Section 408.32a. Medical benefits; reimbursement application.

a. (1) To be reimbursed for payments made in accordance with the provisions of section 862(2) of the act, medical benefits shall have been required by the terms of an award and shall have been paid in accordance with section 315 of the act and the rules promulgated under section 315.

In providing benefits as required by section 862(2) of the act, a carrier shall require that the employee and the provider comply with the requirements of section 315 of the act and the rules promulgated under section 315.

(2)     Reimbursement shall apply only  to  cases  for  which  an   initial application for mediation or hearing is filed after March 31, 1986, under section 847 of the act. Claims shall be made on forms provided by the bureau and sent to the bureau of workers’ disability compensation. If other insurance coverage is or was available to cover medical benefits paid under section 862(2) of the act, then the bureau will not make reimbursement.

(3)   Applications for reimbursement from the bureau shall be made not less than 30 days after the benefit amount is reduced or rescinded by a final determination. An application for reimbursement shall be made not later than 1 year after a final determination  is  entered that  reduces or rescinds benefits.

(4)   Reimbursement from the bureau shall be consistent with benefits awarded in the magistrate’s decision. Reimbursement will only be made for  medical benefits that were provided between the bureau’s mailing date of the magistrate’s award and the mailing date of the  final  determination  of  the appeal or for a shorter period as specified

in  the  award.   A  copy  of the magistrate’s order and all subsequent  appellate  decisions shall accompany each request for reimbursement.

(5)    A copy of the medical bills, proof of payment, and a medical report with sufficient documentation to  demonstrate   that  the  medical  services provided fall within the provision of the magistrate’s decision shall accompany each request for reimbursement. Proof of payment shall include certification from the carrier that it has paid the medical bills or, if requested by the bureau, shall include a receipt from the provider  which shows that payment has been made.

(6)   Reimbursement shall not be paid if the claim was redeemed before the final determination or if the carrier has not provided proper documentation.

(7)   The bureau shall not pay interest on reimbursable amounts.

(8)   If the   bureau  determines   that  all  or  part  of  the   request  for reimbursement is not proper, then the bureau shall notify the carrier  in writing. If the carrier disputes the determination, then it may file  an application for mediation or hearing.

History: 1989 AACS; 1998-2000 AACS.