If any dispute arises as to the condition of the employee, a Request for Independent Medical Examination (PDF) can be filed by any party. A medical examination with a physician selected by the Director of the Office of Workers' Compensation Administration (OWCA) will then be scheduled.
The office of the independent medical examiner cannot be contacted for any reason except to set a deposition. No appointments can be changed except by OWCA. If there is a problem with a scheduled appointment, contact the Medical Services Section at 1-800-201-2494.
The independent medical examiner has 30 days from the date of the examination to issue a report. Any objections to the report of this examiner shall be made by filing Form LWC-WC 1008 (PDF).
There is no set fee for reimbursement of independent medical examinations. Each one is different, depending on the amount of medical records to be reviewed, length of disability, complication of case, etc.
The carrier or employer has 60 days from the receipt of the bill to either pay the bill or formally dispute the bill by the filing of the Disputed Claim for Compensation Form, Form LWC-WC 1008 (PDF).
Approval for outlier is based on medical facts during the hospital admission in question that caused the length of stay to be 1.75 times greater than the per diem, or if a medical admission charges over $75,000, and if a surgical admission charges over $100,000.
The utilization review rules of OWCA require the use of appropriate procedures to establish standards of care, or determining the necessity and advisability of proposed or already performed hospital care or services, medical or surgical treatment, or any non-medical treatment recognized by the laws of this state as legal.
All non-emergency hospital admissions must be pre-certified with an appropriate length of stay being assigned. Continued stay review must also be performed on each approved admission. Emergency hospital admission must meet the specified criteria as outlined in the utilization review rules and must also have concurrent review performed.
The rules also provide appropriate procedures to be followed when seeking approval to continue treatment beyond the statutory limit of $750.
You can download a copy of the HCFA-1500 or UB-92 form from the Centers for
Medicare & Medicaid Services at
www.hhs.gov. Enter the word "Forms" in the search box and press enter. Then search by form number.
The most current medical reimbursement schedule was published in August 1994. Updates to the CPT coding were added in March 2001 using the CPT Codes up to year 2000.
You may download a copy of the Medical Reimbursement Schedule (PDF) here.
Email us at Medical Services Section