Alabama Administrative Code › Title 480 - ALABAMA DEPARTMENT OF LABOR › Chapter 480-5-5 - UTILIZATION MANAGEMENT AND BILL SCREENING › Section 480-5-5-.02 - Definitions

Current through Register Vol. 42, No. 9, June 28, 2024
When used in these rules, the following words and phrases shall
				have the following meanings:
(1)
Accident
- The term, as used in the phrases "personal injuries due
			 to accident" or "injuries or death caused by accident," shall be construed to
			 mean an unexpected or unforeseen event, happening suddenly and violently, with
			 or without human fault, and producing at the time, injury to the physical
			 structure of the body or damage to an artificial member of the body by
			 accidental means.
(2)
Adjudication
- The review of claims to apply prevailing rules that
			 adjust reimbursements for the amount of work required when multiple procedures
			 are performed at the same time; when assisting surgeons are present, to
			 eliminate duplicate billing from the unbending of global fees; and to adjust
			 for the most commonly occurring method adopted for total
			 reimbursement.
(3)
Adjudicator -
An individual, entity or agent that is responsible
			 for adjudication.
(4)
Admission Review
- The initial review after hospitalization of the
			 medical necessity and appropriateness of hospital admission.
(5)
Advanced Life Support (ALS)
- The treatment of potentially life-threatening medical emergencies through the
			 use of invasive medical techniques specified as advanced life support
			 techniques in the applicable rules, which ordinarily would be performed or
			 provided by physicians, but which may be performed by emergency medical
			 technicians pursuant to these rules.
(6)
Agent -
An individual
			 responsible for the administration of a workers' compensation claim for an
			 employer.
(7)
Ambulance
- A vehicle specifically designed and equipped for
			 transporting the wounded, injured, ill, or sick. Workers' Compensation
			 recognizes three levels of ambulance services: Basic Life Support (BLS),
			 Advanced Life Support (ALS), and Non-emergency Ambulance
			 Transportation.
(8)
Ambulatory Review -
The review of the medical necessity and
			 appropriateness of medical services rendered in a non-inpatient
			 setting.
(9)
Ambulatory
			 Surgical Center -
A facility licensed as an ambulatory surgical center
			 that has as its primary purpose the provision of elective surgical
			 care.
(10)
Appeals Process
			 -
A system or systems providing for any aggrieved party to contest an
			 adverse decision relative to utilization review and bill screening by an
			 adjudicator, employer, carrier or agent.
(11)
Average Wholesale Price (AWP)
			 -
The AWP is the amount, which includes cost, tax, shipping, and
			 handling.
(12)
Basic Life
			 Support (BLS)
- A level of pre-hospital care involving non-invasive life
			 support measures.
(13)
Bill
			 Screening
- The evaluation and adjudication of provider bills for
			 appropriateness of reimbursement relative to medical necessity and prevailing
			 rates of reimbursement, duplicate charges, unbundling of charges, relativeness
			 of services to injury or illness, necessity of assistant surgeons, adjudication
			 of multiple procedures, number of modalities, global procedures, and any other
			 prevailing adjudication issues that may apply.
(14)
Clinical Criteria
- Any
			 prevailing and generally accepted medical policies, rules, medical protocols,
			 guides and standards which may include, but are not limited to, criteria set
			 out in the Intensity/Severity/Discharge Manual; the nomenclature and rules set
			 out in the latest edition of Physicians' Current Procedural Terminology (CPT-4)
			 publication; the nomenclature and rules set out in the latest edition of
			 International Classification of Diseases; the nomenclature and rules set out in
			 the latest edition of the American Society of Anesthesiologist Relative Value
			 Guide; rules and nomenclature set out in the latest edition of Global Service
			 Data for Orthopedic Surgery published by the American Academy of Orthopedic
			 Surgeons; criteria established by the Commission on Accreditation of
			 Rehabilitation Facilities (CARF); rules, nomenclature and standards established
			 by the International Association of Rehabilitation Professionals (IARP); rules,
			 nomenclature and standards established by the latest edition of the Health Care
			 Finance Administration Common Procedure Coding Systems (HCPCS); rules and
			 criteria as described in the Professional Activity Study; and prevailing rules,
			 nomenclature and standards established by peer review committees established by
			 medical provider associations used by the utilization review entity to
			 determine certification of medical services; or any other professional groups
			 as recognized by the Alabama Workers' Compensation Medical Services
			 Board.
(15)
Clinical
			 Review
- An objective, analytical review of the medical findings and
			 records.
(16)
Commission on
			 Accreditation of Rehabilitation Facilities (CARF) -
A national, private,
			 nonprofit organization that sets standards of quality and provides
			 accreditation for each specific rehabilitation program for organizations
			 serving persons with disabilities.
(17)
Compensation
- The money
			 benefits to be paid on account of injury or death, as provided in [Articles 3
			 and 4 of the Alabama Workers' Compensation Law],
Code of Ala.
			 1975
, §§
								25-5-50 to
			 25-5-123. The recovery which an
			 employee may receive by action at law under [Article 2 of the Alabama Workers'
			 Compensation Law]
Code of Ala. 1975
, §§
								25-5-30 to
			 25-5-36 is termed "recovery of
			 civil damages," as provided for in
Code of Ala. 1975
,
			 §§
								25-5-31 and
			 25-5-34. "Compensation" does not
			 include medical and surgical treatment and attention, medicine, medical and
			 surgical supplies, and crutches and apparatus furnished an employee on account
			 of an injury.
(18)
Continued
			 Stay Review -
The review of an ongoing inpatient hospitalization to
			 assure the most appropriate setting for the care being rendered, sometimes
			 called concurrent review.
(19)
Core Team
- A group of professionals providing interdisciplinary
			 coordination of services for a specific program within a facility. The members
			 are expected to provide therapeutic, educational and training services
			 consistent with the requirements of CARF standards and the individualized needs
			 of the clients served.
(20)
Current Dental Terminology (CDT-2) or the most current revision
-
			 A listing of descriptive terms and identifying codes published by the American
			 Dental Association for reporting dental services and procedures.
(21)
Department
- The Alabama
			 Department of Labor.
(22)
Dictionary of Occupational Titles (DOT) -
Publication by the U.S.
			 Department of Labor that sets out job descriptions and other related
			 information pertaining to specific jobs.
(23)
Discharge Planning -
The
			 process of assessing and facilitating the need for medically appropriate
			 services and resources as related to the compensable injury after
			 hospitalization to allow for an appropriate and timely discharge.
(24)
Elective Surgery
- Approved
			 surgery which is medically necessary, yet non-emergency in nature, but which
			 may be performed at a later date.
(25)
Emergency Hospitalization -
Inpatient services provided after the sudden onset of a medical condition
			 manifested by symptoms of sufficient severity (which may include, but not be
			 limited to, severe pain), which, in the absence of continued inpatient medical
			 attention, could reasonably be expected by an appropriate health care
			 professional to result in placing the claimant's life in serious jeopardy,
			 serious impairment to bodily function, or serious dysfunction of any bodily
			 organ or part.
(26)
Emergency
			 Services -
Medical services provided after the onset of a medical
			 condition manifested by symptoms of sufficient severity (which may include, but
			 not be limited to, severe pain), which, in the absence of immediate medical
			 attention, could be expected by an ordinary reasonable person to result in
			 placing the claimant's life in jeopardy, impairment to bodily functions, or
			 dysfunction of any bodily organ or part.
(27)
Employer
- Every person who
			 employs another to perform a service for hire and pays wages directly to the
			 person. The term shall include a service company for a self-insurer or any
			 person, corporation, copartnership, or association, or group thereof, and
			 shall, if the employer is insured, include his or her insurer, the insurer
			 being entitled to the employer's rights, immunities, and remedies under the
			 Alabama Workers' Compensation Law, as far as applicable. The inclusion of an
			 employer's insurer within the term shall not provide the insurer with immunity
			 from liability to an injured employee, or his or her dependent in the case of
			 death to whom the insurer would otherwise be subject to liability under
Code of Ala. 1975
, §
								25-5-11. Notwithstanding the
			 provisions of the Alabama Workers' Compensation Law, in no event shall a common
			 carrier by motor vehicle operating pursuant to a certificate of public
			 convenience and necessity be deemed the "employer" of a leased-operator or
			 owner-operator of a motor vehicle or vehicles under contract to the common
			 carrier.
(28)
Employee or
			 Worker
- The terms are used interchangeably, have the same meaning
			 throughout the Alabama Workers' Compensation Law, and shall be construed to
			 mean the same. The terms include the plural and all ages and both sexes. The
			 terms include every person in the service of another under any contract of
			 hire, express or implied, oral or written, including aliens and also including
			 minors who are legally permitted to work under the laws of this state, and also
			 including all employees of Tannehill Furnace and Foundry Commission.
(29)
Functional Capacity Evaluation
			 (FCE) -
Process to evaluate the injured worker's functional and/or
			 vocational status.
(30)
Generally Accepted Criteria
- Written criteria used by clinical
			 reviewers, which may include but are not limited to, ICD10, ISD, PAS, Milliam
			 and Robertson (M&R) and Health Care Insurance Association (HCIA)
			 Publications.
(31)
Global
			 Charge Concept
- One charge covering the professional services and usual
			 associated services necessary to perform the basic approved program or
			 procedure.
(32)
Global Service
			 Data for Orthopedic Surgery (GSDOS) or most current revision -
Publication by the American Academy of Orthopedic Surgeons which outlines
			 services that are appropriate for inclusion and/or exclusion from the
			 intraoperative component of the global service package.
(33)
Global Surgery Procedure
-
			 A global service is a primary procedure that has specific related components
			 that are identified as being inclusive within the already established primary
			 procedure. Fee unbundling occurs when the charge for a specific procedure
			 remains the same, but one or more components of the procedure are separated
			 from the global service package and given a separate additional fee.
(34)
Healthcare Finance Administration
			 Common Procedure Coding System (HCPCS) or most current revision -
Includes CPT-4 descriptive terms and numeric identifying codes and modifiers
			 for reporting medical services and procedures and other materials contained in
			 the CPT-4. HCPCS is designed to promote uniform medical services reporting and
			 statistical data collection.
(35)
Hospital
- A hospital, ambulatory surgical center, outpatient
			 rehabilitation center licensed by the State of Alabama, and diagnostic
			 facilities accredited by the Commission on Accreditation of Rehabilitation
			 Facilities. Rule
			 480-5-5-.19 addresses outpatient
			 rehabilitation centers, Rule
			 480-5-5-.20 applies to hospitals,
			 and Rule 480-5-5-.26 applies to free
			 standing ambulatory surgery centers.
(36)
Independent Medical Examination
			 (IME) -
An independent assessment of an injured workers' physical
			 condition and/or bodily functions that is performed by a non-treating physician
			 at the request of the employer/agent or employee. The non-treating physician
			 shall not be the individual's family physician or a physician who is currently
			 or has previously treated the individual for the same complaint. The IME
			 differs from an impairment rating in that no impairment rating is given. The
			 IME differs from a second opinion in that this examination is not a
			 confirmatory evaluation. The party requesting the IME shall be the responsible
			 party for payment of this service.
(37)
Injury
- "Injury and
			 personal injury" shall mean only injury by accident arising out of and in the
			 course of the employment, and shall not include a disease in any form, except
			 for an occupational disease or where it results naturally and unavoidably from
			 the accident. Injury shall include physical injury caused either by carpal
			 tunnel syndrome disorder or by other cumulative trauma disorder if either
			 disorder arises out of and in the course of the employment, and breakage or
			 damage to eyeglasses, hearing aids, dentures, or other prosthetic devices which
			 function as part of the body, when injury to them is incidental to an
			 on-the-job injury to the body. Injury does not include an injury caused by
			 reasons personal to him or her and not directed against him or her as an
			 employee or because of his or her employment. Injury does not include a mental
			 disorder or mental injury that has neither been produced nor been proximately
			 caused by some physical injury to the body.
(38)
Injuries By An Accident Arising
			 Out Of And In The Course Of The Employment
- Without otherwise affecting
			 either the meaning or interpretation of the clause, the clause does not cover
			 workers except while engaged in or about the premises where their services are
			 being performed or where their service requires their presence as a part of
			 service at the time of the accident and during the hours of service as
			 workers.
(39)
Inpatient
			 Admissions -
Medically necessary services provided to a registered bed
			 patient in a hospital for more than 23 hours.
(40)
Intensity/Severity/Discharge
			 Manual (ISD Manual)or most current revision -
Published by Internal,
			 this manual provides the criteria for inpatient admission to
			 hospitals.
(41)
Interdisciplinary
- An approach to client management which
			 requires the integration of a core team from multiple disciplines which, on an
			 ongoing basis, assesses, plans and implements a complex rehabilitation program
			 for functional restoration. It does not mean an approach wherein multiple
			 disciplines are available as needed but function independently of one another
			 to address isolated, clearly defined problems.
(42)
International Association of
			 Rehabilitation Professionals (IARP) -
An international association
			 dedicated to enhancing the competency of private rehabilitation professionals,
			 advancing the professional field, improving the effectiveness of state level
			 affiliates, and leading in the resolution of public policy issued that affect
			 private sector rehabilitation.
(43)
International Classification of Diseases 9th Edition (ICD-10CM) or most
			 current revisions -
A system of diagnostic coding which identifies and
			 precisely delineates the clinical condition of patients.
(44)
Maximum Fee Schedule (MFS) or most
			 current revision -
The prevailing reimbursement as published in the
			 current Alabama Workers' Compensation Maximum Fee Schedule according to
			 provider type.
(45)
Medical
			 Case Management
- The process of assessing, planning, implementing,
			 coordinating, monitoring and evaluating the services required to respond to an
			 employee's health care needs to attain the goals of quality and cost effective
			 care. Case Management is not intended as a substitute for utilization review
			 and medical necessity determinations under these rules and case managers are
			 not permitted to deviate from or alter a medical regimen ordered by a treating
			 physician.
(46)
Medical
			 Dispute Resolution -
Review by an Ombudsman of medical services that are
			 provided or for which authorization of payment is sought, as defined in
Code of Ala. 1975
, §
								25-5-77(i).
(47)
Medical Necessity -
Services or supplies which are medically necessary to treat the work related
			 illness or injury. To be medically necessary, services and supplies shall meet
			 the following criteria: be consistent with the diagnosis and treatment of the
			 work related illness or injury; be consistent with the standard of care for
			 good medical practice; not be solely for the convenience of the patient,
			 family, hospital, physician or other provider; be in the most appropriate and
			 cost effective medical care setting as determined by the patient's condition;
			 and have scientifically established medical value.
(48)
Medical Services
- All
			 medical services, treatments, surgeries, procedures, equipment, or supplies
			 provided by a provider to an authorized compensable workers' compensation
			 injured worker.
(49)
Modifier
- A modifier provides the means by which the reporting
			 provider can indicate that a service or procedure that has been performed has
			 been altered by some specific circumstance but without changes in its
			 definition or code. The judicious application of modifiers obviates the
			 necessity for separate procedure listings that may describe the modifying
			 circumstance. Modifiers may be used to indicate to the recipient of a report
			 that: a service or procedure has both a professional and technical component; a
			 service or procedure was performed by more than one provider and/or in more
			 than one location; a service or procedure has been increased or reduced; only
			 part of a service was performed; an adjunctive service was performed; a
			 bilateral procedure was performed; a service or procedure was provided more
			 than once; or unusual events occurred.
(50)
National Council for Prescription
			 Drug Programs (NCPDP) -
An association of pharmacists and third-party
			 administrators whose purpose is to standardize electronic claim filing and
			 adjudication.
(51)
Non-emergency Ambulance Transportation -
Non-emergency transport
			 of patients in a recumbent position who require transportation to or from a
			 physician's office, hospital, other health care facility, or residence. This
			 shall not include a hospital operated vehicle used exclusively for
			 intra-hospital facility transfers.
(52)
Ombudsman
- An individual
			 who assists injured or disabled employees, persons claiming death benefits,
			 employers, and other persons in protecting their rights and obtaining
			 information available under the workers' compensation law.
(53)
Outpatient Procedures and Services
			 - Medically
necessary services provided to a patient who is not a
			 registered bed patient and who does not remain in a hospital setting for more
			 than 23 hours.
(54)
Pain
			 Management Program -
A program to reduce pain, improve function and
			 decrease the dependence on the health care system by persons with chronic pain
			 that interferes with physical, psychosocial and vocational functioning through
			 the provision of coordinated, goal oriented, interdisciplinary team
			 services.
(55)
Participating
			 and Nonparticipating Hospitals
- Participating hospitals are those
			 hospitals that have a negotiated rate of reimbursement or payment with the
			 Department of Labor. "Nonparticipating hospitals" means those hospitals that
			 have not negotiated a rate of reimbursement or payment with the Department of
			 Labor.
(56)
Payer
- The
			 employer, carrier, self-insured employer, group self-insured fund, or agent
			 responsible for determining compensability and making payment for medical
			 services provided injured workers.
(57)
Peer -
A provider who is
			 board certified in the same or similar specialty approved by the American Board
			 of Medical Specialists for Physicians or the Advisory Board of Osteopathic
			 Specialists for Osteopaths from the major areas of clinical services or a
			 physician who normally treats that type of case as the ordering provider whose
			 medical services are being reviewed, or for non-physician clinical peers, the
			 recognized professional board for their specialty.
(58)
Physician
- For the
			 purposes of providing services and treatment under the Alabama Workers'
			 Compensation Law,
Code of Ala. 1975
, §
								25-5-77, physician shall mean
			 medical doctor, surgeon, and chiropractor. For the purposes of oversight for
			 services rendered pursuant to the Alabama Workers' Compensation Law set forth
			 in and other functions required by Article 12 of the Alabama Workers'
			 Compensation Law found in
Code of Ala. 1975
,
			 §§
								25-5-310 through
			 25-5-315, physician shall mean a
			 doctor of medicine or doctor of osteopathy licensed to practice
			 medicine.
(59)
Physicians'
			 Current Procedural Terminology 4th Edition (CPT-4) or most current revision
			 -
A listing of descriptive terms and identifying codes published by the
			 American Medical Association for reporting medical services and
			 procedures.
(60)
Pre-certification Review -
The review and assessment of the
			 medical necessity and appropriateness of services before they occur. The
			 appropriateness of the site or level of care is assessed along with the timing,
			 duration and cost effectiveness of the proposed services.
(61)
Prevailing-
The most
			 commonly occurring reimbursements for medical services other than those
			 provided by federal and state programs for the elderly (Medicare) and
			 economically disadvantaged (Medicaid). "Prevailing" shall include not only
			 amounts per procedure code, but also commonly used adjudication rules as
			 applied to multiple procedures, global procedures, use of assistant surgeons,
			 and others as appropriate. For hospitals, "prevailing" rate of reimbursement or
			 payment shall be established by the method contained in
Code of
			 Ala. 1975
, §
								25-5-77.
(62)
Providers
- A medical
			 clinic, pharmacist, dentist, chiropractor, psychologist, podiatrist, physical
			 therapist, pharmaceutical supply company, rehabilitation service, other person
			 or entity providing treatment, service, or equipment, or person or entity of
			 providing facilities at which the employee receives treatment.
(63)
Retrospective Review
- A
			 utilization review conducted after services have been provided to a
			 patient.
(64)
Rule
-
Alabama Department of Labor Administrative Code
as
			 adopted under the Alabama Administrative Procedure Act.
(65)
Singular and Plural
-
			 Wherever the singular is used, the plural shall be included.
(66)
The Court
- The circuit
			 court that would have jurisdiction in an ordinary civil action involving a
			 claim for the injuries or death in question and "the judge" means a judge of
			 that court.
(67)
Utilization
			 Management
- A comprehensive set of integrated components including:
			 pre-certification review, admission review, continued stay review,
			 retrospective review, discharge planning, bill screening and individual medical
			 case management as required.
(68)
Utilization Review (UR)
- The determination of medical necessity
			 for medical and surgical in-hospital, outpatient, and alternative setting
			 treatments for acute and rehabilitation care. It includes pre-certification for
			 elective treatments. Concurrent review and, if necessary, retrospective review
			 are required for emergency cases.
(69)
Utilization Review Accreditation
			 Commission -
A national, nonprofit, organization established to
			 encourage efficient and effective utilization review processes and to provide a
			 method of evaluation and accreditation for utilization review
			 programs.
(70)
Utilization
			 Review Entity (URE) - A private
utilization review vendor, a carrier or
			 its affiliate, a self-insured employer, a third-party administrator, or a group
			 fund that provides utilization review.
(71)
Work Conditioning
- A work
			 related, intensive, goal-oriented treatment program specifically designed to
			 restore an individual's systemic, neuro-musculo-skeletal (strength, endurance,
			 movement, flexibility, and motor control), and cardiopulmonary functions. The
			 objective of the work conditioning program is to restore the client's physical
			 capacity and function so the client can return to work.
(72)
Work Hardening Program -
A
			 highly structured, goal oriented and individualized program that provides
			 transition between acute care and return to work while addressing the issues of
			 productivity, safety, physical tolerance and worker behavior.
(73)
Working Days
- Shall mean
			 Monday through Friday; however, not including legal holidays. In computing any
			 period of time prescribed or allowed by these Rules, the day of the act or
			 event from which the designated period of time begins to run shall not be
			 included. The last day of the period so computed shall be included, unless it
			 is a Saturday, a Sunday, or a legal holiday. As used in these Rules, "legal
			 holiday" includes New Year's Day, President's Day, Memorial Day, Independence
			 Day, Labor Day, Veterans' Day, Thanksgiving Day, Christmas Day, and any other
			 day appointed as a holiday by the President or the Congress of the United
			 States, or as prescribed in
Code of Ala. 1975
, §
								1-3-8.
Author:
Workers Compensation Medical Services
				  Board
Statutory Authority:
Code of Ala.
				  1975
, §
										25-5-293.