Medical Services Flashcards
Which types of medical providers can be AP
Type A
Med Doctors, Doctor of Osteopathic Med, Oral and
Maxillofacial surgeons, Podiatric physicians and
surgeons
Type B
Chiropractors, naturopathic physicians and physician assistants (PA)
*** Nurse Practitioner can be used as an AP even though not listed
How many days of TL or office visits can a Type B provide for medical services
Medical Services - 60 days or 18 visits from first visit or date on initial claim
Time Loss (TL) - 30 days from date of office visit on initial claim
Which Type B provider can also rate impairment
Chiropractors
Can an ER Dr. authorize TL? For how long?
Yes, for up to 14 days from ER visit
Time period for medical provider to submit the 827 form to the insurer when initiating a claim for workers’ comp benefits
72 hours from office visit
Time period to notify insurer of change of Attending Physician (AP)
5 days from first treatment of new AP
How many days does insurer have to respond to a written request for diagnostic preauthorization
Within 14 days of receiving request from provider
How many days does a medical provider have to send medical records to the insurer
Within 14 days of request from insurer
How many days can a ANP provide medical services and/or authorize TL benefits
180 days from initial claim
How many AP can an IW have during the life of a claim
3
How many days do insurers have to pay medical bills on an accepted claim
45 from receipt of bill
How many days do insurers have to pay medical bills which were prior to the claim being accepted
14 days from acceptance
How many days do insurers have to pay worker reimbursements
30 days from receipt
What can a worker request for reimbursement
Meals
Lodging
use of public transportation
use of private vehicle
Prescriptions
Other out of pocket, claim related expenses
Time frame to request reimbursement
Two years from date of claim or when determined to be compensable
Purpose of an Managed Care Organizations (MCO)
To help manage medical services in a claim, ensure treatment is reasonable and necessary, assist with return to work (RTW) information and facilitate claim closure
Who does SAIF currently contract with for MCO
CareMark Comp (CMC)
Kaiser-on-the-job
Majoris Health Systems
What factors to consider for MCO
Disabling claim
Services offered by MCO
AP currently belongs to MCO
Complexity of medical conditions
IW location and access to medical services
Who approves the MCO and services certified
DCBS approves the MCO and all services are certified by Geographical Service Areas (GSA)
What is the purpose of a MCO treatment review
To review current and past course of medical treatment and provide the AP with recommendations with timelines and goals
When to consider a MCO treatment review
No clear diagnosis for ongoing complaints
No treatment plan
IW is not released to appropriate level of work
Treatment is ongoing without resolution
Excessive medication use (Opioid use)
IW may be delaying or stalling recovery
How many days notice does insurer give IW for an Independent Medical Exam (IME)
10 prior to appointment
Minimum days to send cover letter and medical records to IME physician
7 days prior to appointment
If IME has multiple examiners it must be completed within ___ hours to be considered one IME
72 hours
If an IW does not attend the IME what can you NOT do
Stop paying TL
Deny the claim
If an IW does not attend the IME what CAN you do
Request suspension of benefits from WCD or request a penalty
