Oklahoma Administrative Code › Title 810 - Oklahoma Workers' Compensation Commission › Chapter 15 - Medical Services › Subchapter 15 - Medical Dispute Resolution › Section 810:15-15-3 - Medical dispute resolution of fee disputes

Current through Vol. 41, No. 20, July 1, 2024
(a)
Applicability.
This Section
				applies to a request to the Commission for a medical fee dispute resolution
				(MFDR) pertaining to an injury sustained by an injured employee on and after
				February 1, 2014. Medical fee dispute resolution requests involving an injury
				occurring before February 1, 2014 shall be resolved in accordance with the
				statutes and rules applicable to the Oklahoma Workers' Compensation Court of
				Existing Claims.
(b)
Provider
				Request for MFDR.
Requests by a health care provider for MFDR shall be
				filed and processed in the form and manner prescribed in this Section.
(1)
MFDR Form 19.
A provider may
				initiate proceedings to address a medical fee dispute by filing a Commission
				prescribed MFDR Form 19 with the Commission. A copy of the form may be obtained
				from the Commission at its main offices, or from the Commission's
				website.
(2)
Request for
				hearing.
A provider may request a hearing for determination of the
				issues raised on the MFDR Form 19 by filing a request for hearing before an
				administrative law judge of the Commission as provided in
				810:10-5-16.
				The provider shall send a copy of the request for hearing, together with a copy
				of the MFDR Form 19 and the records and supporting documentation required in
				Paragraph (4) of this Subsection, to the insurance carrier. The insurance
				carrier shall file a response to the MFDR Form 19 as provided in Paragraph (5)
				of this Subsection.
(3)
Contents of MFDR Form 19.
The health care provider's MFDR Form 19
				shall include the following information, and such other information as may be
				required on the form, and shall be signed by the provider under penalty of
				perjury:
(A) the name, address, and contact
				information of the provider;
(B)
				the name of the injured employee;
(C) the date of injury;
(D) the date(s) of the service(s) in
				dispute;
(E) the place of
				service;
(F) the treatment or
				service code(s) in dispute;
(G) the
				amount billed by the health care provider for the treatment(s) or service(s) in
				dispute;
(H) the amount paid by the
				workers' compensation insurance carrier for the treatment(s) or service(s) in
				dispute;
(I) the disputed amount
				for each treatment or service in dispute;
(J) a statement of whether or not there is a
				final decision regarding compensability, extent of injury, liability and/or
				medical necessity for the health care related to the dispute; and
(K) a position statement of the disputed
				issue(s) which includes:
(i) the provider's
				reasoning for why the disputed fees should be paid,
(ii) a discussion of how the AWCA, Commission
				rules, and/or the Oklahoma workers' compensation fee schedule impacts the
				disputed fee issues, including reference to the specific general instruction,
				ground rule or other provision of the Oklahoma workers' compensation fee
				schedule serving as the basis for the requested reimbursement, and
(iii) a discussion of how the submitted
				documentation supports the provider's position for each disputed fee
				issue.
(4)
Supplemental records and documentation.
The following records and
				documentation applicable to a provider's MFDR Form 19 shall be sent by the
				provider to the insurance carrier as provided in Paragraph (2) of this
				Subsection, but shall not be attached to the MFDR Form 19 when the form is
				filed with the Commission:
(A) a paper copy of
				all medical bills related to the dispute, as originally submitted to the
				insurance carrier;
(B) a paper copy
				of each explanation of benefits (EOB) related to the dispute as originally
				submitted to the health care provider;
(C) a copy of all applicable medical records
				related to the dates of service in the dispute; and
(D) any other documentation that the provider
				deems applicable to the medical fee dispute.
(5)
Respondent response.
(A) The insurance carrier shall respond to
				the MFDR Form 19 by filing a Commission prescribed MFDR Form 10M within thirty
				(30) days of the file-stamped date of the CC-Form-9 Request for Hearing filed
				by the provider. The response shall provide any missing information not
				provided by the health care provider and known to the respondent. The MFDR Form
				10M shall include the following information, and such other information as may
				be required on the form, and shall be signed by the respondent under penalty of
				perjury:
(i) the name, address, and contact
				information of the respondent; and
(ii) a position statement of the disputed
				issue(s) which includes:
(I) the respondent's
				reasoning for why the disputed fees should not be paid,
(II) a discussion of how the AWCA, Commission
				rules, and/or the Oklahoma workers' compensation fee schedule impacts the
				disputed fee issues, including reference to the specific general instruction,
				ground rule or other provision of the Oklahoma workers' compensation fee
				schedule serving as the basis for the respondent's position, and
(III) a discussion of how the submitted
				documentation supports the respondent's position for each disputed fee
				issue.
(B)
				The respondent shall send the MFDR Form 10M, together with the following
				records and documentation applicable to the respondent's MFDR Form 10M, to the
				provider. The records and documentation shall not be attached to the MFDR Form
				10M when the form is filed with the Commission:
(i) a paper copy of all initial and appeal
				EOBs related to the dispute, as originally submitted to the health care
				provider, related to the health care in dispute not submitted by the health
				care provider, or a statement certifying that the respondent did not receive
				the health care provider's disputed billing before the MFDR Form 19 dispute
				request;
(ii) a paper copy of all
				medical bills related to the dispute, if different from that originally
				submitted to the insurance carrier for reimbursement; and
(iii) a copy of any pertinent medical records
				or other documents relevant to the fee dispute not already provided by the
				health care provider.
(6)
Determination of allowable
				amounts.
(A)
Audits.
Audits of medical bills to determine the amount allowable under the appropriate
				Oklahoma workers' compensation fee schedule may be offered by each party.
				Audits prepared by billing review services, medical bill audit services or
				in-house auditors may be submitted as evidence reflecting the methodology of
				the application of the fee schedule. The fee schedule sets maximum amounts
				allowable but does not prohibit a party from asserting a lesser amount should
				be paid.
(B)
Referral to the
				Health Services Division.
(i) The
				Commission, at its discretion, may refer medical fee disputes which involve
				conflicting interpretations of the Oklahoma workers' compensation fee schedule
				and a reduction by the insurance carrier of the provider's bill for health care
				services determined to be medically necessary and appropriate for the injured
				employee's compensable injury, to the Commission's Health Services Division for
				a recommendation regarding the maximum reimbursement amount allowed under the
				fee schedule for the services rendered.
(ii) Medical fee disputes involving the
				denial by an insurance carrier of a bill for services based on denial of
				compensability of the injured employee's injury or occupational disease, length
				of treatment, necessity of treatment, unauthorized physician or other ground,
				shall not be referred to the Division.
(7)
Hearing dockets.
MFDR Form
				19 hearings shall be scheduled initially on an administrative docket to
				determine the payment status of the disputed medical fee charges. If the
				charges are not paid before the administrative hearing or the parties are
				unable to resolve the dispute at the administrative hearing, the dispute shall
				be set on the assigned administrative law judge's hearing docket.
(8)
Appearances.
Appearances at
				the administrative docket and before the administrative law judge or Commission
				are governed by
				810:10-1-9.
(9)
Mediation.
Nothing in this
				Subchapter is intended to preclude resolution of medical fee disputes by
				mediation or agreement of the parties, as appropriate.