Section 17.01.01.010 - DEFINITIONSThe definitions set forth in Chapter 72, Idaho Code apply to these rules. In addition, the following terms have the meaning set forth below:
01.Adjustor. Means an individual who adjusts worker's compensation claims.02.Ambulatory Payment Classification. Means the payment system adopted by CMS for outpatient services03.Available Funds. Means a sum of money to which a Charging Lien may attach. It does not include any compensation paid or not disputed to be owed prior to Claimant's agreement to retain the attorney.04.Ambulatory Surgery Center. Means a facility providing medical services on an outpatient basis only.05.Approval by Commission. Means the Commission has approved attorney fees in conjunction with an award of compensation or an LSS or otherwise in accordance with Section 802 of this rule upon a proper showing by the attorney seeking to have the fees approved.06.Average Wholesale Price. Means the average wholesale price for medicine obtained from pricing data provided by the original manufacturer of that medicine to industry-wide compilers of drug prices, e.g., Red Book and Medi-Span.07.Charge. Means the expense or cost. For hospitals and ASCs, "charge" means the total charge.a. Acceptable charge. Means a charge calculated in compliance with Section 803 of this rule or as billed by the Provider, whichever is lower, or the charge agreed to pursuant to a written contract.b. Customary charge. Means a charge that has an upper limit no higher than the 90th percentile, as determined by the Commission, of usual charges made by Idaho Providers for a given medical service.c. Reasonable charge. Means a charge that does not exceed the Provider's "usual" charge and does not exceed the "customary" charge.d. Usual charge. Means the most frequent charge made by an individual Provider for a given medical service to non-industrially injured patients.08.Charging Lien. Means a lien against a Claimant's right to any compensation under the Worker's Compensation Law, which may be asserted by an attorney who is able to demonstrate that: a. There are compensation benefits available for distribution on equitable principles;b. The services of the attorney operated primarily or substantially to secure the fund out of which the attorney seeks to be paid;c. It was agreed that counsel anticipated payment from compensation funds rather than from the client;d. The Claim is limited to costs, fees, or other disbursements incurred in the case through which the fund was raised; ande. There are equitable considerations that necessitate the recognition and application of the Charging Lien.09.Claim. Means filing for worker's compensation benefits through a Form 1A-1, First Report of Injury or Illness (FROI) or an application for hearing, referred to as a Complaint, with the Commission.10.Claims Administrator. Means an organization, including insurers, third party administrators, independent adjusters, or self-insured employers, that services worker's compensation claims.11.Claimant. Means a person who has filed a Claim for worker's compensation benefits and includes their agents, such as attorneys.12.Commission. Means the Idaho Industrial Commission.13.Critical Access Hospital. Means a hospital currently designated as a critical access hospital by CMS.14.Current Procedural Terminology. Means the medical code published by the American Medical Association.15.Death Claim. Means a Claim arising from the death of a worker as a result of a work-related injury or occupational disease.16.Electronic Data Interchange. Means a computer to computer exchange of data in a standardized format.17.Fee Agreement. Means a written agreement between a worker and an attorney in conformity with the Idaho Rules of Professional Conduct. a. Reasonable, as used in Section 802 of this rule, means that an attorney's fees are consistent with the fee agreement and are to be satisfied from Available Funds, subject to the element of reasonableness contained in Idaho Rules of Professional Conduct 1.5.18.First Degree of Consanguinity. Means the relationship between parents and their children whether related by blood or affinity. Adopted or step children and their adoptive or step parents are deemed to be within the first degree of consanguinity.19.First Report of Injury. Means the first filing of information with the Industrial Commission that a reportable workplace injury has occurred or an occupational disease has been manifested, as required by Section 72-602(1), Idaho Code; filed in accordance with these rules.20.Gross Direct Premiums Written. Means the gross sum of premiums on policies written, without any deduction for refunds or repayments resulting from cancellations. It does not include premiums on contracts between insurers or reinsurers. For all policies written, gross direct premiums written may reflect experience modifications, deviations, and retrospective rating.21.Healthcare Common Procedure Coding System. Means the set of healthcare procedure codes based on the American Medical Association's Current Procedural Terminology.22.Hospital. Means an acute care facility providing medical or rehabilitation services on an inpatient and outpatient basis.23.IAIABC EDI Release 3.0 or 3.1. Means the IAIABC authored EDI Claims Release 3.0 or 3.1 standards that cover the transmission of claims (FROI and SROI) information through electronic reporting.24.Impairment Rated Claim. Means those claims in which the Provider establishes an impairment rating for the injured worker.25.Implantable Hardware. Means objects or devices that are made to support, replace, or act as a missing anatomical structure or to support or manage proper biological functions or disease processes and where surgical or medical procedures are needed to insert or apply such devices and surgical or medical procedures are required to remove such devices. The term also includes equipment necessary for the proper operation of the implantable hardware, even if not implanted in the body.26.Indemnity Benefits. Means payments made to or on behalf of worker's compensation Claimants, including temporary or permanent total or partial disability benefits, death benefits paid to dependents, retraining benefits, and any other type of income benefits, but excluding medical and related benefits.27.Indemnity Claim. Means any claim made for the payment of indemnity benefits.28.Legacy Claim. Means a FROI that was either filed on paper or electronically prior to the EDI Claims Release 3.1 implementation.29.Litigated Case. Means a case in which a complaint has been filed.30.Medical Only Claim. Means the injured worker will not suffer a disability lasting more than five (5) calendar days as a result of a job-related injury or occupational disease, nor be admitted to a hospital as an inpatient.31.Medical Report. Means and includes without limitation, all bills, chart notes, surgical records, testing results, treatment records, hospital records, prescriptions, and medication records.32.Medicare Severity - Diagnosis Related Group. Means a system adopted by CMS that groups hospital admissions based on diagnosis codes, surgical procedures, and patient demographics.33.Net Premiums Written. Means the amount of gross direct premiums on policies written less returned premiums and premiums on policies not taken. Paid dividends shall not be deducted for the purposes of calculating net premiums written.34.Payor. Means the entity that is responsible for making payment to a Provider for services rendered to treat an industrially injured patient and includes self-insured employers, sureties, adjusters, and their agents.35.Payroll. Means the gross amount paid by an employer for salaries, wages, or commissions earned by its own direct employees, but not including any money paid to another entity or received from another entity for leased employees.36.Pharmacy. Means a facility as defined in Section 54-1705(29), Idaho Code.37.Supplemental or Subsequent Report of Injury. Means the filing of additional information with the Industrial Commission, regarding benefits paid or changes in the status or condition of an injured worker, of a Claim for benefits, as required by Sections 72-602(2), (3), and (4), Idaho Code; filed in accordance with these rules.38.Termination of Disability. Means the date upon which the obligation of the Employer/Surety becomes certain as to duration and amount whether by settlement, decision, or periodic payments in the ordinary course of claims processing. If resolved by LSS, the termination of disability shall occur on the date the LSS is approved and an order approving is filed by the Industrial Commission. If resolved by decision, the termination of disability shall occur on the date the decision resolving all issues becomes final.39.Time Loss Claim. Means the injured worker will suffer, or has suffered, a disability that lasts more than five (5) calendar days as a result of a job-related injury or occupational disease, or the injured worker requires, or required, in-patient treatment as a result of such injury or disease.40.Trading Partner. Means an insurance carrier, self-insured employer, or Claims Administrator that has entered into a Trading Partner Agreement with the Industrial Commission.41.Trading Partner Agreement. Means an agreement between the Industrial Commission and a Trading Partner that sets out the terms and conditions for the electronic reporting of information to the Commission.Idaho Admin. Code r. 17.01.01.010