Code of Maine Rules › 90 - INDEPENDENT AGENCIES › 351 - WORKERS' COMPENSATION BOARD › Chapter 5 - MEDICAL FEES; REIMBURSEMENT LEVELS; REPORTING REQUIREMENTS › Appendix 351-5-I - MEDICAL FEE SCHEDULE

Current through 2024-29, July 17, 2024
PRACTITIONER'S REPORT (FORM M-1)
GUIDELINES FOR COMPLETING THE M1 FORM
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ESTIMATED LENGTH OF TREATMENT
: describe in
				  days, weeks, or months
TREATMENT PLAN
: INCLUDE items like REST,
				  MEDICATION, EXERCISE, or other forms of treatment
MEDICAL REFERRALS
: INCLUDE items like THERAPY,
				  SURGEON, CHIROPRACTIC, etc.
MODIFIED WORK
: INDICATE RIGHT or LEFT as
				  appropriate; FREQUENCY (Never, Occasional <33% use) and DURATION of
				  activities allowed
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DUTIES OF HEALTH CARE PROVIDERS
Pursuant to
				  39-A M.R.S.A.
				  §208(2), duties of
				  health care providers are as follows:
* Except for claims for medical benefits only, within 5
				  business days from the completion of a medical examination or within 5 business
				  days from the date notice of injury is given to the employer, whichever is
				  later, the health care provider treating the employee shall forward to the
				  employer and the employee a diagnostic medical report, on forms prescribed by
				  the board, for the injury for which compensation is being claimed. The report
				  must include the employee's work capacity, likely duration of incapacity,
				  return to work suitability and treatment required. The board may assess
				  penalties up to $500 per violation on health care providers who fail to comply
				  with the 5-day requirement of this subsection.
* If ongoing medical treatment is being provided, every 30
				  days the employee's health care provider shall forward to the employer and the
				  employee a diagnostic medical report on forms prescribed by the board. An
				  employer may request, at any time, medical information concerning the condition
				  of the employee for which compensation is sought. The health care provider
				  shall respond within 10 business days from receipt of the request.
* A health care provider shall submit to the employer and the
				  employee a final report of treatment within 5 working days of the termination
				  of treatment, except that only an initial report must be submitted if the
				  provider treated the employee on a single occasion.
* Upon the request of the employee and in the event that an
				  employee changes or is referred to a different health care provider or
				  facility, any health care provider or facility having medical records regarding
				  the employee, including x rays, shall forward all medical records relating to
				  an injury or disease for which compensation is claimed to the next health care
				  provider. When an employee is scheduled to be treated by a different health
				  care provider or in a different facility, the employee shall request to have
				  the records transferred.
* A health care provider may not charge the insurer or
				  self-insurer an amount in excess of the fees prescribed in §209-A for the
				  submission of reports prescribed by this section and for the submission of any
				  additional records.
* An insurer or self-insurer may withhold payment of fees for
				  the submission of any required reports of treatment to any provider who fails
				  to submit the reports on the forms prescribed by the board and within the time
				  limits provided. The insurer or self-insurer is not required to file a notice
				  of controversy under these circumstances, but must notify the provider that
				  payment is being withheld due to the failure to use prescribed forms or to
				  submit the reports in a timely fashion. In the case of dispute, any interested
				  party may petition the board to resolve the dispute.
Other reminders:
* Except for the header information, the remainder of the M-1
				  form must be completed by the health care provider. This information is vital
				  to the administration of the claim and the employee's return to work.
* The M-1 form is not submitted to the board.
* Pursuant to Board Rules Chapter 5, a health care provider
				  may charge a fee for completing the initial M-1.
* The attachment of narratives is optional; however, an
				  employer/insurer may request, at any time (for a fee), medical information
				  concerning the condition of the employee for which compensation is sought. The
				  health care provider shall respond within 10 business days from receipt of the
				  request. Pursuant to
				  39-A M.R.S.A.
				  §208(1) a medical
				  release is not necessary if the information pertains to an injury claimed to be
				  compensable under the Act (whether or not the claim is
				  controverted/denied).