1. (1) The following criteria shall be used by the Department of Industrial Relations to qualify an employer/agent who may perform the bill screening of medical services for workers' compensation claims. This entity shall be qualified by the Department as required in Rule 480-5-5-.05 and/or 480-5-5-.06, as applicable, of these rules. This entity shall:

   1. (a) Be familiar with medical terms;
   2. (b) Be familiar with the ICD-10-CM, CPT-4, and HCPCS Coding Manuals and Alabama Department of Industrial Relations Administrative Code Utilization Management and Bill Screening Chapter, and reimbursement as published in the most current Alabama Workers' Compensation Maximum Fee Schedule according to provider type;
   3. (c) Be familiar with prevailing adjudication rules;
   4. (d) Protect the confidentiality of medical records; and
   5. (e) Provide a name and telephone number of a person for the Department to contact Monday through Friday during normal business hours, except legal holidays.
2. (2) It is the express intent of these rules that bill screening may be performed by the insurance carrier, employer/agent, self-insured employer, or group self-insurance fund including designated employees of the respective entity. There is no requirement that outside utilization review entity vendors be hired to perform bill screening activities in accordance with these rules.

Author: Workers' Compensation Medical Services Board

Statutory Authority: Code of Ala. 1975, §25-5-293.

History: New Rule: Filed August 9, 1996; effective September 13, 1996. Amended: Filed July 14, 1997; effective August 18, 1997. Amended: Filed June 15, 2011; effective July 20, 2011. Amended: Filed April 26, 2016; effective June 10, 2016.