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"
(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
(5) "Statement for services"
(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
(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
(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
(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
(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
2. Name, Social Security number, date of
birth, and date of work injury or occupational disease and last exposure of the
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
(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
(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
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
(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
(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
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.)