Section 8 AAC 55.010 - Benefits(a) To be eligible for benefits from the fund, a person must be a fisherman who, at the time an injury is sustained, is licensed in the person's own name by the state to engage in commercial fishing under AS 16.05.480 or AS 16.43, and who is actually so engaged in Alaska water or is occupied in the state preparing or dismantling boats or gear used in commercial fishing.(b) Unless required as a result of accidental bodily injury caused by the fishing endeavor, benefits may not be awarded for (1) the services of a dentist;(2) dental prosthetic appliances or the fitting of them;(3) eye refractions and hearing examinations;(4) eye glasses or the fitting of them; or(5) hearing aids or the fitting of them.(c) Benefits may not be awarded for an injury (1) if the injury does not arise out of an accident directly connected with commercial fishing;(2) caused by the fisherman's willful intent to injure or kill self or another;(3) caused by the fisherman's intoxication, or caused by the fisherman being under the influence of drugs unless the drugs were taken as prescribed by a treating physician; in this paragraph, (A) "drugs" has the meaning given in AS 23.30.395;(B) "intoxication" has the meaning given in 8 AAC 20.010; or(4) if the fisherman has knowingly falsified a material fact directly connected with the fisherman's claim against the fund.(d) Benefits may not be awarded unless the following conditions are either met or, in a review under AS 23.35.040(a)(1), excused by the council for just cause: (1) the fisherman receives initial treatment not later than 120 days after the date of injury; the initial treating provider shall submit a Physician's Report (Form 07-6126), unless the department accepts an alternate format that provides the same data in a form that the department can easily use;(2) the claim is submitted no later than one year after the date of initial treatment;(3) the fisherman responds no later than 90 days after receipt of an inquiry seeking clarification of any item on a claim, or of any item on a billing for services performed or goods supplied;(4) there is no unexplained gap in treatment of more than three months;(5) the provider submits price lists and fee determinations to the administrator no later than 30 days after receipt of a request.(e) Transportation to return a fisherman to the fisherman's home may be allowed to the extent that the costs are in addition to those that the fisherman would normally have encountered had the fisherman not been injured.(f) The department may require information regarding insurance coverage, including an insurance benefits statement, and may hold a claim in abeyance pending the receipt of required information. Insurance benefit statements must be received by the department not later than 180 days after a fisherman receives an inquiry seeking clarification.(g) A vessel owner may not recover reimbursement for a protection and indemnity insurance policy deductible payment unless the administrator receives (1) proof of direct payment of medical benefits to or on behalf of the fisherman by the vessel owner, together with a copy of the declaration page of the policy setting out the policy coverage and limits; or(2) proof of direct payment of medical benefits to or on behalf of the fisherman by the vessel owner's protection and indemnity insurance company, together with (A) proof of payment of the policy deductible to the protection and indemnity insurance company by the vessel owner; and(B) a copy of the declaration page of the policy setting out the policy coverage and limits.(h) Provider bills must be submitted to the department in a format approved by the United States Department of Health and Human Services, Centers for Medicare and Medicaid Services (CMS), unless the department accepts an alternate format that provides the same data in a form that the department can easily use.(i) Provider bills must be accompanied by signed and dated chart notes.(j) If an injury requires continuing and multiple treatments of a similar nature, the standards for payment for outpatient treatment for the injury are as follows: (1) payment for a course of treatment may not exceed more than three treatments per week for the first month, two treatments per week for the second and third months, one treatment per week for the fourth and fifth months, and one treatment per month for the sixth through 12th months;(2) a provider shall furnish a written treatment plan if the course of treatment will require more frequent outpatient treatment than allowed under this subsection;(3) the treatment plan shall be furnished to the administrator no later than 14 days after treatment begins;(4) the treatment plan must include objectives, modalities, frequency of treatments, and reasons for the frequency of treatments.Eff. 3/28/74, Register 49; am 4/11/81, Register 78; am 7/28/93, Register 127; am 3/22/2003, Register 165; am 7/13/2012, Register 203; am 8/23/2023, Register 247, October 2023Authority:AS 23.35.050
AS 23.35.070
AS 23.35.100
AS 23.35.145
AS 23.35.150