Rule 13 Accreditation of Physicians
13-1 STATEMENT OF BASIS AND PURPOSE
(A) This rule is promulgated to implement and establish procedures for the physicians accreditation program as set forth in statute, to provide physicians with an understanding of their administrative, legal and medical roles in the workers’ compensation system. Accreditation requirements established shall apply to:
(1) Physicians who seek Level I accreditation under the Act; and
(2) Physicians providing permanent impairment evaluation of claimants; and
(3) Physicians serving on the Division Independent Medical Examination Panel.
13-2 ACCREDITATION
(A) To obtain Level I or Level II Accreditation a physician must:
(1) be qualified under the act;
(2) complete an application form prescribed by the Division and in Level II cases, indicate if full accreditation or limited accreditation is sought;
(3) attend a Division seminar and/or review the Division materials on the worker’s compensation system; for Level II accreditation, this must include the American Medical Association Guides to the Evaluation of Permanent Impairment, Third Edition (Revised), in effect as of July 1, 1991 (‘AMA Guides’), and demonstrate an understanding of such materials by taking an examination administered by the Division; and
(4) certify agreement to comply with all Division rules, including but not limited to the medical treatment guidelines, permanent impairment rating guidelines and utilization standards adopted by the Director, and all relevant statutes.
(B) After paying the accreditation registration fee, a physician must satisfactorily complete the examination administered by the Division. If the physician does not exhibit sufficient knowledge upon completion of the examination on the third attempt, he or she shall be required to wait six months and pay a second registration fee before taking the examination again.
(C) Accreditation begins on the date the physician successfully completes the accreditation examination.
(D) Level II Accreditation expires on December 31ST of the third calendar year following the year the physician successfully completed the Level II Accreditation examinations; Level I Accreditation expires on July 31st of the third year following the year the Level I applicant successfully completed the Level I Accreditation examination.
(E) For Level II Accreditation only:
(1) Full Accreditation: A qualified physician who satisfactorily completes the Level II Accreditation examination as determined and administered by the Division shall be fully accredited to determine permanent impairment ratings on any work-related injury or illness.
(2) Limited Accreditation: A qualified physician who seeks Level II Accreditation in order to rate impairment only in connection with an area of medical specialty and who satisfactorily completes specified portions of the Level II examination as determined and administered by the Division shall receive limited accreditation to determine permanent impairment ratings on the corresponding sections of the AMA Guides.
(A) The Division shall provide accredited physicians not less than sixty (60) days written notice of impending expiration of their accreditation.
(B) A physician who does not renew their accreditation before their accreditation expiration date may reapply and complete the process for initial accreditation under section 13-2.
(C) To renew accreditation, a qualified physician must:
(1) be qualified under the Act;
(2) complete an application form prescribed by the Division and, for Level II accreditation, indicate if full accreditation or limited accreditation is sought;
(3) complete the Division Reaccredidation Curriculum for Level I or Level II as appropriate;
(4) certify agreement to comply with all Division rules, including but not limited to the medical treatment guidelines, permanent impairment rating guidelines, and utilization standards adopted by the Director, and all relevant statutes.
(5) submit his/her first three (3) impairment rating reports to the Division following initial accreditation. Physicians who re-accredit must submit to the Division at least three (3) impairment reports during the three-year period following their reaccredidation. All such impairment rating reports may include Division Independent Medical Examination reports. A physician may not reaccredit until and unless this requirement is met, unless the physician has been unable to complete three impairment ratings during the three-year period for good cause as determined by the Director, and has met any other similar report requirement the Director may substitute. The purpose of providing these impairment reports is for education and feedback to the physician, and to assist the Division in examining its curriculum. Any correspondence or communication regarding this process is confidential and shall not be subject to discovery or examination by any person.
13-4 REVOCATION OF ACCREDITATION
(A) The Director, with input from the Medical Director, may initiate proceedings to revoke a Level I or Level II Accreditation on any of the following grounds:
(1) Refusal to comply, substantial failure to comply, or two or more incidents of failure to comply with the provisions of these Workers’ Compensation Rules of Procedure and all relevant statutes.
(2) a misrepresentation on the application for accreditation, or
(3). by final order of the Director in a proceeding held pursuant to §8-43-501, C.R.S., where the reviewing panel has unanimously recommended that accreditation be revoked.
(B) The severity of any sanctions taken under these rules shall reflect the character of the failure and the attendant circumstances.
(C) A proceeding to revoke a Level I or Level II Accreditation may be initiated by the Director, with input from the medical director, with referral for a hearing before an administrative law judge.
(D) Following a hearing before an administrative law judge to revoke a physician’s accreditation, the administrative law judge shall render proposed findings of fact and conclusions of law, and then make recommendations to the Director, who shall enter an order in the case.
Rule 14 APPLICATIONS FOR ADMISSION AND PAYMENT OF BENEFITS FROM THE MAJOR MEDICAL INSURANCE FUND, THE MEDICAL DISASTER FUND AND REQUEST FOR BENEFITS FROM THE SUBSEQUENT INJURY FUND
14-1 APPLICATIONS FOR ADMISSION TO THE MAJOR MEDICAL INSURANCE FUND AND MEDICAL DISASTER FUND
(A) All applications for admission shall be filed with the Division on the prescribed form along with copies of the payment history, orders, medical records and all available relevant documents that support the application for admission. Upon receipt of an application, the Director shall examine the claim file to determine whether the insurer has exhausted its $20,000 limit of liability for medical benefits as provided in §8-49-101 C.R.S, 1973. Those applications not meeting this requirement shall be dismissed and the applicant will be so notified by the Director.
(B) Applications meeting the above requirement shall be examined by the Director in accordance with the relevant provisions of the act. The Director may approve or disapprove an application for admission to/from the fund without conducting a hearing.
14-2 APPEAL OF ORDER DENYING ADMISSION OR DENYING BENEFITS TO THE MAJOR MEDICAL INSURANCE FUND AND MEDICAL DISASTER FUND
(A) A party who is dissatisfied with an order dismissing or denying an application for admission or dissatisfied with a written denial of benefits may apply for a hearing with the Office of Administrative Courts within 30 days from the date of the order.
(B) When a hearing is requested after a dismissal or denial of an application for admission or for a denial of benefits from the fund, the Director shall be listed as a party and served with all notices, pleadings, reports, and other documents. Where an attorney has entered an appearance for the Director in a case, such service shall be made upon that attorney.
14-3 TERMINATING BENEFITS FROM THE MAJOR MEDICAL INSURANCE FUND
(A) When a party believes that further expenditures from the Major Medical Insurance Fund will not promote recovery, alleviate pain or reduce disability, that party, may file a request with the Director to issue an order to show cause why the Director should not issue a final order to cease payments from the Major Medical Insurance Fund.
(B) Upon the discretion of the Director, an order to show cause why the claim should not be closed from the Major Medical Insurance Fund will be issued. If no response is filed to the order to show cause within 30 days the Director shall issue an order to cease payments from the Major Medical Insurance Fund. If a response to the order to show cause is received within 30 days, the Director shall determine if an order to cease payments shall be issued.
(C) If an order to cease payment is issued, and no objection is filed within 30 days of the order to cease payment, the case shall automatically be closed for payment of benefits from the Major Medical Insurance Fund.
(D) If an objection is timely filed to the order to cease payment the objecting party shall set the case for hearing within 30 days of the date of the objection by filing an application for hearing with the Office of Administrative Courts. The Major Medical Insurance Fund shall continue medical benefits until an application is filed and the matter is resolved by order.
14-4 OFFSET OF LIABILITY TO SUBSEQUENT INJURY FUND FOR ACCIDENTS THAT OCCURRED PRIOR TO 7-1-93 AND OCCUPATIONAL DISEASES THAT OCCURRED PRIOR TO 4-1-94
(A) Offset of liability to the Subsequent Injury Fund, shall be initiated by filing a request for offset with the Division upon the prescribed form and serving the Director with a copy of the request for offset. The party filing the request for offset with the Director shall also simultaneously file with the Director a copy of medical reports, orders and all available relevant documents that support the request for offset.
(B) A request pursuant to §8-46-101, C.R.S., shall list, to the extent available by the requesting party, all prior or pending workers’ compensation cases by name and number, a brief description of each injury and the award in each case.
(C) A request pursuant to §8-41-304(2), C.R.S., shall indicate the types of exposures alleged, the approximate dates of each exposure, and the location and the name of the employer in whose employ each exposure allegedly occurred.
(D) A request for offset shall be filed no later than the date the party requesting offset files an application for hearing or response to application for hearing, unless an administrative law judge rules that good cause has been shown for filing later. However, in no event shall a request for offset be filed after a determination, by admission or order, that a claimant is permanently and totally disabled under §8-46-101 or disabled under §8-41-304(2).
(E) The party requesting offset shall also file a proposed order with the Office of Administrative Courts joining the Director as a party on behalf of the Subsequent Injury Fund. Sufficient copies of the order and pre-addressed envelopes for all parties shall also be filed.
(F) The administrative law judge shall consider the proposed order to join the Director and response and rule on whether to join the Director as a party. The ruling shall be based on whether the procedural requirements of this Rule 14 have been met and whether the request states a sufficient basis upon which offset could be granted. Until the Director is joined, notices and orders are not binding on the Subsequent Injury Fund.
(G) When the Director is joined as a party and when an attorney has entered an appearance on behalf of the Subsequent Injury Fund, copies of all reports, pleadings or other documents thereafter filed by any party shall be served upon that attorney.
14-5 STATUS OF DIRECTOR ON BEHALF OF THE SUBSEQUENT INJURY FUND, IN FATAL CASES
(A) The Director shall be deemed to be an interested party in all fatal cases and shall be served with all pleadings, notices, reports, and documents as required for any party. Where an attorney has entered an appearance for the Director in a case, such service shall be made upon that attorney.
(B) In the event a compensable injury results in a death which has not been reported to the Division, the Director may initiate a claim for the death benefits provided by statute.
Rule 15 Vocational Rehabilitation Rules Applicable to Claims based upon an Injury or Illness Occurring prior to July 2, 1987 at 4:16 p.m.
15-1 STATEMENT OF BASIS AND PURPOSE
The rules of procedure governing the vocational rehabilitation component of worker's compensation as originally promulgated pursuant to §8-49-101(4), C.R.S 1973 (repealed 1987) provide a qualified worker an opportunity to re-enter the workforce by establishing guidelines for vocational rehabilitation.
15-2 DEFINITIONS
In addition to the definitions already adopted in the rules, the following definitions apply to vocational rehabilitation procedures:
(A) "Job Modification" is the adaptation of a job either through the use of aids or devices or the alteration of the physical environment of the job, or both, to allow an impaired individual to perform within the scope of tasks originally designed for the job flow.
(B) "Qualified Worker" means a claimant who because of the effects of a work-related injury or occupational disease, (a) is permanently precluded from engaging in his/her usual and customary occupation and is unable to perform work for which the individual has previous training or experience, and (b) can reasonably be expected to attain suitable, gainful employment upon successful completion of a vocational rehabilitation program.
(C) "Qualified Rehabilitation Consultant" means a person authorized by a rehabilitation vendor to conduct a vocational evaluation and develop a rehabilitation plan for a qualified worker.
(D) "Rehabilitation Vendor" means an individual, firm or facility which exists to provide any or all of the services necessary to determine a claimant’s eligibility as a qualified worker, and/or provide those services designed to return an individual to work.
(E) "Suitable Gainful Employment" means employment which is reasonably attainable and which offers an opportunity to restore the qualified worker as soon as possible and as nearly as possible to employment with the claimant’s qualifications, including but not limited to the claimant’s age, education, previous work history, interests and skills. Special consideration shall also be given to the economic level of the claimant at the time of injury and to the present and future labor markets, to attempt to restore him/her to the maximum level attainable.
(F) "Transferable Skills" means those skills an individual possesses which were attained through previous training or experience and are readily marketable and a need for them exists in the current labor market and would provide suitable gainful employment.
(G) "Vocational Evaluation" means the rehabilitation services and testing required by the Director to determine a claimant’s eligibility as a qualified worker.
(H) "Vocational Rehabilitation Plan" means a written document completed and signed by a qualified rehabilitation consultant which describes the manner and means by which it is proposed that a qualified worker may be returned to suitable gainful employment through the participation in a rehabilitation program.
(I) "Vocational Rehabilitation Program" means the actual providing of services as prescribed in the vocational rehabilitation plan and approved by the Director as reasonably necessary to restore a qualified worker to suitable gainful employment.
15-3 INITIATION OF VOCATIONAL EVALUATION AND DIRECTOR'S DETERMINATION OF ELIGIBILITY
(A) A vocational evaluation shall be provided by a rehabilitation vendor designated by the insurer, or upon failure of such designation, by the Division in consultation with the claimant, immediately upon knowledge that a claimant is unlikely to be able to return to his/her usual and customary occupation on a permanent basis as determined by competent medical evidence and opinion.
(B) A vocational evaluation summary report shall be submitted to the Director on a form prescribed by the Director and shall include the minimum elements listed on the form. The Director may request additional information necessary to determine eligibility.
(C) The vocational evaluation summary report shall be signed by a qualified rehabilitation consultant responsible for the evaluation and shall contain a recommendation by the consultant whether the claimant is eligible for a vocational rehabilitation program. If the recommendation indicates the claimant is in need of vocational rehabilitation and would benefit from vocational rehabilitation, the summary shall include a description of suggested occupation(s) that would be considered for plan development.
(D) A vocational evaluation shall be completed within sixty (60) days of assignment to the rehabilitation vendor.
(E) Upon submission of the vocational evaluation summary report, the insurer shall indicate whether it is providing vocational rehabilitation voluntarily or is requesting that the Director determine eligibility. Upon a request to determine eligibility the Director shall issue a “Notice of Determination of Eligibility for Vocational Rehabilitation Benefits” within twenty days.
(F) A party may object to the determination of eligibility by filing an application for hearing with the Office of Administrative Courts within fifteen (15) days of the date of the Director's determination.
15-4 SUBMISSION AND IMPLEMENTATION OF THE VOCATIONAL REHABILITATION PLAN
(A) If the claimant is determined a qualified worker, the Director shall order that a vocational rehabilitation plan be developed. The plan shall be developed and submitted to the Director and the parties within forty-five (45) days of the Director's determination of eligibility, unless said determination has been contested.
(B) In developing the plan, the rehabilitation vendor shall strive to return the qualified worker to suitable gainful employment within the qualified worker’s medical and physical limitations as determined in the vocational evaluation in the following priorities:
(1) Return to work for the same employer to a modified job requiring rehabilitation services.
(2) Return to work for the same or a new employer in a related occupation, for which the individual has received rehabilitation services to upgrade skills attained from previous training or experience.
(3) Return to work in an on-the-job training capacity.
(4) Return to work after the completion of a vocational program into a new occupation.
(C) Once developed, the proposed plan shall be written and submitted to the parties on the form prescribed by the Director. The written plan shall include the minimum elements listed on the form. All parties shall sign the vocational plan prior to submitting the plan to the Director for approval. The Director may request additional information necessary to determine if the plan should be approved.
(D) The Director, upon receipt of a proposed vocational rehabilitation plan and upon review, shall order the plan either approved or disapproved or modified. Implementation of the plan may begin as soon as the qualified worker is capable of participating in the program, as indicated by competent medical evidence. The plan shall begin upon the Director's approval or the date specified in the plan as applicable, whichever is later. The insurer shall continue to provide temporary disability benefits, if applicable, until implementation of the plan and the employee begins his vocational rehabilitation program.
(E) All matters regarding rehabilitation plans or programs shall be initially submitted to the Director except in those cases where the question of need for vocational rehabilitation first arises during the course of a hearing or hearings on other issues.
(F) If there is a dispute regarding the vocational rehabilitation plan, the disputing party shall request a hearing by filing an application for hearing at the Office of Administrative Courts.
(G) If the qualified worker does not choose to enroll in a vocational rehabilitation program, nothing in these rules and regulations shall require the qualified worker to do so.
15-5 MODIFICATION, SUSPENSION OR TERMINATION OF THE VOCATIONAL REHABILITATION PLAN OR VOCATIONAL EVALUATION
(A) If a vocational evaluation or an approved vocational plan is modified, terminated or suspended for any reason, and the parties are in agreement, the Director shall be notified. Plan modifications shall be submitted to the Director for approval on the prescribed form for vocational plans.
(B) If there is a dispute regarding the progress of a vocational evaluation or vocational rehabilitation plan, the disputing party shall request a hearing by filing an application for hearing at the Office of Administrative Courts.
All vocational rehabilitation forms and reports based upon an injury occurring on or prior to July 2, 1987 at 4:16 P.M. shall be filed with the Division and all parties copied.
15-7 QUALIFIED REHABILITATION VENDOR
(A) A vendor will be considered qualified by the Director if the vendor has the services of a consultant who had previously registered with the Division when the registration program existed or can demonstrate one of the following credentials:
(1) The individual is a Certified Rehabilitation Counselor under the guidelines of the Commission on Rehabilitation Counselor Certification or can demonstrate equivalent credentials.
(2) The individual has a Master's degree in Vocational Rehabilitation, Guidance and Counseling, Psychology, or in a related field or can demonstrate equivalent work experience on a year for year basis for formal education. The individual must also have one (1) year of experience as a practitioner in the field of vocational rehabilitation.
(3) The individual has a Bachelor's degree in Vocational Rehabilitation, Guidance and Counseling, Psychology, or a related field or can demonstrate equivalent work experience on a year for year basis for formal education. The individual must also have two (2) years experience as a practitioner in the field of vocational rehabilitation.
(B) If a dispute occurs concerning a counselor’s credentials, the counselor shall submit to the Director a resume, transcripts, diploma and any other requested documentation. The Director will determine whether the counselor is qualified.
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, 2008. 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 health care provider selected by the injured worker when the injured worker has the right to select a provider;
(4) A health care 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) Day -- for the purpose of Rule 16, day is defined as a calendar day unless otherwise noted.
(J) Hospital – as identified and licensed by the Colorado Department of Public Health and Environment.
(K) Long-Term Care Facility – as identified and Medicare certified by the Colorado Department of Public Health and Environment
(L) Medical Fee Schedule -- Division's Rule 18, its Exhibits, and the documents incorporated by reference in that rule.
(M) Medical Treatment Guidelines -- the medical treatment guidelines as incorporated into Rule 17, "Medical Treatment Guidelines."
(N) Payer -- an insurer, employer, or their designated agent(s) who is responsible for payment of medical expenses.
(O) Private Psychiatric Facilities – Licensed as a psychiatric hospital by the Colorado Department of Public Health and Environment.
(P) Provider -- a person or entity providing authorized healthcare service, whether involving treatment or not, to a worker in connection with work-related injury or occupational disease.
(Q) Rehabilitation Facilities – licensed as a rehabilitation hospital by the Colorado Department of Public Health and Environment.
(R) Rural Health Facility – as identified and Medicare certified by the Colorado Department of Public Health and Environment.
(S) State Psychiatric Hospitals and State Mental Health Institutions – licensed as a psychiatric facility and operated by the state.
(T) “Supply et al.” -- any single supply, durable medical equipment (DME), orthotic, prosthesis, biologic, or single drug dose, for which the billed amount exceeds $500.00 and all implants.
(U) Veterans’ Administration Medical Facilities – all medical facilities overseen by the Federal Veterans’ Administration.
16-3 REQUIRED USE OF THE MEDICAL TREATMENT GUIDELINES
16-4 REQUIRED USE OF THE MEDICAL FEE SCHEDULE
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; and
(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) Audiologist (AU.D., CCC-A) – certified by the American Speech/Language and Hearing Association or board certified in audiology from the American Board of Audiology;
(2) Acupuncturist (LAc) – licensed by the Office of Acupuncturist Registration, Colorado Department of Regulatory Agencies;
(3) Licensed Clinical Social Worker (LCSW) – licensed by the Colorado State Board of Social Work Examiners;
(4) Licensed Practical Nurse (LPN) – licensed by the Colorado State Board of Nursing;
(5) Licensed Professional Counselor (LPC) – licensed by the Colorado State Board of Professional Counselor Examiners;
(6) Marriage and Family Therapist (LMFT) – licensed by the Colorado State Board of Marriage and Family Therapist Examiners;
(7) Advanced Practice Nurse– licensed by the Colorado State Board of Nursing; Advanced Practice Nurse Registry;
(8) Occupational Therapist (OTR) – certified by the National Occupational Therapy Certification Board;
(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) Psychologist (PsyD, PhD, EdD) – licensed by the Colorado State Board of Psychologist Examiners;
(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) Registered Nurse (RN) – licensed by the Colorado State Board of Nursing;
(15) Respiratory Therapist (RTL) – certified by the National Board of Respiratory Care and licensed by the Colorado Department Of Regulatory Agencies;
(16) Speech Language Pathologist (CCC-SLP) – certified by the American Speech and Hearing Association; and
(17) Surgical Technologist (CST) – certified under direction of the Association of Surgical Technologists.
(2) 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.
(3) All non-physician providers must have a referral from an authorized treating physician. An authorized 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.
(4) 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) Upon request, healthcare providers must provide copies of license, registration, certification or evidence of healthcare training for billed services.
(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 provider; or
(2) In accordance with § 8-43-404 (5)(a), C.R.S.
(2) Injured Worker Referred
(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 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 in the fee schedule shall require prior authorization from the payer as set forth in Rule 16-9 Prior Authorization and Rule 16-10 Contest of a Request for Prior Authorization. Determination of the payment amount shall be made by the payer and reflect the complexity, time, level of training and expertise required to perform the service or procedure, but shall at no time exceed the amount billed. The methodology for determination of payment used by the payer shall be made available to the provider upon request. If the payer uses a usual and customary rate data base (UCR), the payer must specify the percentile used, the zip code used and the source of the data base. Rule 16-11, Payment of Medical Benefits, sets forth the procedures for contesting any portion of a bill. If there are no reasonable methods to determine a fee, the payer shall pay the billed charges.
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.
(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 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, 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.
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. Currently national provider identification (NPI) numbers are not required for workers’ compensation bills.
(D) Inaccurate Billing Forms or Codes
(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 for this workers’ compensation injury. 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 physician determines the injured worker has reached maximum medical improvement (MMI) for all injuries or diseases covered under this workers’ compensation claim. 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 is Level II Accredited, or
(2) Referral to a Level II Accredited physician designated to perform the permanent impairment rating when a rating is necessary and the authorized treating physician is not determining the permanent impairment rating.
(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.
(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.
(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.
(5) 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.)
(6) In accordance with Rule 16-11, the payer may contest payment for billed services until the provider completes and submits the required accompanying documentation as specified by Rule 16-7(E).
16-8 REQUIRED MEDICAL RECORD DOCUMENTATION
(A) A 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:
(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;
(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
(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.).
(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).
(B) All 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(E). The duty to respond to a provider's written request applies without regard for who transmitted the request.
(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.
(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 Division form titled "Physician's Report of Workers’ Compensation Injury” (WC164).
(E) To complete a prior authorization request, the provider shall concurrently explain 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.
(F) To contest a request for prior authorization, the payer is required to comply with the provisions outlined in Rule 16-10.
(G) The Division recommends payers confirm in writing, to providers and all parties, when a request for prior authorization is approved.
(H) If, after the service was provided, the payer agrees the service provided was reasonable and necessary, lack of prior authorization for payment does not warrant denial of payment.
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).
(B) If the payer is contesting a request for prior authorization for medical reasons, the payer shall, within seven (7) business days of the completed request:
(1) Have all the submitted documentation under Rule 16-9(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; and
(2) After reviewing all the submitted documentation, the reviewing provider may call the requesting provider to expedite communication and processing of prior authorization requests. However, the written contest or approval still needs to be completed within the specified seven (7) days under Rule 16-10(B).
(3) Furnish the provider and the parties with either a verbal or written approval, or a written contest that sets forth the following information:
(a) An explanation of the specific medical reasons for the contest, including the name and professional credentials of the person performing the medical review and a copy of the medical reviewer's opinion;
(b) The specific cite from the Division’s Medical Treatment Guidelines exhibits to Rule 17, when applicable;
(c) Identification of the information deemed most likely to influence the reconsideration of the contest when applicable; and
(d) A certificate of mailing to the provider and parties.
(C) Prior Authorization Disputes
(1) The requesting party or provider shall have seven (7) business days from the date of the certificate of mailing on the written contest to provide a written response to the payer, including a certificate of mailing. The response is not considered a "special report" when prepared by the provider of the requested service.
(2) The payer shall have seven (7) business days from the date of the certificate of mailing of the response to issue a final decision, including a certificate of mailing to the provider and parties.
(3) In the event of continued disagreement, the parties should follow dispute resolution and adjudication procedures available through the Division or Office of Administrative Courts..
(D) An urgent need for prior authorization of health care services, as recommended in writing by an authorized treating provider, shall be deemed good cause for an expedited hearing.
(E) Failure of the payer to timely comply in full with the requirements of Rule 16-10(A) or (B), shall be deemed authorization for payment of the requested treatment unless a hearing is requested within the time prescribed for responding as set forth in Rule 16-10(A) or (B).
(F) Unreasonable delay or denial of prior authorization, as determined by the Director or an administrative law judge, may subject the payer to penalties under the Workers’ Compensation Act.
16-11 PAYMENT OF MEDICAL BENEFITS
(A) Uncontested Payment For Billed Services
(1) 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.
(2) Unless contested in accordance with the provisions set forth in this section 16-11(B) and (C), 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. Date of receipt may be established by the payer’s date stamp or electronic acknowledgement date; otherwise, receipt is presumed to occur three (3) days after the date the bill was mailed to the payer’s correct address. The payer shall notify the billing provider that the injured worker shall not be balance-billed for services related to a compensable work-related injury or occupational disease.
(3) When the payer fails to make timely payment of uncontested billed services, the billing party shall first attempt to resolve payment with the payer. Where such attempt is unsuccessful, the billing party may request assistance from the Division’s Carrier Practices Unit.
(B) Contested Payment for Billed Services Based on Non-Medical Issues.
(1) Non-medical reasons for contesting payment may include, but are not limited to: 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; or the billed code does not appear to be accurate based upon the information submitted.
(2) IIf 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 insurer 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 by the payer, the payer shall, within thirty (30) days of receipt of the bill, submit to the billing party a written notification of contest.
The written non-medical notification of contest shall include the following information:
(a) Name of the injured worker;
(b) Date(s) of service(s) being contested;
(c) Payer’s accident number and/or Division’s workers’ compensation claim number;
(d) If applicable, acknowledgement of specific uncontested and paid items submitted on the same bill as contested services;
(e) Reference to the bill and each item of the bill being contested;
(f) Reason(s) for contesting the payment of any item. The explanation shall include the citing of appropriate statutes, rules and/or documents supporting the payer’s reasons for contesting payment; and
(g) Notice that the billing party may resubmit the bill or corrected bill within sixty (60) days.
(a) IIf 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)(3) 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) Contested Payment for Billed Services Based on Medical Issues:
(1) Have the bill and all supporting medical documentation under Rule 16-7(E) reviewed by a physician or other healthcare 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. However, the written contest or payment still needs to be completed within the specified thirty (30) days under Rule 16-11.
(2) Furnish the provider and the parties with a written contest setting forth the following information:
(a) An explanation of the specific 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;
(b) The specific cite from the Division’s Medical Treatment Guidelines exhibits to Rule 17, when applicable;
(c) Identification of the information deemed most likely to influence the reconsideration of the contest, when applicable; and
(d) A certificate of mailing to the provider and parties.
(1) The billing party shall have sixty (60) days to respond to the payer’s written notification of contest. The payer shall have thirty (30) days to respond to the provider’s response to the notification of contest. If the parties are unable to resolve a dispute relating to the Medical Fee Schedule, either party may contact the Medical Policy Unit (MPU) at the Division.
(2) 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.
(3) When seeking clarification or dispute resolution from the MPU, the requesting party must provide:
(a) A copy of the bill with the contested codes and dates of services in dispute;
(b) A copy of the payer’s explanation as to why the billed services are being contested; and
(c) 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.
(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.
(E) Retroactive Adjustments of Medical Bills
(1) All medical bills paid by a payer shall be considered final unless adjustments are made within twelve months after the date of the original explanation of benefits.
(2) A written notice shall be sent to a provider prior to any recovery of overpayments being undertaken by the payer. The written notice shall contain complete and specific explanation of the amounts being recovered, the specific reasons why these amounts are believed to be overpayments, and evidence that these payments were in fact made. The provider shall have at least 60 days to respond to the written notice before any recovery of the overpayment is started.
(F) 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 (Rule 18), 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.
G) 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
(A) The payer may conduct a review of billed and non-billed hospital or medical facility charges related to a specific workers’ compensation claim.
(B) The payer shall comply with the following procedures:
(1) Name of the injured worker;
(2) Claim and/or hospital or other medical facility I.D. number associated with the injured worker's bill;
(3) An outline of the items to be reviewed; and
(4) If applicable, the name, address and telephone number of any person who has been designated by the payer to conduct the review (reviewer).
(C) The hospital or other medical facility shall comply with the following procedures:
(1) Allow the review to begin within thirty (30) days of the payer's notification;
(5) Participate in the exit conference in an effort to resolve discrepancies.
(D) The reviewer shall comply with the following procedures:
(1) Obtain from the injured worker a signed information release form;
(2) Negotiate the starting date for the review;
(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-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) working days of the exit conference.
Rule 17 MEDICAL TREATMENT GUIDELINES
17-1. STATEMENT OF PURPOSE
(A) In an effort to comply with its legislative charge to assure appropriate medical care at a reasonable cost, the director of the Division has promulgated these "Medical Treatment Guidelines." This rule provides a system of evaluation and treatment guidelines for high cost or high frequency categories of occupational injury or disease to assure appropriate medical care at a reasonable cost.
(B) Pursuant to section 8-42-101(3)(a)(I), C.R.S., prior to July 1 of each year the Division Director shall review all medical treatment guidelines. Written comments which have been submitted by the public to the director or the Division's medical director will be considered during such reviews.
17-2. USE OF THE MEDICAL TREATMENT GUIDELINES
(A) All health care providers shall use the medical treatment guidelines adopted by the Division.
(B) Payers shall routinely and regularly review claims to ensure that care is consistent with the Division's medical treatment guidelines.
17-3. STANDARD TERMINOLOGY FOR THIS RULE
See Rule 16, Utilization Standards.
17-4. PROVIDER'S RESPONSIBILITIES
(A) The health care provider shall prepare a diagnosis-based treatment plan that includes specific treatment goals with expected time frames for completion in all cases where treatment falling within the purview of the medical treatment guidelines continues beyond 6 weeks.
(B) Within 14 days of request by any party, the provider shall supply a copy of the treatment plan both to the patient and to the payer. Should the patient otherwise require care that deviates from the medical treatment guidelines, the provider shall supply the patient and the payer with a written explanation of the medical necessity for such care.
17-5. PROCEDURE FOR QUESTIONING CARE
(A) In cases where treatment falls within the purview of a medical treatment guideline, prior authorization for payment is unnecessary unless the guideline specifies otherwise, or Rule 16-9 (A)(I)-(4) apply.
(B) If prior authorization is required by the Medical Treatment Guidelines or a provider requests prior authorization then the procedure for contesting a request for prior authorization for payment is under Rule 16-10.
(C) The treatment guidelines set forth care that is generally considered reasonable for most injured workers. However, the Division recognizes that reasonable medical practice may include deviations from these guidelines, as individual cases dictate. For cases in which the provider requests care outside the guidelines the provider should follow the procedure for prior authorization in Rule 16-9.
(2) If the payer questions whether treatment is consistent with the medical treatment guidelines then the procedure for contesting payment of a billed service is covered under Rule 16-11 (B) and (C)
17-6. FAILURE TO COMPLY
See Rule 1, General Definitions and General Provisions
17-7. EXHIBITS TO RULE 17
(A) Exhibit 1 – Low Back Pain Medical Treatment Guidelines
(B) Exhibit 2 –Carpal Tunnel Syndrome Medical Treatment Guidelines
(C) Exhibit 3 - Thoracic Outlet Syndrome Medical Treatment Guidelines
(D) Exhibit 4 – Shoulder Injury Medical Treatment Guidelines
(E) Exhibit 5 – Cumulative Trauma Disorder Medical Treatment Guidelines
(F) Exhibit 6 – Lower Extremity Medical Treatment Guidelines
(G) Exhibit 7 –Complex Regional Pain Syndrome/Reflex Sympathetic Dystrophy Medical Treatment Guidelines
(H) Exhibit 8 – Cervical Spine Injury Medical Treatment Guidelines
(I) Exhibit 9 – Chronic Pain Disorder Medical Treatment Guidelines
(J) Exhibit 10 – Traumatic Brain Injury Medical Treatment Guidelines
18-1 STATEMENT OF PURPOSE
Pursuant to § 8-42-101(3)(a)(I) C.R.S. and Section 8-47-107, C.R.S., the Director promulgates this medical fee schedule to review and establish maximum allowable fees for health care services falling within the purview of the Act. The Director adopts and hereby incorporates by reference as modified herein the 2007 edition of the Relative Values for Physicians (RVP©), developed by Relative Value Studies, Inc., published by Ingenixâ St. Anthony Publishing, and Medicare Severity Diagnosis Related Groups (MS-DRGs) Definitions Manual, Version 25.0 (DRGs Definitions Manual) developed and published by 3M Health Information Systems using MS-DRGs effective after October 1, 2007. The incorporation is limited to the specific editions named and does not include later revisions or additions. For information about inspecting or obtaining copies of the incorporated materials, contact the Medical Fee Schedule Administrator, 633 17th Street, Suite 400, Denver, Colorado 80202-3660. These materials may be examined at any state publications depository library. All guidelines and instructions are adopted as set forth in the RVP© or MS-DRGs: Definitions Manual, unless otherwise specified in this rule.
This rule applies to all services rendered on or after January 1, 2008. All
other bills shall be reimbursed in accordance with the fee schedule in effect at
the time service was rendered.
18-2 STANDARD TERMINOLOGY FOR THIS RULE
(A) CPTâ - CPTâ 2007 Current Procedural Terminology, copyrighted and distributed by the American Medical Association (AMA).
(B) DoWC – Colorado Division of Workers’ Compensation created codes
(C) DRGs Definitions Manual – version 25.0 incorporated by reference in Rule 18-1.
(D) RVP© – the 2007 edition incorporated by reference in Rule 18-1.
(E) For other terms, see Rule 16-2, Utilization Standards.
18-3 HOW TO OBTAIN COPIES
All users are responsible for the timely purchase and use of Rule 18 and its supporting documentation as referenced herein. The Division shall make available for public review and inspection copies of all materials incorporated by reference in Rule 18. Copies of the RVP© may be purchased from Ingenixâ St. Anthony Publishing, the MS-DRGs Definitions Manual may be purchased from 3M Health Information Systems, and the Colorado Workers' Compensation Rules of Procedures with Treatment Guidelines, 7 CCR 1101-3, may be purchased from LexisNexis Matthew Bender & Co., Inc., Albany, NY. Interpretive Bulletins and unofficial copies of all rules, including Rule 18, are available on the Colorado Department of Labor and Employment web site at www.coworkforce.com/DWC/ . An official copy of the rules is available on the Secretary of State’s webpage http://www.sos.state.co.us/CCR/Welcom.do .
The following CFs shall be used to determine the maximum allowed fee. The maximum fee is determined by multiplying the following section CFs by the established relative value unit(s) (RVU) found in the corresponding RVP© sections:
RVP© SECTION CF
Anesthesia $48.89/RVU
Surgery $90.97/RVU
Surgery X Procedures $37.69/RVU
(see Rule 18-5(D)(1)( d))
Radiology $17.26/RVU
Pathology $12.99/RVU
Medicine $ 7.56/RVU
Physical Medicine $ 5.57/RVU
Physical Medicine and Rehabilitation
Medical Nutrition Therapy and
Acupuncture
Evaluation & Management (E&M) $ 8.47/RVU
18-5 INSTRUCTIONS AND/OR MODIFICATIONS TO THE RVP©
(A) Maximum allowance for all providers under Rule 16-5 is 100% of the RVP© value or as defined in this Rule 18.
(B) Interim relative value procedures (marked by an “I” in the left-hand margin of the RVP©) are accepted as a basis of payment for services; however deleted CPT® codes (marked by an “M” in the RVP©) are not, unless otherwise advised by this rule. The CPT® 2007 may be referenced for further clarification of descriptions and billing, but if conflicts arise between the RVP© and the CPT® 2007, the RVP© should control.
(C) Temporary codes listed in the RVP© may be used for billing with agreement of the payer as to reimbursement. Payment shall be in compliance with Rule 16-6(B).
(D) Surgery/Anesthesia
(1) Anesthesia Section:
(a) All anesthesia base values shall be established by the use of the codes as set forth in the RVP©, Anesthesia Section. Anesthesia services are only reimbursable if the anesthesia is administered by a physician or Certified Registered Nurse Anesthetist (CRNA) who remains in constant attendance during the procedure for the sole purpose of rendering anesthesia.
When anesthesia is administered by a CRNA:
(1) Not under the medical direction of an anesthesiologist, reimbursement shall be 90% of the maximum anesthesia value,
(2) Under the medical direction of an anesthesiologist, reimbursement shall be 50% of the maximum anesthesia value. The other 50% is payable to the anesthesiologist providing the medical direction to the CRNA,
(3) Medical direction for administering the anesthesia includes performing the following activities:
• Performs a pre-anesthesia examination and evaluation,
• Prescribes the anesthesia plan,
• Personally participates in the most dem