Current through Register Vol. 71, No. 24, June 14, 2024
Rule 7-123 - MEDICAL BENEFITS AND SERVICES; EMPLOYEE RESPONSIBILITY123.1(a) All medical services, appliances, or supplies provided to an injured employee or claimant must be pre-authorized by the Program in order to be paid or reimbursed by the Program, except as provided in paragraph (b) of this subsection.(b) If there is a need for emergency treatment the employee or claimant may, without prior authorization by the Program, select a healthcare provider to provide reasonably necessary emergency medical care prescribed by a qualified health professional for an injury sustained in the performance of duty, and such medical services, appliances, or supplies may be paid or reimbursed by the Program, subject to utilization review, if notice of such medical care is given to the Program no later than thirty (30) days after the care is rendered.123.2 In order for the Program to pay for the medical services, appliances, or supplies provided by a healthcare provider and prescribed by a qualified health professional, t he healthcare provider must be a member of the Program's Panel of Healthcare Providers, except as provided in §§ 123.1(b) and 123.4 of this chapter.
123.3 The Program's reimbursement for any expenses incurred for medical services, appliances, or supplies provided pursuant to Section 2303 of the Act (D.C. Official Code § 1-623.03 ) shall be limited by the fee schedule prescribed in this chapter.
123.4 Once an employee or claimant selects a qualified health professional from the Program's Panel of Healthcare Providers, the Program will not pay for or reimburse the costs of medical care provided or prescribed by another qualified health professional without authorization of the Program, except as provided in § 123.1(b) of this chapter.
123.5 An employee or claimant who is not satisfied with medical services provided by the qualified health professional selected from the Program's Panel of Healthcare Providers shall file Form M3 with the Program to request to change the qualified health professional, with justification in support of the request. The Program shall authorize a change where the Program finds the change is in the best interest of the employee or claimant.
123.6 An employee or claimant may request reimbursement of expenses for medical services, appliances, or supplies that are incurred prior to (i) acceptance of the claim or (ii) reinstatement of the claim pursuant to a compensation order by completing and submitting Form MR with a copy of the bill and medical record to the Program, provided such expenses have not otherwise been paid for by insurance.
(a) If the Program does not respond within thirty (30) days of receipt of a request for reimbursement submitted pursuant to this subsection, the Claimant may file a request for an audit to request review of the reimbursement request by the Chief Risk Officer pursuant to § 153 of this chapter.Final Rulemaking published at 59 DCR 8766, 8790 (July 27, 2012); amended by Final Rulemaking published at 64 DCR 6325 (7/7/2017); amended by Final Rulemaking published at 66 DCR 4246 (4/5/2019)Authority: Chief Risk Officer of the Office of Risk Management (ORM), Executive Office of the Mayor, pursuant to the authority set forth in section 2344 of the District of Columbia Government Merit Personnel Act of 1978 (CMPA), effective March 3, 1979 (D.C. Law 2-139; D.C. Official Code § 1-623.44 (2012 Supp.)); section 7 of Reorganization Plan No. 1 of 2003 for the Office of Risk Management, effective December 15, 2003; and Mayor's Order 2004-198, effective December 14, 2004