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Rule 16: Utilization Standards and Rule 18: Medical Fee Schedule
The Colorado Department of Labor and Employment/Division of Workers' Compensation has adopted revisions to Rule 16, Utilization Standards and Rule 18, Medical Fee Schedule. The rules become effective 1/1/13.
The significant impact of this law includes, but is not limited to the following:
- A revised medical fee schedule which will apply to all services rendered on or after 1/1/13, as well as a new ambulance fee schedule
- Prior authorization exceptions for billed services not identified or identified but without established value
- Procedures to complete a prior authorization request
- Dispute resolution procedures for medical billing
- Changes to billing of compounded drugs
The Medical Fee Schedule's exhibits are referenced throughout this summary and can be viewed at the following link:
http://www.colorado.gov/cs/Satellite?c=Page&childpagename=CDLE-WorkComp%2FCDLELayout&cid=1251566826034&pagename=CDLEWrapper
Ohio
Rule 4123-6-02.2: HPP Provider Credentialing Criteria
The Ohio Bureau of Workers' Compensation has adopted revisions to Rule 4123-6-02.2, HPP Provider Credentialing Criteria. This rule will become effective 12/11/12. The revisions to this new law include, but are not limited to the following:
- Revises minimum credentialing criteria for certain providers to participate in the HPP
- Adds provisions for providers to be ineligible to participate in the HPP
Please note - QHP clients are required to follow the HPP credentialing rules
North Carolina
The North Carolina Industrial Commission has adopted revisions to several workers' compensation rules. These rules will become effective 1/1/2013.
The revisions include, but are not limited to the following:
- Communication for medical information
- Preauthorization for surgery and inpatient treatment
- Rehabilitation Professional's communication/interaction with physician
- Medical provider fee dispute procedure
- Electronic medical billing and payment
New Jersey
NJ PIP Rule Changes: NJ 19724 2011
The New Jersey Department of Banking and Insurance and Office of Property and Casualty have adopted new rules, effective 11/05/12.
The new rules:
- Create registration requirements for PIP vendors that provide utilization management
- Establish an internal appeals process for adverse determinations made by the insurer
- Update fee schedules and reimbursement guidelines including those for ASCs
- Updates benefits that may be provided by a network
Texas
Medical Quality Review Panel Rules
The Texas Workers' Compensation Division has adopted rules relating to the Medical Quality Review Panel (MQRP). The rules become effective January 1, 2013 and include the following:
- Explain the purpose of the MQRP
- Authorizes medical case review by the MQRP
- Describes the medical quality review process
- Explains the rights and responsibilities of persons involved in the MQRP
Note: This information is neither intended to be all-inclusive for the industry, nor for public redistribution. Please feel free to send your questions, comments, suggestions, and requests for further information to Coventry at Regulatory@cvty.com
© 2012 Coventry Health Care Workers Compensation, Inc. All rights reserved. The information which is provided herein and links to other related web sites are offered as a courtesy to our clients. All material is intended for information, communication and educational purposes only and is in no manner an endorsement, recommendation or approval of any information. Coventry Workers' Comp Services accepts no liability for the consequences of any actions taken on the basis of the information provided. | 
