Medical Services

Question 1

Type A Providers

Answer 1

• medical doctors
• doctors of osteopathic medicine
• oral and maxillofacial surgeons
• and podiatric physicians and surgeons.

Question 2

Type B Providers

Answer 2

• Chiropractors
• Naturopathic Physicians
• Physician Assistants

Question 3

Type B Medical Provider provide medical services for

Answer 3

60 days or 18 office visits from the date of the first visit on the initial claim

Question 4

Type B Medical Providers authorize time loss

Answer 4

30 days from the date of the first office visit

Question 5

What type B medical provider can rate impairment?

Answer 5

Chiropractors

Question 6

Can ER physician authorize time loss benefits? How long?

Answer 6

Yes and up to 14 days from ER visit

Question 7

When do medical providers need to submit form 827 when the worker is initiating a claim for work comp benefits?

Answer 7

72 hours

Question 8

How many days do medical providers have to submit the form 827 when notifying the insurer of a change in the AP?

Answer 8

5 days form first tx with new dr

Question 9

How many days does an insurer have to respond in writing to a written request for diagnostic preautho?

Answer 9

within 14 days of receiving the request from the provider

Question 10

How many days does a medical provider have to send medical records to the insurer?

Answer 10

within 14 days

Question 11

how many days can NP provide medical services?

Answer 11

180 days from the first visit on the initial claim

Question 12

How long can a NP quthorize time loss benefits?

Answer 12

180 days from the date of the first visit on the initial claim

Question 13

how many AP can a worker hav during the LIFE of a claim?

Answer 13

Three

Question 14

What are NOT considered changes by the choice of the worker?

Answer 14

• Emergency services by a physician
• Exams requested by the insurer
• Consultations or referrals for specialized treatment or services requested by AP
• Referrals to radiologists or pathologists for diagnostic studies
• When a worker is required to change providers because their medical service provider is no longer qualified as an AP or authorized to provide medical services
• Changes due to conditions beyond the worker’s control
• A Worker Requested Medical Exam (WRME)
• When AP works in a group setting or facility and worker is seen by another group member due to team practice, coverage, or on-call routines
• When the AP is not available and worker sees a covering physician

Question 15

How many days do insurers have to pay medical bills in an accepted claim?

Answer 15

45 days from recipet of bill

Question 16

How many days do insurers have to pay medical bills that were received prior to the claim decision once the claim has been accepted?

Answer 16

14 days from date of acceptance

Question 17

How many days do insurers have to pay worker reimbursements?

Answer 17

30 days from the receipt of the request for reimbursement.

Question 18

What types of things can a worker request reimbursement for?

Answer 18

• Meals
• Lodging
• Use of public transportation
• Use of a private vehicle
• Prescriptions
• Other out-of-pocket, claims-related expenses

Question 19

What is the time frame for an injured worker to request reimbursement?

Answer 19

• Two years from the date the costs were incurred or from the date the claim or medical condition is finally determined

Question 20

What is the purpose of the MCO?

Answer 20

• help manage the medical services in a claim
• to ensure the medical treatment is reasonable and necessary
• to assist with obtaining return-to-work information, a
• to facilitate claim closure.

Question 21

SAIF currently contracts with which MCOs?

Answer 21

• CareMark Comp (CMC)
• Kaiser-on-the-Job
• Majoris Health Systems

Question 22

What factors do you consider when enrolling a worker in an MCO?

Answer 22

• If the claim is disabling (most disabling claims should be enrolled in an MCO),
• The services offered by the MCO,
• To which MCO panel of providers the current AP belongs,
• The complexity of the medical conditions,
• The worker’s location and access to medical services.

Question 23

Who must approve the MCO and how are the MCO services certified?

Answer 23

DCBS approves the MCO, and the services are certified by Geographical Service Areas (GSAs).

Question 24

Purpose of an MCO Medical Tx Review

Answer 24

to review the current and past course of medical treatment and provide the AP with treatment course recommendations with specific timelines and goals

Question 25

When to consider an MCO treatment review

Answer 25

• No clear diagnosis for ongoing symptoms/complaints,
• No treatment plan,
• Worker is not released to an appropriate level of work,
• Treatment is ongoing without resolution,
• Excessive ongoing medication use (especially with opioids),
• Worker may have motivational issues delaying or stalling the recovery.

Question 26

What is the claims communication standard for contact with injured workers about an IME appointment?

Answer 26

Contact the injured worker prior to scheduling an IME appointment to discuss the purpose of the appointment and to address any scheduling conflicts or potential travel concerns and transportation needs.

Question 27

How many days’ notice do you have to provide to an injured worker for a scheduled IME appointment?

Answer 27

10 days prior to the IME appointment.

Question 28

At a minimum, how many days prior to the scheduled IME appointment should your cover letter and medical records be sent to the IME physician?

Answer 28

Seven days prior to the appointment date.

Question 29

An IME with multiple examiners must be completed within what period of time in order to be considered one IME?

Answer 29

72 hours.

Question 30

When should you consider using a panel of IME physicians?

Answer 30

on claims with distinctly different conditions requiring different types of medical expertise.

Question 31

What two claims processing steps can you NOT do if the worker fails to attend an IME appointment?

Answer 31

• Unilaterally stop paying time loss benefits.

- Deny the claim.

Question 32

What can you do if a worker fails to attend the IME?

Answer 32

Request suspension of benefits from WCD or request a penalty.

Question 33

What should a worker do if he or she objects to the location of the IME appointment? What is the timeframe to do this?

Answer 33

The worker can appeal the location of the IME appointment to the Director of WCD within six days from the mailing date of the notice of appointment.

Question 34

Is the order issued by WCD regarding IME location appealable?

Answer 34

No.

Question 35

What should you do if the IME report does not address the questions in your cover letter?

Answer 35

• Contact the IME provider to discuss concerns and ask for an addendum.
• Contact the SAIF IME liaison to assist with any concerns with the vendor.

Question 36

In what situations would an IME report be given deference over a report of the attending physician?

Answer 36

• When it is well-reasoned and provides a better explanation than the medical opinion from the attending physician.
• When the exam is done by a specialist and the AP is a general practice physician.

Question 37

If an injured worker does not believe he or she was treated appropriately during the IME examination, what should the worker do?

Answer 37

• The worker can file a complaint with WCD.

- The worker can talk with you. You should involve your supervisor and IME liaison in the discussions.

Question 38

What are some SAIF resources that can help you compose questions for the IME physician?

Answer 38

Online resources, Nurse consultant, Attorneys, Staffings