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Flashcards in Medical Services Deck (38)
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Type A Providers

- medical doctors
- doctors of osteopathic medicine
- oral and maxillofacial surgeons
- and podiatric physicians and surgeons.


Type B Providers

- Chiropractors
- Naturopathic Physicians
- Physician Assistants


Type B Medical Provider provide medical services for

60 days or 18 office visits from the date of the first visit on the initial claim


Type B Medical Providers authorize time loss

30 days from the date of the first office visit


What type B medical provider can rate impairment?



Can ER physician authorize time loss benefits? How long?

Yes and up to 14 days from ER visit


When do medical providers need to submit form 827 when the worker is initiating a claim for work comp benefits?

72 hours


How many days do medical providers have to submit the form 827 when notifying the insurer of a change in the AP?

5 days form first tx with new dr


How many days does an insurer have to respond in writing to a written request for diagnostic preautho?

within 14 days of receiving the request from the provider


How many days does a medical provider have to send medical records to the insurer?

within 14 days


how many days can NP provide medical services?

180 days from the first visit on the initial claim


How long can a NP quthorize time loss benefits?

180 days from the date of the first visit on the initial claim


how many AP can a worker hav during the LIFE of a claim?



What are NOT considered changes by the choice of the worker?

- Emergency services by a physician
- Exams requested by the insurer
- Consultations or referrals for specialized treatment or services requested by AP
- Referrals to radiologists or pathologists for diagnostic studies
- When a worker is required to change providers because their medical service provider is no longer qualified as an AP or authorized to provide medical services
- Changes due to conditions beyond the worker’s control
- A Worker Requested Medical Exam (WRME)
- When AP works in a group setting or facility and worker is seen by another group member due to team practice, coverage, or on-call routines
- When the AP is not available and worker sees a covering physician


How many days do insurers have to pay medical bills in an accepted claim?

45 days from recipet of bill


How many days do insurers have to pay medical bills that were received prior to the claim decision once the claim has been accepted?

14 days from date of acceptance


How many days do insurers have to pay worker reimbursements?

30 days from the receipt of the request for reimbursement.


What types of things can a worker request reimbursement for?

- Meals
- Lodging
- Use of public transportation
- Use of a private vehicle
- Prescriptions
- Other out-of-pocket, claims-related expenses


What is the time frame for an injured worker to request reimbursement?

- Two years from the date the costs were incurred or from the date the claim or medical condition is finally determined


What is the purpose of the MCO?

- help manage the medical services in a claim
- to ensure the medical treatment is reasonable and necessary
- to assist with obtaining return-to-work information, a
- to facilitate claim closure.


SAIF currently contracts with which MCOs?

- CareMark Comp (CMC)
- Kaiser-on-the-Job
- Majoris Health Systems


What factors do you consider when enrolling a worker in an MCO?

- If the claim is disabling (most disabling claims should be enrolled in an MCO),
- The services offered by the MCO,
- To which MCO panel of providers the current AP belongs,
- The complexity of the medical conditions,
- The worker’s location and access to medical services.


Who must approve the MCO and how are the MCO services certified?

DCBS approves the MCO, and the services are certified by Geographical Service Areas (GSAs).


Purpose of an MCO Medical Tx Review

to review the current and past course of medical treatment and provide the AP with treatment course recommendations with specific timelines and goals


When to consider an MCO treatment review

- No clear diagnosis for ongoing symptoms/complaints,
- No treatment plan,
- Worker is not released to an appropriate level of work,
- Treatment is ongoing without resolution,
- Excessive ongoing medication use (especially with opioids),
- Worker may have motivational issues delaying or stalling the recovery.


What is the claims communication standard for contact with injured workers about an IME appointment?

Contact the injured worker prior to scheduling an IME appointment to discuss the purpose of the appointment and to address any scheduling conflicts or potential travel concerns and transportation needs.


How many days’ notice do you have to provide to an injured worker for a scheduled IME appointment?

10 days prior to the IME appointment.


At a minimum, how many days prior to the scheduled IME appointment should your cover letter and medical records be sent to the IME physician?

Seven days prior to the appointment date.


An IME with multiple examiners must be completed within what period of time in order to be considered one IME?

72 hours.


When should you consider using a panel of IME physicians?

on claims with distinctly different conditions requiring different types of medical expertise.