PREVIOUS
11 CAR § 25-125. Medical cost containment program
11 CAR § 25-125. Medical cost containment program.
(a) General provisions.
(1) Scope.
(A) This section does all of the following:
(i)(a) Establishes procedures by which the employer shall furnish, or cause to be furnished, to an employee who receives a personal injury arising out of and in the course of employment, reasonable and necessary medical, surgical, and hospital services and medicines, or other attendance or treatment recognized by the laws of the state as legal, when needed.
(b) The employer shall also supply to the injured employee dental services, crutches, artificial limbs, eyes, teeth, eyeglasses, hearing apparatus, and other appliances necessary to cure, so far as reasonably and necessarily possible, and relieve from the effects of the injury;
(ii) Establishes schedules of maximum fees by a health facility or healthcare provider for such:
(a) Treatment or attendance;
(b) Service;
(c) Device;
(d) Apparatus; or
(e) Medicine;
(iii) Establishes procedures by which a healthcare provider shall be paid the lesser of the:
(a) Provider’s usual charge;
(b) Maximum fee established under this section; or
(c) MCO/PPO contracted price, where applicable;
(iv) Provides for:
(a) The identification of utilization of health care and health services above the usual range of utilization for such services, based on medically accepted standards; and
(b) Acquiring by a carrier and by the Medical Cost Containment Division (MCCD) of the necessary records, medical bills, and other information concerning any health care or health service under review;
(v) Establishes a system for the evaluation by a carrier of the appropriateness in terms of both the level of and the quality of health care and health services provided to injured employees, based upon medically accepted standards;
(vi) Authorizes carriers to withhold payment from or recover payment from, health facilities or healthcare providers which have:
(a) Made excessive charges; or
(b) Required unjustified and/or unnecessary:
(1) Treatment;
(2) Hospitalization; or
(3) Visits;
(vii) Provides for the review by the Workers’ Compensation Commission of the records and medical bills of any health facility or healthcare provider which has been determined not to be in compliance with this section or to be requiring unjustified and/or unnecessary:
(a) Treatment;
(b) Hospitalization; or
(c) Office visits;
(viii) Establishes that when a healthcare facility or healthcare provider provides health care or healthcare service that is not usually associated with, is longer in duration than, is more frequent than, or extends over a greater number of days than that health care or service usually does with the diagnosis or condition for which the patient is being treated, the healthcare provider may be required by the carrier to explain the necessity in writing;
(ix)(a) Provides for the implementation of the MCCD review and decision responsibility.
(b) This section and its definitions are not intended to supersede or modify:
(1) The workers’ compensation laws;
(2) The administrative rules of the commission; or
(3) Court decisions interpreting the laws or the commission’s administrative rules;
(x) Provides for the certification of carriers determined to be in compliance with the criteria and standards established by this section in their utilization review of services and charges by healthcare facilities and healthcare providers;
(xi) Establishes maximum fees for depositions/witnesses;
(xii) Establishes maximum fees for medical reports;
(xiii) Provides for uniformity of billing for provider services;
(xiv) Establishes the effective date for implementation of this section;
(xv) Adopts by reference as part of this section the medical fee schedule and any amendments to that fee schedule;
(xvi) Establishes procedures for balance billing;
(xvii) Establishes procedures for reporting of medical claims;
(xviii) Establishes procedures for obtaining medical services by out-of-state providers; and
(xix)(a) Establishes procedures for preauthorization of nonemergency hospitalizations, transfers between facilities, and outpatient services expected to exceed one thousand dollars ($1,000) in billed charges for a single date of service by a provider.
(b) See Arkansas Workers’ Compensation Commission Inpatient Hospital Fee Schedule Part III.
(B) An independent medical examination performed to evaluate legal liability of a case, or for purposes of litigation of a case, shall be exempt from this section.
(2) Procedure codes.
(A)(i) Services must be coded with valid procedure or supply codes of the Health Care Financing Administration Common Procedure Coding System (HCPCS).
(ii) Procedure codes used in this section were developed and copyrighted by the American Medical Association.
(B) The most current edition of the Current Procedural Terminology (CPT) should be used for this section.
(3) Procedures for which codes are not listed.
(A)(i) If a procedure is performed which is not listed in the Medicare Resource Based Relative Value Scale (RBRVS), the healthcare provider must use an appropriate CPT procedure code.
(ii) The provider must submit:
(a) An explanation, such as copies of:
(1) Operative reports;
(2) Consultation reports;
(3) Progress notes;
(4) Office notes; or
(5) Other applicable documentation; or
(b) A description of equipment or supply (when that is the charge).
(B)(i) The CPT contains procedure codes for unlisted procedures.
(ii) These codes should only be used when there is no procedure code which accurately describes the service rendered.
(iii) A special report is required as these services are reimbursed BR (by report).
(C) Reimbursement by the carrier for BR procedures should be based upon the carrier’s review of the submitted documentation, the recommendations from the carrier’s medical consultant, and the carrier’s review of the prevailing charges for similar services as identified by the carrier based on data which is representative of Arkansas charges.
(4) Modifier codes.
(A) Modifiers listed in the CPT shall be added to the procedure code when the service or procedure has been altered from the basic procedure described by the descriptor.
(B)(i) The use of modifiers does not imply or guarantee that a provider will receive reimbursement as billed.
(ii) Reimbursement for modified services or procedures must be:
(a) Based on documentation of reasonableness and necessity; and
(b) Determined on a case-by-case basis.
(C)(i) When Modifier 21, 22, or 25 is used, a report explaining the medical necessity of the situation must be submitted to the carrier.
(ii) It is not appropriate to use Modifier 21, 22, or 25 for routine billing.
(5) Total procedures billed separately.
(A)(i) Certain diagnostic procedures (neurologic testing, radiology and pathology procedures, etc.) may be performed by two (2) separate entities who also bill separately for the professional and technical components.
(ii) When this occurs, the total reimbursement must not exceed the maximum medical fee schedule allowable for the five-digit procedure code listed.
(B) When billing for the professional component only, Modifier 26 must be added to the appropriate five-digit procedure code.
(C) When billing for the technical component only, Modifier TC (technical component) must be added to the appropriate five-digit code.
(6) Definitions. As used in this section:
(A) “Act” means the Workers’ Compensation Law, Arkansas Code § 11-9-101 et seq.;
(B) “Adjust” means that a carrier or a carrier’s agent reduces a healthcare provider’s request for payment such as:
(i) Applies the commission maximum fee;
(ii) Applies an agreed-upon discount to the provider’s usual charge;
(iii) Adjusts to a reasonable amount when the maximum fee is by report;
(iv) Recodes a procedure; or
(v) Reduces payment as a result of utilization review;
(C) “Appropriate care” means health care that is suitable for a particular:
(i) Person;
(ii) Condition;
(iii) Occasion; or
(iv) Place;
(D) “Bill” means a request by a provider submitted to a carrier for payment for healthcare services provided in connection with a covered injury or illness;
(E) “Bill adjustment” means a reduction of a fee on a provider’s bill;
(F)(i) “BR (by report)” means that the procedure is not assigned a maximum fee and requires a written description.
(ii) The description shall be included on the bill or attached to the bill and shall include the following information, as appropriate:
(a) Copies of operative reports;
(b) Consultation reports;
(c) Progress notes;
(d) Office notes or other applicable documentation; and
(e) Description of equipment or supply (when that is the charge);
(G)(i) “Carrier” means any stock company, mutual company, or reciprocal or interinsurance exchange or self-insured employer authorized to write or carry on the business of workers’ compensation insurance in this state.
(ii) Whenever required by the context, the term “carrier” shall be deemed to include duly qualified self-insureds or self-insured groups;
(H) “Case” means a covered injury or illness occurring on a specific date and identified by the worker’s name and date of injury or illness;
(I) “Case record” means the complete healthcare record maintained by the carrier pertaining to a covered injury or illness occurring on a specific date, and includes:
(i) The circumstances or reasons for seeking health care;
(ii) The supporting facts and justification for initial and continual receipt of health care;
(iii) All bills filed by a healthcare service provider; and
(iv) Actions of the carrier which relate to the payment of bills filed in connection with a covered injury or illness;
(J) “Commission” means the Workers’ Compensation Commission;
(K) “Complete procedure” means a procedure containing a series of steps which are not to be billed separately;
(L)(i) “Consultant service” means, in regard to the health care of a covered injury and illness, an examination, evaluation, and opinion rendered by a specialist when requested by the authorized treating practitioner or by the employee, and which includes:
(a) A history;
(b) An examination;
(c) An evaluation of treatment; and
(d) A written report.
(ii) If the consulting practitioner assumes responsibility for the continuing care of the patient, subsequent service ceases to be a consultant service;
(M) “Covered injury or illness” means an injury or illness for which treatment is mandated;
(N) “Critical care” is defined in the most current CPT;
(O) “Day” means calendar day;
(P) “Diagnostic procedure” means a service which aids in determining the nature and cause of a disease or injury;
(Q) “Dispute” means a disagreement between a carrier or a carrier’s agent and a healthcare provider on the application of this section;
(R) “DRG (diagnosis related group)” means one (1) of the classifications of diagnoses in which patients demonstrate similar resource consumption and length-of-stay patterns;
(S) “Durable medical equipment” is equipment which:
(i) Can withstand repeated use;
(ii) Is primarily and customarily used to serve a medical purpose;
(iii) Generally is not useful to a person in the absence of illness or injury; and
(iv) Is appropriate for use in the home;
(T) “Established patient” is defined in the most current CPT;
(U) “Expendable medical supply” means a disposable article which is needed in quantity on a daily or monthly basis;
(V) “Focused review” means the evaluation of a specific healthcare service or provider to establish patterns of use and dollar expenditures;
(W) “Follow-up care” means the care which is related to the recovery from a specific procedure and which is considered part of the procedure’s maximum allowable payment, but does not include care for complications;
(X) “Follow-up visits” means the number of office visits following a surgical procedure which are included in the procedure’s maximum allowable payment, but does not include care for complications;
(Y) “Follow-up visits” means the number of office visits following a surgical procedure which are included in the procedure’s maximum allowable payment, but does not include care for complications;
(Z) “Healthcare organization” means a group of practitioners or individuals joined together to provide healthcare services and includes, but is not limited to:
(i) A freestanding surgical outpatient facility;
(ii) A health maintenance organization;
(iii) An industrial or other clinic;
(iv) An occupational healthcare center;
(v) A home health agency;
(vi) A visiting nurse association;
(vii) A laboratory;
(viii) A medical supply company; or
(ix) A community mental health center;
(AA) “Healthcare review” means the review of a healthcare case or bill, or both, by a carrier or the carrier’s agent;
(BB) “Inappropriate health care” means health care that is not suitable for a particular person, condition, occasion, or place;
(CC) “Incidental surgery” means a surgery:
(i) Performed through the same incision;
(ii) On the same day;
(iii) By the same doctor; and
(iv) Not related to the diagnosis;
(DD) “Independent medical examination” means an examination and evaluation conducted by a practitioner different from the practitioner providing care;
(EE) “Independent procedure” means a procedure which may be carried out by itself, separate, and apart from the total service that usually accompanies it;
(FF) “Inpatient services” means services rendered to a person who is formally admitted to a hospital or whose length of stay exceeds twenty-three (23) hours;
(GG) “Institutional services” means all nonphysician services rendered within the institution by an agent of the institution;
(HH) “Maximum allowable payment” means the maximum fee for a procedure established by this section or the provider’s usual and customary charge, whichever is less, except as otherwise might be specified;
(II) “Maximum fee” means the maximum allowable fee for a procedure established by this section;
(JJ) “Medical admission” means any hospital admission where the primary services rendered are not surgical, psychiatric, or rehabilitative in nature;
(KK) “Medical only case” means a case which does not involve lost work time;
(LL) “Medically accepted standard” means a measure which is set by a competent authority as the rule for evaluating quantity or quality of health care or healthcare services and which may be defined in relation to any of the following:
(i) Professional performance;
(ii) Professional credentials;
(iii) The actual or predicted effects of care; and
(iv) The range of variation from the norm;
(MM) “Medically appropriate care” means health care that is suitable for a particular:
(i) Person;
(ii) Condition;
(iii) Occasion; or
(iv) Place;
(NN) “Medical supply” means either a piece of durable medical equipment or an expendable medical supply;
(OO) “Modifier code” means a two-digit number used in conjunction with the procedure code to describe unusual circumstances which arise in the treatment of an injured or ill employee;
(PP) “New patient” means a patient who is new to the provider for a particular covered injury or illness and who needs to have medical and administrative records established;
(QQ) “Operative report” means the practitioner’s written description of the surgery and includes all of the following:
(i) A preoperative diagnosis;
(ii) A postoperative diagnosis;
(iii) A step-by-step description of the surgery;
(iv) An identification of problems which occurred during surgery; and
(v) The condition of the patient when leaving the operating room, the practitioner’s office, or the healthcare organization;
(RR) “Optometrist” means an individual licensed to practice optometry;
(SS) “Optometry” shall be defined according to Arkansas Code § 17-90-101;
(TT) “Orthotic equipment” means an orthopedic apparatus designed to support, align, prevent, correct deformities, or improve the function of a movable body part;
(UU) “Orthotist” means a person skilled in the construction and application of orthotic equipment;
(VV) “Outpatient service” means a service provided by the following, but not limited to, types of facilities:
(i) Physicians’ offices and clinics;
(ii) Hospital emergency rooms;
(iii) Hospital outpatient facilities;
(iv) Community mental health centers;
(v) Outpatient psychiatric hospitals;
(vi) Outpatient psychiatric units; and
(vii) Freestanding surgical outpatient facilities;
(WW)(i) “Package” means a surgical procedure that includes, but is not limited to, all of the following components:
(a) The operation itself;
(b) Local infiltration;
(c) Topical anesthesia when used; and
(d) The normal, uncomplicated follow-up care/visits.
(ii) This includes a standard postoperative period of thirty (30) days, except CPT-starred procedures;
(XX) “Pharmacy” means the place where the science, art, and practice of preparing, preserving, compounding, dispensing, and giving appropriate instruction in the use of drugs is practiced;
(YY) “Practitioner” means a person licensed, registered, or certified as:
(i) An audiologist;
(ii) A doctor of chiropractic;
(iii) A doctor of dental surgery;
(iv) A doctor of medicine;
(v) A doctor of osteopathy;
(vi) A doctor of podiatry;
(vii) A doctor of optometry;
(viii) A nurse;
(ix) A nurse anesthetist;
(x) A nurse practitioner;
(xi) An occupational therapist;
(xii) An orthotist;
(xiii) A pharmacist;
(xiv) A physical therapist;
(xv) A physician’s assistant;
(xvi) A prosthetist;
(xvii) A psychologist; or
(xviii) Any other person licensed, registered, or certified as a healthcare professional;
(ZZ) “Primary procedure” means the therapeutic procedure most closely related to the principle diagnosis;
(AAA) “Procedure” means a unit of health service;
(BBB) “Procedure code” means a five-digit numerical sequence or a sequence containing an alpha or alphas and followed by three (3) or four (4) digits, which identifies the service performed and billed;
(CCC)(i) “Properly submitted bill” means a request by a provider for payment of healthcare services submitted to a carrier on the appropriate forms which are completed pursuant to this section.
(ii) “Properly submitted bills” shall include appropriate documentation as required by this section;
(DDD) “Prosthesis” means an artificial substitute for a missing body part;
(EEE) “Prosthetist” means a person skilled in the construction and application of a prosthesis;
(FFF) “Provider” means a facility, healthcare organization, or a practitioner;
(GGG) “Reasonable amount” means a payment based upon the amount generally paid in the state for a particular procedure code using data available from but not limited to the provider, the carrier, or the Workers’ Compensation Commission;
(HHH) “Reject” means that a carrier or a carrier’s agent denies payment to a provider or denies a provider’s request for reconsideration;
(III) “Secondary procedure” means a surgical procedure which is:
(i) Performed to ameliorate conditions that are found to exist during the performance of a primary surgery; and
(ii) Considered an independent procedure that may not be performed as a part of the primary surgery or for the existing condition;
(JJJ) “Specialist” means a board-certified practitioner, board-eligible practitioner, or a practitioner otherwise considered an expert in a particular field of healthcare service by virtue of education, training, and experience generally accepted by practitioners in that particular field of healthcare service;
(KKK) “Specialist service” means, in regard to the health care of a covered injury and illness, the treatment by a specialist, when requested by the treating practitioner, carrier, or by the employee, and includes:
(i) A history;
(ii) An examination;
(iii) An evaluation of medical data;
(iv) Treatment; and
(v) A written report;
(LLL) “Stop-loss payment (SLP)” means an independent method of payment for an unusually costly or lengthy stay;
(MMM) “Stop-loss reimbursement factor (SLRF)” means a factor established by the Workers’ Compensation Commission to be used as a multiplier to establish a reimbursement amount when total hospital charges have exceeded specific stop-loss thresholds;
(NNN) “Stop-loss threshold (SLT)” means a threshold of charges established by the Workers’ Compensation Commission, beyond which reimbursement is calculated by multiplying the applicable stop-loss reimbursement factor times the total charges identifying that particular threshold;
(OOO) “Surgical admission” means any hospital admission where the primary services rendered are not medical, psychiatric, or rehabilitative in nature;
(PPP)(i) “Transfer between facilities” means to move or remove a patient from one facility to another for a purpose related to obtaining or continuing medical care.
(ii) It may or may not involve a change in the admittance status of the patient, i.e., patient transported from one facility to another to obtain specific care, diagnostic testing, or other medical services not available in the facility in which the patient has been admitted.
(iii) This includes costs related to transportation of patient to obtain medical care;
(QQQ) “Usual and customary charge” means a particular provider’s average charge for a procedure to all payment sources, and includes itemized charges previously billed separately which are included in the package for that procedure as defined by this section;
(RRR) “Wage loss” case means a case that involves the payment of wage loss compensation; and
(SSS) “Workers’ compensation standard per diem amount (SPDA)” means a standardized per diem amount established for the reimbursement for hospitals for services rendered.
(7) Information program regarding section.
(A) The Medical Cost Containment Division shall institute an ongoing information program regarding this section for providers, carriers, and employers.
(B) The program shall include, at a minimum, information sessions throughout the state, as well as the distribution of appropriate information materials.
(8) Independent medical examination to evaluate medical aspects of case.
(A)(i) An independent medical examination shall include a study of previous history and medical care information, diagnostic studies, diagnostic x-rays, and laboratory studies, as well as an examination and evaluation.
(ii) This service may be necessary in order to:
(a) Make a judgment regarding the current status of the injured or ill worker; or
(b) Determine the need for further health care.
(B)(i) An independent medical examination, performed to evaluate the medical aspects of a case, shall be billed using the independent medical examination procedure code 99199 (BR), and shall include the practitioner’s time only.
(ii) The office visit charge is included with the code 99199 and may not be billed separately.
(C) Any laboratory procedure, x-ray procedure, and any other test which is needed to establish the worker’s ability to return to work shall be identified by the appropriate procedure code established by this section.
(9) Payment.
(A)(i) Reimbursement for healthcare services shall be the lesser of the:
(a) Provider’s usual charge;
(b) Maximum fee calculated according to the Workers’ Compensation Commission Official Fee Schedule, and/or any amendments to that fee schedule; or
(c) MCO/PPO contracted price, where applicable.
(ii) A licensed provider shall receive no more than the maximum allowable payment, in accordance with this section, for appropriate healthcare services rendered to a person who is entitled to healthcare service.
(C)(i) The Medicare RBRVS is adopted by reference as part of this section.
(ii) The Medicare RBRVS is distributed by the Office of the Federal Register and is also available on the internet.
(D)(i) When extraordinary services resulting from severe head injuries, major burns, and severe neurologic injuries or any injury requiring an extended period of intensive care are required, a greater fee may be allowed up to one hundred fifty percent (150%) of the fee schedule.
(ii) Such cases should be billed with Modifier 21 or 22 (for CPT-coded procedures) and should contain a detailed written description of the extraordinary service rendered and the need therefor.
(E) Billing for provider services shall be submitted on the forms approved by the commission, UB-92 and HFCA-1500.
(F) A carrier shall not make a payment for a service unless all required review activities pertaining to that service are completed.
(G)(i) A carrier’s payment shall reflect any adjustments in the bill made through the carriers’ utilization review program.
(ii) A carrier must provide an explanation of medical benefits to a healthcare provider whenever the carrier’s reimbursement differs from the amount billed by the provider.
(iii) A provider shall not attempt to collect from the injured employee, employer, or carrier any amounts reduced by the carrier pursuant to this section.
(H)(i) A carrier shall date-stamp medical bills and reports upon receipt and shall pay an undisputed and properly submitted bill within thirty (30) days of receipt.
(ii) Any carrier not paying an undisputed and properly submitted bill within thirty (30) days of receipt shall be assessed a penalty of eighteen percent (18%), upon a determination by MCCD.
(I)(i) When a carrier disputes a bill or portion thereof, the carrier shall pay the undisputed portion of the bill within thirty (30) days of receipt of a properly submitted bill.
(ii) Any carrier not paying an undisputed portion of the bill within thirty (30) days of receipt can be assessed a penalty of eighteen percent (18%) on the undisputed portion of the bill, upon a determination by MCCD.
(J)(i) Any penalty for late payment will be assessed by the division after an administrative review has been conducted.
(ii) The penalty is payable to the medical provider.
(K)(i) Billings not submitted on the proper form may be returned to the provider for correction and resubmission.
(ii) If a carrier returns such billings, it must do so within twenty (20) days of receipt of the bill.
(iii) The number of days between the date the carrier returns the billing to the provider and the date the carrier receives the corrected billing shall not apply toward the thirty (30) days within which the carrier is required to make payment.
(10) Reimbursement for employee-paid services. Notwithstanding any other provision of this section, if an employee has personally paid for a healthcare service and at a later date a carrier is determined to be responsible for the payment, then the employee shall be fully reimbursed by the carrier.
(11) Recovery of payment.
(A)(i) Nothing in this section shall preclude the recovery of payment for services and bills which may later be found to have been medically paid at an amount which exceeds the maximum allowable payment.
(ii) This also includes payments reimbursed to an employee pursuant to subdivision (a)(10) above.
(B) A carrier may recover a payment to a provider, whether by an employee or a carrier, if the carrier requests the provider for the recovery of the payment, with a statement of reasons for the request, within one (1) year of the date of payment.
(C) Within thirty (30) days of receipt of the carrier’s request for recovery of the payment, the provider shall do either of the following:
(i) If in agreement with the request, refund the payment to the carrier; or
(ii) If not in agreement with the request, supply the carrier with a written detailed statement of the reasons for its disagreement, along with a refund of the portion, if any, of the payment that the provider agrees should be refunded.
(D)(i) If the carrier does not accept the reason for disagreement supplied by the provider, the carrier may file a request for administrative review within thirty (30) days of receipt of the provider’s statement of disagreement.
(ii) The request for review shall be filed with the Administrator of the Medical Cost Containment Division and the carrier shall supply a copy to the provider.
(E) If, within sixty (60) days of the carrier’s request for recovery of a payment, the carrier does not receive either a full refund of the payment or a statement of disagreement, then, at the option of the carrier, the carrier may do either or both of the following:
(i) File a request for administrative review, of which the carrier shall supply a copy to the provider; or
(ii) Reduce the payable amount on the provider’s subsequent bills (in the case in question or any other case) to the extent of the request for recovery of payment.
(F) If, within thirty (30) days of a final order of any decision of the commission a provider does not pay in full any refund ordered, the carrier may reduce the payable amount on the provider’s subsequent bills to the extent of the request for recovery of payment plus an additional eighteen percent (18%).
(12) Amounts in excess of fees. The provider shall not bill the employee, employer, or carrier for any amount for healthcare services provided for the treatment of a covered injury or illness when that amount exceeds the maximum allowable payment established by this section.
(13) Missed appointment.
(A) A provider shall not receive payment for a missed appointment unless the appointment was arranged by the carrier or the employer.
(B) If the carrier or employer fails to cancel the appointment not less than twenty-four (24) hours prior to the time of the appointment and the provider is unable to arrange for a substitute appointment for that time, the provider may bill the carrier for the missed appointment using procedure code 99199 with a maximum fee of BR.
(14) Medical report of initial visit and progress reports for other than inpatient hospital care.
(A) Except for inpatient hospital care, a provider shall furnish the carrier with a narrative medical report for the initial visit, all information pertinent to the covered injury or illness if requested at reasonable intervals, and a progress report for every sixty (60) days of continuous treatment for the same covered injury or illness.
(B) If the provider continues to treat an injured or ill employee for the same covered injury or illness at intervals which exceed sixty (60) days, then the provider shall provide a progress report following each treatment that is at intervals exceeding sixty (60) days.
(C) The narrative medical report of the initial visit and the progress report shall include all of the following information:
(i) Subjective complaints and objective findings, including interpretation of diagnostic tests;
(ii) For the narrative medical report of the initial visit, the history of the injury, and for the progress report or reports, significant history since the last submission of a progress report;
(iii) The diagnosis;
(iv) As of the date of the narrative medical report or progress report, the projected treatment plan, including the type, frequency, and estimated length of treatment;
(v) Physical limitations; and
(vi) Expected work restrictions and length of time if applicable.
(D)(i) Cost of the narrative medical reports required by subdivision (a)(14)(A) of this section shall be reimbursed at the following rates:
(a) Initial report, forty dollars ($40.00);
(b) Subsequent reports, eleven dollars ($11.00); and
(c) Final report, twenty-eight dollars ($28.00).
(ii) Under no circumstances may a provider bill for more than one (1) report per visit.
(iii) Initial reports should be billed using procedure code WC101, subsequent reports should be billed using procedure code WC102, and final reports should be billed using procedure code WC103.
(E) A medical provider may not charge any fee for completing a medical report form required by the commission.
(15) Additional reports. Nothing in this section shall preclude a carrier or an employee from requesting reports from a provider in addition to those specified in the preceding section.
(16) Deposition/witness fee limitation.
(A) Any provider who gives a deposition shall be allowed a witness fee.
(B) Procedure code 99075 must be used to bill for a deposition.
(C) Reimbursement for a deposition is limited to twenty-eight dollars ($28.00) per quarter hour, including preparation time.
(D) This limitation does not apply to an expert witness who has never provided direct professional services to a party or who has provided only direct professional services which were unrelated to the workers’ compensation case.
(17) Joint petition cases. See 11 CAR § 25-115.
(18) Out-of-state providers.
(A) All services and requests for change-of-physician to out-of-state providers must be made to providers who agree to abide by the commission medical fee schedule.
(B) Providers shall sign an agreement stating they shall comply with this section.
(C) Carriers/self-insured employers which are not contracted with a certified managed care organization shall be responsible for obtaining this agreement.
(19) Preauthorization.
(A) Preauthorization is required for all nonemergency hospitalizations, transfers between facilities, and outpatient services expected to exceed one thousand dollars ($1,000) in billed charges for a single date of service by a provider.
(B) A denial decision for payment for any type of healthcare services and/or treatment resulting from a utilization review, as opposed to a determination of whether such service or treatment is related to a compensable injury, shall only be made by an Arkansas certified private review agent.
(C) The Department of Health utilization review certification number is required upon request.
(D) See Arkansas Workers’ Compensation Hospital Inpatient Fee Schedule Part III for procedures for requesting preauthorization.
(E) Upon emergency admission, notice must be given to the carrier within twenty-four (24) hours or for the next business day.
(b) Process for resolving differences between carrier and provider regarding bill.
(1) Carrier’s dispute of a bill.
(A) When a carrier adjusts and/or disputes a bill or portion thereof, the carrier shall notify the provider:
(i) Within thirty (30) days of the receipt of the bill of the specific reasons for adjusting and/or disputing the bill or portion thereof; and
(ii) Of its right to provide additional information and to request reconsideration of the carrier’s action.
(B) If the provider sends a bill to a carrier and the carrier does not respond in thirty (30) days, and if a provider sends a second bill and receives no response within sixty (60) days from the date the provider supplied the first bill, the provider may then file a request for administrative review with the administrator, with a copy to the carrier.
(C)(i) The carrier shall notify the employer, employee, and the provider that this part prohibits a provider from billing an employee, employer, or carrier for any amount for healthcare services provided for the treatment of a covered work-related injury or illness when that amount:
(a) Is disputed by the carrier pursuant to its utilization review program; or
(b) Exceeds the maximum allowable payment established by the fee schedule.
(ii) The carrier shall request the employee to notify the carrier if the provider so bills the employee or employer.
(D)(i) The carrier shall notify the division when a provider attempts to balance bill or attempts to bill when a dispute exists between a carrier and a provider regarding services.
(ii) A desk audit shall be conducted by the division on all notices regarding balance billing.
(iii) The provider and carrier shall be notified of the results of the desk audit.
(iv) Providers found guilty of balance billing shall be counseled (first offense) and may be referred to the appropriate authority (second offense).
(v) Providers found guilty of balance billing may ask for a review of the decision before referral by the division to the appropriate authority.
(2) Provider’s request for reconsideration of bill.
(A) A provider may request reconsideration of its adjusted and/or disputed bill by a carrier within thirty (30) days of receipt of a notice of an adjusted and/or disputed bill or portion thereof.
(B) The provider’s request to the carrier for reconsideration of the adjusted and/or disputed bill shall include a statement in detail of the reasons for disagreement with the carrier’s adjustment and/or dispute of a bill or portion thereof.
(3) Carrier’s response to provider’s request for reconsideration of bill — Provider’s right to appeal.
(A)(i) Within thirty (30) days of receipt of a provider’s request for reconsideration, the carrier shall notify the provider of the actions taken and a detailed statement of the reasons.
(ii) The carrier’s notification shall include an explanation of the appeal process provided under this section.
(B) If a provider is in disagreement with the action taken by the carrier on its request for reconsideration, the provider may file a request for administrative review within thirty (30) days from the date of receipt of a carrier’s denial of the provider’s request for reconsideration, and the provider shall supply a copy to the carrier.
(C) If within sixty (60) days of the provider’s request for reconsideration, the provider does not receive payment for the adjusted and/or disputed bill or portion thereof, or a written detailed statement of the reasons for the actions taken by the carrier, then the provider may make application for administrative review.
(4) Disputes.
(A)(i) Unresolved disputes between a carrier and provider due to conflicting interpretation of this section and/or the official medical fee schedule may be appealed to, and resolved by, the administrator.
(ii) A request for administrative review may be submitted to:
Administrator of the Medical Cost Containment Division
Arkansas Workers’ Compensation Commission
P.O. Box 950
Little Rock, AR 72203-0950
(B) Valid requests for administrative review do not require a particular form but must be legible and contain copies of the following:
(i) Copies of the original and resubmitted bills in dispute which include:
(a) Dates of service;
(b) Procedure codes;
(c) Charges for services rendered and any payment received; and
(d) An explanation of unusual services or circumstances;
(ii) Copies of the specific reimbursement;
(iii) Supporting documentation and correspondence, if any;
(iv) Specific information regarding contact with the carriers;
(v) A verified or declared written medical report signed by the physician; and
(vi) A specific written request for administrative review.
(C) The party requesting administrative review must send a copy of the request and all documentation accompanying the request to the opposing party.
(c) Hearings.
(1) Administrative review procedure.
(A)(i) When the request for administrative review is received by the administrator and it is determined that the commission has jurisdiction over the cause of action, all parties shall be notified by certified mail return receipt requested.
(ii) All parties shall have thirty (30) days from the date of receipt of notification to submit further evidence, documentation, or clarifications to the administrator.
(iii) After thirty (30) days, a decision will be determined by the administrator and an order will be issued to the parties.
(iv) Prior to this determination, the administrator may request all parties to attend a hearing on the matter.
(v) The hearing shall be recorded verbatim.
(vi) Failure to appear at such hearing may result in dismissal of request for administrative review.
(B)(i) Any party feeling aggrieved by the order of the administrator shall have ten (10) days from the date of notification to request a rehearing.
(ii) A request for rehearing shall:
(a) Be in writing; and
(b) State the grounds upon which the moving party relies.
(iii) Upon a finding that the record is not complete or that error was made in the hearing process, the administrator may order a rehearing.
(iv) A rehearing shall follow the same procedure as subdivision (c)(1)(A) of this section, above.
(C)(i) Any party feeling aggrieved by the rehearing order of the administrator shall have ten (10) days from the date of notification to appeal the ruling to an administrative law judge of the commission.
(ii) Notice of appeal shall be filed with the Clerk of the Commission.
(iii) The notice of appeal shall contain the following:
(a) A copy of the administrative review order appeal form;
(b) Copies of all materials submitted to the administrator in the administrative review proceedings;
(c) A statement identifying each portion of the administrator’s order claimed to be in error; and
(d) An explanation of how each portion of the administrator’s order conflicts with the schedule of medical fees or this section.
(D)(i) The appealing party shall mail a copy of all materials which are filed in the appeal to each opposing party.
(ii) No response to the appeal of the administrator’s order is required.
(iii) A decision must be entered by the administrator before any appeal may be brought.
(iv) A judge of the commission may affirm the decision of the administrator, or reverse or modify said decision only if it is found to be contrary to the medical fee schedule and rules existing at the time the said medical care or treatment was provided.
(E) If any bill for services rendered under Arkansas Code § 11-9-508 by a provider of health care is not paid within thirty (30) days after it has been approved by the commission and returned to the responsible party by certified mail return receipt requested, there shall be added to such unpaid bill an amount equal to eighteen percent (18%) thereof, which shall be paid at the same time as, but in addition to, such medical bill unless such late payment is excused by the commission.
(2) Computation of time periods.
(A) In computing a period of time prescribed or allowed by this section, the day of the act, event, or default from which the designated period of time begins to run shall not be included.
(B) The last day on which a compliance therewith is required shall be included.
(C)(i) If the last day within which an act shall be performed or an appeal filed is a Saturday, Sunday, or a legal holiday:
(a) The day shall be excluded; and
(b) The period shall run until the end of the next day which is not a Saturday, Sunday, or legal holiday.
(ii) “Legal holiday” means those days designated as a holiday by the President of the United States or United States Congress or so designated by the laws of this state.
(3) Extension of time — Request — Waiver.
(A) A request for an extension of time for the filing of any document shall be filed with the administrator in advance of the day on which the document is due to be filed.
(B) This requirement may be waived for good cause shown.
(d) Utilization review.
(1) Scope.
(A) Requirements contained in this section shall pertain to utilization review activity as defined by Arkansas Code § 20-9-901 et seq., with respect to all bills (except repriced bills) submitted for payment by a provider for health care or health-related services furnished as a result of a covered injury or illness arising out of and in the course of employment.
(B) A private review agent who approves or denies payment or who recommends approval or denial of payment for hospital or medical services or whose review results in approval or denial of payment for hospital or medical services on a case-by-case basis, may not conduct utilization review in this state unless the State Board of Health has granted the private review agent a certificate.
(C) Merely repricing (matching CPT codes to the fee schedule) patient bills against the Arkansas Fee Schedule will not be required to certify with the board as a private review agent.
(D) Denying, recommending denial, or negotiating inpatient or outpatient bill payment or BRs requires certification by the board as a private review agent.
(2) Carrier’s utilization review program.
(A) The carrier shall have a utilization review program.
(B) Utilization review shall be conducted in a reasonable manner and in accordance with this section.
(C) Under the utilization review program, the carrier shall do all of the following:
(i) Perform ongoing utilization review of medical bills to identify overutilization of services and improper billing;
(ii)(a) Determine the accuracy of the procedure coding.
(b) If the carrier determines, based upon review of the bill and any related material which describes the procedure performed, that the procedure is incorrectly or incompletely coded, the carrier may recode the procedure, but shall notify the provider of the reasons for the recoding within thirty (30) days of receipt of the bill;
(iii) Reduce the bill to the maximum allowable payment for that procedure;
(iv) Refer to the commission providers whose billing practices indicate overutilization; and
(v) A carrier may have another certified entity perform utilization review activities on its behalf.
(D)(i) The utilization review program, whether operated by the carrier or an entity on behalf of the carrier, shall be certified by the board.
(ii) For information regarding certification, parties should contact the Department of Health.
(E) The carrier shall provide the division with the name, address, and license number, and a copy of the contract agreement between the carrier and other entity, if applicable, of the entity responsible for conducting the carrier’s utilization review program.
(F) The carrier is responsible for notifying the division when changing reviewing entities.
(G) For purposes of this section, a carrier which has another entity perform utilization review activities on its behalf maintains full responsibility for compliance with this section.
(H) Under the carrier’s utilization review program, the carrier shall make determinations concerning a covered injury or illness through one (1) of the following approaches:
(i) Review by licensed, registered, or certified healthcare professionals;
(ii) The application of criteria developed by licensed, registered, or certified healthcare professionals; or
(iii) A combination of approaches in subdivisions (d)(2)(H)(i) and (ii) of this section according to the type of covered injury or illness.
(I) Licensed, registered, or certified healthcare professionals shall be involved in determining the carrier’s response to a request by a provider for reconsideration of its bill.
(J) These licensed, registered, or certified healthcare professionals shall have suitable occupational injury or disease expertise, or both, to render an informed clinical judgment on the medical appropriateness of the services provided.
(3) Commission utilization review and monitoring responsibilities.
(A) The commission shall monitor the carriers to:
(i) Ensure they have a utilization review plan that complies with commission requirements and Arkansas Code § 20-9-201 et seq.; and
(ii) Monitor their claims handling and reimbursement practices.
(B) The commission shall perform utilization review of healthcare providers who have been identified to have trends or patterns of overutilization or inappropriate billing, as well as to investigate patterns of abuse.
(C) The commission is responsible for the review process and the implementation of penalties and/or sanctions for findings of overutilization and/or violations by carriers and/or providers.
(4) Commission investigative process.
(A) The commission shall perform two (2) types of utilization review regarding carriers and/or providers:
(i)(a) Individual claimant review.
(b) The review of an individual case with all applicable documentation; and
(ii)(a) Random sample review.
(b) The review of a random sample of a healthcare provider’s workers’ compensation cases for a given time based on a valid referral from a carrier, claimant, or governmental source or based on commission reports which indicate provider patterns which deviate from the norm.
(B) The division may recommend corrective actions, such as provider or carrier education, referrals to professional organizations, referrals to the State Insurance Department and other appropriate authorities, for providers or carriers whose practices are determined to be questionable.
(C) Monitoring activities by the commission can result in penalties imposed upon:
(i) A provider for findings of improper practice patterns; or
(ii) A carrier for inappropriate claims handling practices.
(e) Rule review.
(1) The commission encourages participation in the development of and changes to the medical cost containment program and fee schedules by:
(A) All groups;
(B) Associations; and
(C) The public.
(2)(A) Any such group, association, or other party desiring input into or changes made to this section and associated schedules must make their recommendations in writing to the administrator.
(B) After analysis, the commission may incorporate such recommended changes into this section after appropriate public comment pursuant to Arkansas Code § 11-9-205.
(3) The medical fee schedule shall be reviewed July, 2001, and every two (2) years thereafter.
(f) Provider and facility fees for copies of medical records.
(1)(A) Healthcare providers and facilities are entitled to recover a reasonable amount to cover the cost of copying documents which have been requested by the carrier, self-insured employer, employee, attorneys, etc.
(B)(i) Certain procedure code descriptors and this section’s guidelines require the submission of records and/or reports.
(ii) The amount of reimbursement is designated in this section for these.
(C) Documentation which is submitted by the provider and/or facility, but was not specifically requested by the carrier, is not allowed a copy charge.
(2)(A) Healthcare providers and facilities must furnish an injured employee or his or her attorney and carriers/self-insureds or their attorneys copies of his or her records and reports upon request.
(B) The charge shall be the same as set out in Arkansas Code § 16-46-106(a)(2).
(3) Healthcare providers and facilities may charge the actual direct cost of copying x-rays, microfilm, or other nonpaper records.
(4) The copying charge shall be paid by the party who requests the records.
(5) An itemized invoice shall accompany the copy.
(g) Medical fee schedule.
(1) Services rendered under worker’s compensation laws.
(A) The official medical fee schedule of the commission shall be based upon the Health Care Financing Administration’s Medicare Resource Based Relative Value Scale (RBRVS), utilizing the Health Care Financing Administration’s national relative value units and Arkansas specific conversion factors adopted by the commission.
(B) Parties using this schedule should also be familiar with this section, the most current CPT, the Health Care Financing Administration Common Procedure Coding System (HCPCS), and the ASA Relative Value Guide.
(2) Effective date and coding references.
(A) This fee schedule shall replace the current commission fee schedule on May 15, 2000, and the most current versions of CPT and the Medicare RBRVS shall automatically be applicable upon their effective dates.
(B)(i) Due to the length of the medical fee schedule, it is not being reproduced herein.
(ii) Anyone desiring a copy of the medical fee schedule can obtain same by contacting the commission (800-622-4472).
(3) Commission inpatient hospital fee schedule.
(A) Due to the length of the inpatient hospital fee schedule, it is not being reproduced herein.
(B) Anyone desiring a copy of the inpatient hospital fee schedule can obtain same by contacting the commission (800-622-4472).
"MCO/PPO" means managed care organization/preferred provider organization.
This section as promulgated prior to codification into the Code of Arkansas Rules provided as follows:
"Pursuant to Ark. Code Ann. § 11-9-517 (Repl. 1996) the following rule is hereby established in order to implement a medical cost containment program."
Subdivision (f)(5) of this section as promulgated prior to codification into the Code of Arkansas Rules provided as follows:
"(Adopted September 15, 1992; Revised Effective September 1, 1994; Revised effective May 15, 2000 for services rendered on and subsequent to this date.)"