Arizona Administrative Code › Title 20 - COMMERCE, FINANCIAL INSTITUTIONS, AND INSURANCE › Chapter 05 - INDUSTRIAL COMMISSION OF ARIZONA › Article 13 - TREATMENT GUIDELINES › Section R20-5-1302 - Definitions

Current through Register Vol. 30, No. 28, July 12, 2024
In this Article and
				  R20-5-106(A)(12),
				  unless the context otherwise requires:
"Act" means the Arizona Workers' Compensation Act, A.R.S.
				  Title 23, Chapter 6.
"Active Practice" means performing patient care for a minimum
				  of eight hours per week in one of the five preceding years.
"Administrative Law Judge" or "ALJ" means a hearing officer
				  appointed under A.R.S. §
									23-108.02.
"Administrative Review" means a process that includes a peer
				  review for preauthorization of a request for medical treatment or services
				  conducted pursuant to
				  R20-5-1311.
				  The administrative review process will be managed by the Medical Resource
				  Office (MRO) at the Industrial Commission of Arizona.
"American Board of Medical Specialties" means the
				  organization that develops a uniform system for specialty boards to administer
				  examinations for certification of physicians within specific medicine
				  specialties.
"American Osteopathic Association" means the organization
				  that develops a uniform system for specialty boards to administer examinations
				  for certification of osteopathic physicians within specific osteopathic
				  medicine specialties.
"Applicability" means the body parts and medical conditions
				  that are covered under this Article and authorized by the Commission under
				  R20-5-1301(B)
				  and (C).
"Claim" means the workers' compensation claim filed by the
				  injured employee under the Act.
"Contractor" means an independent peer review organization
				  accredited by URAC.
"Fast Track ALJ Dispute Resolution Program" or "fast track
				  process" means the voluntary dispute resolution process set forth in
				  R20-5-1312(B).
"International Classification of Diseases Code" or "ICD Code"
				  means a set of medical diagnostic codes that creates a universal language for
				  reporting diseases and injury.
"International Classification of Diseases" or "ICD" means an
				  official list of categories of diseases, physical and mental, that is issued
				  and maintained by the World Health Organization.
"IME" means an independent medical examination scheduled
				  under
				  R20-5-114.
"Injured Employee" means a person defined in A.R.S. §
									23-901
				  whose claim has been accepted for workers' compensation benefits.
"Medical File Review Opinions" means a formal examination of
				  patient data and medical records for the purpose of determining the need for
				  medical treatment, services or both.
"Payer" means an insurance carrier defined under A.R.S.
				  §
									23-901,
				  a self-insured employer defined in
				  R20-5-102,
				  a third-party administrator, and the Special Fund of the Industrial Commission
				  of Arizona.
"Peer Review" means an independent medical review conducted
				  by an individual meeting the requirements of
				  R20-5-1311(I).
"Preauthorization" means the written request prescribed by
				  R20-5-1303
				  from a provider to a payer requesting approval to provide medical treatment or
				  services to an injured employee.
"Provider" means a physician as defined in
				  R20-5-102.
"Reconsideration" means a written request to the payer or
				  identified review organization by an injured employee or medical provider to
				  reconsider a previous payer decision to deny medical treatment or services and
				  that identifies the specific justification to support the request.
"Third-Party Administrator" means an organization that
				  processes insurance or employee benefit claims for a separate entity.
"Treatment Guidelines" or "guidelines" means medical
				  treatment guidelines that are used as a tool to support clinical decision
				  making and quality health care delivery to injured employees.
"URAC" refers to URAC, a non-profit organization formerly
				  known as the Utilization Review Accreditation Commission.