Current through Register Vol. 46, No. 19, March 20, 2024
(1) The purpose
of this rule and rule
876-4.46 (17A,85,86) is to
establish the procedures for resolving a dispute under Iowa Code section
85.27
between a provider and a responsible party over the treatment rendered by a
provider to an injured worker. Utilization of these procedures by a responsible
party is not an admission of liability for any other proceeding. This rule is
effective October 7, 1992.
(2)
Definitions. The following definitions apply to this rule and rule
876-4.46 (17A,85,86).
"Dispute " means a disagreement between a
provider and responsible party over the necessity of service or reasonableness
of charges or both; a disagreement between a provider and a responsible party
over the necessity for or the reasonableness of charges for crutches,
artificial members and appliances; and includes only those situations where
liability or extent of liability is not an issue.
"Workers' compensation commissioner" means the
workers' compensation commissioner or the workers' compensation commissioner's
designee.
"Person" means individual, corporation,
government or governmental subdivision or agency, business trust, estate,
trust, partnership or association, or any other legal entity.
"Provider" means any person furnishing
surgical, medical, dental, osteopathic, chiropractic, podiatric, physical
rehabilitation, nursing, ambulance, hospital services and supplies, crutches,
artificial members and appliances.
"Responsible party" means the person who is
liable for payment of medical services provided pursuant to the Iowa workers'
compensation laws and includes an employer, an employer who has been relieved
from insurance pursuant to Iowa Code section
87.11,
and an insurance carrier which provides an employer workers' compensation
insurance.
(3) Informal
resolution of disputes.
a. The charges not in
controversy shall be paid to the provider prior to utilization of the
procedures outlined in this rule.
b. A responsible party who refuses to pay the
amount in controversy of a dispute shall give the provider written notice of
the dispute within 60 days of receiving a bill with proper supporting
documentation. The written notice shall specify:
(1) The name of the
patient-employee;
(2) The name of
the employer on the date of injury;
(3) The date of the treatment in
dispute;
(4) The amount charged for
the treatment, the amount of the charge the responsible party agrees to pay,
and the amount in dispute;
(5) The
reason for belief that the bill is excessive or unnecessary and documentation
relied upon to formulate the belief;
(6) The address to use in directing
correspondence to the responsible party regarding the dispute;
(7) The provider's right to utilize the
procedures specified in this rule and rule
876-4.46 (17A,85,86);
(8) The provisions of 10.3(3)"c,
" 10.3(3)"d, " and 876-subrule 4.46(2);
(9) The provider or the responsible party is
prohibited by Iowa Code section
85.27
from seeking payment from the injured worker when there is a dispute regarding
reasonableness of a fee.
c. If the provider agrees to accept the
amount of the charge the responsible party has paid, the provider shall notify
the responsible party.
d. If the
provider does not agree to accept the amount of the charge the responsible
party agrees to pay, the provider shall notify the responsible party in
writing. The provider and the responsible party shall submit the dispute to a
mutually agreed upon person for review. The person reviewing the dispute under
this rule will not be the workers' compensation commissioner. If the provider
and the responsible party cannot agree upon the person to make the review, they
shall, within 90 days of time the provider notified the responsible party of
the disagreement, each recommend to the workers' compensation commissioner one
person to do the review. The workers' compensation commissioner may choose the
person or persons recommended to make the review. A person other than the
persons recommended may be chosen at the discretion of the workers'
compensation commissioner. The selected person or persons shall review
information submitted by the provider and the responsible party and make a
determination.
e. The person making
the review shall make a determination of the amount that is reasonable and
necessary. The determination shall be made as soon as practicable and shall be
dated. It shall be in writing and specify the facts relied upon. The person
making the review may choose any amount to set the reasonableness of a charge.
If the person chosen to make the review does not make a determination within a
reasonable time, that person may be discharged without being paid.
f. Costs. The costs of the person making the
review shall be paid as mutually agreed by the provider and the responsible
party. In the event of no agreement the costs shall be paid by whomever chose
an amount further from the determination of the person reviewing the matter. If
the amount is equally close to both parties, the costs shall be shared equally.
However, if the workers' compensation commissioner selects the person or
persons to do the review, the costs shall be shared equally.
g. Nothing in this rule is intended to
prevent providers and responsible parties from developing other procedures to
informally resolve their disputes.
(4) See rule
876-4.46 (17A,85,86) for
contested case procedures.
(5) WCES
shall not be used for health service dispute matters.
This rule is intended to implement Iowa Code sections
17A.10,
17A.12,
85.27
and
86.8.
