Iowa Admin. Code r. 876-10.3

Current through Register Vol. 47, No. 11, December 11, 2024

Rule 876-10.3 - Health service dispute resolution

(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.

Iowa Admin. Code r. 876-10.3

Amended by IAB July 31, 2019/Volume XLII, Number 3, effective 7/10/2019