Alabama Administrative Code › Title 355 - STATE OF ALABAMA DEPARTMENT OF FINANCE › Chapter 355-8-1 - DIVISION OF RISK MANAGEMENT › Section 355-8-1-.02 - General Provisions

Current through Register Vol. 42, No. 9, June 28, 2024
(a)
			 Definitions. Throughout this program, the following words and phrases as used
			 therein shall be considered to have the following meanings, respectively,
			 unless the context shall clearly indicate a different meaning in the connection
			 used:
(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 unbundling of global fees, and to adjust for the most commonly occurring
			 method adopted for total reimbursement.
(3)
Benefits
. The
			 term shall in all cases be construed to mean compensation, medical, vocational
			 or other benefits expended by the program on behalf of the employee.
(4)
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.
(5)
Child or
			 Children
. The terms include posthumous children and all other
			 children entitled by law to inherit as children of the deceased; stepchildren
			 who were members of family of the deceased, at the time of the accident, and
			 were dependent upon him or her for support; a grandchild of the deceased
			 employee, whose father is dead or is an invalid, and who was supported by and a
			 member of the family of the deceased grandparent at the time of the
			 accident.
(6)
Compensation
. The money benefits to be paid on account
			 of injury or death, as provided in Articles 2, 3 and 4. "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.
(7)
Contract Employee
. A person employed by written
			 contract who is deemed to be an employee, as opposed to an independent
			 contractor, according to Internal Revenue Service criteria as applied by the
			 State Comptroller and State Personnel Board.
(8)
Dependent Child or
			 Orphan
. An unmarried child under the age of 18 years or one over
			 that age who is physically or mentally incapacitated from earning.
(9)
Division of Risk
			 Management
. A division of the State of Alabama, Department of
			 Finance, charged with the implementation of this program. Also known as
			 "DORM".
(10)
Employee
			 or Worker
. The terms are used interchangeably and have the same
			 meaning throughout this program. The terms include the plural and all ages and
			 both sexes. The terms expressly include elected state officials and every
			 person in the full time paid service of the employer, who is covered by the
			 State Employees Insurance Board's medical insurance plan and whose wages are
			 paid through the office of the state comptroller, provided that the assessed
			 costs for the program have been paid by the employing agency. Other classes of
			 employees may be covered if pre-approved by the Risk Manager, but coverage will
			 not be effective until receipt by DORM of payment of assessed costs. Any
			 reference in this program to a "worker" or "employee" shall, if the worker or
			 employee is dead, include his or her dependent, as defined in this
			 program.
(11)
Employer
. The State of Alabama and its agencies,
			 departments, boards or commissions. The term shall include the Division of Risk
			 Management, and service companies or agents with which it contracts for the
			 administration of this program.
(12)
Gender
. Where
			 the masculine gender is used, the feminine and neuter shall be
			 included.
(13)
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.
(14)
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. Only injuries by an
			 accident during the employee's duties while under the right of control of the
			 employer shall be considered as arising out of and in the course of
			 employment.
(15)
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 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 the act of a third person or fellow employee intended to
			 injure the employee because of 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.
			 Injury does not include physical injury caused by carpel tunnel syndrome
			 disorder unless said disorder is a secondary condition which developed as a
			 result of a specific injury by accident which occurred after the effective date
			 of this program.
(16)
Loss of Hand or Foot
. Amputation between the elbow and
			 wrist shall be considered as the equivalent to the loss of a hand, and the
			 amputation between the knee and ankle shall be considered as the equivalent of
			 the loss of a foot.
(17)
Medical
. All services, treatment, or equipment
			 provided by a provider.
(18)
Participating and Nonparticipating Hospitals
. Those
			 hospitals that have a negotiated rate of reimbursement or payment with the
			 Division of Risk Management. "Nonparticipating hospitals" means those hospitals
			 that have not negotiated a rate of reimbursement or payment with the Division
			 of Risk Management.
(19)
Prevailing
. The most commonly occurring reimbursements
			 for health 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, used of assistant surgeons, and others as appropriate. For
			 hospitals, "prevailing" rate of reimbursement or payment shall be established
			 by the method contained in Rule .04(p).
(20)
Providers
. A
			 medical clinic, pharmacist, dentist, chiropractor, psychologist, podiatrist,
			 physical therapist, pharmaceutical supply company, rehabilitation service, or
			 other person or entity providing treatment, service, or equipment, or person or
			 entity providing facilities at which the employee receives treatment.
(21)
Review Board
. A
			 panel composed of three persons designated by the Risk Manager to hear and
			 consider claims by employees whose disagree with the determination by the
			 employer or its agent or service company as to the employee's entitlement to
			 compensation and medical benefits under this program and to approve settlements
			 when required by this program. The Risk Manager and employees of the Division
			 of Risk Management, along with other state employees, may be members of the
			 Review Board.
(22)
Singular and Plural
. Wherever the singular is used,
			 the plural shall be included.
(23)
Utilization Review
. The determination of medical
			 necessity for medical and surgical in-hospital, out-patient, and alternative
			 settings treatments for acute and rehabilitation care. It includes
			 precertification for elective treatments. Concurrent review and, if necessary,
			 retrospective review are required for emergency cases.
(24)
Wages or Weekly
			 Wages
.
(i) The terms shall in all
			 cases be construed to mean weekly earnings at the time of the injury, based on
			 those earnings subject to federal income taxation and reportable on the State
			 of Alabama tax form which shall include fringe benefits as defined herein.
			 "Fringe benefits" shall mean the employer's portion of health insurance
			 premiums and Retirement Systems of Alabama payments. Weekly earnings shall not
			 include fringe benefits if and only if the employer continues the benefits
			 during the time for which compensation is paid.
(ii) Determination of Average Weekly Earnings
			 for Classes of Employees Who Are Other Than Full Time. Compensation under this
			 section shall be computed on the basis of the average weekly earnings. Average
			 weekly earnings shall be based on the wages of the injured employee in the
			 state employment in which he or she was working at the time of the injury
			 during the period of 52 weeks immediately preceding the date of the injury
			 divided by 52, but if the injured employee lost more than seven consecutive
			 calendar days during the period, although not in the same week, then the
			 earnings for the remainder of the 52 weeks shall be divided by the number of
			 weeks, remaining after the time so lost has been deducted. Where the employment
			 prior to the injury extended over a period of less than 52 weeks, the method of
			 dividing the earnings during the period by the number of weeks and parts
			 thereof during which the employee earned wages shall be followed, provided
			 results just and fair to both parties will thereby be obtained. Where by reason
			 of the shortness of the time during which the employee has been in the
			 employment of his or her employer or the casual nature of terms of the
			 employment it is impracticable to compute the average weekly earnings as above
			 defined, regard shall be had to the average weekly amount which during the 52
			 weeks prior to the injury was being earned by a person in the same grade,
			 employed at the same work by the same employer, and if there is no person so
			 employed, by a person in the same grade employed in the same class of
			 employment in the same District. Whatever allowances of any character made to
			 an employee in lieu of wages are specified as part of the wage contract shall
			 be deemed a part of his or her earnings if and only if the employer does not
			 continue those allowances.