W. Va. Code R. § 85-20-3

Current through Register Vol. XLI, No. 37, September 13, 2024

Section 85-20-3 - Definitions

As used in these rules, the following terms have the stated meanings unless the context of a specific use clearly indicates another meaning is intended.

3.1. "Code of West Virginia" and "West Virginia Code" means the West Virginia Code of 1931 as amended.

3.2. "Executive Director" means the Executive Director of the West Virginia Workers' Compensation Commission as provided pursuant to the provisions of W. Va. Code § 23-1-1b.

3.3. "Commission" means the West Virginia Workers' Compensation Commission as provided for by W. Va. Code § 23-1-1, et seq.

3.4. "Health Care Vendor" or "Health Care Provider" refers to health care providers, including providers of rehabilitation services within the meaning of W. Va. Code § 23-4-9, both in- and out-of-state who have signed provider agreements with the West Virginia Workers' Compensation Commission, insurance commissioner, self-insured employer or private carrier, whichever is applicable, to provide health care for injuries or illnesses covered by Chapter 23 of the Code. For this Rule, the terms shall mean any person, firm, corporation, partnership, association, agency, institution, or other legal entity providing any kind of services or equipment. The terms include, but are not limited to, hospitals, medical doctors, dentists, chiropractors, vocational rehabilitation counselors, vocational rehabilitation service providers, qualified rehabilitation professional, osteopathic physicians, pharmacists, podiatrists, physical therapists, occupational therapists, massage therapists, psychologists, naturopathic physicians, and durable medical equipment suppliers.

3.5. "Office of Judges" refers to the Office of Judges, as set forth in W. Va. Code § 23-5-8.

3.6. "This rule" means the present exempt legislative rule that is designated in the caption here as title 85, series 20.

3.7. The following will be referred to throughout the rule by the abbreviation indicated.

a. Magnetic resonance imaging - MRI

b. Encephalogram - EEG

c. Computer Assisted Tomogram - CT scan d. Electromyelogram - EMG

3.8. "Guides Fourth" means the "Guides to the Evaluation of Permanent Impairment," (4^th ed. 1993), as published by the American Medical Association.

3.9. "Maximum medical improvement" means a condition that has become static or stabilized during a period of time sufficient to allow optimal recovery, and one that is unlikely to change in spite of further medical or surgical therapy.

3.10. "Permanent impairment" means a permanent alteration of an individual's health status and is assessed by medical means and is a medical issue. An impairment is a deviation from normal in a body part or organ system and its functioning. An injured worker's degree of permanent whole body medical impairment is to be determined in keeping with the determination of whole person permanent impairment as set forth in the applicable Guides. For the purposes of this Rule, the Guides' use of the term "whole person" impairment is the equivalent of the term "whole body" impairment.

3.11. Chart Notes: This type of documentation may also be referred to as "office" or "progress" notes or "narrative report." Providers must maintain charts and records in order to support and justify the services provided. "Chart" means a compendium of medical records on an individual patient. "Record" means dated reports supporting bills submitted to the department or self-insurer for medical services provided in an office, nursing facility, hospital, outpatient, emergency room, or other place of service. Records of service shall be entered in a chronological order by the practitioner who rendered the service. For reimbursement purposes, such records shall be legible, and shall include, but are not limited to:

a. Date(s) of service;

b. Patient's name and date of birth;

c. Claim number;

d. Name and title of the person performing the service;

e. Chief complaint or reason for each visit;

f. Pertinent medical history;

g. Review of medication

h. Pertinent findings on examination;

i. Medications and/or equipment/supplies prescribed or provided;

j. Description of treatment (when applicable);

k. Recommendations for additional treatments, procedures, or consultations;

l. X rays, tests, and results; and

m. Plan of treatment/care/outcome.

3.12. "Injured worker" means an individual seeking to received benefits available under Chapter 23 of the Code and/or has received and/or is receiving benefits under Chapter 23 of the Code.

3.13. "Insurance Commissioner" means the insurance commissioner of West Virginia as provided in section one, article two, chapter thirty-three of the West Virginia Code, or designated third-party administrator of the Insurance Commissioner.

3.14. "Private Carrier" means any insurer, including the successor to the Commission, authorized by the insurance commissioner to provide workers' compensation insurance pursuant to chapters twenty-three and thirty-three of the West Virginia Code, but shall not include self-insured employers.

3.15. "Self-insurer" and "self-insured employer" mean employers who are eligible and have been granted self-insured status under the provisions of W. Va. Code § 23-2-9.

W. Va. Code R. § 85-20-3