Rule 50 - DISPUTES REGARDING PAYMENT FOR HEALTH OR REHABILITATION SERVICESA. General: Disputes regarding payment for health or rehabilitation services rendered pursuant to the Workers' Compensation Code may be addressed as set out in this rule. A Form 18 proceeding is a review of disputed medical charges by the Court Administrator when there are conflicting interpretations of the Schedule of Medical and Hospital Fees. A Form 19 proceeding may involve judicial resolution of disputed charges for health services. Mediation refers to a process of resolving disputes with the assistance of a mediator outside of a formal court proceeding.B. Jurisdictional requirement: No Form 18 or Form 19 will be processed by the Workers' Compensation Court unless a Form 2, 3, 3A or 3B is filed with the Court; provided, a Form 18 may be processed if the payer's legal representative executes and provides the Court with a submission to limited jurisdiction.C. Payment for medical care required by the Workers' Compensation Code is due within forty-five (45) days of the employer's or insurance carrier's receipt of a complete and accurate invoice. The late payment of medical charges, absent good cause, may subject the payer to a Court ordered penalty, payable to the provider, of up to twenty-five percent (25%) of any amount due under the Court's Schedule of Medical and Hospital Fees that remains unpaid. The Court also may assess a civil penalty of up to Five Thousand Dollars ($5,000.00) per occurrence if the Court finds a payer has engaged in a pattern of willfully and knowingly delaying payments for medical care, payable as directed by the Court.D. Form 18 Proceedings: 1. Disputes arising after a medical charge has been paid, involving conflicting interpretations of the Schedule of Medical and Hospital Fees may be addressed by filing a Form 18. A copy of the Form 18 and all supplemental materials, including the specific general instruction, ground rule, or other provision of the Schedule of Medical and Hospital Fees serving as the basis for the requested reimbursement, shall be sent by the medical provider to the employer or its insurance carrier if insured. A copy of the actual medical bill in dispute must include dates of service, procedure codes, charges for services rendered and any payment received, and an explanation of unusual services or circumstances. Once appropriate jurisdictional requirements are met, the Administrator shall notify all parties of the right within thirty (30) days to submit further evidence, documentation or clarifications as part of the Form 18 review. The payer must submit a written explanation of benefits to the Administrator that states clear and persuasive reasons for contesting the payment of any item specific to the medical provider's billing, including the citing of the appropriate specific general instruction, ground rule, or other provision of the Schedule of Medical and Hospital Fees supporting the payer's reasons for contesting payment. The Administrator may schedule a hearing with all parties before rendering an order disposing of the Form 18 issue. The Administrator may refer the Form 18 matter to a regularly assigned judge of the Court for fact finding and determination and possible imposition of sanctions against a payer for failure for good cause to pay for medical care within forty-five (45) days of receipt of a complete and accurate invoice, for a pattern of delayed payment for medical care, or for inappropriate use of the Form 18 process.2. Either party aggrieved by the Administrator's order directing or denying the payment of medical charges may appeal such order to a judge of the Workers' Compensation Court by filing a Form 19 and a Form 9 within ten (10) days after the Administrator's order is entered. The Form 19 must be appropriately marked to indicate that it is being used to appeal the Administrator's order. The following shall be attached to the Form 9 when filed:a. A copy of the order appealed from;b. Copies of all materials submitted to the Administrator in the review proceedings;c. A statement identifying each portion of the Administrator's order claimed to be in error; andd. An explanation of how each portion of the Administrator's order urged in error conflictswith the Schedule of Medical and Hospital Fees. The appealing party must mail a copy of all materials which are filed in the appeal to each opposing party. No response to the appeal of the Administrator's order is required.
E. Form 19 Proceedings: 1. A rehabilitation provider, case manager or a medical provider may institute proceedings to recover charges rendered for rehabilitation or health services, medicines or supplies which have been provided to a claimant, by the filing of a Form 19, Part I, if the provider has not received payment within forty-five (45) days of the employer's or insurance carrier's receipt of a complete and accurate invoice. A Form 19 may also be filed if the uninsured or own risk employer or insurance carrier has refused liability for the payment of the charges on one or more of the following grounds:b. Necessity of treatment;c. Unauthorized physician;d. Denial of compensability of the claimant's accidental injury or occupational disease; ore. Any other objection requiring a judicial determination for resolution.2. A provider may request a trial for a determination of the issues raised on the Form 19 by filing a Form 9. The provider shall mail a copy of the Form 9, together with a copy of the Form 19 and itemized bill(s), to the uninsured or own risk employer or insurance carrier in the case. The uninsured or own risk employer or insurance carrier shall file a Form 10M no later than thirty (30) days after the Form 9 is filed.3. A medical report signed by a physician shall be offered by both parties in any claim made for the payment or non-payment of medical services when the dispute involves the necessity of the medical services, including claims for treatment rendered in excess of applicable treatment guidelines.4. Audits of medical bills to determine the amount allowable under the appropriate Schedule of Medical and Hospital Fees may be offered by either party. Audits prepared by billing review services, medical bill audit services or in-house auditors may be submitted as evidence reflecting the methodology of the application of the Schedule of Medical and Hospital Fees. The Schedule of Medical and Hospital Fees sets maximum amounts allowable but does not prohibit a party from asserting a lesser amount should be paid.5. Form 19 hearings may be scheduled periodically for the Administrator's docket to determine the status of the payment of disputed rehabilitation, case management and medical charges. If the rehabilitation, case management or medical charges are not paid before the hearing or the parties are unable to resolve the dispute at the hearing, the dispute shall be assigned to a judge of the Workers' Compensation Court for hearing on the same date. All parties involved in a Form 19 hearing shall be prepared for trial on such disputed charges.F. Appearances: Appearances are governed by Rule 7.G. Mediation: Mediation is governed by Rule 52 and Rule 53.Okla. Stat. tit. 85, § 50
Adopted by order of the Supreme Court, 2002 OK 6 , eff. 3/1/2002; Renumbered from former Rule 24 and amended by order of the Supreme Court, 2006 OK 6, eff. 1/30/2006. Amended by order of the Supreme Court, 2012 OK 19, eff. 3/6/2012 .