting party shall strike one name and inform the other party and the Division.  Within five (5) business days of receiving that information from the requesting party, the other party shall strike one of the two remaining physicians and inform the Division’s IME Unit, with confirmation to the requesting party, of the name of the remaining physician.  That information shall be provided to the Division via fax or telephone.  The parties may exchange information under this rule via fax, e-mail or telephone.  
Where no summary disclosure forms have been requested of the physicians, and if the Division is not notified of the selected physician within fifteen (15) business days of the date the Division issued the three-physician panel the Division shall randomly select one name from the three-physician list. If physicians’ summary disclosure forms have been requested, and the Division is not notified of the selected physician within ten (10) business days from the date the Division provides the disclosure forms to the parties, the Division shall randomly select one name from the three-physician panel.  If one party fails to timely strike a physician from the list, the other party shall notify the Division and at the same time provide to the Division the name of the physician that party wishes to strike.  In that situation the Division will randomly select one name from the remaining two physicians.  The Division shall confirm to the parties by telephone and/or in writing the name of the selected physician. 
If the selected physician declines or is unable to perform the IME, the Division shall provide one replacement name to the original list of three physicians, and present that revised list to the parties where each shall strike one name according to the procedures set forth in this section.  Additionally, if a physician is removed from the three-physician panel for any reason other than having been struck by one of the parties, the Division will issue one replacement name using the same criteria and process set forth in section 11-3(C), above. 
(H) 	When a physician is selected from the three-physician panel to perform the IME, the Division will remove his/her name from the revolving list of physicians for a period of time so that he/she is not available for assignment to another three-physician panel.  This period of time may be adjusted by the Division as necessary to balance the mandate to reduce over utilization of individual physicians, yet ensure that an adequate pool of physicians is available in each geographic area.  This procedure shall not preclude the parties from agreeing-upon such physicians to perform division IMEs. 
(I) 	Appointment Date:  The date of the examination shall be set in accordance with section 11-2(A).  The requesting party shall call the IME physician within five (5) business days after providing and/or receiving notice of the final IME physician selection to schedule the examination, and shall immediately notify the Division and the opposing party by telephone, and confirm in writing, the date and time of the examination. Absent good cause as determined by the Director or an administrative law judge, failure to make the appointment and advise all parties within five (5) business days permits the opposing party, after notifying the Division of such failure, to either schedule the IME appointment or to request cancellation of the IME.
(J) 	Submission of Medical Records:  The insurer shall concurrently provide to the IME physician and all other parties, a complete copy of all medical records in their possession pertaining to the subject injury, postmarked or hand-delivered no fewer than fourteen (14) calendar days prior to the IME examination.  If the insurer or its representative fails to timely submit medical records to the designated IME physician, the claimant may request the Division cancel the IME; or the claimant may submit all medical records he/she has available no later than ten (10) calendar days prior to the IME examination; or as otherwise arranged by the Division with the IME physician.  This rule does not prohibit the rescheduling of the IME. The defaulting party may supplement the records pursuant to section 11-3(L).  
(K) 	Form/Content of Medical Records Package:  Pertinent medical records shall include all medical reports and medical records reflecting the diagnosis and treatment of the claimant’s work-related injury, and shall include available medical records regarding relevant pre-existing condition(s) or work-related injury(ies).  The medical file shall be two-hole punched at the top center of each page and clipped at the top with paper fasteners.  A dated cover sheet shall be included listing the claimant’s name, IME physician’s name, date and time of the appointment, and the workers’ compensation number.  The medical file shall be in chronological order and tabbed by year.  It shall include a written summary of medical providers with the range of dates of treatment.  Medical records not meeting these requirements shall be resubmitted to the IME physician and all other parties in the correct format within three (3) business days of notification by the Division.  Failure to timely and properly resubmit such records may result in cancellation of the IME by the Director, at the cost of the submitting party.  Penalties otherwise available under these rules and the Act may be determined by the Director.
	Medical bills, adjustor notes, surveillance tapes, admissions, denials, vocational rehabilitation reports, non-treating case manager records or commentaries to the IME physician shall not be submitted without written agreement of all parties, order of an administrative law judge, or prior permission of the Division.
(L) 	Submission of Supplemental Medical Records:  Supplemental medical records shall be prepared according to section 11-3(K), above, and may be mailed or hand-delivered by any party concurrently to the IME physician and all other parties no later than seven (7) calendar days prior to the IME examination.
(M) 	Depositions:  Medical depositions may be submitted as part of the medical records package only by written agreement of all parties or pursuant to an order issued by the director or an administrative law judge.  The IME physician shall be reimbursed for time spent reviewing medical depositions at the rate set forth in Rule 18, Testimony Fees.  The party submitting the medical deposition shall be responsible for payment of the additional fees.
(N)	Interpreter:  The claimant shall be responsible for notifying the insurer of the necessity for a language interpreter, a minimum of fourteen (14) calendar days before the examination.  The paying party shall be responsible for arranging for the services of and paying for such language interpreter.  The language interpreter shall be impartial and independent, and have no professional or personal affiliation with any party to the claim or the IME physician.
(O) 	IME Proceedings Held in Abeyance:  If a party files a motion involving a pending IME proceeding, the moving party shall provide a copy of the motion directly to the Division’s IME Unit.  The IME proceeding shall be held in abeyance until the Division IME Unit is notified of the disposition as provided in this rule.  When the motion is disposed of by written order or other means, the moving party shall provide a copy of the order or other dispositive document to the Division’s IME Unit