Section 418.101204. Carrier's professional health care review program.

(1) A carrier may have another entity perform professional health care review activities on its behalf.

(2)     The  workers'  compensation   agency  shall  certify  a  carrier's professional health care review program pursuant to R 418.101206.

(3)   The carrier shall submit  a   completed  form  entitled  "Application for Certification of the Carrier's Professional Health Care Review Program" to the agency. If the carrier is a self- insured employer or self-insured group fund, then the service company information shall be included  on  the form  in addition to the carrier and review company information. In  addition to  the completed form, the carrier shall submit all of the following:

(a)   The methodology used to perform professional review.

(b)       A listing  of  the   licensed,  registered,  or   certified  health care professionals reviewing the health care bills or establishing guidelines for technical review. In addition, the proof of current licensure and qualifications for the health care professionals shall be included with the completed application.

(c)   A list of the carrier's peer review staff, including specialty.

(4)    The workers' compensation carrier as defined by these rules maintains full responsibility for compliance with these rules.

(5)   The carrier shall determine medical appropriateness for the services provided in connection with the treatment of a covered injury or illness, using published, appropriate standard medical practices and resource documents.  Utilization review shall be performed using 1 or both of  the following approaches:

(a)   Review by licensed, registered, or certified health care professionals.

(b)       The application by others  of   criteria  developed  by   licensed, registered, or certified health care professionals.

(6)    The licensed, registered, or certified health care professionals shall be involved in determining the carrier's response to a request by a provider for reconsideration of its bill.

(7)   The licensed, registered, or certified health care professionals shall have suitable occupational injury or disease expertise, or both,  to render an informed clinical judgment on the medical appropriateness  of the services provided.

(8)   When peer review is utilized, a health  care  professional    of   the same specialty type as the provider of the medical  service  shall  perform the review.

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