N.H. Admin. Code § Lab 506.01

Current through Register No. 35, August 29, 2024

Section Lab 506.01 - Claims Processing

(a) Carriers shall familiarize themselves with the provisions of the statute and these rules.

(b) Carriers shall obtain and maintain a supply of mandated state forms which they shall supply to their insured's and their own claims offices.

(c) Carriers shall keep their insured informed of the current address, telephone number, and email address of their nearest claims office.

(d) Carriers shall provide facilities within the state to service claims.

(e) If the carrier elects to substitute an unaffiliated adjustment service, or a third party administrator, it shall:

(1) Confirm that the third party administrator is licensed by the state;

(2) Delegate sufficient authority to comply with the statute and these rules;

(3) Notify the department of labor and the injured worker;

(4) Notify the department and injured worker of any subsequent change in the election of the third party as soon as possible after the change is made to the department and injured worker; and

(5) Include in each notification shall include the claim number, the address, the email address, and phone number of the third party administrator.

(f) Carriers shall process all claims as quickly as possible. After receiving the first notice of a claim, the claim shall be paid or denied within 21 days as provided in Lab 506.02.

(g) Carriers shall promptly and critically review employers' supplemental reports for the purpose of making a determination as to compensable disability within 21 days of receipt of the report.

(h) The carrier or self-insurer who determines that a medical examination of an injured employee is needed under RSA 281-A:38 shall:

(1) At least 10 days prior to the scheduled examination, notify the employee by letter, copy to the department, of the time and place of the examination;

(2) Set forth the employee's rights, obligations and possible penalties under RSA 281-A:38 and RSA 281-A:39;

(3) Provide transportation to the examination if needed and requested or reimburse the claimant for mileage and toll costs to the examination as provided by Lab 506.02(i).

(4) Not schedule an examination more than 50 miles radius from the employee's current residence, unless a waiver has been obtained from the commissioner, as follows:

a. Provide the current address of the injured worker and the address of location of the proposed examination;

b. Demonstrate to the commissioner there is no qualified independent medical provider available within the 50-mile radius who will perform the examination;

c. Demonstrate that unique circumstances exist that would make scheduling an independent medical examination outside the 50-mile radius necessary;

d. Obtain the waiver prior to the scheduling of the examination;

e. State that the concurrence to the request has been sought from the opposing party;

f. State that the opposing party objects, consents or takes no position to the request;

g. State all attempts that were made to contact the opposing party, if unable to contact or elicit a response; and

h. Receive a response from the commissioner within 10 days of the request;

(5) Not schedule more than 2 examinations within a year's time, unless they have obtained a waiver from the commissioner as follows:

a. Demonstrate that the injured workers condition requires an independent medical examination by a practitioner in a different specialty; or.

b. Demonstrate that a change in the injured workers condition has occurred since the last independent medical examination that necessitates a review of the current treatment; or

c. Indicate that an intervening incident has occurred since the last independent medical examination that requires additional review of current treatment or;

d. Demonstrate that unique circumstances exists that would make scheduling an additional examination necessary.

e. Obtain the waiver prior to the scheduling of the examination;

f. State that concurrence to the request has been sought from opposing party;

g. State if opposing party objects, consents, or takes or takes no position to the request;

h. State all attempts that were made to contact opposing party, if unable to contact or elicit a response; and

i. Receive a response from the commissioner within 10 days of receipt of the request; and

(6) Determine that the health care provider is certified by the appropriate specialty board as recognized by the American Board of Medical Specialties or the health care provider shall have obtained the approval of the commissioner for those specialties not recognized by such board by fulfilling requirements substantially similar to those of the American Board of Medical Specialties.

(i) Failure to comply with (h), above, shall preclude the carrier from suspending benefits for the employee's failure to comply.

N.H. Admin. Code § Lab 506.01

#2256, eff 1-2-83; ss by #2935, eff 12-27-84, EXPIRED: 12-27-90

New. #5041, eff 1-9-91; ss by #5235, eff 9-27-91, EXPIRED: 9-27-97

New. #6631, INTERIM, eff 11-16-97, EXPIRED: 3-16-98

New. #6806, eff 7-18-98); ss by #8682, INTERIM, eff 7-15-06, EXPIRED: 1-11-07

New. #9019, eff 11-1-07

Amended by, Volume XXXVI Number 14, Filed April 7, 2016, Proposed by #11067, Effective 4/1/2016, Expires 4/1/2026.