Section 418.10104. Reimbursement to injured worker or to health insurer for compensable medical services.

Rule 104. (1) Notwithstanding any other provision of  these  rules,  if an injured worker has paid for a health care service and at a  later  date a carrier is determined to be responsible for  the   payment,    then   the injured worker shall be fully reimbursed by the carrier.

(2)    The injured worker may submit the request for reimbursement on  a medical or dental claim form, but shall supply to the carrier a copy of a statement including the provider name, the date of service, the procedure and diagnosis and documentation of the amount paid.

(3)   When a health insurer pays for a medical service to treat an injured worker and subsequently requests reimbursement from the workers' compensation carrier, the health insurer is not required to submit the request on  a  CMS 1500, or a UB-04 claim  form,  or other medical or dental claim form. The health insurer shall supply to the workers' compensation carrier, or the carrier's designee, a claim  detail   showing the date of  service, the amount billed and paid, the procedure code and diagnosis for the rendered services.The workers' compensation carrier shall reimburse the health insurer the provider's usual and customary fee or the maximum allowable fee, whichever is less, for the compensable medical services in accordance with these rules.If the health insurer reimbursed the provider less than the amount allowed by these rules, then the workers' compensation carrier shall reimburse the amount paid by the health insurer.

History: 1998-2000 AACS; 2003 AACS; 2005 AACS; 2008 AACS.