11 N.C. Admin. Code 23A.0614

Current through Register Vol. 39, No. 9, November 1, 2024

Section 23A .0614 - HEALTH CARE PROVIDER FEE DISPUTE PROCEDURE

(a) Health care providers seeking to resolve a dispute regarding payment of charges for medical compensation shall make an inquiry directly to the employer or employer's workers compensation insurance carrier responsible for the payment of medical fees by using an Industrial Commission Form 26I Medical Provider Dispute Resolution Questionnaire.

(b) The Commission shall assist a health care provider who has been unsuccessful in obtaining carrier contact information. No information regarding a specific claim shall be provided by the Commission to the health care provider.

(c) When an employer or carrier does not respond to a health care provider's Form 26I Medical Provider Dispute Resolution Questionnaire inquiry regarding a medical fee dispute within 20 days, or denies liability as a Form 26I Medical Provider Dispute Resolution Questionnaire response, the health care provider may file a written request seeking assistance from the Commission regarding the fee dispute.

(d) The Commission shall conduct a conference between the health care provider and the employer or carrier in an effort to resolve the dispute.

(e) When the health care provider, with assistance from the Commission is unable to resolve the dispute, the health care provider may request limited intervention in the workers' compensation claim for the sole purpose of resolving the fee dispute.

(f) A health care provider seeking limited intervention in a workers' compensation claim shall file a motion to intervene with the Commission. The Motion to Intervene must include the following:

(1) the Commission file number, if known;

(2) the employee's name, address, and last four digits of his or her social security number;

(3) the date of injury and a description of the workplace injury, including the body parts known to be affected;

(4) an itemized list of the medical fees in dispute, including CPT codes relating specific charges to the Workers' Compensation Medical Fee Schedule, and explanations directly relating each charge to the employee's workplace injury;

(5) a copy of the Form 26I Medical Provider Dispute Resolution Questionnaire submitted by the health care provider, including all accompanying materials, and any response received back by the health care provider from the employer or carrier contacted;

(6) a copy of the written request for assistance submitted to the Medical Fees Section of the Commission;

(7) a copy of the written summary by the Medical Fees Section of the informal resolution process and outcome;

(8) a sworn affidavit by the health care provider that states:

(A) the health care provider has treated the employee;

(B) the medical fees itemized by the health care provider are current and unpaid; and

(C) the health care provider reasonably believes that the employer or carrier named on the Form 26I Medical Provider Dispute Resolution Questionnaire is obligated to pay the fees under the Workers' Compensation Act; and

(9) a certification of service upon both the employee and the employer or carrier named on the Form 26I Medical Provider Dispute Resolution Questionnaire.

(g) A health care provider who has been denied intervention may request a review by the Commission by filing a written request with the Docket Section of the Industrial Commission within 10 days of receipt of the order denying intervention.

(h) The request for review by the Commission shall be served on all parties to the workers' compensation claim and include:

(1) a statement of facts necessary to an understanding of the issue(s);

(2) a statement of the relief sought;

(3) a copy of the motion to intervene, including all attachments required by Paragraph (f) of this Rule; and

(4) a copy of the order denying intervention.

(i) Within 10 days after service of a request for review by the Commission, any party to the workers' compensation claim may file a response, including supporting affidavits or documentation not previously filed with the Commission.

(j) The Commission's determination shall be made on the basis of the request for review and any response(s), including supporting documentation. No briefs or oral argument are allowed by the Commission.

(k) In accordance with the G.S. 97-90.1, when a health care provider is allowed to intervene by the Commission, the intervention is limited to the medical fee dispute.

(l) Following intervention, a health care provider may request and obtain information from the Commission related to the medical fee. The request for information must be in writing, include a copy of the order allowing the health care provider to intervene, and be directed to the Claims Section of the Commission.

(m) Discovery by a health care provider shall be allowed following a Commission order allowing intervention but is limited to matters related to the medical fee dispute.

(n) A health care provider who has intervened in a workers' compensation claim may obtain a hearing before the Commission on a medical fee dispute by filing an Industrial Commission Form 33I Intervenor's Request that Claim be Assigned for Hearing and paying a filing fee.

(o) Upon resolution of a medical fee dispute, costs shall be determined and assessed by the Commission and the health care provider shall be dismissed from the claim. The health care provider shall retain standing to request review of an order from the Commission.

11 N.C. Admin. Code 23A .0614

Authority G.S. 97-26(i); 97-80(a);
Eff. January 1, 1990;
Amended Eff. November 1, 2014; January 1, 2011; June 1, 2000; March 15, 1995;
Recodified from 04 NCAC 10A .0614 Eff. June 1, 2018.

Authority G.S. 97-26(i); 97-80(a);
Eff. 1/1/1990;
Amended Eff. 11/1/2014; 1/1/2011; 6/1/2000; 3/15/1995;
Recodified from 04 NCAC 10A .0614 Eff. 6/1/2018.