Iowa Administrative Code › Agency 876 - Workers' Compensation Division › Chapter 10 - Informal Dispute Resolution Procedures › Rule 876-10.3 - Health Service Dispute Resolution

Current through Register Vol. 47, No. 3, July 24, 2024
(1) The purpose
			 of this rule and rule
			 876-4.46 (17A,85,86) is to
			 establish the procedures for resolving a dispute under Iowa Code section
			 85.27
			 between a provider and a responsible party over the treatment rendered by a
			 provider to an injured worker. Utilization of these procedures by a responsible
			 party is not an admission of liability for any other proceeding. This rule is
			 effective October 7, 1992.
(2)
			 Definitions. The following definitions apply to this rule and rule
			 876-4.46 (17A,85,86).
"Dispute "
means a disagreement between a
				provider and responsible party over the necessity of service or reasonableness
				of charges or both; a disagreement between a provider and a responsible party
				over the necessity for or the reasonableness of charges for crutches,
				artificial members and appliances; and includes only those situations where
				liability or extent of liability is not an issue.
"Workers' compensation commissioner"
means the
				workers' compensation commissioner or the workers' compensation commissioner's
				designee.
"Person"
means individual, corporation,
				government or governmental subdivision or agency, business trust, estate,
				trust, partnership or association, or any other legal entity.
"Provider"
means any person furnishing
				surgical, medical, dental, osteopathic, chiropractic, podiatric, physical
				rehabilitation, nursing, ambulance, hospital services and supplies, crutches,
				artificial members and appliances.
"Responsible party"
means the person who is
				liable for payment of medical services provided pursuant to the Iowa workers'
				compensation laws and includes an employer, an employer who has been relieved
				from insurance pursuant to Iowa Code section
				87.11,
				and an insurance carrier which provides an employer workers' compensation
				insurance.
(3) Informal
			 resolution of disputes.
a. The charges not in
			 controversy shall be paid to the provider prior to utilization of the
			 procedures outlined in this rule.
b. A responsible party who refuses to pay the
			 amount in controversy of a dispute shall give the provider written notice of
			 the dispute within 60 days of receiving a bill with proper supporting
			 documentation. The written notice shall specify:
(1) The name of the
			 patient-employee;
(2) The name of
			 the employer on the date of injury;
(3) The date of the treatment in
			 dispute;
(4) The amount charged for
			 the treatment, the amount of the charge the responsible party agrees to pay,
			 and the amount in dispute;
(5) The
			 reason for belief that the bill is excessive or unnecessary and documentation
			 relied upon to formulate the belief;
(6) The address to use in directing
			 correspondence to the responsible party regarding the dispute;
(7) The provider's right to utilize the
			 procedures specified in this rule and rule
			 876-4.46 (17A,85,86);
(8) The provisions of 10.3(3)
"c,
			 "
10.3(3)
"d, "
and 876-subrule 4.46(2);
(9) The provider or the responsible party is
			 prohibited by Iowa Code section
			 85.27
			 from seeking payment from the injured worker when there is a dispute regarding
			 reasonableness of a fee.
c. If the provider agrees to accept the
			 amount of the charge the responsible party has paid, the provider shall notify
			 the responsible party.
d. If the
			 provider does not agree to accept the amount of the charge the responsible
			 party agrees to pay, the provider shall notify the responsible party in
			 writing. The provider and the responsible party shall submit the dispute to a
			 mutually agreed upon person for review. The person reviewing the dispute under
			 this rule will not be the workers' compensation commissioner. If the provider
			 and the responsible party cannot agree upon the person to make the review, they
			 shall, within 90 days of time the provider notified the responsible party of
			 the disagreement, each recommend to the workers' compensation commissioner one
			 person to do the review. The workers' compensation commissioner may choose the
			 person or persons recommended to make the review. A person other than the
			 persons recommended may be chosen at the discretion of the workers'
			 compensation commissioner. The selected person or persons shall review
			 information submitted by the provider and the responsible party and make a
			 determination.
e. The person making
			 the review shall make a determination of the amount that is reasonable and
			 necessary. The determination shall be made as soon as practicable and shall be
			 dated. It shall be in writing and specify the facts relied upon. The person
			 making the review may choose any amount to set the reasonableness of a charge.
			 If the person chosen to make the review does not make a determination within a
			 reasonable time, that person may be discharged without being paid.
f. Costs. The costs of the person making the
			 review shall be paid as mutually agreed by the provider and the responsible
			 party. In the event of no agreement the costs shall be paid by whomever chose
			 an amount further from the determination of the person reviewing the matter. If
			 the amount is equally close to both parties, the costs shall be shared equally.
			 However, if the workers' compensation commissioner selects the person or
			 persons to do the review, the costs shall be shared equally.
g. Nothing in this rule is intended to
			 prevent providers and responsible parties from developing other procedures to
			 informally resolve their disputes.