Current through Register Vol. XLI, No. 50, December 13, 2024
Section 85-20-5 - Qualified Providers and Registration5.1. To receive payment as a health care provider, a provider must be enrolled as an active vendor with the Commission. Providers may be reimbursed only for services actually provided or supervised and for which the vendor is duly licensed. To enroll, the provider must submit the applicable application to the Commission, completed in its entirety, along with all documentation requested by the Commission, including, but not limited to, all professional licenses, board certificates, business licenses, accreditation certificates, and/or operating permits held by the provider in this or any other state. a. Upon termination of the Commission, no registration is required of health care providers. Health care professionals are required to verify and provide proof of their licensing and certification, including, but not limited to, all professional licenses, board certificates, business licenses, accreditation certificates, and/or operating permits held by the provider in this or any other state, to the Insurance Commissioner, self-insured employer or private carrier, whomever services are provided under this rule. In turn the Insurance Commissioner, self-insured employer or private carrier, is required to maintain this proof that the health care provider is qualified to provide services under this rule.b. Providers must advise the Commission, the Insurance Commissioner, self-insured employer or private carrier, whichever is applicable, if their license to practice medicine has ever been suspended or terminated by the appropriate authority in West Virginia or any other state and whether the provider has been convicted of any crime in relation to his or her practice, or any felony. Providers with address or telephone number changes must advise the Commission, the Insurance Commissioner, self-insured employer or private carrier, whichever is applicable, in writing (by mail or facsimile), providing both old and new information and their tax identification number on letterhead.5.2. Any provider who has had his or her license to practice medicine suspended or terminated by the appropriate authority in West Virginia or any other state, any provider who has been convicted of any crime in relation to his or her practice, or any felony, and/or any provider who has been suspended or terminated by the Commission or Insurance Commissioner, whichever is applicable, pursuant to W. Va. Code § 23-4-3c, or any other provision, may be excluded by the Commission or Insurance Commissioner, whichever is applicable, in any managed care plan created by the Commission, the Insurance Commissioner, self-insured employer or private carrier, whichever are applicable,.5.3. Providers must submit their usual and customary charges for commonly billed codes when applying for enrollment. If the provider is ultimately enrolled, the provider shall only be permitted to charge the provider's usual and customary charges, and not the maximum amount allowed under the Commission's, Insurance Commissioner's, private carrier's or self-insured employer's, whichever is applicable, fee schedule.5.4. Licensed practitioners are eligible to treat injured workers to the extent of the practitioner's license certification. Providers not independently licensed must practice under direct supervision of a licensed health care professional whose scope of practice and specialty training includes service provided by the paraprofessional.5.5. Reimbursement for care will only be authorized if the provider has provided documentation of credentialing consistent with the type of care provided.5.6. Until the termination of the Commission, a new Application is required to be filed with the Commission if a provider's name or tax identification number changes. The Application must have the original signature of an authorized person and may be faxed initially to the Commission's Provider Registration unit. Activation is not official until a complete signed application has been received and a confirmation letter is sent at that time. The hard-copy original must be sent to: Workers' Compensation Commission
ATTN: Provider Registration
P.O. Box 4228
Charleston, WV 25364-4228
a. Upon termination of the Commission, the provider is required to keep current provider information on file with the Insurance Commissioner, self-insured employer or private carrier, whomever services are provided under this rule.5.7. The provision of health care services to injured workers under the workers' compensation system of this state constitutes an agreement to: a. Accept the Commission's, or Insurance Commissioner's fee schedule, as amended from time to time by the Commission or Insurance Commissioner; 1. In instances when the commission, and effective upon termination of the commission, private carriers, self-insured employers or other payors, have entered into preferred provider or managed care agreements which provides for fees and other payments which deviate from the schedule of maximum disbursements set forth in accordance with the provisions of W. Va. Code § 23-4-3(a), such acceptable level of payments may be set forth in the preferred provider or managed care agreement(s);b. Submit reports and to make continuing reports in a timely manner and as otherwise required and on forms required by the Commission, the Insurance Commissioner, self-insured employer or private carrier, whichever are applicable, as from time to time amended;c. Retain medical records, including, but not limited to, general medical records and X-Ray's, for ten (10) years and invoices, electronic or paper, for three years;d. Timely and fully participate in all physical and vocational rehabilitation efforts of the Commission, the Insurance Commissioner, self-insured employer or private carrier, whichever are applicable,;e. Accept all provisions of this Rule, and all policies, procedures, and other requirements adopted from time to time by the Commission or Insurance Commissioner, whichever is applicable; andf. To remain updated and familiar with all medical billing instructions, and other rules, regulations, and procedures of the Commission, the Insurance Commissioner, self-insured employer or private carrier, whichever are applicable,.5.8. Health Care Providers. Certain procedures performed by health care providers are reimbursable by the Commission, the Insurance Commissioner, self-insured employer or private carrier, whichever are applicable, only when providers have certification in accordance with W. Va. Code § 30-16-20. Health care providers must provide evidence of certification if they wish to perform videofluroscopy, diagnostic ultrasound, electromyography, nerve conduction velocity studies, somatosensory testing, neuromuscular junction testing, and any other diagnostic testing identified by the Commission, the Insurance Commissioner, self-insured employer or private carrier, whichever is applicable,.5.9. Independent Medical Examiners. Registered providers may apply to be recognized by the Commission as independent medical examiners, who provide independent examinations and recommend impairment ratings of injured workers. A separate application, Independent Medical Examiner Application, must be submitted and approved by the Commission. Approval shall only be granted if the applicant is board certified under a certification granted by the American Board of Medical Specialties (ABMS) or the Bureau of Osteopathic Specialists certifying boards of the American Osteopathic Association (AOA), where such board exists. The Commission, Insurance Commissioner, private carrier or self-insured employer, whichever is applicable, reserves the right, in its sole discretion, to direct the examinee to the examiner of its choosing. All independent medical examiners shall comply with all Commission policies and procedures as a pre-requisite to payment. a. Upon termination of the Commission, no registration is required of independent medical examiners. Independent medical examiners are required to verify and provide proof of their ABMS or AOA certification to the Insurance Commissioner, self-insured employer or private carrier, or to their third party administrator or managed care provider, whomever services are provided under this rule. In turn, the Insurance Commissioner, self-insured employer or private carrier, or their third party administrator or managed care provider, is required to maintain this proof of certification of the independent medical examiner.5.10. Out-of-State Providers. If an injured worker elects or is directed to receive health care services from an out-of-state provider, and that provider does not accept the Commission's insurance commissioner's, private carrier's or self-insured employer's, whichever is applicable, fee as payment in full, then the injured worker may be liable for the difference between the payment and the amount charged by the out-of-state health care provider.5.11. Given the above, it is essential that all physicians be aware of the injured worker's potential liability when selecting a referral, consulting, surgical, or other provider located in another state. Accordingly, all referrals should be to providers registered with the Commission or within the network of physicians authorized to provide health care services to its injured workers by the Insurance Commissioner, private carrier or self-insured employer, whichever is applicable, and referrals to non-registered providers requires pre-authorization from the Commission, Insurance Commissioner, private carrier or self-insured employer, whichever is applicable. Unless the following exceptions apply, referral to an out-of-state provider will put the injured worker at risk for out-of-pocket payment for medical service. a. Emergencies: Where there is an urgent need for immediate medical attention to prevent death or serious and permanent harm, the injured worker will not be personally liable for the difference between fee schedule and the amount charged by the out-of-state provider. The exception no longer applies when, after emergency admission, the injured worker attains a stable medical condition and can be transferred to either a West Virginia health care provider or an out-of-state health care provider who has agreed to accept the scheduled fee as payment in full. If the injured worker refuses to be transferred, then he or she will be personally liable for the difference in costs between the fee schedule amount and the amount charged by the provider for services after attaining medical stability.b. No Nearby Qualified Provider: If no health care provider qualified to provide needed medical services and who has agreed to accept the Commission's, Insurance Commissioner's, private carrier's or self-insured employer's, whichever is applicable, fee schedule as payment in full is reasonably near to the injured worker's home, the injured worker may request authorization for an out-of-state provider. If the Commission, Insurance Commissioner, private carrier or self-insured employer, whichever is applicable, authorizes medical services from the out-of-state provider, the injured worker will not be personally liable for the difference between fee schedule and the amount charged by the out-of-state provider.