803 KAR 25:096. Selection of physicians, treatment plans and statements for medical services

Link to law: http://www.lrc.ky.gov/kar/803/025/096.htm
Published: 2015

      803 KAR 25:096. Selection of physicians,

treatment plans and statements for medical services.

 

      RELATES TO: KRS Chapter 342

      STATUTORY AUTHORITY: KRS 342.020,

342.035, 342.260, 342.320, 342.735

      NECESSITY, FUNCTION, AND CONFORMITY: KRS

342.260 requires the Executive Director of the Office of Workers' Claims to promulgate

administrative regulations necessary to carry on the work of the office under

KRS Chapter 342. KRS 342.735 requires the executive director to promulgate

administrative regulations to expedite the payment of medical expense benefits.

This administrative regulation regulates the selection of physicians and

provides for treatment plans under KRS Chapter 342 in order to assure high

quality medical care at a reasonable cost.

 

      Section 1. Definitions. (1)

"Designated physician" means the physician selected by the employee

for treatment pursuant to KRS 342.020(5).

      (2) "Emergency care" means:

      (a) Those medical services required for

the immediate diagnosis or treatment of a medical condition that if not

immediately diagnosed or treated could lead to a serious physical or mental

disability or death; or

      (b) Medical services which are

immediately necessary to alleviate severe pain.

      (3) "Long-term medical care"

means:

      (a) Medical treatment or medical

rehabilitation that is reasonably projected to require a regimen of medical

care for a period extending beyond ninety (90) days;

      (b) Medical treatment that continues for

a period of more than ninety (90) days; or

      (c) Medical treatment including the recommendation

that the employee not engage in the performance of the employee's usual work

for a period of more than sixty (60) days.

      (4) "Physician" is defined in

KRS 342.0011(32).

      (5) "Statement for services"

means:

      (a) For a nonpharmaceutical bill, a completed

Form HCFA 1500, or for a hospital, a completed Form UB-92, with an attached

copy of legible treatment notes, hospital admission and discharge summary, or

other supporting documentation for the billed medical treatment, procedure, or

hospitalization; and

      (b) For a pharmaceutical bill, a bill

containing the identity of the prescribed medication, the number of units

prescribed, the date of the prescription, and the name of the prescribing

physician.

      (6) "Treatment plan" means a

written plan that:

      (a) May consist of copies of charts,

consultation reports or other written documents maintained by the employee's

designated physician discussing symptoms, clinical findings, results of

diagnostic studies, diagnosis, prognosis, and the objectives, modalities,

frequency, and duration of treatment;

      (b) Shall include, as appropriate,

details of the course of ongoing and recommended treatment and the projected

results; and

      (c) May be amended, supplemented or

changed as conditions warrant.

 

      Section 2. Employer's Obligation to

Supply Kentucky Workers' Compensation Designation and Medical Release Card

(Form 113). Within ten (10) days following receipt of notice of a work injury

or occupational disease causing lost work time or necessitating continuing

medical treatment, the medical payment obligor shall mail a Form 113 to the employee,

including a self-addressed, postage prepaid envelope for returning the Form

113. Failure by the medical payment obligor to timely mail the form shall waive

an objection to treatment by other than a designated physician prior to receipt

by the employee of the form.

 

      Section 3. Employee Selection of

Physician. (1) Except for emergency care, treatment for a work-related injury

or occupational disease shall be rendered under the coordination of a single

physician selected by the employee. The employee shall give notice to the

medical payment obligor of the identity of the designated physician by

tendering the completed Form 113, including a written acceptance by the designated

physician, within ten (10) days after treatment is commenced by that physician.

      (2) Within ten (10) days following

receipt of a Form 113 designating a treating physician, the medical payment

obligor shall tender a card to the employee, which shall be presented to a medical

provider each time that a medical service is sought in connection with the

work-related injury or occupational disease.

      (3) The card shall serve as notice to a

medical provider of the identity of the designated physician, who shall have

the sole authority to make a referral to a treatment facility or to a

specialist.

      (a) The card shall bear the legend

"First Designated Physician-Workers' Compensation" and shall further

contain the following information:

      1. Name and telephone number of the first

designated physician;

      2. Name, Social Security number, date of

birth, and date of work injury or occupational disease and last exposure of the

employee; and

      3. Name and telephone number of the

medical payment obligor.

      (b) The reverse side of the first designated

physician card shall contain:

      1. A notice that treatment shall be

performed by or on referral from the first designated physician; and

      2. Shall further contain space for the

identification and notification of a change of designated physician.

      (4) Failure by the medical payment

obligor to timely mail the "First Designated Physician" card shall

waive an objection to treatment by other than a designated physician prior to

receipt by the employee of the card.

      (5) The unreasonable failure of an employee

to comply with the requirements of this section may suspend all benefits

payable under KRS Chapter 342 until compliance by the employee and receipt of

the Form 113 by the medical payment obligor has occurred.

 

      Section 4. Change of Designated Physician.

(1) Following initial selection of a designated physician, the employee may

change designated physicians once without authorization of the employer or its

medical payment obligor. Referral by a designated physician to a specialist

shall not constitute a change of designated physician unless the latter

physician is specifically selected by the employee as the second designated

physician.

      (2) Within ten (10) days of a decision to

change the designated physician, the employee shall complete the back of the

first designated physician card and return the card with the name of the second

designated physician, including a written acceptance by the second designated

physician, to the medical payment obligor, which shall issue a second card

within ten (10) days.

      (3) The card shall bear the legend

"Second Designated Physician-Workers' Compensation" and shall further

contain the information required on the first designated physician card. The

reverse side of the card shall contain a notice that:

      (a) Treatment shall be performed by or on

referral from the second designated physician; and

      (b) A further change of designated

physician shall require the written consent of the employer, its medical

payment obligor, arbitrator, or the administrative law judge.

      (4) Failure by the medical payment

obligor to timely mail the "Second Designated Physician" card shall

waive an objection to treatment by other than a designated physician prior to

receipt by the employee of the card.

      (5) If an employee's two (2) choices of

designated physician have been exhausted, he shall not, except as required by

medical emergency, make an additional selection of a physician without the

written consent of the employer, its medical payment obligor, arbitrator, or

the administrative law judge. This consent shall not be unreasonably withheld.

      (6) If the employer provides medical

services through a managed health care system, it may establish alternate

methods for provider selection within the managed health care plan.

 

      Section 5. Treatment Plan. (1) A

treatment plan shall be prepared if:

      (a) Long-term medical care is required as

a result of a work-related injury or occupational disease;

      (b) The employee has received treatment

with passive modalities, including electronic stimulation, heat or cold packs,

massage, ultrasound, diathermy, whirlpool, or similar procedures for a period

exceeding sixty (60) days. The treatment plan shall detail the need for the

passive treatment, the benefits, if any, derived from the treatment, the risks

attendant with termination of the treatment, and the projected period of future

treatment; or

      (c) An elective surgical procedure or

placement into a resident work hardening, pain management, or medical

rehabilitation program is recommended. The treatment plan shall set forth

specific and measurable performance goals for the employee through the surgery,

work hardening, or medical rehabilitation program.

      (2) The designated physician shall

provide a copy of the treatment plan to the medical payment obligor seven (7)

days in advance of an elective surgical procedure or placement into a resident

work hardening, pain management, or medical rehabilitation program. In all

other instances when a treatment plan is required, a copy of the treatment plan

shall be provided within fifteen (15) days following a request by the medical

payment obligor. An amendment, supplement, or change to a treatment plan shall

be furnished within fifteen (15) days following a request.

      (3) Preparation of a treatment plan shall

be a necessary part of the care to be rendered and shall be an integral part of

the fee authorized in the medical fee schedule for the underlying services. An

additional fee shall not be charged for the preparation of a treatment plan or

progress report, except for the reasonable cost of photocopying and mailing the

records.

 

      Section 6. Tender of Statement for

Services. If the medical services provider fails to submit a statement for

services as required by KRS 342.020(1) without reasonable grounds, the medical

bills shall not be compensable.

 

      Section 7. Written Denial of Statement

for Services Prior to the Resolution of Claim. (1) Prior to resolution of a

workers' compensation claim by opinion or order of an arbitrator or

administrative law judge, the medical payment obligor shall notify the medical

provider and employee of its denial of a specific statement for services, or

payment for future services from the same provider, in writing within thirty

(30) days following receipt of a completed statement for services.

      (2) A copy of the denial shall be mailed

to the employee, employer, and medical service provider.

      (3) The denial shall:

      (a) Include a statement of the reasons

for denial and a brief synopsis of available utilization review or medical bill

audit procedures with relevant telephone contact numbers; and

      (b) Be made for a good faith reason.

      (4) Upon receipt of a denial from a

medical payment obligor, a medical provider may tender a statement for services

to another potential payment source or to the patient.

 

      Section 8. Payment or Challenge to

Statement for Services Following Resolution of Claim. (1) Following resolution

of a claim by an opinion or order of an arbitrator or administrative law judge,

including an order approving settlement of a disputed claim, the medical payment

obligor shall tender payment or file a medical fee dispute with an appropriate

motion to reopen the claim, within thirty (30) days following receipt of a

completed statement for services.

      (2) The thirty (30) day period provided

in KRS 342.020(1) shall be tolled during a period in which:

      (a) The medical provider submitted an

incomplete statement for services. The payment obligor shall promptly notify

the medical provider of a deficient statement and shall request specific

documentation. The medical payment obligor shall tender payment or file a medical

fee dispute within thirty (30) days following receipt of the required documentation;

      (b) A medical provider fails to respond

to a reasonable information request from the employer or its medical payment

obligor pursuant to KRS 342.020(4);

      (c) The employee's designated physician

fails to provide a treatment plan if required by this administrative

regulation; or

      (d) The utilization review required by

803 KAR 25:190 is pending. The thirty (30) day period for filing a medical fee

dispute shall commence on the date of rendition of the final decision from the

utilization review. A medical fee dispute filed thereafter shall include a copy

of the final utilization review decision and the supporting medical opinions.

      (3) An obligation for payment or

challenge shall not arise if a statement for services clearly indicates that

the services were not performed for a work-related condition.

 

      Section 9. Payment Pursuant to Fee

Schedules. (1) If the statement for services contains charges in excess of

those provided in the applicable fee schedule established in 803 KAR 25:089,

803 KAR 25:091, and 803 KAR 25:092, the medical payment obligor shall make

payment in the scheduled amount and shall serve a written notice of denial

setting forth the reason for refusal to pay a greater amount.

      (2) Following receipt of a final medical

bill audit reconsideration decision pursuant to 803 KAR 25:190, the medical

provider shall file within thirty (30) days a medical fee dispute in accordance

with 803 KAR 25:012 to dispute the amount of payment.

 

      Section 10. Patient Billing. (1) A

medical provider may tender a statement for services to a patient once it has

received:

      (a) A written denial from the medical

payment obligor; or

      (b) An opinion by an arbitrator or

administrative law judge finding that the services were unrelated to a work

injury or occupational disease.

      (2) The medical provider shall not bill a

patient for services which have been found to be unreasonable or unnecessary by

an arbitrator or administrative law judge, if the medical provider has been

joined as a party to a workers' compensation claim or to a medical fee dispute

and has had an opportunity to present contrary evidence.

      (3) The medical provider shall not bill a

patient for services which have been denied by the payment obligor for failure

to submit bills following treatment within forty-five (45) days as required by

KRS 342.020 and Section 6 of this administrative regulation.

 

      Section 11. Request for Payment for

Services Provided or Expenses Incurred to Secure Medical Treatment. (1) If an

individual who is not a physician or medical provider provides compensable

services for the cure or relief of a work injury or occupational disease,

including home nursing services, the individual shall submit a fully completed

Form 114 to the employer or medical payment obligor within sixty (60) days of

the date the service is initiated and every sixty (60) days thereafter, if appropriate,

for so long as the services are rendered.

      (2) Expenses incurred by an employee for

access to compensable medical treatment for a work injury or occupational

disease, including reasonable travel expenses, out-of-pocket payment for

prescription medication, and similar items shall be submitted to the employer

or its medical payment obligor within sixty (60) days of incurring of the expense.

A request for payment shall be made on a Form 114.

      (3) Failure to timely submit the Form

114, without reasonable grounds, may result in a finding that the expenses are

not compensable.

 

      Section 12. Incorporation by Reference.

(1) The following material is incorporated by reference:

      (a) Form 113, "Notice of Designated

Physician", (August 15, 1996 Edition), Office of Workers' Claims; and

      (b) Form 114, "Request for Payment

for Services or Reimbursement for Compensable Expenses", (August 15, 1996

Edition), Office of Workers' Claims.

      (2) This material may be inspected,

copied, or obtained at the Office of Workers' Claims, Monday through Friday, 9

a.m. to 4 p.m., at the following locations:

      (a) Prevention Park, 657 Chamberlin Avenue,

Frankfort, Kentucky 40601;

      (b) 410 West Chestnut Street, Louisville, Kentucky 40202;

      (c) 220B North 8th Street, Paducah,

Kentucky 42001; or

      (d) 107 Coal Hollow Road, Pikeville, Kentucky 41501. (19 Ky.R. 1498; Am. 1806; 2043; 2246; eff. 3-9-93; 23 Ky.R.

1455; 2177; 2485; eff. 12-13-96; 24 Ky.R. 942; eff. 12-15-97; 2166; 2681; eff.

6-15-98; TAm eff. 8-9-2007.)
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