Current through Register Vol. 47, No. 5, March 10, 2024
17-1.
STATEMENT OF PURPOSE
The Director adopts the Medical Treatment Guidelines pursuant
to §
8-42-101 (3.5)(a)(II). The purpose
of these Guidelines is to comply with §
8-40-102(1) and
assure the quick and efficient delivery of disability and medical benefits to
injured workers at a reasonable cost to employers, without the necessity of any
litigation.
17-2. USE OF
THE MEDICAL TREATMENT GUIDELINES
(A) All
health care providers shall use the Medical Treatment Guidelines promulgated by
the Director, as required by §
8-42-101(3)(B).
(B) Payers shall routinely and regularly
review claims to ensure that care is consistent with the Division's Medical
Treatment Guidelines.
17-3. 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.
17-4.
PROCEDURE FOR QUESTIONING CARE
(A) The Medical
Treatment Guidelines set forth reasonable medical care for high cost or high
frequency categories of occupational injury or disease. However, the Division
recognizes reasonable medical care may include deviations from the Guidelines
in individual cases.
The provider shall request Prior Authorization if the
proposed treatment falls outside the Medical Treatment Guidelines or if the
Guidelines or Division Rules require Prior Authorization for a proposed
treatment. The provider may submit a Notification to Treat to
receive a guarantee of payment.
(B) Rule 16 governs the contest of a request
for Prior Authorization or a claim for payment.
17-5. EXHIBITS TO RULE 17
(A) Exhibit 1 - Low Back Pain
(B) Exhibit 2A - Mild Traumatic Brain
Injury
(C) Exhibit 2B -
Moderate/Severe Traumatic Brain Injury
(D) Exhibit 3 - Thoracic Outlet
Syndrome
(E) Exhibit 4 - Shoulder
Injury
(F) Exhibit 5 - Cumulative
Trauma Conditions
(G) Exhibit 6 -
Lower Extremity
(H) Exhibit 7 -
Complex Regional Pain Syndrome / Reflex Sympathetic Dystrophy
(I) Exhibit 8 - Cervical Spine
Injury
(J) Exhibit 9 - Chronic Pain
Disorder
