Current through September 18, 2024
Authority: IC
22-3-1-3
Affected: IC
22-3-3-5
Sec. 32.
The board, under IC
22-3-1-3,
and in order to regulate proceedings under IC
22-3-3-5,
adopts the following:
(1) The
following definitions shall apply:
(A) "CMS"
refers to Centers for Medicare and Medicaid Services, an agency of the U.S.
Department of Health and Human Services.
(B) "CPT" refers to the current procedural
terminology manual published annually by the American Medical
Association.
(C) "Payer" means an
agent, a designee, an employee, an assignee, or an independent contractor of
the employer including a billing review service utilized by the payer for
services performed under the act.
(D) "Written communication" means the written
statement made by a payer to a health care provider, in response to a claim for
payment submitted to the payer by the provider, wherein the payer notifies the
provider of the payer's determination of the employer's pecuniary liability for
the medical treatment, services, and supplies that comprised the provider's
claim for payment.
(2)
Payment of medical benefits shall be made as follows:
(A) Where the compensability of billed
services is not contested, payment for billed services shall be as follows:
(i) Providers shall submit bills for services
rendered within one hundred twenty (120) days of the date of service. Bills
submitted by providers for payment shall state the provider's actual charges
for the treatment rendered. A provider's statement of actual charges is not to
be construed as a request for payment in excess of the medical fee cap or
schedule. The billing statement must be in detailed line item form. The payer
to whom the bill is submitted shall calculate the proper amount of the payment
for the treatment rendered.
(ii)
Unless contested in accordance with the provisions set forth in this section,
all bills submitted by a provider are due and payable in accordance with IC
22-3-3-5
within ninety (90) 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. Payer may request additional
documentation to support medical bills submitted for payment by the provider,
as long as the additional documentation is relevant to the treatment for which
payment is sought. If a payer requests additional information or records from a
provider, the ninety (90) day period shall be tolled until the documentation is
received by payer.
(iii) The payer
shall supply a written explanation of review (EOR) to the provider describing
the calculation of payment of medical bills submitted by the provider. If
payment is based on changes to a provider's codes, the EOR shall specifically
state the justification for changing the original codes. If payment of a bill
is denied entirely, the payer shall provide a written, detailed explanation for
the denial of each covered item.
(B) 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 of
the appropriate amount due under the act.
(C) The payer may only make changes to a
provider's billing codes consistent with American Medical Association (AMA)
guidelines and definitions in CPT coding instructions, Medicare guidelines, the
act, and the Indiana Administrative Code.
(3) Medical bill disputes shall be addressed
as follows:
(A) When the payer fails to make
timely payment of uncontested billed services, the provider shall first attempt
to resolve payment with the payer or the medical review service, or both, by
any means set out in a relevant contract between the parties and those steps
set out on the board's website. Where such attempts are unsuccessful, the
billing party may request assistance from the board by first contacting the
board's medical claims reviewer and thereafter filing an application for
adjustment of claim for provider fee (application) if necessary.
(B) In all cases where a billed service is
contested by the payer, the payer shall, within ninety (90) days of receipt of
the bill, submit to the provider a written notification of contest setting out
the reason for denial.
(C) The
written notification of contest shall include the following information:
(i) The name of the injured worker.
(ii) The date or dates of the service or
services being contested.
(iii) The
payer's accident number or board's claim number, or both, if
applicable.
(iv) If applicable,
acknowledgement of specific uncontested and paid items submitted on the same
bill as contested services.
(v)
Reference to the bill and each item of the bill being contested.
(vi) The reason or reasons for contesting the
payment of any item. The explanation shall include the citing of appropriate
statutes, rules, and documents supporting the payer's reasons for contesting
payment.
(D) The provider
shall have sixty (60) days to respond to the payer's written or electronic
notification of contest. Thereafter, 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 correct payment of a
bill, an application may be filed after first contacting the board's medical
claims reviewer for assistance.
(4) The responsibilities of the provider
seeking adjudication of a claim for fees shall be as follows:
(A) Prior to filing an application, the
medical provider, the employer, its insurer, and/or its billing review service
must engage in a good faith attempt to negotiate an agreed payment.
(B) When seeking clarification or dispute
resolution from the board, the provider must provide the following upon the
request of the board:
(i) The fully completed
and signed provider fee application, which must identify the specific charges
for which provider seeks (additional) reimbursement beyond any reimbursement
allowed by the payer.
(ii) A copy
of CMS 1500 or UB04, whichever is applicable, or its replacement.
(iii) A copy of the first and final requests
for reimbursement by the provider to the payer. These requests must indicate
the following:
(AA) The name and address of
the person contacted.
(BB) The
employee's name, address, and date of service.
(CC) Any other information that will assist
the carrier or employer in identifying the claim.
(iv) All information submitted by the
provider to the payer including a detailed copy of the bill with the contested
codes and dates of service in dispute.
(v) A complete copy of the payer's
explanation as to why the billed services are being contested.
(vi) Documentation of provider and payer's
negotiation proceedings and independent attempts to settle the matter
(vii) A copy of all relevant medical record
documentation.
(viii) Applications
submitted without all of the necessary documentation will not be
filed.
(C) The provider
shall furnish a copy of the application and all attachments to the employer,
its insurer, or the billing review service if designated by the employer or its
insurer.
(5) The payer's
responsibilities in the adjudication of a claim for medical fees shall be as
follows:
(A) Within thirty (30) days of the
filing of providers' application, the payer must submit to the board a written
response setting forth the reasons that (additional) reimbursement is not
required. Evidence rebutting the provider's demand shall accompany its
response, including the data relied on to adjust the bill, if
relevant.
(B) The payer shall
furnish the provider with copies of the evidence provided to the board in
response to the provider's application. Thereafter, within thirty (30) days of
the filing of the payer's response, the provider shall file with the board
rebuttal evidence, if any, it intends to use in support of its claim.
(6) Multiple procedures. When
performing more than one (1) surgical procedure in a single surgical setting,
multiple surgery guidelines (one hundred percent (100%) of the listed value for
the primary procedure and fifty percent (50%) of the listed value for
additional procedures) shall apply. The fifty percent (50%) reduction does not
apply to procedures that are identified in the applicable edition of the CPT as
"Add-on" or Modifier 51-exempt procedures.
(7) Fragmenting or unbundling of charges by
providers. A provider may not fragment or unbundle charges except as consistent
with AMA guidelines, CPT coding instructions, or Medicare rules and
regulations.
(8) Payment for
out-of-state medical treatment of the injured worker shall be made as follows:
(A) Out-of-state medical providers treating
injured employees pursuant to the Indiana act shall be reimbursed according to
the worker's compensation act of Indiana and these administrative provisions.
The filing of a first report of injury with the board shall be prima facie
proof of jurisdiction in Indiana.
(B) When an injured employee is treated
outside of Indiana, the applicable fee shall be that which would apply if the
care had been provided in this state, at a location with a similar population
and medical community as that of the location of care. If such comparison is
not possible or practicable, reimbursement shall be that which would apply in
the community defined as the geographic service area served by the Zip codes
with the first three (3) digits 462. Categorization of a hospital or facility
provider according to any Indiana standards shall also apply.
(9) Reimbursement for special
reports shall be as follows:
(A) Payment shall
be made for special reports (CPT code 99080) only if these reports are
specifically requested by the payer. Office notes and other documentation that
are necessary to support billed provider codes may not be considered special
reports.
(B) Payment for special
reports shall be at one hundred percent (100%) of the provider's usual and
customary charge.
(10)
Surgical assists. Assists in surgery will be reimbursed if indicated by the
relevant surgical specialty society, CMS, or Medicare guidelines as medically
necessary. The rate of reimbursement is indicated by attaching modifier 80, 81,
or 82 to surgical procedures. Reimbursement for procedures modified by 80 or 82
will be at twenty percent (20%) of the applicable fee schedule or rate for the
code presented. Reimbursement for procedures modified by 81 will be made at ten
percent (10%). Multiple and bilateral procedure rules apply.
(11) Utilization review. The board recognizes
the Utilization Review Accreditation Commission's (URAC) Workers' Compensation
Management 2008 guidelines to medical utilization practices, as well as the
Official Disability Guidelines (ODG) published by the Work Loss Data Institute
and the American College of Occupational and Environmental Medicine (ACOEM)
guidelines. Recommendations from these, and other, reputable sources may be
offered as one (1) form of evidence regarding appropriate medical care;
however, it will not be considered as conclusive evidence by the single hearing
member or the full board.
