7 Colo. Code Regs. § 1101-3-17-16

Current through Register Vol. 47, No. 24, December 25, 2024

Rule 7 CCR 1101-3-17-16 - Utilization Standards

16-1 STATEMENT OF PURPOSE

In an effort to comply with the legislative charge to assure the quick and efficient delivery of medical benefits at a reasonable cost, the Director (Director) of the Division of Workers' Compensation (Division) has promulgated these utilization standards, effective January 1, 2025. This Rule defines the standard terminology, administrative procedures, and dispute resolution procedures required to implement the Division's Medical Treatment Guidelines (Rule 17) and Medical Fee Schedule (Rule 18).

16-2 STANDARD TERMINOLOGY FOR RULES 16, 17, AND 18

A. Ambulatory Surgical Center (ASC) means licensed as such by the Colorado Department of Public Health and Environment (CDPHE).

B. Authorized Treating Provider (ATP) means any of the following:

1. The treating physician designated by the employer and selected by the injured worker;

2. A healthcare Provider to whom an ATP refers the injured worker for treatment, consultation, or impairment rating;

3. A physician selected by the injured worker when the injured worker has the right to select a Provider;

4. A physician authorized by the employer when the employer has the right or obligation to make such an authorization;

5. A healthcare Provider determined by the Director or an administrative law judge to be an ATP;

6. A Provider who is designated by the agreement of the injured worker and the Payer.

C. Billed Service(s) means any billed service, procedure, equipment, or supply provided to an injured worker by a Provider.

D. Billing Party means a service Provider or an injured worker who has incurred authorized medical expenses.

E. Children's Hospital means federally qualified, and certified by CDPHE, and licensed as a general hospital by CDPHE.

F. Critical Access Hospital means federally qualified, and certified by CDPHE, and licensed as a general hospital by CDPHE. A list is available on the federal Health Resources and Services Administration website. For dates of service on or after July 1, 2026, Critical Access Hospital means licensed as such by CDPHE pursuant to § 25-1.5-114.5.

G. Day means a calendar day unless otherwise noted. In computing any period of time prescribed or allowed by Rules 16, 17, or 18, the parties shall refer to Rule 1-2.

H. Designated Provider List means a list of physicians as required under § 8-43-404(5)(a)(I) and Rule 8.

I. Freestanding Facility means an entity that furnishes healthcare services and is not integrated with any other entity as a main Provider, a department of a Provider, remote location of a hospital, satellite facility, or a Provider-based entity.

J. Hospital means licensed as such by CDPHE.

K. Long-Term Acute Care Hospital means federally certified and licensed as such by CDPHE.

L. Medical Fee Schedule means Division's Rule 18, its exhibits, and the documents incorporated by reference in that Rule.

M. Medical Treatment Guidelines (MTGs) means Division's Rule 17, its exhibits, and the documents incorporated by reference in that Rule.

N. Non-Physician Provider means individual who is registered, certified or licensed by:

(1) the Colorado Department of Regulatory Agencies (DORA) or an equivalent licensing board of a state that participates in an interstate compact applicable to the type of Provider and codified in Title 24 of the Colorado Revised Statutes;

(2) the Colorado Secretary of State; or

(3) a national entity recognized by the State of Colorado

1. Acupuncturist (L.Ac) licensed by the Office of Acupuncture Licensure;

2. Advanced Practice Registered Nurse (APRN) licensed by the Board of Nursing and registered on the Advanced Practice Registry;

3. Anesthesiologist Assistant (AA) licensed by the Medical Board;

4. Athletic Trainer (ATC) licensed by the Office of Athletic Trainer Licensure;

5. Audiologist (AU.D. CCC-A) licensed by the Office of Audiology and Hearing Aid Provider Licensure;

6. Certified Medical Interpreter certified by the Certification Commission for Healthcare Interpreters or the National Board of Certification for Medical Interpreters.

7. Certified Registered Nurse Anesthetist (CRNA) licensed by the Board of Nursing and registered on the Advanced Practice Registry;

8. Clinical Social Worker (LCSW) licensed by the Board of Social Work Examiners;

9. Complementary Integrative Medicine Practitioner (excluding acupuncturist) certified by the National Certification Commission for Acupuncture and Oriental Medicine;

10. Durable Medical Equipment, Prosthetic, Orthotics, and Supplies (DMEPOS) Supplier licensed by the Colorado Secretary of State;

11. Marriage and Family Therapist (LMFT) licensed by the Board of Marriage and Family Therapist Examiners;

12. Massage Therapist licensed as a massage therapist by the Office of Massage Therapy Licensure;

13. Nurse Practitioner (NP) licensed by the Board of Nursing and registered on the Advanced Practice Registry;

14. Occupational Therapist (OTR) licensed by the Office of Occupational Therapy;

15. Occupational Therapist Assistant (OTA) licensed by the Office of Occupational Therapy;

16. Pharmacist licensed by the Board of Pharmacy;

17. Physical Therapist (PT) licensed by the Physical Therapy Board;

18. Physical Therapist Assistant (PTA) licensed by the Physical Therapy Board;

19. Physician Assistant (PA) licensed by the Medical Board;

20. Practical Nurse (LPN) licensed by the Board of Nursing;

21. Professional Counselor (LPC) licensed by the Board of Professional Counselor Examiners;

22. Psychologist (PsyD, PhD, EdD) licensed by the Board of Psychologist Examiners;

23. Registered Nurse (RN) licensed by the Board of Nursing;

24. Respiratory Therapist (RTL) licensed by the Office of Respiratory Therapy Licensure;

25. Speech Language Pathologist (CCC-SLP) certified by the Office of Speech-Language Pathology Certification;

26. Surgical Assistant registered by the Office of Surgical Assistant and Surgical Technologist Registration.

O. Over-the-Counter Drugs means medications that are available for purchase by the general public without a prescription.

P. Payer means an insurer, self-insured employer, or designated agent(s) responsible for payment of medical expenses. (Use of agents, including but not limited to preferred provider organization (PPO) networks, bill review companies, third party administrators (TPAs), and case management companies shall not relieve the insurer or self-insured employer from their legal responsibilities for compliance with these Rules).

Q. Physician means individual who is licensed by the State of Colorado through one of the following boards or an equivalent licensing board of a state that participates in an interstate compact applicable to the type of Provider and codified in Title 24 of the Colorado Revised Statutes:

1. Medical Board;

2. Dental Board;

3. Podiatry Board;

4. Board of Optometry; or

5. Board of Chiropractic Examiners.

R. Prior Authorization means a guarantee of payment for treatment requested in accordance with this Rule.

S. Provider means a person or entity providing authorized health care service, whether involving treatment or not, to a worker in connection with a work-related injury or occupational disease.

T. Psychiatric Hospital means licensed as such by CDPHE.

U. Rehabilitation Hospital means licensed as such by CDPHE.

V. Rural Health Clinic means a clinic located in areas designated by the United States Census Bureau as rural, or the state as medically underserved, that is federally qualified, and certified as such by CDPHE. A list is available at www.colorado.gov/pacific/cdphe/rural-health-clinic-consumer-resources.

W. Skilled Nursing Facility (SNF) means federally certified and licensed as a nursing care facility by CDPHE.

X. State-run Psychiatric Hospital means mental health institute operated by the Colorado Department of Human Services, Office of Behavioral Health.

Y. Telemedicine means two-way, real time interactive communication between the injured worker and the Provider at a distant site. This electronic communication involves, at a minimum, audio and video telecommunications equipment. Telemedicine enables the remote evaluation and diagnosis of injured workers in addition to the ability to detect fluctuations in their medical condition(s) at a remote site in such a way as to confirm or alter the treatment plan, including medications and/or specialized therapy.

Z. Treatment means any service, procedure, or supply prescribed by an ATP as may reasonably be needed at the time of the injury or occupational disease and thereafter to cure and/or relieve the employee from the effects of the injury or occupational disease.

AA. Veterans Administration Hospital means all medical facilities overseen by the United States Department of Veterans' Affairs.

AB. Writing, for the purposes of Rules 16 and 18, means transmitted by letter, email, fax, or other electronic means of communication.

16-3 GENERAL REQUIREMENTS

A. Any Provider not listed in 16-2 must obtain Prior Authorization when providing services related to a compensable injury.

B. Upon request, healthcare Providers must provide copies of accreditation, licensure, registration, certification, or evidence of healthcare training for billed services.

C. To the extent not otherwise precluded by the laws of this state, contracts between Providers, Payers, and any agents acting on behalf of Providers or Payers shall comply with this Rule.

D. Referrals:

1. All Providers must have a referral from a Physician managing the claim (or NP/PA working under that Physician). A Physician making the referral to another Provider shall, upon request of any party, answer any questions and clarify the scope of the referral, prescription, or the reasonableness or necessity of the care.

2. A Payer or employer shall not redirect or alter the scope of a referral to another Provider for evaluation or treatment of a compensable injury. Any party who has concerns regarding a referral or its scope shall advise the other parties and Providers involved.

E. Use of PAs and NPs:

1. All Colorado workers' compensation (WC) claims (medical only and lost time) shall have a Physician responsible for all services rendered to an injured worker by any PA or NP.

2. For services performed by a PA or NP, the attending Physician must counter-sign patient records related to the injured worker's inability to work resulting from the claimed work injury or disease and the injured worker's ability to return to regular or modified employment, as required by §§ 8-42-105(2)(b) and (3)(c) and (d). The attending Physician must sign the WC 164 Form, certifying that all requirements of this rule have been met.

3. The Physician must evaluate the injured worker at least once within the first three visits to the Designated Provider's office.

16-4 OUT-OF-STATE PROVIDERS

A. Relocated Injured Worker

1. Upon receipt of the "Employer's First Report of Injury" or the "Worker's Claim for Compensation" Form, the Payer shall notify the injured worker that the procedures for change of Provider can be obtained from the Payer should the injured worker relocate out of state.

2. A change of Provider must be made through referral by the Physician managing the claim or in accordance with § 8-43-404(5)(a).

B. In the event an injured worker has not relocated out of state but is referred to an out-of-state Provider for treatment not available within Colorado, the referring Provider shall obtain Prior Authorization. The referring Physician's written request for out of state treatment shall include:

1. Description of treatment requested, including medical justification, the estimated frequency and duration, and known associated medical expenses;

2. Explanation as to why the requested treatment cannot be obtained within Colorado;

3. Name, complete mailing address, and phone number of the out-of-state Provider; and

4. Out-of-state Provider's qualifications to provide the requested treatment.

16-5 REQUIRED USE OF THE MEDICAL TREATMENT GUIDELINES

When an injury or occupational disease falls within the purview of Rule 17, Medical Treatment Guidelines and the injury occurs on or after July 1, 1991, Providers and Payers shall use the MTG, in effect at the time of service, to prepare or review their treatment plan(s) for the injured worker. A Payer may not dictate the type or duration of medical treatment or rely on its own internal guidelines or other standards for medical determination when the treatment falls within the purview of the MTGs. Initial recommendations for a treatment or modality should not exceed the time to produce functional effect parameters in the applicable MTG. When treatment exceeds or is outside of the MTGs, Prior Authorization is required. Requesters and reviewers should consider how their decision will affect the overall treatment plan for the individual patient. In all instances of denial, appropriate processes to deny are required.

16-6 NOTIFICATION TO TREAT

A. The Notification to Treat process applies to treatment that is consistent with the MTGs and has an established value under the Medical Fee Schedule. Providers may, but are not required to, utilize Notification to ensure payment for medical treatment that falls within the purview of the MTGs. The lack of response from the Payer within the time requirement set forth below shall deem the proposed treatment authorized for payment.

B. Notification to Treat may be submitted by phone during regular business hours, or by submitting the "Authorized Treating Provider's Notification to Treat" Form (WC 195). Notification to Treat must include:

1. Provider's certification that the proposed treatment is medically necessary and consistent with the MTGs.

2. Citation of the specific MTG applicable to the proposed treatment.

3. Provider's email address or fax number to which the Payer can respond.

C. Payers shall respond to a Notification to Treat submission within seven days from the receipt of the submission with an approval or a denial of the proposed treatment. Providers may accept verbal confirmation or may request written confirmation, which the Payer should provide upon request.

1. The Payer may limit its approval of initial treatment to the number or duration specified in the relevant MTG without a medical review. If subsequent medical records document functional progress, additional treatment should be approved.

2. If Payer proposes to discontinue treatment before the maximum number of treatments/treatment duration has been reached due to lack of functional progress, Payer shall support that decision with a medical review compliant with this rule.

D. Payers may deny proposed treatment for the following reasons only:

1. For claims that have been reported to the Division, no admission of liability or final order finding the injury compensable has been issued;

2. Proposed treatment is not related to the admitted injury;

3. Provider submitting Notification is not an ATP or is proposing treatment to be performed by a Provider who is not eligible to be an ATP.

4. Injured worker is not entitled to the proposed treatment pursuant to statute or settlement;

5. Medical records contain conflicting opinions among the ATPs regarding proposed treatment;

6. Proposed treatment falls outside of the MTGs.

E. If the Payer denies a Notification to Treat per sections 16-6 D 2, 5, or 6, the Payer shall notify the Provider, allow the submission of relevant supporting medical documentation as defined in section 16-7 C and review the submission as a Prior Authorization request, allowing 10 additional days for review.

F. Appeals for denied Notifications to Treat shall be made in accordance with the Prior Authorization Appeals Process outlined in this rule.

G. Any Provider or Payer who incorrectly applies the MTGs in the Notification to Treat process may be subject to penalties under the Workers' Compensation Act.

16-7 PRIOR AUTHORIZATION

A. Prior Authorization may be requested using the "Authorized Treating Provider's Request for Prior Authorization" (Form WC 188) or in the alternative, shall be clearly labeled as a Prior Authorization request. Prior Authorization for payment shall only be requested when:

1. A prescribed treatment exceeds the recommended limitations set forth in the MTGs.

2. The MTGs require Prior Authorization for that specific service;

3. A prescribed treatment is not priced in the Medical Fee Schedule or is identified in Rule as requiring Prior Authorization for payment.

B. Prior Authorization for prescribed treatment may be granted immediately and without a medical review. However, the Payer shall respond to all Prior Authorization requests in writing within 10 days from receipt of a completed request as defined per this Rule.

The Payer, unless it has previously notified the Provider, shall give notice to the Provider of the procedures for obtaining Prior Authorization for payment upon receipt of the initial bill from that Provider.

C. When submitting a Prior Authorization request, a Provider shall concurrently explain the reasonableness and medical necessity of the treatment requested and shall provide relevant supporting documentation (documentation used in the Provider's decision-making process to substantiate need for the requested treatment). A complete Prior Authorization request includes the following:

1. An adequate definition or description of the nature, extent and necessity for the treatment;

2. Identification of the appropriate MTG if applicable; and

3. Final diagnosis.

16-7-1 PRIOR AUTHORIZATION DENIALS

A. If an ATP requests Prior Authorization and indicates in writing, including reasoning and supporting documentation, that the requested treatment is related to the admitted WC claim, the Payer cannot deny solely for relatedness without a medical opinion as required by this Rule. The medical review, independent medical examination (IME) report, or report from an ATP that addresses relatedness of the requested treatment to the admitted claim may precede the Prior Authorization request if:

1. The opinion was issued within 365 days prior to the date of the Prior Authorization request; and

2. An admission of liability has not been filed admitting the relatedness of the requested treatment to the admitted claim or a final order has not been entered finding the specific medical condition related to the admitted injury.

If not, the medical review, IME report, or report from the ATP must be subsequent to the prior authorization request.

B. The Payer may deny a request for Prior Authorization for medical or non-medical reasons. Examples of non-medical reasons are listed in section 16-10-2 A.

1. If the Payer is denying a request for non-medical reasons, the Payer shall, within 10 days of receipt of the complete request, furnish the requesting ATP and the parties with a written denial that sets forth clear and persuasive reasons for the denial, including citation of appropriate statutes, rules, and/or supporting documents (e.g., a copy of claim denial or a detailed explanation why the requesting Provider is not authorized to treat).

2. If the Payer is denying a request for medical reasons, the Payer shall, within 10 days of receipt of the complete request:

a. Have all the submitted documentation reviewed by a Physician, who holds a license in the same or similar specialty as would typically manage the medical condition or treatment under review. The Physician performing this review shall be Level I or II Accredited. In addition, clinical Pharmacists (Pharm.D.) may review Prior Authorization requests for medications, and Psychologists may review requests for mental health services, without having received Level I or II Accreditation.

After reviewing all of the submitted documentation and documentation referenced in the Prior Authorization request that is available to the Payer, the reviewing Physician may call the requesting Provider to expedite the communication and processing of the Prior Authorization request.

The Payer may limit approval of initial treatment to the number or duration specified in the relevant MTG without a medical review.

b. Furnish the requesting ATP and the parties with a written denial that sets forth an explanation of the specific medical reasons for the denial, including the name and professional credentials of the Provider performing the medical review and a copy of the reviewer's opinion; the specific citation from the MTGs, when applicable; and identification of the information deemed most likely to influence a reconsideration of the denial, when applicable.

C. Failure of the Payer to timely comply in full with all Prior Authorization requirements outlined in this rule shall be deemed authorization for payment of the requested treatment unless the Payer has scheduled an independent medical examination (IME) and notified the requesting Provider of the IME within the time prescribed for responding.

1. The IME must occur within 30 days, or upon first available appointment, of the Prior Authorization request, not to exceed 60 days absent an order extending the deadline.

2. The IME physician must serve all parties concurrently with the report within 20 days of the IME.

3. The Payer shall respond to the Prior Authorization request within 10 days of the receipt of the IME report.

4. If the injured worker does not attend or reschedules the IME, the Payer may deny the Prior Authorization request pending completion of the IME.

5. The IME shall comply with Rule 8 as applicable.

16-7-2 PRIOR AUTHORIZATION APPEALS

A. The requesting ATP shall have 10 days from the date of the written denial to submit an appeal with additional information to support the request. A written response is not considered a "special report" as defined in Rule 18.

B. The Payer shall have 10 days from the date of the appeal to issue a final decision and provide documentation of that decision to the Provider and parties.

C. If the Payer is upholding a denial for medical reasons, the Payer shall have all the submitted documentation reviewed by a Provider that meets the requirements of section 16-7-1(B)(2)(a).

D. In the event of continued disagreement, the parties should follow dispute resolution and adjudication procedures available through the Division or the Office of Administrative Courts.

E. An urgent need for Prior Authorization of health care services, as recommended in writing by an ATP, shall be deemed good cause for an expedited hearing.

16-8 REQUIRED USE OF THE FEE SCHEDULE

A. All Providers and Payers shall use the Medical Fee Schedule to determine the maximum allowable payments for any medical treatments or services within the purview of the Workers' Compensation Act of Colorado and the Colorado Workers' Compensation Rules of Procedure, unless one of the following exceptions applies:

1. If billed charges are less than the fee schedule, the payment shall not exceed the billed charges.

2. The Payer and an out-of-state Provider may negotiate reimbursement in excess of the fee schedule when required to obtain reasonable and necessary care for an injured worker.

3. Pursuant to § 8-67-112(3), the Uninsured Employer Board may negotiate rates of reimbursement for Providers.

B. The Medical Fee Schedule does not limit the billing charges.

C. Payment for treatment not identified or identified but without established value in the Medical Fee Schedule shall require Prior Authorization, except for when the treatment is an emergency. Similar established code values from the Medical Fee Schedule, determined in compliance with section 16-10-1 B, shall govern payment.

16-8-1 REQUIRED BILLING FORMS AND CODES

A. Effective January 1, 2026, all Payers (excluding self-insured employers) shall accept electronic bills and acknowledge receipt of a complete electronic medical bill (837) by retuning an acknowledgement within two working days of submission to the submitting party.

Payers must provide an electronic remittance advice (835) no later than 30 days after receipt of a complete electronic medical bill or within five days of generating a payment. This requirement applies only to the date the electronic remittance advice is sent and does not modify the medical bill processing timeframes outlined in 16-10.

B. Effective January 1, 2026, all Providers or their billing representative submitting 25 or more workers' compensation medical bills per month shall submit these via a HIPAA compliant electronic transaction, to Payers that have established connectivity to the Provider's system or clearinghouse. Providers must follow the Payer's requirements for submission of attachments, whether by electronic submission, mail, fax, email or web upload. When medical bills are submitted electronically, Providers shall not submit a duplicate paper form of the medical bill to the Payer.

C. The national standard formats for billing, remittance and acknowledgements are those adopted by the United States Department of Health and Human Services rules (45 CFR Parts 160 and 162). The formats adopted under this Rule that are aligned with the current federal HIPAA implementation and the IAIABC standard include:

X12N/005010X222A1 Health Care Claim: Professional (837);

X12N/005010X223A2 Health Care Claim: Institutional (837);

X12N/005010X224A2 Health Care Claim: Dental (837);

X12N/005010X221A1 Health Care Claim Payment/Advice (835);

X12N/005010X212 Health Care Claim Status Request and Response (276/277);

X12N005010TA1 Interchange Acknowledgment;

X12C005010X231 Implementation Acknowledgment for Health Care Insurance (999);

X12N005010X214 Health Care Claim Acknowledgment (277);

NCPDP Telecommunication Standard Implementation Guide Version D.0; and

NCPDP Batch Standard Implementation Guide 1.2.

The following acknowledgement formats and the attachment format have not been adopted in the current HIPAA rules but are also based on X12 standards:

1. The X12N/005010X213 Request for Additional Information (277) is used to request additional attachments that were not originally submitted with the electronic medical bill.

2. The X12N/005010X210 Additional Information to Support a Health Care Claim or Encounter (275) is used to transmit electronic documentation associated with an electronic medical bill. The 005010X210 can accompany the original electronic medical bill, or may be sent in response to a 005010X213 Request for Additional Information.

The NCPDP Telecommunication Standard Implementation Guide Version D.0 contains the corresponding request and response messages to be used for pharmacy transactions.

D. Providers shall use only the billing formats and forms listed or exact electronic form reproductions. If the Payer agrees, Providers may place identifying information in the margin of the form. Payment for any service not billed in the format or on the forms identified may be denied.

1. An 837P file or CMS-1500 Form shall be used when billing for professional services, DMEPOS, and ambulance services, unless otherwise specified. Providers shall provide their name and credentials in segment CLM06 in an 837P file or item 31 of the CMS-1500 Form. Non-hospital based ASCs may bill using an 837P file or the CMS-1500 Form, however an SG modifier must be appended to the technical component of services to indicate a facility charge and to qualify for reimbursement as a facility claim.

When resubmitting a claim, Providers must append the appropriate frequency code in segment CLM05-3 with the claim control number in segment REF02 in an 837P file, or resubmission code in item 22 of the CMS-1500 Form along with the original claim number:

1 - original claim (duplicate of a previously submitted that was never processed)

7 - replacement/corrected claim (previously adjudicated with new or amended information)

8 - void/cancel prior claim (previously paid claim that was submitted in error)

2. An 837I file or a UB-04 Form shall be used by all hospitals and facilities meeting definitions found in section 16-2, hospital-based ambulance, and hospital-based ASCs.

a. Some outpatient hospital therapy services may also be billed on an 837I file or a UB-04 Form. For these services, the bill must have Form Locator Type 13x, 074x, 075x, or 085x, and one of the following revenue codes:

042X - Physical Therapy

043X - Occupational Therapy

044X - Speech Therapy

b. When resubmitting a claim, Providers must append the appropriate value in segment CLM05-3 and document control number in segment REF01 in an 837I file or item 64 of the UB-04 Form:

XX7 - correction/replacement or prior claim

XX8 - void/cancel of prior claim

3. An 837D or American Dental Association's Dental Claim Form, Version 2019 or 2024 shall be used by all Providers billing for dental treatment.

4. The Telecommunication Standard Implementation Guide, Version D.0, or the NCPDP (National Council for Prescription Drug Programs) Workers' Compensation/Property and Casualty Universal Claim Form, version 1.1 shall be used by dispensing pharmacies.

5. Payers and Providers may exchange electronic data in a non-prescribed format by mutual agreement. All data elements required in the Division prescribed formats must be present in a mutually agreed upon format.

6. An invoice or other agreed upon form may be used for services incident to medical treatment, such as guardian ad litem and conservator services, language interpreting, or mileage reimbursement.

E. Provider bills shall list the International Classification Diseases, Tenth Revision (ICD-10) Clinical Modification (CM) diagnosis code(s) that are current, accurate, and specific to each patient encounter, in accordance with the ICD-10-CM Chapter Guidelines provided by CMS (Centers for Medicare & Medicaid Services). Bills should include the External Causes code(s). ICD-10 codes shall not be used as a sole factor to establish work-relatedness of an injury or treatment.

F. Providers must accurately report their services using applicable billing codes, modifiers, instructions, and parenthetical notes as incorporated by reference in Rule 18. The Provider may be subject to penalties for inaccurate billing when the Provider knew or should have known that the treatment billed was inaccurate, as determined by the Director or an administrative law judge.

G. National provider identification (NPI) numbers are required for WC bills. Provider types ineligible to obtain NPI numbers are exempt from this requirement. The NPI shall be that of the rendering Provider and shall include the correct place of service code(s) at the line level.

16-8-2 TIMELY FILING

A. Providers shall submit their bills for treatment rendered within 120 days of the date of service or the bill may be denied unless extenuating circumstances exist.

1. For bills submitted through electronic data interchange (EDI), Providers may prove timely filing by showing a Payer acknowledgement (claim accepted). Rejected claims or clearinghouse acknowledgement reports are not proof of timely filing.

2. For paper bills, Providers may prove timely filing with a signed certificate of mailing listing the original date mailed and the Payer's address; a fax acknowledgement report; or a certified mail receipt showing the date the Payer received the bill.

3. All timely filing issues will be considered final 10 months from the date of service unless extenuating circumstances exist.

B. Injured workers shall submit requests for mileage reimbursement within 120 days of the date of service or reimbursement may be denied unless good cause exists.

C. Extenuating circumstances/good cause may include, but are not limited to, delays in compensability being determined or the party has not been informed of this benefit or where to send the bill.

16-9 REQUIRED MEDICAL RECORD DOCUMENTATION

A. The treating Provider shall maintain medical records for each injured worker when billing for the provided treatment. The rendering Provider shall sign the medical records. Electronic signatures are accepted.

B. All medical records shall legibly document the treatment billed and shall include at least the following information:

1. Patient's name;

2. Date of treatment;

3. Name and professional designation of person providing treatment;

4. Assessment or diagnosis of current condition with appropriate objective findings;

5. Treatment provided;

6. Treatment plan, when applicable; and

7. If being completed by an authorized treating physician, all pertinent changes to work and or activity restrictions which reflect lifting, standing, stooping, kneeling, hot or cold environment, repetitive motion or other appropriate physical considerations.

C. All treatment provided to injured workers is expected to be documented in the medical record at the time it is rendered. Occasionally, certain entries related to treatment provided are not made timely. In this event, the documentation will need to be amended, corrected, or entered after rendering treatment. Amendments, corrections, and delayed entries must comply with Medicare's widely accepted recordkeeping principles as outlined in the Medicare Program Integrity Manual Chapter 3, section 3.3.2.5, implemented August 2020. (This section does not apply to injured workers' requests to amend records as permitted by the Health Insurance Portability and Accountability Act (HIPAA)).

D. The ATP must sign (or counter sign) and submit to the Payer, within 14 days of the initial and final visit, a completed WC 164 Form.

1. The Form shall be completed as an "initial" report when the injured worker has the initial visit with the Designated Physician, or in the case of a transfer of care, the new Designated Physician. If applicable, the emergency department (ED) or urgent care physician initially treating the injury may also complete a WC 164 initial report. In such cases, the initial report from the ED or urgent care physician, and the Designated Physician shall be reimbursed. Unless requested or prior authorized by the Payer, no other physician should complete and bill for the WC 164 initial report. See Rule 18 for required fields.

2. The Form shall be completed as a "closing" report when the ATP managing the total WC claim determines the injured worker has reached maximum medical improvement (MMI) for all covered injuries or diseases, with or without permanent impairment. See Rule 18 for required fields.

3. The ATP shall supply the injured worker with a copy of the WC 164 at the time of completion, at no charge.

E. Providers other than hospitals shall provide the Payer with all supporting documentation and treatment records at the time of billing unless the parties have made other agreements. Hospitals shall provide documentation to the Payer upon request. Payers shall specify what portion of a hospital record is being requested (for example, only the ED chart notes, in-patient physician orders and chart notes, x-rays, pathology reports, etc.). The Payer may deny payment for billed treatment until the Provider submits the required medical documentation.

16-10 PAYMENT REQUIREMENTS FOR MEDICAL BILLS

A. All bills submitted by a Provider are due and payable in accordance with the Medical Fee Schedule within 30 days after receipt by the Payer, unless the Payer provides timely and proper reasons set forth by section 16-10-2 or 3.

B. For every medical treatment bill submitted by a Provider, the Payer shall reply with a written notice (explanation of benefits) within 30 days of receipt of the bill that includes the following:

1. Injured worker's name;

2. Payer's name and address;

3. Date(s) of service;

4. Each procedure code billed; and

5. Amount paid.

C. If any adjustment is made to the amount submitted on the bill, the Payer's written notice shall also include:

1. Payer's claim number and/or Division's WC number;

2. Specific identifying information coordinating the notice with any payment instrument associated with the bill;

3. Notice that the billing party may submit a corrected bill or an appeal within 60 days;

4. Name of insurer with admitted, ordered, or contested liability for the WC claim, when known;

5. Name and address of any third-party administrator (TPA) and/or bill reviewer associated with processing the bill;

6. Name and contact information of a person who has responsibility and authority to discuss and resolve disputes on the bill;

7. Name and address of the employer, when known;

8. For compensable treatment related to a work injury, the Payer shall notify the billing party that the injured worker shall not be balance-billed;

9. If applicable, a statement that the payment is being held in abeyance because a hearing is pending on a relevant issue.

D. Any written notice that fails to include the required information is defective and does not satisfy the 30-day notice requirement.

E. If the Payer discounts a bill and the Provider requests clarification in writing, the Payer shall furnish to the requester the specifics of the discount within 30 days, including a copy of any contract relied upon for the discount. If no response is forthcoming within 30 days, the Payer must pay the maximum Medical Fee Schedule allowance or the billed charges, whichever is less.

F. The Payer must offer at least one method of payment to the Provider that does not require an associated fee and shall not restrict the method or form of payment so that the only acceptable method is a credit card payment. If the Payer initiates a payment using electronic funds transfer, including virtual credit card payments, the Payer shall:

1. Notify the Provider if any fee is associated with a particular payment method; and

2. Advise the Provider of the available payment methods and provide clear instructions as to how to select an alternative.

G. Date of bill receipt by the Payer may be established by the Payer's date stamp or electronic acknowledgment date required by Rule 4; otherwise, receipt is presumed to occur five days after the date the bill was mailed to the Payer's correct address.

H. Payers shall reimburse injured workers for mileage expenses as required by statute or provide written notice of the reason(s) for denying reimbursement within 30 days of receipt.

I. An injured worker shall never be required to directly pay for admitted or ordered medical benefits covered under the Workers' Compensation Act. In the event the injured worker has directly paid for medical treatment that is then admitted or ordered under the Workers' Compensation Act, the Payer shall reimburse the injured worker for the amounts actually paid for authorized treatment within 30 days of receipt of the bill. If the actual costs exceed the maximum fee allowed by the Medical Fee Schedule, the Payer may seek a refund from the Provider for the difference between the amount charged to the injured worker and the maximum fee.

16-10-1 MODIFIED, UNLISTED, AND UNPRICED CODES

A. Prior to modifying a billed code, the Payer must contact the billing Provider and determine if the code is accurate. If the Payer disagrees with the level of care billed, the Payer may deny the claim or contact the Provider to explain why the billed code does not meet the level of care criteria.

1. If the billing Provider agrees with the Payer, then the Payer shall process the service with the agreed upon code and shall document on the written notice the agreement with the Provider. The written notice shall include the name of the party at the billing office who made the agreement.

2. If the billing Provider disagrees with the Payer, then the Payer shall proceed with a denial.

B. When no established fee is identified in the Medical Fee Schedule and the Payer agrees the service or procedure is reasonable and necessary, the Payer shall list on the written notice one of the following payment options.

1. Payment based on a similar established code value as recommended by the billing Provider.

2. A reasonable value based upon a similar established code value as determined by the Payer.

If the Payer disagrees with the billing Provider's recommended code value, the denial shall include an explanation of why the requested fee is not reasonable, identification of the similar code as determined by Payer, and how the Payer calculated its fee recommendation. If the Provider disagrees with the Payer's determination, it can follow the process for appealing billed treatment denials.

16-10-2 DENYING PAYMENT OF BILLED TREATMENT FOR NON-MEDICAL REASONS

A. Non-medical reasons are administrative issues that do not require medical documentation review other than to verify the appropriate use of a billed code. Examples of non-medical reasons for denying payment include the following: no WC claim has been filed with the Payer; compensability has not been established; the Provider is not authorized to treat; the insurance coverage is at issue; typographic or date errors on the bill; failure to submit medical documentation; or unrecognized or improper use of a CPT® code.

B. If an ATP bills for medical treatment and indicates in writing, including reasoning and relevant documentation that the medical services are related to the admitted WC claim, the Payer cannot deny payment solely for relatedness without a medical opinion as required by section 16-10-3. The medical review, IME report, or report from an ATP that addresses the relatedness of the requested treatment to the admitted claim may precede the date of service, unless the requesting physician presents new evidence as to why treatment is now related.

C. In all cases where a billed treatment is denied for non-medical reasons, the Payer's written notice shall include all notice requirements set forth in sections 16-10 B and C, and shall also include:

1. Reference to each code being denied; and

2. Clear and persuasive reasons for denying payment, including citation of appropriate statutes, rules, and/or documents supporting the Payer's reason(s).

D. If after the treatment was provided, the Payer agrees the service was reasonable and necessary, lack of prior authorization does not warrant denial of payment. However, the Provider may still be required to provide additional supporting documentation as outlined in section 16-7 for a complete Prior Authorization request.

16-10-3 DENYING PAYMENT OF BILLED TREATMENT FOR MEDICAL REASONS

A. The Payer shall have the bill and all supporting medical documentation reviewed by a Physician who holds a license and is in the same or similar specialty as would typically manage the medical condition or treatment under review. The Physician shall be Level I or II Accredited. In addition, a clinical Pharmacist (Pharm.D.) may review billed services for medications, and a Psychologist may review billed services for mental health, without having received Level I or II Accreditation. After reviewing the supporting medical documentation, the reviewing Provider may call the billing Provider to expedite communication and timely processing of the bill.

B. In all cases where a billed treatment is denied for medical reasons, the Payer's written notice shall include all notice requirements set forth in sections 16-10 B and C, and shall also include:

1. Reference to each code being denied;

2. Clear and persuasive medical reasons for denying payment, including the name and professional credentials of the Provider performing the medical review and a copy of the reviewer's opinion;

3. Citation from the MTGs, when applicable; and

4. Identification of additional information deemed likely to influence reconsideration, when applicable.

16-10-4 APPEALING BILLED TREATMENT DENIALS

A. The billing party shall have 60 days from the date of the written notice to request reconsideration. The billing party's appeal must include:

1. A copy of the original or corrected bill with condition code W3;

2. A copy of the written notice;

3. Identification of the specific code being appealed; and

4. Clear and persuasive reason(s) for the appeal, including additional supporting documentation when applicable.

B. If the billing party appeals the denial in compliance with above requirements, the Payer shall:

1. When denied for non-medical reasons, have the bill and all supporting documentation reviewed by a person who has knowledge of the bill. After reviewing the Provider's appeal, the reviewer may call the appealing party to expedite the communication and timely processing of the appeal.

2. When denied for medical reasons, have the bill and all supporting documentation reviewed by a Physician who holds a license and is in the same or similar specialty as would typically manage the medical condition or treatment under review. The Physician shall be Level I or II Accredited. In addition, a clinical pharmacist (Pharm.D.) may review appeals for payment of medications and a Psychologist may review appeals for payment of mental health services without having received Level I or II Accreditation. After reviewing the supporting medical documentation, the reviewing Provider may call the appealing Provider to expedite communication and timely processing of the appeal.

3. If after reviewing the appeal the Payer agrees with the billing party, payment for treatment is due and payable in accordance with the Medical Fee Schedule within 30 days of receipt of the appeal. Date of receipt may be established by the Payer's date stamp or electronic acknowledgment date required by Rule 4; otherwise, receipt is presumed to occur five days after the date the response was mailed to the Payer's correct address.

4. If after reviewing the appeal the Payer upholds its denial, the Payer shall send the billing party written notice within 30 days of receipt of the appeal. The written notice shall include all notice requirements set forth in sections 16-10 B and C, and shall also include:

a. Reference to each code being denied;

b. Clear and persuasive medical or non-medical reasons for upholding the denial, including the name and professional credentials of the reviewer and a copy of the reviewer's opinion when medically based;

c. Citation of appropriate statutes, rules, and/or documents supporting the Payer's reason(s).

5. In the event of continued disagreement, the parties should follow dispute resolution and adjudication procedures available through the Division or the Office of Administrative Courts. The parties shall do so within 12 months of the date of the original bill should have been processed in compliance with section 16-10, unless extenuating circumstances exist.

16-11 RETROACTIVE REVIEW OF MEDICAL BILLS

A. All medical bills shall be considered final at 12 months after the date of the original written notice unless the Provider is notified that:

1. A hearing is requested within the 12-month period; or

2. A request for utilization review has been filed pursuant to § 8-43-501.

B. If the Payer conducts a retroactive review to recover overpayments from a Provider based on non- medical reasons, the Payer shall send the billing party written notice that includes all notice requirements set forth in sections 16-10 B and C, and shall also include:

1. Reference to each item of the bill for which the Payer seeks to recover payment:

2. Clear and persuasive reason(s) for seeking recovery of overpayment(s), including citation of appropriate statutes, rules and/or documents supporting the Payer's reason(s).

3. Evidence that these payments were in fact made to the Provider.

C. If the Payer conducts a retroactive review to recover overpayments from a Provider based on medical reasons, the Payer shall have the bill and all supporting documentation reviewed by a Physician who holds a license and is in the same or similar specialty as would typically manage the medical condition or treatment under review. The Physician shall be Level I or II Accredited. In addition, a clinical pharmacist (Pharm.D.) may review billed medications, and a Psychologist may review billed services for mental health, without having received Level I or II Accreditation. The Payer shall send the billing party written notice that includes all notice requirements set forth in sections 16-10 B and C, and 16-11 B.

D. In the event of disagreement, the parties may follow dispute resolution and adjudication procedures available through the Division or the Office of Administrative Courts.

16-11-1 ONSITE REVIEW OF HOSPITAL OR MEDICAL FACILITY CHARGES

A. If the Payer conducts a review of billed and non-billed hospital or medical facility charges related to a specific workers' compensation claim, the Payer shall comply with the following procedures:

1. Within 30 days of receipt of the bill, send written notification to the hospital or medical facility of its intent to conduct a review. Notification shall include the following information:

a. Name of the injured worker;

b. Division's WC number and/or hospital or medical facility patient identification number;

c. An outline of the items to be reviewed; and

d. Name and contact information of a person designated by the Payer to conduct the review, if applicable.

B. The reviewer shall comply with the following procedures:

1. Obtain a signed release of information form from the injured worker;

2. Negotiate with the hospital or medical facility on a starting date for the review;

3. Assign staff members who are familiar with medical terminology, general hospital or medical facility charging, and medical documentation procedures or have a level of knowledge equivalent at least to that of an LPN;

4. Establish a schedule for the review which shall include, at a minimum, the dates for the delivery of preliminary findings to the hospital or medical facility, a 14 day response period for the hospital or medical facility, the delivery of an itemized list of any discrepancies, and an exit conference upon completion of the review; and

5. Provide the Payer and hospital or medical facility with a written summary of the review within 30 days of the exit conference.

C. The hospital or medical facility shall comply with the following procedures:

1. Allow the review to begin within 30 days from the Payer's notification;

2. Upon receipt of the injured worker's signed release of information form, allow the reviewer access to all items identified on the form;

3. Designate an individual to serve as the primary liaison between the hospital or medical facility and the reviewer, who will acquaint the reviewer with the documentation and charging practices of the hospital or medical facility;

4. Provide a written response to each preliminary review finding within 14 days of receipt of those findings; and

5. Participate in the exit conference in an effort to resolve any discrepancies.

16-12 DISPUTE RESOLUTION PROCESS

When seeking dispute resolution from the Division's Medical Dispute Resolution Unit, the requesting party must complete the Division's "Medical Dispute Resolution Intake Form" (WC 181) found on the Division's web page. The items listed on the bottom of the Form must be provided at the time of submission. If necessary items are missing or if more information is required, the Division will forward a request for additional information and initiation of the process may be delayed.

When the request is properly made and the supporting documentation submitted, the Division will confirm receipt. If, after reviewing the materials, the Division believes the dispute criteria have not been met, the Division will issue an explanation of those reasons. If the Division determines there is cause for facilitating the disputed items, the other party will be sent a notice requiring response within 14 days.

The Division will facilitate the dispute by reviewing the parties' compliance with Rules 11, 16, 17, and 18 within 30 days of receipt of the complete supporting documentation; or as soon thereafter as possible. In addition, the Payer shall pay interest at the rate of eight percent per annum in accordance with § 8-43-410(2), upon all sums not paid timely and in accordance with the Division Rules. The interest shall be paid at the same time as any delinquent amount(s).

Upon review of all submitted documentation, disputes resulting from violation of Rules 11, 16, 17, and 18, as determined by the Director, may result in a Director's Order that cites the specific violation.

Evidence of compliance with the order shall be provided to the Director. If the party does not agree with the findings, it shall state with particularity and in writing its reasons for all disagreements by providing a response with all relevant legal authority, and/or other relevant proof in support of its position(s).

Failure to respond or cure violations may result in penalties in accordance with § 8-43-304. Daily fines up to $1,000/day for each such offense will be assessed until the party complies with the Director's Order.

Resolution of disputes not pertaining to Rule violations will be facilitated by the Division to the extent possible. In the event both parties cannot reach an agreement, the parties will be provided additional information on pursuing resolution and adjudication procedures available through the Office of Administrative Courts. Use of the dispute resolution process does not extend the 12-month application period for hearing.

7 CCR 1101-3-17-16

37 CR 13, July 10, 2014, effective 7/30/2014

38 CR 01, January 10, 2015, effective 2/1/2015

38 CR 05, March 10, 2015, effective 4/1/2015

38 CR 11, June 10, 2015, effective 7/1/2015

38 CR 17, September 10, 2015, effective 1/1/2016

39 CR 04, February 25, 2016, effective 3/16/2016

39 CR 13, July 10, 2016, effective 7/30/2016

39 CR 16, August 25, 2016, effective 9/14/2016

39 CR 19, October 10, 2016, effective 1/1/2017

40 CR 03, February 10, 2017, effective 3/2/2017

40 CR 11, June 10, 2017, effective 7/1/2017

40 CR 21, November 10, 2017, effective 11/30/2017

40 CR 18, September 25, 2017, effective 1/1/2018

40 CR 20, October 25, 2017, effective 1/1/2018

41 CR 11, June 10, 2018, effective 7/1/2018

41 CR 19, October 10, 2018, effective 1/1/2019

41 CR 20, October 25, 2018, effective 1/1/2019

41 CR 23, December 10, 2018, effective 1/1/2019

42 CR 01, January 10, 2019, effective 1/30/2019

42 CR 11, June 10, 2019, effective 6/30/2019

42 CR 12, June 25, 2019, effective 7/15/2019

42 CR 21, November 10, 2019, effective 11/30/2019

42 CR 20, October 25, 2019, effective 1/1/2020

42 CR 23, December 10, 2019, effective 1/1/2020

43 CR 03, February 10, 2020, effective 1/1/2020

43 CR 07, April 10, 2020, effective 4/30/2020

43 CR 11, June 10, 2020, effective 7/1/2020

43 CR 16, August 25, 2020, effective 10/14/2020

43 CR 21, November 10, 2020, effective 1/1/2021

44 CR 07, April 10, 2021, effective 4/30/2021

44 CR 08, April 25, 2021, effective 7/1/2021

44 CR 13, July 10, 2021, effective 7/30/2021

44 CR 20, October 25, 2021, effective 1/1/2022

44 CR 23, December 10, 2021, effective 1/1/2022

44 CR 23, December 10, 2021, effective 1/10/2022

45 CR 01, January 10, 2022, effective 1/30/2022

45 CR 11, June 10, 2022, effective 7/1/2022

45 CR 13, July 10, 2022, effective 8/10/2022

45 CR 21, November 10, 2022, effective 12/6/2022

46 CR 01, January 10, 2023, effective 12/6/2022

45 CR 19, October 10, 2022, effective 1/1/2023

46 CR 02, January 25, 2022, effective 1/1/2023

46 CR 02, January 25, 2023, effective 3/2/2023

46 CR 05, March 10, 2023, effective 3/30/2023

47 CR 21, November 10, 2024, effective 1/1/2025