Ala. Admin. Code r. 480-5-5-.01

Current through Register Vol. 43, No. 1, October 31, 2024

Section 480-5-5-.01 - Scope

(1) These rules are designed to cover permissive bill screening and permissive utilization review undertaken on behalf of an employer by a person or entity other than an employee of the employer and following a determination that an employee has suffered an injury by accident arising out of and in the course of the employee's employment. These rules are not to be interpreted as limiting the employer's on prerogative.

(a) Nothing in Rule 480-5-5-.06 shall be construed to restrict or deny the employer's prerogative to authorize medical care pursuant to the Workers' Compensation Law.

(b) These Rules shall address medical services provided to compensable workers' compensation cases (claims) approved and authorized by the employer.

(c) These Rules shall not apply to medical services provided to an injured employee during the period of investigation to determine if the injury was the result of an accident arising out of and in the course of the employee's employment, but the employer/agent may apply these Rules retrospectively if compensability is accepted by the employer.

(2) These Rules do not and shall not mandate the -contracting of any outside vendor to perform utilization review and/or bill screening services for an employer or carrier.

(3) These Rules shall not take precedence over any arrangement between any employer, workers' compensation insurance carrier, self-insured employer, group fund or agent and provider of medical services regarding any rate, fees, or level of reimbursement which does not exceed that which is set by law or bill screening and/or utilization management agreements.

(4) Nothing in these Rules, including an employer's contracting with an outside vendor for bill screening and/or utilization review, is intended to alter the employer's rights, immunities and remedies under the Alabama Workers' Compensation Law. Nothing in these Rules shall be construed as to create any cause of action.

(5) In the event that Utilization Review and Bill Screening is mandated by Law, these Rules shall be reviewed in accordance with the change.

(6) These Rules shall be reviewed at least annually for continued appropriateness.

(7) Utilization review and bill screening services may be performed at the option of the employer.

Author: Workers' Compensation Division

Ala. Admin. Code r. 480-5-5-.01

New Rule: Filed August 9 1996; effective September 13, 1996.

Statutory Authority:Code of Ala. 1975, § 25-5-293.