Section 418.101304. Disputes.

(1) If a carrier adjusts or rejects a bill or a portion of a bill under these rules, then a notice given under R  418.101301(1) creates  an ongoing dispute for the purpose of section 801 of the act.The time for making payment of a bill under section 801 of the act shall not  run  unless the bill is properly submitted according to applicable rules and statutes.

(2)   Any dispute that concerns any of the following shall be resolved as if an application for mediation or hearing was filed under section 847 of the act:

(a)   The medical appropriateness of health care or a health care service.

(b)   Utilization of health care or a health care service.

(c)   The need for health care or a health care service.

(d)  Any dispute over the cost of health care or a health care service.

(3)   If the dispute results in the denial of medical treatment for a worker, or if there is a petition by an employer to stop the employer's liability for medical benefits previously ordered, including proceedings under subrule (6) of this rule, then the dispute shall receive the same expedited treatment accorded to 60-day cases under section 205 of the act, except that the agency may refer the matter to mediation under section 223 of the act.

(4)   A dispute under this rule may  be  submitted  to   arbitration     under section 864 of the

act.

(5)   A dispute under this rule may be handled  as  a   small   claim      under section 841(2) to

(10)   of the act  if  it  meets  the requirements of  that section.

(6)   If a carrier is required by the terms  of  an  award   to    provide medical benefits, then the  carrier   shall  continue  to  provide  those benefits  until there is a different order by any of the following entities:

(a)   A magistrate.

(b)   The appellate commission.

(c)   The court of appeals.

(d)  The supreme court. This subrule shall not preclude the use of the maximum allowable payments provided by these rules for the payment of bills by carriers. If a carrier files an application to stop or limit its liability under this subrule, the carrier shall receive the expedited treatment provided for under subrule (3) of this rule.

(7)   If the agency believes that a provider is not in compliance with these rules, then the agency may file an application for mediation or hearing under this rule.

History: 2000 AACS; 2005 AACS.