Kentucky Administrative Regulations › Title 803 - LABOR CABINET › Chapter 25 - Department of Workers' Claims › Section 803 KAR 25:012 - Resolution of medical disputes

Current through Register Vol. 51, No. 1, July 1, 2024
RELATES TO:
				KRS
				342.020,
				342.035,
				342.125,
				342.260,
				342.325,
				342.735
NECESSITY, FUNCTION, AND CONFORMITY:
				KRS
				342.260(1) requires the
				Executive Director of the Office of Workers' Claims to promulgate
				administrative regulations necessary to implement KRS Chapter 342.
				KRS
				342.325 requires that a question arising
				under KRS Chapter 342 which is not settled by agreement of the parties shall be
				determined by an administrative law judge.
				KRS
				342.735(1) requires the
				executive director to promulgate administrative regulations to expedite the
				payment of medical expense benefits. This administrative regulation establishes
				a procedure for the resolution of a medical dispute before an administrative
				law judge.
Section 1. Procedure.
(1) A dispute regarding payment, nonpayment,
			 reasonableness, necessity, or work-relatedness of a medical expense, treatment,
			 procedure, statement, or service which has been rendered or will be rendered
			 under KRS Chapter 342 shall be resolved by an administrative law judge
			 following the filing of a Form 112 (Medical Dispute).
(2) Form 112 may be filed by an employee,
			 employer, carrier or medical provider.
(3)
(a) The
			 Form 112 shall be accompanied by the following items:
1. Copies of all disputed bills;
2. Supporting affidavit setting forth facts
			 sufficient to show that the movant is entitled to the relief sought;
3. Necessary supporting expert testimony;
			 and
4. The final decision from a
			 utilization review or medical bill audit with the supporting physician
			 opinion.
(b) A single
			 Form 112 may encompass statements, services, or treatment previously rendered
			 as well as future statements, services, or treatment of the same nature or for
			 the same condition, if specifically stated.
(4)
(a) If
			 an application for adjustment of claim concerning the injury or disease which
			 is the subject of the dispute has not been filed, copies of the Form 112 and
			 attachments sufficient to serve the other parties, including the employee,
			 employer, and medical provider, shall be filed with the executive director, who
			 shall make service on the named parties.
(b) An opposing party may, within twenty (20)
			 days after service by the executive director, file a response, accompanied by
			 affidavit setting forth facts sufficient to show that the movant is not
			 entitled to the relief sought.
(c)
			 A response shall be served on the executive director and all other parties
			 within the twenty (20) day limit established in paragraph (b) of this
			 subsection.
(d) The dispute shall
			 be assigned to the Frankfort motion docket, where it shall be summarily decided
			 upon the pleadings or assigned for further proceedings before an administrative
			 law judge.
(5) If an
			 application for adjustment of claim is pending concerning the injury or disease
			 which is the subject of the dispute, the movant shall file a Form 112 with the
			 executive director and shall also serve copies on the other parties of record.
			 The movant shall further file a motion to join the medical provider as a party
			 to the claim. This motion shall conform with the requirements of
			 803 KAR
			 25:010, Section 4.
(6) Following resolution of a workers'
			 compensation claim by final order, a motion to reopen pursuant to
			 803 KAR
			 25:010, Section 4(6), shall be filed in addition to
			 the Form 112.
(a) Unless utilization review
			 has been initiated, the motion to reopen and Form 112 shall be filed within
			 thirty (30) days following receipt of a complete statement for services
			 pursuant to
			 803
			 KAR 25:096.
(b) The motion to reopen and Form 112 shall
			 be served on the parties, upon the employee, even if represented by counsel,
			 and upon the medical providers whose services or charges are at issue. If
			 appropriate, the pleadings shall also be accompanied by a motion to join the
			 medical provider as a party.
(c)
			 This dispute shall be assigned to the Frankfort motion docket, where it shall
			 be either summarily decided upon the pleadings, or assigned to an
			 administrative law judge for further proof time and final resolution.
(7)
(a) Except as provided by paragraph (b) of
			 this subsection, a Form 112 shall be accompanied by a motion for a partial
			 remand to the administrative law judge assigned to the claim if an appeal is
			 pending before the Workers' Compensation Board concerning the injury or disease
			 which is the subject of the dispute.
(b) If entitlement to medical services is
			 dependent upon resolution of an issue on appeal, the Form 112 shall be
			 accompanied by a motion to the Workers' Compensation Board to hold the Form 112
			 in abeyance pending a final decision on the appeal.
(8) If the contested expense is subject to
			 utilization review, a medical dispute shall not be filed prior to exhaustion of
			 the utilization review process. The employer or its medical payment obligor
			 shall have thirty (30) days following the final utilization review decision to
			 file a medical dispute.
(9)
			 Repeated filing of identical Form 112's concerning the same subject matter
			 shall not be necessary if an administrative law judge has ruled on both the
			 past expenses and the necessity of future expenses.
(10) A party aggrieved by a decision of the
			 administrative law judge in a medical dispute may appeal to the Workers'
			 Compensation Board by following the procedures established in
			 803 KAR
			 25:010, Section 20.