reglab/statecodes huggingface dataset:
West Virginia Code of State Rules › Agency 85 - Workers' Compensation › Title 85 - PROCEDURAL RULE WORKERS' COMPENSATION RULES OF THE WEST VIRGINIA INSURANCE COMMISSIONER › Series 85-20 - Medical Management Of Claims, Guidelines For Impairment Evaluations, Evidence, And Ratings, And Ranges Of Permanent Partial Disability Awards › Section 85-20-68 - Payment for Evaluations

Current through Register Vol. XLI, No. 28, July 12, 2024
The Commission, Insurance Commissioner, private carrier or
				  self-insured employer, whichever is applicable, shall not make payment to any
				  impairment examiner whose reports, opinions, examinations, or evaluations are
				  not conducted, performed, and composed in accordance with this Rule. In the
				  event payment was made prior to a determination that the report, opinion,
				  examination, or evaluation was not conducted, performed, or composed in
				  accordance with this Rule, then the amount so paid shall be recovered from the
				  examiner either by way of a direct repayment to the Commission, Insurance
				  Commissioner, private carrier or self-insured employer, whichever is
				  applicable, or by way of an offset against any future sums that may be owed by
				  the Commission, Insurance Commissioner, private carrier or self-insured
				  employer, whichever is applicable, to the examiner for any services rendered
				  for or to the Commission, Insurance Commissioner, private carrier or
				  self-insured employer, whichever is applicable, or for or to an injured worker.
				  A later submission or supplement to the report, which demonstrates compliance
				  with these rules, shall serve to permit such payment.
West Virginia Code of State Rules › Agency 85 - Workers' Compensation › Title 85 - PROCEDURAL RULE WORKERS' COMPENSATION RULES OF THE WEST VIRGINIA INSURANCE COMMISSIONER › Series 85-20 - Medical Management Of Claims, Guidelines For Impairment Evaluations, Evidence, And Ratings, And Ranges Of Permanent Partial Disability Awards › Section 85-20-69 - Violation and Penalties

Current through Register Vol. XLI, No. 28, July 12, 2024
Without limiting the general nature of various statutes
				  respecting criminal fraud, and by way of illustration and not in limitation,
				  the following are deemed unlawful acts and practices:
a. Billing for services not actually
				performed;
b. Billing for expenses
				not actually incurred;
c. Billing
				services on dates other than the date on which they were actually
				performed;
d. Offering
				consideration of any kind, including gifts, services or gratuities to
				Commission, Insurance Commissioner, private carrier or self-insured employer,
				whichever is applicable, employees in exchange for or as a past reward for
				referring cases to the provider;
e.
				Failing to close claims at the earliest practicable date when the injured
				worker can no longer benefit from such services;
f. Providing false information in any
				statement to the Commission, Insurance Commissioner, private carrier or
				self-insured employer, whichever is applicable, or forging or falsifying any
				record required to be kept by these Rules or any other statute or rule
				governing providers; and g. "Rolling in" unreimbursable time or expenses by
				adding hours for billable time or expenses.
All providers and employers shall retain for five (5) years
				  and provide to the Commission, Insurance Commissioner, private carrier or
				  self-insured employer, whichever is applicable, on request and without a
				  subpoena hard copies of the source underlying any bill, invoice, report, etc.
				  submitted to the Commission, Insurance Commissioner, private carrier or
				  self-insured employer, whichever is applicable, by electronic or other
				  means.
West Virginia Code of State Rules › Agency 85 - Workers' Compensation › Title 85 - PROCEDURAL RULE WORKERS' COMPENSATION RULES OF THE WEST VIRGINIA INSURANCE COMMISSIONER › Series 85-20 - Medical Management Of Claims, Guidelines For Impairment Evaluations, Evidence, And Ratings, And Ranges Of Permanent Partial Disability Awards › Section 85-20-71 - Severability

Current through Register Vol. XLI, No. 28, July 12, 2024
If any provision of this Rule or the application thereof to
				  any entity or circumstance shall be held invalid, such invalidity shall not
				  affect the provisions or the applications of this Rule which can be given
				  effect without the invalid provisions or application and to this end the
				  provisions of this rule are declared to be severable.
West Virginia Code of State Rules › Agency 85 - Workers' Compensation › Title 85 - PROCEDURAL RULE WORKERS' COMPENSATION RULES OF THE WEST VIRGINIA INSURANCE COMMISSIONER › Series 85-20 - Medical Management Of Claims, Guidelines For Impairment Evaluations, Evidence, And Ratings, And Ranges Of Permanent Partial Disability Awards › Table 85-20-A - Impairment of Pulmonary Function. Page 1 of 3

Current through Register Vol. XLI, No. 28, July 12, 2024
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West Virginia Code of State Rules › Agency 85 - Workers' Compensation › Title 85 - PROCEDURAL RULE WORKERS' COMPENSATION RULES OF THE WEST VIRGINIA INSURANCE COMMISSIONER › Series 85-20 - Medical Management Of Claims, Guidelines For Impairment Evaluations, Evidence, And Ratings, And Ranges Of Permanent Partial Disability Awards › Table 85-20-B - Schedule of Controlled Substances

Current through Register Vol. XLI, No. 28, July 12, 2024
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West Virginia Code of State Rules › Agency 85 - Workers' Compensation › Title 85 - PROCEDURAL RULE WORKERS' COMPENSATION RULES OF THE WEST VIRGINIA INSURANCE COMMISSIONER › Series 85-20 - Medical Management Of Claims, Guidelines For Impairment Evaluations, Evidence, And Ratings, And Ranges Of Permanent Partial Disability Awards › Table 85-20-C - PPD Ranges for Lumbar Spine Impairments

Current through Register Vol. XLI, No. 28, July 12, 2024
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West Virginia Code of State Rules › Agency 85 - Workers' Compensation › Title 85 - PROCEDURAL RULE WORKERS' COMPENSATION RULES OF THE WEST VIRGINIA INSURANCE COMMISSIONER › Series 85-20 - Medical Management Of Claims, Guidelines For Impairment Evaluations, Evidence, And Ratings, And Ranges Of Permanent Partial Disability Awards › Table 85-20-D - PPD Ranges for Thoracic Spine Injury

Current through Register Vol. XLI, No. 28, July 12, 2024
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West Virginia Code of State Rules › Agency 85 - Workers' Compensation › Title 85 - PROCEDURAL RULE WORKERS' COMPENSATION RULES OF THE WEST VIRGINIA INSURANCE COMMISSIONER › Series 85-20 - Medical Management Of Claims, Guidelines For Impairment Evaluations, Evidence, And Ratings, And Ranges Of Permanent Partial Disability Awards › Table 85-20-E - PPD Ranges for Cervical Disorders

Current through Register Vol. XLI, No. 28, July 12, 2024
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West Virginia Code of State Rules › Agency 85 - Workers' Compensation › Title 85 - PROCEDURAL RULE WORKERS' COMPENSATION RULES OF THE WEST VIRGINIA INSURANCE COMMISSIONER › Series 85-20 - Medical Management Of Claims, Guidelines For Impairment Evaluations, Evidence, And Ratings, And Ranges Of Permanent Partial Disability Awards › Table 85-20-F

Current through Register Vol. XLI, No. 28, July 12, 2024
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West Virginia Code of State Rules › Agency 85 - Workers' Compensation › Title 85 - PROCEDURAL RULE WORKERS' COMPENSATION RULES OF THE WEST VIRGINIA INSURANCE COMMISSIONER › Series 85-20 - Medical Management Of Claims, Guidelines For Impairment Evaluations, Evidence, And Ratings, And Ranges Of Permanent Partial Disability Awards › Exhibit A

Current through Register Vol. XLI, No. 28, July 12, 2024
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West Virginia Code of State Rules › Agency 85 - Workers' Compensation › Title 85 - PROCEDURAL RULE WORKERS' COMPENSATION RULES OF THE WEST VIRGINIA INSURANCE COMMISSIONER › Series 85-20 - Medical Management Of Claims, Guidelines For Impairment Evaluations, Evidence, And Ratings, And Ranges Of Permanent Partial Disability Awards › Exhibit B

Current through Register Vol. XLI, No. 28, July 12, 2024
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West Virginia Code of State Rules › Agency 85 - Workers' Compensation › Title 85 - PROCEDURAL RULE WORKERS' COMPENSATION RULES OF THE WEST VIRGINIA INSURANCE COMMISSIONER › Series 85-20 - Medical Management Of Claims, Guidelines For Impairment Evaluations, Evidence, And Ratings, And Ranges Of Permanent Partial Disability Awards › Exhibit C

Current through Register Vol. XLI, No. 28, July 12, 2024
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West Virginia Code of State Rules › Agency 85 - Workers' Compensation › Title 85 - PROCEDURAL RULE WORKERS' COMPENSATION RULES OF THE WEST VIRGINIA INSURANCE COMMISSIONER › Series 85-20 - Medical Management Of Claims, Guidelines For Impairment Evaluations, Evidence, And Ratings, And Ranges Of Permanent Partial Disability Awards › Appendix 2

Current through Register Vol. XLI, No. 28, July 12, 2024
Medium Work - Exerting 20 to 50 pounds of force occasionally
				  and/or 10 to 25 pounds of force frequently and/or greater than negligible up to
				  10 pounds of force constantly to move objects. Physical Demand requirements are
				  in excess of those for Light Work.
Heavy Work - Exerting 50 to 100 pounds of force occasionally
				  and/or 25 to 50 pounds of force frequently and/or 10 to 20 pounds of force
				  constantly to move objects. Physical Demand requirements are in excess of those
				  for Medium Work.
Very Heavy Work - Exerting in excess of 100 pounds of force
				  occasionally and/or in excess of 50 pounds of force frequently and/or in excess
				  of 20 pounds of force constantly to move objects. Physical Demand requirements
				  are in excess of those for Heavy Work.
Additional physical demands of work, as defined in the
				  Revised Handbook for Analyzing Jobs, include Climbing, Balancing, Stooping,
				  Kneeling, Crouching, Crawling, Reaching, Handling, Fingering and
				  Feeling.
Climbing means ascending or descending ladders, stairs,
				  scaffolding, ramps, poles and the like, using feet and legs or hands and arms.
				  Body agility is emphasized.
West Virginia Code of State Rules › Agency 85 - Workers' Compensation › Title 85 - PROCEDURAL RULE WORKERS' COMPENSATION RULES OF THE WEST VIRGINIA INSURANCE COMMISSIONER › Series 85-21 - Managed Health Care Plans › Section 85-21-1 - General

Current through Register Vol. XLI, No. 28, July 12, 2024
1.1. Scope. -- This
				exempt legislative rule establishes the requirements and procedures to be
				followed by the West Virginia Workers' Compensation Commission, parties to
				claims pending before the Commission, employers, private carriers, and managed
				health care plan administrators and others involved in the delivery or proposed
				delivery of managed care to injured workers pursuant to W. Va. Code
				§§
									23-4-3(b)(2)
				and
				23-2C-17(d)(1)
				and (2).
1.2. Authority. -- W. Va. Code §
									23-4-3(b)(2).
				Pursuant to W. Va. Code Section §
									23-1-1
				a(j)(3), rules adopted by the Workers Compensation Board of Managers are not
				subject to legislative approval as would otherwise be required under W. Va.
				Code Section § 29A-3-1 et seq. Public notice requirements of that chapter
				and article, however, must be followed. Upon termination of the Commission,
				regulatory enforcement of this exempt legislative rule shall transfer to the
				Insurance Commissioner. W. Va. Code §
									23-2C-22.
1.3. Filing Date. -- June 29, 2005.
1.4. Effective Date. -- August 1,
				2005.
West Virginia Code of State Rules › Agency 85 - Workers' Compensation › Title 85 - PROCEDURAL RULE WORKERS' COMPENSATION RULES OF THE WEST VIRGINIA INSURANCE COMMISSIONER › Series 85-21 - Managed Health Care Plans › Section 85-21-2 - Purpose of Rule; Cooperation

Current through Register Vol. XLI, No. 28, July 12, 2024
It is a goal of the workers' compensation program to assist
				  workers to return to work as soon as practicable after a compensable injury and
				  to otherwise provide for high quality, cost effective medical care to injured
				  workers. It is the shared responsibility of the employer, the injured worker,
				  the managed health care plan, private carriers, and the Commission, or upon
				  termination of the Commission, the Insurance Commissioner, to cooperate to
				  achieve this goal.
West Virginia Code of State Rules › Agency 85 - Workers' Compensation › Title 85 - PROCEDURAL RULE WORKERS' COMPENSATION RULES OF THE WEST VIRGINIA INSURANCE COMMISSIONER › Series 85-21 - Managed Health Care Plans › Section 85-21-3 - Definitions

Current through Register Vol. XLI, No. 28, July 12, 2024
As used in this exempt legislative rule, the following terms
				  have the stated meanings unless the context of a specific use clearly indicates
				  another meaning is intended.
3.1.
				"Executive Director" means the executive director of the West Virginia Workers'
				Compensation Commission pursuant to W. Va. Code §
									23-1-1b.
3.2. "Commission" means the West Virginia
				Workers' Compensation Commission as provided for by W. Va. Code §
									23-1-1.
3.3. "Injury" and derivative words have the
				meaning ascribed to the term "injury" by W. Va. Code §
									23-4-1.
3.4. "Injured worker" and "claimant" mean an
				employee entitled to workers' compensation benefits as the result of a
				work-related injury, as provided under W. Va. Code §
									23-4-1.
3.5. "Employer" has the meaning ascribed to
				that term by W. Va. Code §
									23-2-1,
				which includes, but is not limited to, any individual, sole proprietor, firm,
				partnership, limited partnership, limited liability company, joint venture,
				association, corporation, company, organization, receiver, estate, trust,
				guardian, executor, administrator, government entity or any other entity
				regularly employing another person or persons for the purpose of carrying on
				any form of industry, service or business in this state.
3.6. "Managed health care plan" means a plan
				that establishes, operates, or maintains a network of health care providers
				that have entered into agreements with the plan to provide health care services
				to injured workers to whom the plan has the ultimate obligation to arrange for
				the provision of or payment for services through organizational arrangements
				for ongoing quality assurance, utilization review programs, or dispute
				resolution.
3.7. "Provider" means
				any physician, hospital or other person or organization, which is licensed or
				otherwise authorized in this state to provide health care services or
				supplies.
3.8. "Utilization review"
				means the critical examination of health care services provided to patients
				especially for the purpose of controlling costs and monitoring the quality of
				care.
3.9. "Insurance Commissioner"
				means the insurance commissioner of West Virginia as provided in section one,
				article two, chapter thirty-three of the West Virginia Code.
3.10. "Insurer" shall mean 1) a self-insured
				employer; or 2) a private carrier.
3.11. "Private Carrier" means any insurer
				authorized by the insurance commissioner to provide workers' compensation
				insurance pursuant to chapters twenty-three and thirty-three of the West
				Virginia Code, but shall not include self-insured employers.
West Virginia Code of State Rules › Agency 85 - Workers' Compensation › Title 85 - PROCEDURAL RULE WORKERS' COMPENSATION RULES OF THE WEST VIRGINIA INSURANCE COMMISSIONER › Series 85-21 - Managed Health Care Plans › Section 85-21-5 - Application Process

Current through Register Vol. XLI, No. 28, July 12, 2024
5.1. The
				following process shall govern the application process for managed health care
				plans submitted to the Commission or upon termination of the Commission, the
				insurance commissioner, for approval pursuant to West Virginia Code Section
				23-4-3(b)(2).
				All managed health care plans must be approved by the Commission or upon
				termination of the Commission, the insurance commissioner, before utilized.
				Employers may participate in one (1) or more approved managed health care
				plans. Applications for initial certification and renewal shall be submitted,
				in triplicate, in a form acceptable to the Commission or upon termination of
				the Commission, the insurance commissioner, and shall contain the following
				information:
a. Plan identification.
1. Plan name and address.
2. Date and state of incorporation.
3. Name, address, and phone number of each
				corporate officer and director, and of the person who will be the day-to-day
				plan administrator.
4. Name and
				address of each owner of more than five (5) percent of the stock or controlling
				interest in the entity.
5. Name,
				address, and phone number of the medical director, who shall be a medical
				doctor (M.D. or D.O. physician) and who shall oversee and monitor compliance
				with the quality care, utilization review and credentialing provisions of the
				managed care plan.
6. Name,
				address, and phone number of the case manager who shall be qualified as either
				a certified case manager, certified rehabilitation counselor, certified
				insurance rehabilitation specialist, or certified rehabilitation registered
				nurse who shall oversee and monitor case management provisions of the managed
				care plan.
7. Description of the
				system's organizational structure.
West Virginia Code of State Rules › Agency 85 - Workers' Compensation › Title 85 - PROCEDURAL RULE WORKERS' COMPENSATION RULES OF THE WEST VIRGINIA INSURANCE COMMISSIONER › Series 85-21 - Managed Health Care Plans › Section 85-21-6 - Approval by the Commission

Current through Register Vol. XLI, No. 28, July 12, 2024
6.1.
				The Commission or upon termination of the Commission, the insurance
				commissioner, shall notify the applicant in writing of the determination made
				upon the application for certification or modification thereof, within sixty
				(60) days of receipt of a complete application. A denial shall be final and
				unappealable.
6.2. A certificate
				shall be valid for a period of two (2) years and only for the service area and
				managed care plan or plans specified by the Commission or upon termination of
				the Commission, the insurance commissioner. Upon written request made at least
				sixty (60) days prior to expiration of the current certificate, the Commission
				may recertify a plan for additional successive two (2) year periods.
				Geographical areas may be added upon the filing of a supplemental application
				demonstrating the managed health care system's ability to serve the expanded
				area.
6.3. If an application does
				not meet the requirements for certification or expansion, the Commission or
				upon termination of the Commission, the insurance commissioner, shall notify
				the applicant in writing and specify those items deemed deficient. The
				applicant is granted thirty (30) days from the date of notice by the Commission
				or upon termination of the Commission, the insurance commissioner, to correct
				deficiencies through an amended application.
6.4. Certifications of a managed care plan
				are not transferable. A new application for certification must be filed when
				fifty (50) percent or more of the ownership or controlling interest of a system
				has been transferred.
West Virginia Code of State Rules › Agency 85 - Workers' Compensation › Title 85 - PROCEDURAL RULE WORKERS' COMPENSATION RULES OF THE WEST VIRGINIA INSURANCE COMMISSIONER › Series 85-21 - Managed Health Care Plans › Section 85-21-7 - Plan Modifications

Current through Register Vol. XLI, No. 28, July 12, 2024
7.1. A
				managed health care plan, which either implements or experiences material
				variations as to any matter set forth in the original application or managed
				care plan, shall obtain approval for the modification by filing a request for
				modification with the Commission or upon termination of the Commission, the
				insurance commissioner.
a. Intended
				variations shall not be implemented until approved by the Commission or upon
				termination of the Commission, the insurance commissioner.
b. A modification outside the control of the
				system shall be filed with the Commission within fifteen (15) days of its
				occurrence.
West Virginia Code of State Rules › Agency 85 - Workers' Compensation › Title 85 - PROCEDURAL RULE WORKERS' COMPENSATION RULES OF THE WEST VIRGINIA INSURANCE COMMISSIONER › Series 85-21 - Managed Health Care Plans › Section 85-21-8 - Suspension or Revocation of Certification

Current through Register Vol. XLI, No. 28, July 12, 2024
8.1. The certification of a managed care plan
				by the Commission or upon termination of the Commission, the insurance
				commissioner, may be suspended or revoked if:
a. Service is not being provided according to
				the terms of the certified managed care plan, or in accordance with prevailing
				treatment standards, or in accordance with treatment standards or practice
				parameters adopted by the Commission, or upon termination of the Commission,
				the insurance commissioner;
b. The
				plan for providing services or the contract with the insurer or health care
				provider fails to meet the requirements of the West Virginia Code or applicable
				state rules and regulations;
c. Any
				material false or misleading information is intentionally submitted by the
				managed health care system or participating provider to the Commission or upon
				termination of the Commission, the insurance commissioner, the employer, or the
				insurer;
d. The managed health care
				system knowingly or negligently utilizes a health care provider whose license,
				registration, or certification has been suspended or revoked, or who is
				otherwise ineligible to provide treatment of the type rendered to an injured
				employee; or
e. For any other good
				faith basis as determined in the sole discretion of the Commission or upon
				termination of the Commission, the insurance commissioner.
West Virginia Code of State Rules › Agency 85 - Workers' Compensation › Title 85 - PROCEDURAL RULE WORKERS' COMPENSATION RULES OF THE WEST VIRGINIA INSURANCE COMMISSIONER › Series 85-21 - Managed Health Care Plans › Section 85-21-9 - Other Administrative Provisions

Current through Register Vol. XLI, No. 28, July 12, 2024
9.1. An employee who reports an injury
				alleged to be work-related or files an application for adjustment of a claim
				shall execute a waiver and consent of any privilege with respect to any
				condition or complaint reasonably related to the condition for which the
				employee claims compensation. Notwithstanding any other provision of the West
				Virginia Code, any physician, psychiatrist, chiropractor, podiatrist, hospital,
				or health care provider shall, within a reasonable time after written request
				by the employee, employer, or Commission or upon termination of the Commission,
				the insurance commissioner, provide the requesting party with any information
				or written material reasonably related to any injury or disease for which the
				employee claims compensation.
9.2.
				When a provider of medical services or treatment makes referrals for medical
				services or treatment to a provider or entity in which the provider making the
				referral has an investment interest, the referring provider shall disclose that
				investment interest to the employee, the Commission or upon termination of the
				Commission, the insurance commissioner, and the employer or the third party
				administrator responsible for paying for the medical services or treatment,
				within thirty (30) days from the date the referral was made.
9.4. Employers may contract with multiple
				managed health care plans in order to maximize access for their
				employees.
9.5. Temporary total
				disability must be certified by a provider within the approved managed health
				care plan, unless the opt-out provisions of this rule have been
				satisfied.
West Virginia Code of State Rules › Agency 85 - Workers' Compensation › Title 85 - PROCEDURAL RULE WORKERS' COMPENSATION RULES OF THE WEST VIRGINIA INSURANCE COMMISSIONER › Series 85-21 - Managed Health Care Plans › Section 85-21-10 - Minimum Grievance Standards

Current through Register Vol. XLI, No. 28, July 12, 2024
10.1. Each workers' compensation managed care
				plan shall contain an expeditious, informal grievance procedure to resolve
				disputes by employees and providers relative to the rendition of medical
				services. A detailed description of the employee grievance procedure shall be
				included in informational materials provided to employees and a detailed
				description of the provider grievance procedure shall be included in all
				provider contracts.
10.2. The
				grievance procedure shall meet the following minimum requirements:
a. Notice. A grievance is made when a written
				complaint or written request is delivered by the employee or provider to the
				managed health care system setting forth the nature of the complaint and
				remedial action requested.
b. Time
				frame to file grievance. The employee or provider shall file a grievance within
				thirty (30) days of the occurrence of the event giving rise to the
				dispute.
c. Resolution. The managed
				health care system shall render a written decision upon a grievance within
				thirty (30) days of receipt by the managed health care system of the
				grievance.
d. Arbitration. Managed
				care plans may provide for alternate means of dispute resolution including
				arbitration and mediation. In that event final resolution of a grievance shall
				not be subject to the time constraints set forth in paragraph c of this
				subsection. In all cases, resolution mechanisms shall be expeditious and where
				treatment matters are at issue reflect the need for prompt resolution.
West Virginia Code of State Rules › Agency 85 - Workers' Compensation › Title 85 - PROCEDURAL RULE WORKERS' COMPENSATION RULES OF THE WEST VIRGINIA INSURANCE COMMISSIONER › Series 85-21 - Managed Health Care Plans › Section 85-21-11 - Reporting Requirements

Current through Register Vol. XLI, No. 28, July 12, 2024
11.1.
				Each certified managed health care plan shall submit a report to the Commission
				or upon termination of the Commission, the insurance commissioner,
				semi-annually containing the following information:
a. Number of employees treated by the managed
				care plan;
b. Number of
				work-related injuries or diseases by ICD-9 code treated under the managed care
				plan in the preceding year;
c.
				Breakdown by ICD-9 codes of injuries and diseases treated;
d. Total medical costs;
e. Average medical cost per injured employee
				by type of injury;
f. Average
				medical cost per diseased employee by type of disease;
g. Breakdown of medical cost elements as to
				type of physician utilized, hospital costs, drug costs, and other
				costs;
h. Number of grievances
				filed, and summary of action taken; and
i. Number of days by type of injury and
				disease for which an employee has been released from work.
West Virginia Code of State Rules › Agency 85 - Workers' Compensation › Title 85 - PROCEDURAL RULE WORKERS' COMPENSATION RULES OF THE WEST VIRGINIA INSURANCE COMMISSIONER › Series 85-21 - Managed Health Care Plans › Section 85-21-12 - Provider Verification

Current through Register Vol. XLI, No. 28, July 12, 2024
12.1.
				Each employer which provides medical services through a managed care plan will
				provide to the injured employee a written certification of workers'
				compensation managed care coverage as soon as practicable following notice of a
				compensable injury or disease requiring medical services. The verification
				shall contain the following information:
a.
				Employer name, address, and phone number;
b. Name and telephone number of the managed
				health care system to be contacted; and
c. Employee name and Social Security
				number.
West Virginia Code of State Rules › Agency 85 - Workers' Compensation › Title 85 - PROCEDURAL RULE WORKERS' COMPENSATION RULES OF THE WEST VIRGINIA INSURANCE COMMISSIONER › Series 85-21 - Managed Health Care Plans › Section 85-21-13 - Injured Worker Opt-Out Standards

Current through Register Vol. XLI, No. 28, July 12, 2024
13.1. Injured workers may access providers
				who are not participating plan providers:
a.
				For emergency care when access to a health care provider within the managed
				health care plan is unobtainable for the acute phase of care;
b. When authorized treatment is unavailable
				through the managed care plan; or c. To obtain a second opinion when a managed
				health care plan physician recommends surgery and another qualified physician
				within the plan is not available for consultation.
West Virginia Code of State Rules › Agency 85 - Workers' Compensation › Title 85 - PROCEDURAL RULE WORKERS' COMPENSATION RULES OF THE WEST VIRGINIA INSURANCE COMMISSIONER › Series 85-21 - Managed Health Care Plans › Section 85-21-14 - Severability

Current through Register Vol. XLI, No. 28, July 12, 2024
If any provision of these rules or the application thereof
				  to any entity or circumstance is held invalid, the invalidity will not effect
				  the provisions or the applications of these rules which can be given affect
				  without the invalid provisions or application and to this end the provisions of
				  these rules are declared to be severable.
West Virginia Code of State Rules › Agency 85 - Workers' Compensation › Title 85 - PROCEDURAL RULE WORKERS' COMPENSATION RULES OF THE WEST VIRGINIA INSURANCE COMMISSIONER › Series 85-22 - Guidelines For Psychiatric Permanent Impairment, Evaluations, Evidence And Ratings Of Psychiatric Impairment Due To Workers' Compensation Injuries › Section 85-22-2 - Purpose of these rules

Current through Register Vol. XLI, No. 28, July 12, 2024
The purpose of these rules is to implement the provisions of
				  West Virginia Code, §
									23-4-3,
				  §
									23-4-3b,
				  §
									23-4-7a(a),
				  - 7a(b) and -7a(h), §
									23-4-8
				  and §
									23-4-1f
				  which relate to the development of guidelines for the evaluation and permanent
				  impairment rating of claimants for psychiatric disabilities arising from
				  injuries sustained in the course of and resulting from employment. The
				  protocols and guidelines adopted by this rule have been approved by the health
				  care advisory panel and recommended to the compensation programs performance
				  council for its adoption. This rule is applicable to evidence submitted by any
				  party to a claim and to evidence gathered by the division.
West Virginia Code of State Rules › Agency 85 - Workers' Compensation › Title 85 - PROCEDURAL RULE WORKERS' COMPENSATION RULES OF THE WEST VIRGINIA INSURANCE COMMISSIONER › Series 85-22 - Guidelines For Psychiatric Permanent Impairment, Evaluations, Evidence And Ratings Of Psychiatric Impairment Due To Workers' Compensation Injuries › Section 85-22-3 - Definitions

Current through Register Vol. XLI, No. 28, July 12, 2024
As used in these rules, the following terms have the stated
				  meanings unless the context of a specific use clearly indicates another meaning
				  is intended.
3.1. "Commissioner" means
				the Commissioner of the Bureau of Employment Programs pursuant to West Virginia
				Code, S21A-2-1,
				and West Virginia Code, §
									23-1-1,
				and any deputies designated pursuant to West Virginia Code, §
									21A-2-12
				& -13.
3.2. "Division" means
				the Workers' Compensation Division within the Bureau of Employment "Programs as
				provided for by West Virginia Code, §
									21A-1-4,
				and West Virginia Code, §
									23-1-1
				et seq.
3.3. Work injury-related
				psychiatric disorders - Those psychiatric disorders caused by or aggravated by
				a work injury or disease.
3.4.
				Causation, legal standard - "The fact of being the cause of something produced
				or of happening. The act by which an effect is produced." (That which produces
				or- is the cause of a psychiatric condition and/or impairment)
3.5. Aggravation, legal standard - "The
				result of an act," action, or circumstance that intensifies or makes worse a
				medical condition; an unfavorable progression of the claimant's medical
				condition."
3.6. Apportionment -
				"The act of allocating, usually in terms of a percentage, between various
				causes, injuries or diseases."
3.7.
				Psychiatric impairment - The loss of, loss of use of, or derangement of mental,
				emotional or brain functioning.
3.8. Permanent psychiatric impairment -
				Impairment that is static or well stabilized with or without psychiatric
				treatment, or that is not likely to remit despite psychiatric treatment of the
				impairing condition.
3.9. Permanent
				partial psychiatric impairment - Impairment that is assigned a percentage of
				impairment rating from the West Virginia Workers' Compensation Guidelines for
				Psychiatric Impairment.
3.10.
				Temporary total disability, psychiatric - A psychiatric condition that in and
				of itself, or in combination with a physical condition, makes the claimant
				unable to function in the work setting.
3.11. Maximum medical improvement,
				psychiatric (Stabilized Psychiatric Condition) - A disorder is stable when,
				after a period of time particular to that disorder, no further improvement is
				likely with or without treatment. This ranges from six months for functional
				disorders to two years for brain injury cases.
West Virginia Code of State Rules › Agency 85 - Workers' Compensation › Title 85 - PROCEDURAL RULE WORKERS' COMPENSATION RULES OF THE WEST VIRGINIA INSURANCE COMMISSIONER › Series 85-22 - Guidelines For Psychiatric Permanent Impairment, Evaluations, Evidence And Ratings Of Psychiatric Impairment Due To Workers' Compensation Injuries › Section 85-22-4 - Evidentiary Requirements

Current through Register Vol. XLI, No. 28, July 12, 2024
4.1.
				The evidentiary weight to be given to a report will be influenced by how well
				it demonstrates that the evaluation and examination that it memorializes were
				conducted in accordance with the rule, the attached dictation aid (Appendix F),
				guideline (Appendix A) and four additional appendices. The examiner must
				address and memorialize each bold" face section found in the attached
				guideline. Appendix B lists conditions likely and unlikely to be related to
				trauma or work, appendix C provides a guideline and schedule for assigning
				impairment ratings, Appendix D provides a list illustrating when psychiatric
				impairment is probable and appendix E provides a list to aid in the
				identification of malingerers.
West Virginia Code of State Rules › Agency 85 - Workers' Compensation › Title 85 - PROCEDURAL RULE WORKERS' COMPENSATION RULES OF THE WEST VIRGINIA INSURANCE COMMISSIONER › Series 85-22 - Guidelines For Psychiatric Permanent Impairment, Evaluations, Evidence And Ratings Of Psychiatric Impairment Due To Workers' Compensation Injuries › Section 85-22-7 - Appendices

Current through Register Vol. XLI, No. 28, July 12, 2024
7.1. The following
				appendices are attached hereto and are incorporated herein as if fully set
				forth.
a. Appendix A - The psychiatric
				examination guideline provides the examiner with guide by which to conduct an
				examination. The examiner must address all bold face headings and memorialize
				the the findings in his or her report.
b. Appendix B lists conditions likely and
				unlikely to be related to trauma or work.
c. Appendix C provides the West Virginia
				Workers' Compensation Guidelines for Psychiatric Impairment.
d. Appendix D provides a list illustrating
				when psychiatric impairment is probable.
e. Appendix E provides a list to aid in the
				identification of malingerers.
f.
				Appendix F is a dictation aid which may be used in conjunction with the
				guideline in Appendix A.
West Virginia Code of State Rules › Agency 85 - Workers' Compensation › Title 85 - PROCEDURAL RULE WORKERS' COMPENSATION RULES OF THE WEST VIRGINIA INSURANCE COMMISSIONER › Series 85-22 - Guidelines For Psychiatric Permanent Impairment, Evaluations, Evidence And Ratings Of Psychiatric Impairment Due To Workers' Compensation Injuries › Section 85-22-8 - Severability

Current through Register Vol. XLI, No. 28, July 12, 2024
If any provision of these rules or the application thereof to
				  any entity or circumstance shall be held invalid, such invalidity shall not
				  effect the provisions or the applications of these rules which can be given
				  affect without the invalid provisions or application and to this end the
				  provisions of these rules are declared to be severable.
West Virginia Code of State Rules › Agency 85 - Workers' Compensation › Title 85 - PROCEDURAL RULE WORKERS' COMPENSATION RULES OF THE WEST VIRGINIA INSURANCE COMMISSIONER › Series 85-23 - Loss Prevention › Section 85-23-1 - General

Current through Register Vol. XLI, No. 28, July 12, 2024
1.1. Scope. - These
				rules implement the provisions of W.Va. Code, §
									23-2B-2,
				regarding mandatory safety programs.
1.2. Authority. - W. Va.Code §§
									23-2B-2;
				23-2-4;
				and
				23-1-1.
				Pursuant to W. Va. Code §
									23-1-1a(j)(3).
				rules adopted by the board of managers and the commission are not subject to
				legislative approval as would otherwise be required under W. Va. Code, §
									29A-3-1
				et seq. Public notice requirements of that chapter and article, however, must
				be followed.
1.3. Filing
				Date.
1.4. Effective
				Date.
West Virginia Code of State Rules › Agency 85 - Workers' Compensation › Title 85 - PROCEDURAL RULE WORKERS' COMPENSATION RULES OF THE WEST VIRGINIA INSURANCE COMMISSIONER › Series 85-23 - Loss Prevention › Section 85-23-2 - Purpose

Current through Register Vol. XLI, No. 28, July 12, 2024
The purpose of this rule is to implement the provisions of W.
				  Va, Code, §
									23-2B-2,
				  to promote workplace health and safety programs and encourage compliance with
				  occupational safety and health laws, regulations and standards. The goal of
				  this rule is to establish workers' compensation reforms which result in a
				  reduction of occupational injuries and illnesses in the State of West Virginia
				  and consequently a reduction in the workers' compensation fund deficit. This
				  rule does not apply to employers who have elected to self insure their workers'
				  compensation risk pursuant to the provisions of W. Va. Code §
									23-2-9.
a. In accordance with the provisions of
				Senate Bill 1004, as passed in the First Special Session of the two
				thousand-five Legislature, the board of managers terminates upon termination of
				the commission. Upon that occurrence, this rule will also terminate.
West Virginia Code of State Rules › Agency 85 - Workers' Compensation › Title 85 - PROCEDURAL RULE WORKERS' COMPENSATION RULES OF THE WEST VIRGINIA INSURANCE COMMISSIONER › Series 85-23 - Loss Prevention › Section 85-23-4 - Tier One: Focus Program Employer

Current through Register Vol. XLI, No. 28, July 12, 2024
4.1. Notification. The commission shall
				notify all employers whose performance criteria falls within the focus program
				employer classification. The commission shall include in such notification an
				analysis of the occupational injuries and diseases incurred by the employer and
				a list of qualified safety consultants and agencies.
4.2. Seminar. All focus program employers
				must attend a seminar on basic safety programs sponsored or approved by the
				commission.
4.3. Reports. The
				workers' compensation commission shall provide a report to each focus program
				employer at the conclusion of each review period. The report shall detail
				claims information for the review period.
4.3.1. The focus program employer shall
				provide a copy of each report required under this section to all bargaining
				units or bargaining agents representing the employees.
West Virginia Code of State Rules › Agency 85 - Workers' Compensation › Title 85 - PROCEDURAL RULE WORKERS' COMPENSATION RULES OF THE WEST VIRGINIA INSURANCE COMMISSIONER › Series 85-23 - Loss Prevention › Section 85-23-5 - Tier Two: Target Program Employer

Current through Register Vol. XLI, No. 28, July 12, 2024
5.1. Notification. The commission shall
				notify all employers whose performance criteria falls within the target program
				employer classification. The commission shall include in such notification an
				analysis of the occupational injuries and diseases incurred by the employer and
				a list of qualified safety consultants and agencies.
5.2. Seminar. All target program employers
				must attend a seminar on basic safety programs sponsored or approved by the
				commission.
5.3. Joint Safety
				Committee. All target program employers shall establish a joint labor and
				management safety committee.
5.3.1. An
				employer that is a member of a multi-employer group operating under a
				collective bargaining agreement that contains provisions regulating the
				formation and operation of a safety committee that meets or exceeds the minimum
				requirements of this rule shall be considered to have met the requirements of
				this rule.
West Virginia Code of State Rules › Agency 85 - Workers' Compensation › Title 85 - PROCEDURAL RULE WORKERS' COMPENSATION RULES OF THE WEST VIRGINIA INSURANCE COMMISSIONER › Series 85-23 - Loss Prevention › Section 85-23-6 - Tier Three Employer

Current through Register Vol. XLI, No. 28, July 12, 2024
6.1.
				Classification. The commission shall classify as tier three employers all
				properly classified (for ratemaking purposes under the provisions of W. Va.
				Code §
									23-2-4)
				employers:
6.1.1. Who do not participate in
				the focus program employer program requirements;
6.1.2. Who do not participate in the target
				program employer program requirements; or
6.1.3. Who do not comply with the
				requirements of a target program employer.
West Virginia Code of State Rules › Agency 85 - Workers' Compensation › Title 85 - PROCEDURAL RULE WORKERS' COMPENSATION RULES OF THE WEST VIRGINIA INSURANCE COMMISSIONER › Series 85-23 - Loss Prevention › Section 85-23-7 - New Subscriber Employers

Current through Register Vol. XLI, No. 28, July 12, 2024
7.1. All
				employers without the requisite experience to calculate an experience
				modification factor shall be afforded a new subscriber experience modification
				factor for purposes of classification as a focus program employer or target
				program employer under the provisions of this rule.
7.1.1. A new subscriber experience
				modification factor shall be calculated for each employer at the close of the
				second full quarter after business start-up or after the effective date of this
				rule, if the employer has accumulated two (2) full quarters of claims
				experience, whichever is applicable.
7.1.2. The new subscriber experience
				modification factor shall be calculated in a similar manner as other experience
				modification factors.
West Virginia Code of State Rules › Agency 85 - Workers' Compensation › Title 85 - PROCEDURAL RULE WORKERS' COMPENSATION RULES OF THE WEST VIRGINIA INSURANCE COMMISSIONER › Series 85-23 - Loss Prevention › Section 85-23-8 - General Provisions: Classification and Reclassification

Current through Register Vol. XLI, No. 28, July 12, 2024
8.1. Discretion. In
				matters involving classification and reclassification, the commission shall not
				be required to classify or reclassify an employer solely as a result of the
				measurement of performance criteria. The commission shall have discretion to
				consider other relevant issues as contained in, but not limited to, the
				provisions of 10.4.1 of this rule.
West Virginia Code of State Rules › Agency 85 - Workers' Compensation › Title 85 - PROCEDURAL RULE WORKERS' COMPENSATION RULES OF THE WEST VIRGINIA INSURANCE COMMISSIONER › Series 85-23 - Loss Prevention › Section 85-23-9 - Notification

Current through Register Vol. XLI, No. 28, July 12, 2024
The commission shall notify each employer classified or
				  reclassified as a focus program employer, target program employer, or tier
				  three employer under the provisions of this rule by certified mail addressed to
				  the employer at the employer's last known residence or place of business:
				  Provided, That, if an employer is represented by an attorney or other
				  representative, then notice to the attorney or other representative shall be
				  sufficient notice to the party so represented.
West Virginia Code of State Rules › Agency 85 - Workers' Compensation › Title 85 - PROCEDURAL RULE WORKERS' COMPENSATION RULES OF THE WEST VIRGINIA INSURANCE COMMISSIONER › Series 85-23 - Loss Prevention › Section 85-23-11 - Experience Modification Factors

Current through Register Vol. XLI, No. 28, July 12, 2024
Calculations of experience modification factors for purposes
				  of this rule shall not affect ratemaking procedures under the provisions of any
				  other commission rule, except to the extent that such other rule expressly
				  incorporates the provisions of this rule.
West Virginia Code of State Rules › Agency 85 - Workers' Compensation › Title 85 - PROCEDURAL RULE WORKERS' COMPENSATION RULES OF THE WEST VIRGINIA INSURANCE COMMISSIONER › Series 85-23 - Loss Prevention › Section 85-23-12 - Forms

Current through Register Vol. XLI, No. 28, July 12, 2024
The shall prepare and make available to all mandated
				  employers standardized forms for reports required under the provisions of this
				  rule.
West Virginia Code of State Rules › Agency 85 - Workers' Compensation › Title 85 - PROCEDURAL RULE WORKERS' COMPENSATION RULES OF THE WEST VIRGINIA INSURANCE COMMISSIONER › Series 85-23 - Loss Prevention › Section 85-23-13 - Retaliation Complaint Procedure

Current through Register Vol. XLI, No. 28, July 12, 2024
13.1. A member of a joint labor and
				management safety committee shall not experience any loss of wages or other
				retaliation while attending safety committee meetings or performing duties at
				the direction of the safety committee.
13.2. Filing. Any member of a joint labor and
				management safety committee who experiences such loss of wages or retaliation
				may file a complaint within thirty (30) days of occurrence regarding such
				activity.
13.2.1. The complaint shall be
				filed with the president or chief executive officer of the employer, if the
				employer is a corporation or a limited corporation; with the managing partner
				if the employer is a partnership; with the general partner if the employer,
				parent or related business is a limited partnership; or, with all the members
				if the employer is a limited liability company; or with the owner if the
				employer is a sole proprietorship.
13.2.2. A copy of the complaint shall be
				filed with a commission designee.
13.2.3. A copy of the complaint shall be
				filed with the joint labor and management safety committee and shall be made a
				part of the minutes of their next scheduled meeting.