Idaho Regulations 17.02.04.322

a. Commission means the Idaho Industrial Commission. (2-20-95)

b. Medical Only Claim means the injured worker will not suffer a disability lasting more than five (5) calendar days as a result of a job-related injury or occupational disease. (2-20-95)

c. Rehabilitation Division means the Rehabilitation Division of the Industrial Commission and includes its field offices. (2-20-95)

d. Time loss claim means the injured worker will suffer, or has suffered, a disability that lasts more than five (5) calendar days as a result of a job-related injury or occupational disease, or the injured worker requires,or required, in-patient treatment as a result of such injury or disease. (2-20-95)

e. Impairment rated claim means those claims in which the provider establishes an impairment rating for the injured worker. (2-20-95)

f. Medical report includes without limitation, all bills, chart notes, surgical records, testing results, treatment records, hospital records, prescriptions, and medication records. (2-20-95)

g. Employer is defined in Section 72-402(11), Idaho Code and includes agents of employers such as attorneys, sureties, and adjusters. (2-20-95)

h. Provider means anyone who provides medical services as defined in Section 72-102(16), Idaho Code. (2-20-95)

i. ISIF means the Industrial Special Indemnity Fund, which is commonly referred to as the Second Injury Fund. (2-20-95)

j. Payor means the entity that is responsible for making payment to the Provider for services rendered to treat an industrially injured patient and includes self-insured employers, sureties, adjusters and their agents. (2-20-95)

k. Claimant means the patient who sought treatment for an industrial accident or occupational disease and includes agents such as attorneys. (2-20-95)

02. Procedure for Submitting Medical Reports. (2-20-95)

a. In all cases in which a particular injury or occupational disease results in a workers compensation claim, the Provider shall submit written medical reports for each medical visit to the Payor. Payers and Providers may contract with one another to identify specific records that will be provided in support of billings. The Provider shall also submit the same written medical reports to the Claimant upon request. These reports shall be submitted within fourteen (14) days following each evaluation, examination and/or treatment. The first copy of any such reports shall be provided to the Payor and the Claimant at no charge. If duplicate copies of reports already provided are requested by either the Payor or the Claimant, the Provider may charge the requesting party a reasonable charge to provide the additional reports. Whenever possible, billing information shall be coded using the Current Procedural Terminology (CPT). In the case of hospitals, reports shall include a Uniform Billing (UB) Form 92. In the case of physicians and other providers supplying outpatient services, this reporting requirement shall include a Health Care Financing Administration (HCFA) Form 1500. (2-20-95)

b. If an injury or occupational disease results in a claim, the Employer/Surety/Adjuster or Provider shall submit written reports tot he Commission upon request. Such request either may e in writing or telephonic. If a claim is referred to the Rehabilitation Division, medical reports shall be furnished by the Payor or Provider directly to the office that request such reports. The Payor or Provider shall consider this an on-going request until notice is received that the reports are no longer required. (2-20-95)

c. If the injury or occupational disease results in a time-loss claim, the Payor shall submit copies of medical records containing information regarding the beginning and ending of disability, releases to work whether light duty or regular duty, impairment ratings, physical restrictions. Notices of Change of Status or Summaries of Payments shall be supported with medical reports when they are submitted to the Commission. Other medical reports shall be submitted to the Commission only upon request. (2-20-95)

d. ISIF shall receive all copies of medical reports, without charge, from either the Claimant or the Payor, depending upon who seeks to join it as a party to a workers compensation claim. (2-20-95)

e. If the Commission requests medical reports from the Payor or Provider, the information shall be provided within a reasonable time period without charge. If information is received for which the Commission has no need, the information may be discarded or destroyed. (2-20-95)

03. Report Form and Content. The medical reports required by this regulation shall be submitted on eight and one half inch by eleven inch (8 1/2 by 11) paper. Upon approval of the Commission, medical reports may be submitted in electronic or other machine-readable form usable to all parties. (2-20-95)

04. Timely Response Requirement. When the Commission requests a medical report from a Payor or Provider for use in monitoring a workers compensation claim, the Payor or Provider shall provide the requested information promptly. The Commission request may be either in writing or telephonic. (2-20-95)

05. Forfeiture of Payment. If a provider fails to give records to the Payor or Claimant, the Payor or Claimant may petition the Commission for an order requiring the Provider to provide the requested information. The petition shall set forth the Petitioners efforts to obtain the information, the responses to those efforts, and why the Petitioner believes that the Provider has the information. In response to the petition, the Commission may enter an Order requiring the Provider to furnish the requested records or demonstrate that the records are not available. If a Provider fails to provide records when ordered by the Commission, the Commission may enter an Order of Forfeiture. In the event such an Order is entered, the Provider will forfeit its right to payment from both the Payor and Claimant, until such time as the records are provided. (2-20-95)