125 MEDICAL BENEFITS AND SERVICES; HEALTHCARE PROVIDER RESPONSIBILITY

125.1 A healthcare provider who provides medical services, appliances, or supplies to an injured employee or claimant must comply with the provisions in this chapter.

125.2 Unless otherwise directed or required by the Program, the following information shall be included in a Form 3, Form 3S, Form 3RC, or other Program-approved medical report(s) submitted by a qualified health professional:

1. (a) Date(s) of examination and treatment, if any;
2. (b) History given by the employee;
3. (c) Physical findings;
4. (d) Results of diagnostic tests;
5. (e) Medical records reviewed;
6. (f) Diagnosis;
7. (g) Nature of injury;
8. (h) Manner and mechanism of injury, to include the qualified health professional's opinion, with medical reasons and bases, as to the probable cause and mechanism of injury;
9. (i) Description of any other conditions found that are not due to the claimed injury, including indications of pre-existing conditions that may be the cause of or contribute to any alleged disabling condition;
10. (j) Treatment given, if any;
11. (k) Course of treatment, including treatment plan recommended for the claimed injury or recurrence of disability to bring about maximum medical improvement, if any;
12. (l) In the case of a claimed recurrence of disability, the qualified health professional's opinion, with medical reasons and bases, as to causal relationship between the diagnosed condition(s) and the original work-place injury and resulting condition(s);
13. (m) Nature, extent, and expected duration of disability affecting the

employee's or claimant's ability to work due to the injury;

(n) Prognosis for recovery, including an estimate regarding when the employee or claimant will be able to return to work; and

(o) All other material findings.

125.3 Unless otherwise authorized by the Program, a qualified health professional shall, within five (5) business days after any medical care is provided following the initial examination of the injured employee or claimant, transmit Form 3S or other Program-approved medical report(s) containing information required under § 125.4 of this chapter to the Program electronically at the email address or fax number designated on the Healthcare Provider Information Page of the Office of Risk Management website.

125.4 Unless otherwise authorized by the Program, within seven (7) business days after an initial examination of the injured employee or claimant, a qualified health professional shall transmit Form 3 or other Program-approved medical report(s) containing information required under § 125.4 of this chapter to the Program electronically at the email address or fax number designated on the Healthcare Provider Information Page of the Office of Risk Management website.

125.5 A healthcare provider who provides medical services, appliances or supplies, to an injured employee or claimant shall, at no cost, provide medical reports and records pertaining to the services, appliances, or supplies rendered no later than ten (10) days after receipt of the Program's request for such reports and records.

125.6 A healthcare provider shall include in each medical report for services rendered under the Act, the code, as published by the American Medical Association (AMA) in the most current edition of the Current Procedural Terminology (CPT codes), for detailing the billing of each medical procedure provided by the healthcare provider and the diagnosis code established by the most recent edition of the International Classification of Diseases (ICD), as published by the U.S. Department of Health and Human Services, for diagnosing the claimant's condition. If there is no standard CPT code for a procedure provided by the healthcare provider, additional CPT Codes may be prescribed by the Program, as published on the ORM website.

125.7 In order to be paid by the Program for compensable medical services, appliances, or supplies provided to an employee or a claimant, a healthcare provider must be a member of the Program's Panel of Healthcare Providers at the time service is provided, unless:

(a) The medical care is provided pursuant to § 123.1(b) of this chapter;

(b) The healthcare provider belongs to a network of healthcare providers to which the Program has secured access to care for employees or claimants through a license or working agreement and within two hundred and forty (240) days after first treating an injured District government employee or claimant as a healthcare provider participating within such a network:

(1) Is designated a member of the Panel by the Program; or

(2) With respect to a qualified health professional, applies for admission to the Program's Panel of Healthcare Providers (only for so long as the application is pending).

(c) The healthcare provider is a pharmacy or pharmacist licensed in the jurisdiction where medication or prescription drugs are dispensed.

125.8 A qualified health professional must apply to be a member of the Program's Panel of Healthcare Providers to provide or prescribe medical care to a claimant or employee, and any other healthcare provider must be designated a member of the panel by the Program in order to provide services, appliances or supplies, except as provided in § 125.7.

125.9 A healthcare provider selected to be a member of the Program's Panel of Healthcare Providers shall:

(a) Submit the following documentation, as applicable, pertaining to the jurisdiction in which the healthcare provider is licensed

(1) License number;

(2) Board name;

(3) The name of the state in which the provider is certified or licensed; and

(4) At the Program's request, information regarding any sanctions the provider may have received since licensure or certification;

(b) Possess and maintain appropriate insurance as determined by the Program;

(c) Notify the Program of any material changes, including changes to licensure, insurance coverage, staff who provide treatment to injured employees or claimants, or certification or history of sanctions or adverse action taken

against the provider or staff, within fourteen (14) days of a change;

(d) Comply with the payment guidelines prescribed by the District of Columbia Office of the Chief Financial Officer, published on the Healthcare Provider Information Page of the Office of Risk Management website; and

(e) Comply with the terms and conditions of a Provider Agreement (if any).

125.10 A healthcare provider who provides compensable medical care to a District government employee or claimant shall comply with the medical billing rules prescribed at § 126 of this chapter as a condition for payment of services rendered.

125.11 Unless the medical care is needed for emergency care pursuant to § 123.1 of this chapter or the service to be rendered is limited to an office or clinic visit with a qualified health professional, any prescribed medical services, appliances, or supplies requires prior authorization from the Program.

125.12 To seek prior authorization, a qualified health professional shall complete and electronically submit Form 3PA to the Program in the manner prescribed on the Healthcare Provider Information page found at the ORM website.

125.13 The cost of physical examinations ordered by the Program shall be paid by the Program.

125.14 A Panel healthcare provider who provides medical services, appliances, or supplies to a District government employee or claimant for a condition that is accepted by the Program as compensable under the Act shall not attempt to collect payment for such medical services, appliances, or supplies from the employee or claimant.

SOURCE: Final Rulemaking published at 28 DCR 2307 (May 22, 1981); as amended by Emergency and Proposed Rulemaking published at 57 DCR 9540 (October 8, 2010)[EXPIRED]; as amended by Final Rulemaking published at 57 DCR 12224, 12229 (December 24, 2010); as amended by Final Rulemaking published at 59 DCR 8766, 8771 (July 27, 2012); as amended by Final Rulemaking published at 64 DCR 6325 (July 7, 2017); as amended by Final Rulemaking published at 66 DCR 4246 (April 5, 2019).