Alabama Administrative Code › Title 480 - ALABAMA DEPARTMENT OF LABOR › Chapter 480-5-5 - UTILIZATION MANAGEMENT AND BILL SCREENING › Section 480-5-5-.33 - Time Limits For Claims Payments

Current through Register Vol. 42, No. 9, June 28, 2024
(1) In accordance with
Code of
			 Ala. 1975
, Section
			 25-5-77(h), the
			 employer/agent shall process and pay all undisputed claims within 25 working
			 days of receipt of an approved claim form. However, all authorized workers'
			 compensation claims shall be filed to allow processing and reimbursement within
			 twelve (12) months from the date of service. All actions against an authorized
			 claim cease when the said 12-month time limitation has expired.
(2) A provider who submits an authorized
			 claim to the employer/agent shall receive reimbursement, notice of dispute, or
			 a request for additional information in accordance with Rule
			 480-5-5-.03. If payment is not
			 received within the time constraints of Rule
			 480-5-5-.03, the provider should
			 contact the employer/agent for the current status of an authorized
			 claim.
(3) Providers should contact
			 the Workers' Compensation Division if there are problems with an authorized
			 workers' compensation claim. However, when a provider's efforts are fruitless,
			 the provider should write to the Workers' Compensation Division before the
			 12-month limitation expires.
(4)
			 Administrative Review of Claims Denied as Outdated.
(a) A provider who is denied payment on an
			 outdated authorized claim may request an administrative review of the claim. A
			 written request for an administrative review, conducted by the Medical Services
			 Dispute Resolution Section, shall be addressed to the Workers' Compensation
			 Division within sixty (60) days of the date the authorized claim becomes
			 outdated, which is 12-months from the date of service.
(b) It is the responsibility of the provider,
			 when submitting an outdated authorized claim for an administrative review, to
			 furnish adequate documentation of the provider's good faith attempts to obtain
			 payment of the claim, including copies of relevant explanation of payments
			 (EOP) and correspondence with the employer/agent. The provider shall also
			 include an error free claim to furnish the employer/agent in cases where the
			 decision is favorable.
(c) When the
			 provider has timely requested an administrative review, and research of the
			 claim reveals that the authorized claim was originally filed in accordance with
			 Rules 480-5-5-.04 and .22, and the
			 provider has established a good faith effort to file an authorized claim on the
			 approved claim form, the Workers' Compensation Division shall have the
			 authority to instruct the employer/agent to waive the filing limitation and
			 process the authorized claim.
(d)
			 The provider shall be notified in writing of the administrative review
			 decision. A provider who has timely requested an administrative review and
			 received an adverse decision may request an appeal in accordance with the
			 Department of Industrial Relations Administrative Code 480-1-4. Such request
			 shall be in writing and received by the Workers' Compensation Division within
			 60 days of receipt of the date of the administrative review denial
			 letter.
(e) If all administrative
			 remedies have been exhausted and the authorized claim is denied, the provider
			 cannot collect from either the employer/agent or employee.
Author:
Workers' Compensation Medical Services
				Board