Ala. Admin. Code r. 480-5-5-.33

Current through Register Vol. 42, No. 8, May 31, 2024

Section 480-5-5-.33 - Time Limits For Claims Payments

(1) In accordance with Code of Ala. 1975, Section 25-5-77(h), the employer/agent shall process and pay all undisputed claims within 25 working days of receipt of an approved claim form. However, all authorized workers' compensation claims shall be filed to allow processing and reimbursement within twelve (12) months from the date of service. All actions against an authorized claim cease when the said 12-month time limitation has expired.

(2) A provider who submits an authorized claim to the employer/agent shall receive reimbursement, notice of dispute, or a request for additional information in accordance with Rule 480-5-5-.03. If payment is not received within the time constraints of Rule 480-5-5-.03, the provider should contact the employer/agent for the current status of an authorized claim.

(3) Providers should contact the Workers' Compensation Division if there are problems with an authorized workers' compensation claim. However, when a provider's efforts are fruitless, the provider should write to the Workers' Compensation Division before the 12-month limitation expires.

(4) Administrative Review of Claims Denied as Outdated.

(a) A provider who is denied payment on an outdated authorized claim may request an administrative review of the claim. A written request for an administrative review, conducted by the Medical Services Dispute Resolution Section, shall be addressed to the Workers' Compensation Division within sixty (60) days of the date the authorized claim becomes outdated, which is 12-months from the date of service.

(b) It is the responsibility of the provider, when submitting an outdated authorized claim for an administrative review, to furnish adequate documentation of the provider's good faith attempts to obtain payment of the claim, including copies of relevant explanation of payments (EOP) and correspondence with the employer/agent. The provider shall also include an error free claim to furnish the employer/agent in cases where the decision is favorable.

(c) When the provider has timely requested an administrative review, and research of the claim reveals that the authorized claim was originally filed in accordance with Rules 480-5-5-.04 and .22, and the provider has established a good faith effort to file an authorized claim on the approved claim form, the Workers' Compensation Division shall have the authority to instruct the employer/agent to waive the filing limitation and process the authorized claim.

(d) The provider shall be notified in writing of the administrative review decision. A provider who has timely requested an administrative review and received an adverse decision may request an appeal in accordance with the Department of Industrial Relations Administrative Code 480-1-4. Such request shall be in writing and received by the Workers' Compensation Division within 60 days of receipt of the date of the administrative review denial letter.

(e) If all administrative remedies have been exhausted and the authorized claim is denied, the provider cannot collect from either the employer/agent or employee.

Author: Workers' Compensation Medical Services Board

Ala. Admin. Code r. 480-5-5-.33

New Rule: Filed July 14, 1997; effective August 18, 1997.

Statutory Authority:Code of Ala. 1975, § 25-5-293.