Section 418.10117. Carrier responsibilities.

(1) The carrier or its designated agent shall assure that a billing form is completed properly before  making  payment  to  the licensed provider or licensed facility.

(2)    A carrier may designate a third party to receive provider bills on its behalf. If a carrier instructs the provider to send the medical bills directly to the third party, then the 30-day limit of this rule begins when the third party receives the  bill.  The  carrier  is responsible for forwarding bills and medical documentation when there is a third party reviewing medical bills for the carrier.

(3)   A carrier or designated agent shall make payment of an unadjusted and properly submitted bill within 30 days of receipt of a properly submitted bill or shall add a self- assessed 3% late penalty to the maximum allowable payment or  the  provider's  charge, whichever is less, as  required by these rules.

(4)   A carrier or designated agent shall record payment decisions on a form entitled "The Carrier's Explanation of Benefits" using a format approved by the workers' compensation agency. The carrier or designated agent shall keep a copy of the explanation of benefits and shall send a copy to the provider and to the injured worker. The carrier's explanation of benefits shall list a clear reason for the payment adjustment or amount disputed and shall notify the provider what information is required for additional payment.

(5)   A carrier or designated agent shall make payment of an adjusted bill or portion of an adjusted bill within 30 days of receipt of the properly submitted bill.  If a carrier or designated agent rejects  a   bill in  its entirety, then the carrier or designated agent  shall  notify the provider of the rejection within 30 days after receipt of a properly submitted bill.

(6)   If a carrier requests the provider to send duplicated copies of the documentation required in part 9 or additional medical records  not required by these rules, then the carrier shall reimburse the provider for the copying charges in accord with R 418.10118.

(7)   When the carrier has disputed a case and has not issued  a  copy   of the formal notice of  dispute  to   the  medical  provider,   then   the carrier's explanation   of  benefits  shall   be sent  in  response  to   the provider's   initial bill. The carriers' explanation of benefits shall   serve as  notice  to  the provider that nonpayment  of the  bill  is  due  to  the dispute.

History: 1998-2000 AACS; 2002 AACS; 2003 AACS; 2005 AACS; 2009 AACS.