La. Admin. Code tit. 40 § I-5105

Current through Register Vol. 50, No. 11, November 20, 2024

Section I-5105 - Verification of Coverage

A. The carrier/self-insured employer is responsible for 100 percent of the maximum allowable reimbursement rate for covered services rendered for treatment of compensable conditions. The claimant is not required to contribute a co-payment and does not have to meet any deductibles.

1. Prior to the provision of medical services, supplies, or other non-medical services the determination that the illness, injury, or condition, is work related must be made, and must be accomplished in the following manner:

a. carrier/self-insured employer should be contacted for verification of coverage/liability;

b. the name and title of the individual verifying coverage/liability must be recorded in the claimant's records;

c. denial of coverage/liability must be immediately communicated to the claimant.

2. Those procedures identified in this reimbursement schedule as noncovered are not billable to the claimant if rendered in treatment of compensable conditions unless the claimant is informed beforehand that he will be responsible for the charges.

3. In certain circumstances, the provider collects his fees from the claimant because he is unsure or unaware of the occupational nature of the injury or condition. If the provider decides to bill the workers' compensation carrier/self-insured employer after compensability has been established, he must, to the best of his knowledge, make certain that the claimant has not already filed for reimbursement. If the claimant has not filed, the provider should bill the carrier/self-insured employer and reimburse the claimant. To avoid duplicate billings, the provider should file for the claimant, billing the full amount; or, the claimant should bill the full amount himself.

B. For covered services, if there is a difference between the provider's billed amount and the Office of Workers' Compensation maximum allowable reimbursement, the claimant, employer and carrier cannot under any circumstances, be billed for the difference.

La. Admin. Code tit. 40, § I-5105

Promulgated by the Department of Labor, Office of Workers' Compensation, LR 19:54 (January 1993), repromulgated LR 19:212 (February 1993), amended LR 20:1299 (November 1994).

AUTHORITY NOTE: Promulgated in accordance with R.S. 23:1034.2.