IDAPA 17.01.01
This rule applies to the following stakeholders:
This rule covers the administration and regulation of the Idaho Worker’s Compensation Act, including, but not limited to: coverage requirements, benefits administration, medical fee schedule and process for medical fee disputes, reporting requirements, and claims administration requirements. For rules regarding the complaint and litigation process, please see the Judicial Rules of Practice and Procedure on the Commission’s website at https://iic.idaho.gov/rules-and-legislation/.
This rule implements the following statutes passed by the Idaho Legislature:
Idaho Industrial Commission 11321 W. Chinden Blvd. Boise, ID 83714
P.O. Box 83720 Boise, ID 83720-0041 Phone: (208) 334-6000 Fax: (208) 332-7559 Email: commissionsecretary@iic.idaho.gov Web: https://iic.idaho.gov/
This rule chapter will be reviewed in compliance with Section 67-5292, Idaho Code, and in accordance with the 8-year rule review schedule linked here.
17.01.01 – Administrative Rules Under the Worker's Compensation Law
000. Legal Authority. ... 3
001. (Reserved) ... 3
002. Incorporation By Reference. ... 3 003 -- 009. (Reserved) ... 3
010. Definitions. ... 3
011. -- 200. (Reserved) ... 6
201. Rule Governing 72-212(5) Exemptions. ... 6
202. -- 300. (Reserved) ... 6
301. Rules Governing Qualifications To Write Insurance Or Self-Insure. ... 6
302. Rules Governing Continuing Requirements To Underwrite Insurance Or Self-Insure. ... 8
303. Rule Governing The Collection Of Premium Tax On Worker's Compensation Insurance Policies. ... 12
304. Rule Governing Premium Tax Computation For Self-Insured Employers. ... 12
305. Requirements For Maintaining Idaho Worker's Compensation Claims Files. . 13
306. Rule Prohibiting Use Of Sick Leave Or Other Alternative Compensation. ... 15
307. Rule Governing Reporting Indemnity And Medical Payments And Making Payment Of Industrial Special Indemnity Fund (ISIF) Assessment. ... 16
308. -- 400. (Reserved) ... 16
401. Rule Governing Computation Of Average Weekly Wage. ... 16
402. Rule Governing Average of Multiple Impairment Ratings. ... 17
403. Rule Governing Compensation For Disability Due To Loss Of Teeth. ... 17
404. Submission Of Medical Reports From Providers ... 17
405. Rule Governing Reimbursement For Travel Expenses. ... 18
406. -- 500. (Reserved) ... 18
501. Rule Governing Protection And Disclosure Of Rehabilitation Division Records. ... 18
502. Rule Governing Reports Of Attorney Costs And Fees In Litigated Cases. ... 18
503. -- 600. (Reserved) ... 18
601. Submission Of FROI And SROI. ... 18
602. Final Reports. ... 19
603. -- 800. (Reserved) ... 19
801. Rule Governing Change Of Status Notice To Claimants. ... 20
802. Rule Governing Approval Of Attorneys Fees. ... 20
803. Medical Fees. ... 21
804. -- 999. (Reserved) ... 27
72-301, 72-301A, 72-304, 72-327, 72-432, 72-508, 72-528, 72-602, 72-803, and 72-806, Idaho Code. (7-1-25)
These rules incorporate by reference the following documents, which may be obtained from the main office of the Industrial Commission or are available on the agency's website. (7-1-25)
01. EDI Implementation Guide. The Industrial Commission uses the International Association of Industrial Accident Boards and Commissions (IAIABC) Electronic Data Interchange (EDI) Claims Implementation Guide ('EDI Implementation Guide'), as published annually, available at http://www.iaiabc.org/edi-claims, and the IAIABC Claims EDI Implementation Guide and Trading Partner Tables available at https://iic.idaho.gov/. See Rule 601 of these rules. (7-1-25)
02. CMS Fee Schedules. Pursuant to Idaho Code § 72-803, these rules incorporate by reference the Physician Fee Schedule, Hospital Outpatient Prospective Payment System, and Ambulatory Surgical Center Payment System, as published by the Centers for Medicare and Medicaid Services (CMS), effective January 1, 2024, available at https://www.cms.gov/medicare/payment/fee-schedules/physician; https://www.cms.gov/medicare/payment/prospective-payment-systems/hospital-outpatient; https://www.cms.gov/medicare/payment/prospective-payment-systems/ambulatory-surgical-center-asc respectively. Additionally, these rules incorporate by reference the Acute Inpatient Prospective Payment System, as published by the CMS, effective October 1, 2024, available at https://www.cms.gov/medicare/payment/prospective-payment-systems/acute-inpatient-pps. See Rule 803 of these rules. (7-1-25)
03. CPT Codes. Pursuant to Idaho Code § 72-803, these rules incorporate by reference the Current Procedural Terminology (CPT) codes, as published by the American Medical Association, effective January 1, 2024, available at ama-assn.org/practice-management/cpt. See Rule 803 of these rules. (7-1-25)
The definitions set forth in Chapter 72, Idaho Code apply to these rules. In addition, the following terms have the meaning set forth below: (3-23-22)
01. Adjustor. Means an individual who adjusts worker's compensation claims. (3-23-22)
02. Ambulatory Payment Classification (APC). Means the payment system adopted by Centers for Medicare and Medicaid Services (CMS) for outpatient services (7-1-25)
03. Available Funds. Means a sum of money to which a Charging Lien may attach. It does not include any compensation paid or not disputed to be owed prior to Claimant's agreement to retain the attorney. (3-23-22)
04. Ambulatory Surgery Center (ASC). Means a facility providing medical services on an outpatient basis only. (7-1-25)
05. Approval by Commission. Means the Commission has approved attorney fees in conjunction with an award of compensation or a Settlement Agreement (SA) or otherwise in accordance with Section 802 of this rule upon a proper showing by the attorney seeking to have the fees approved. (7-1-25)
06. Average Wholesale Price (AWP). Means the average wholesale price for medicine obtained from pricing data provided by the original manufacturer of that medicine to industry-wide compilers of drug prices, e.g., Red Book and Medi-Span. (7-1-25)
07. Charge. Means the expense or cost. For hospitals and ASCs, 'charge' means the total charge. (3-23-22)
a. Acceptable charge. Means a charge calculated in compliance with Section 803 of this rule or as billed by the Provider, whichever is lower, or the charge agreed to pursuant to a written contract. (3-23-22)
b. Customary charge. Means a charge that has an upper limit no higher than the 90th percentile, as
determined by the Commission, of usual charges made by Idaho Providers for a given medical service. (3-23-22)
c. Reasonable charge. Means a charge that does not exceed the Provider's 'usual' charge and does not exceed the 'customary' charge. (3-23-22)
d. Usual charge. Means the most frequent charge made by an individual Provider for a given medical service to non-industrially injured patients. (3-23-22)
08. Charging Lien. Means a lien against a Claimant's right to any compensation under the Worker's Compensation Law, which may be asserted by an attorney who is able to demonstrate that: (3-23-22)
a. There are compensation benefits available for distribution on equitable principles; (3-23-22)
b. The services of the attorney operated primarily or substantially to secure the fund out of which the attorney seeks to be paid; (3-23-22)
c. It was agreed that counsel anticipated payment from compensation funds rather than from the client; (3-23-22)
d. The Claim is limited to costs, fees, or other disbursements incurred in the case through which the fund was raised; and (3-23-22)
e. There are equitable considerations that necessitate the recognition and application of the Charging Lien. (3-23-22)
09. Claim. Means filing for worker's compensation benefits through a Form 1A-1, First Report of Injury or Illness (FROI) or an application for hearing, referred to as a Complaint, with the Commission. (3-23-22)
10. Claims Administrator. Means an organization, including insurers, third party administrators, independent adjusters, or self-insured employers, that services worker's compensation claims. (3-23-22)
11. Claims Services. Aspects of claims handling to include but are not limited to reserve setting, three-point contacts, accident investigations, acceptance or denial of claims, authorization of medical treatment, authorization and triggering of the medical and income benefit payments to be issued. Medical fee schedule adjustments and issuance of authorized benefit payments may be considered ministerial or administrative functions. (7-1-25)
12. Claimant. Means a person who has filed a Claim for worker's compensation benefits and includes their agents, such as attorneys. (3-23-22)
13. Critical Access Hospital. Means a hospital currently designated as a critical access hospital by CMS. (3-23-22)
14. Current Procedural Terminology (CPT). Means the medical code published by the American Medical Association. (7-1-25)
15. Death Claim. Means a Claim arising from the death of a worker as a result of a work-related injury or occupational disease. (3-23-22)
16. Electronic Data Interchange (EDI). Means a computer to computer exchange of data in a standardized format. (7-1-25)
17. Fee Agreement. Means a written agreement between a worker and an attorney in conformity with the Idaho Rules of Professional Conduct. (3-23-22)
a. Reasonable, as used in Section 802 of this rule, means that an attorney's fees are consistent with the fee agreement and are to be satisfied from Available Funds, subject to the element of reasonableness contained in
Idaho Rules of Professional Conduct 1.5. (3-23-22)
18. First Degree of Consanguinity. Means the relationship between parents and their children whether related by blood or affinity. Adopted or step children and their adoptive or step parents are deemed to be within the first degree of consanguinity. (3-23-22)
19. First Report of Injury (FROI). Means the first filing of information with the Industrial Commission that a reportable workplace injury has occurred or an occupational disease has manifested, as required by Section 72-602(1), Idaho Code; filed in accordance with these rules. (7-1-25)
20. Gross Direct Premiums Written. Means the gross sum of premiums on policies written, without any deduction for refunds or repayments resulting from cancellations. It does not include premiums on contracts between insurers or reinsurers. For all policies written, gross direct premiums written may reflect experience modifications, deviations, and retrospective rating. (3-23-22)
21. Healthcare Common Procedure Coding System (HCPCS). Means the set of healthcare procedure codes based on the American Medical Association's Current Procedural Terminology. (7-1-25)
22. Hospital. Means an acute care facility providing medical or rehabilitation services on an inpatient and outpatient basis. (3-23-22)
23. IAIABC EDI Claims. Means the IAIABC authored EDI Claims standards that cover the transmission of claims (FROI and SROI) information. (7-1-25)
24. Impairment Rated Claim. Means those claims in which the Provider establishes an impairment rating for the claimant or the claimant has a statutory impairment award per the schedule. (7-1-25)
25. Implantable Hardware. Means objects or devices that are made to support, replace, or act as a missing anatomical structure or to support or manage proper biological functions or disease processes and where surgical or medical procedures are needed to insert or apply such devices and surgical or medical procedures are required to remove such devices. The term also includes equipment necessary for the proper operation of the implantable hardware, even if not implanted in the body. (3-23-22)
26. Indemnity Benefits. Means payments made to or on behalf of worker's compensation Claimants, including temporary or permanent total or partial disability benefits, death benefits paid to dependents, retraining benefits, and any other type of income benefits, but excluding medical and related benefits. (3-23-22)
27. Indemnity Claim. Means any claim made for the payment of indemnity benefits. (3-23-22)
28. Litigated Case. Means a case in which a complaint has been filed. (3-23-22)
29. Medical Only Claim. Means the claimant will not suffer a disability lasting more than five (5) calendar days as a result of a job-related injury or occupational disease, nor be admitted to a hospital as an inpatient. (7-1-25)
30. Medical Report. Means and includes without limitation, all bills, chart notes, surgical records, testing results, treatment records, hospital records, prescriptions, and medication records. (3-23-22)
31. Medicare Severity - Diagnosis Related Group. Means a system adopted by CMS that groups hospital admissions based on diagnosis codes, surgical procedures, and patient demographics. (3-23-22)
32. Net Premiums Written. Means the amount of gross direct premiums on policies written less returned premiums and premiums on policies not taken. Paid dividends shall not be deducted for the purposes of calculating net premiums written. (3-23-22)
33. Payor. Means the entity that is responsible for making payment to a Provider for services rendered to treat a claimant and includes self-insured employers, sureties, adjusters, and their agents. (7-1-25)
34. Payroll. Means the gross amount paid by an employer for salaries, wages, or commissions earned by its own direct employees, but not including any money paid to another entity or received from another entity for leased employees. (3-23-22)
35. Pharmacy. Means a facility as defined in Section 54-1705(29), Idaho Code. (3-23-22)
36. Supplemental or Subsequent Report of Injury (SROI). Means the filing of additional information with the Industrial Commission, regarding benefits paid or changes in the status or condition of a claimant, of a Claim for benefits, as required by Sections 72-602(2), (3), and (4), Idaho Code; filed in accordance with these rules. (7-1-25)
37. Termination of Disability. Means the date upon which the obligation of the Employer/Surety becomes certain as to duration and amount whether by settlement agreement (SA), decision, or periodic payments in the ordinary course of claims processing. If resolved by SA, the termination of disability shall occur on the date the SA is filed or an order approving is filed by the Industrial Commission. If resolved by decision, the termination of disability shall occur on the date the decision resolving all issues becomes final. (7-1-25)
38. Time Loss Claim. Means the claimant will suffer, or has suffered, a disability that lasts more than five (5) calendar days as a result of a job-related injury or occupational disease, or the claimant requires, or required, in-patient treatment as a result of such injury or disease. (7-1-25)
39. Trading Partner. Means an insurance carrier, self-insured employer, or Claims Administrator that has entered into a Trading Partner Agreement with the Industrial Commission. (3-23-22)
40. Trading Partner Agreement. Means an agreement between the Industrial Commission and a Trading Partner that sets out the terms and conditions for the electronic reporting of information to the Commission. (3-23-22)
011. -- 200. (RESERVED)
01. Exemptions. Each person who elects to exempt themselves from coverage or revoke their exemption under Section 72-212(5), Idaho Code, must file an IC53 Declaration form with the Industrial Commission. The form is available on the Commission's website. (3-23-22)
02. Form. The form must be signed by both the employee and the employer. An original and one (1) copy of the IC53 form shall be filed with the Commission. Upon approval by the Commission, the copy will be returned to the employee filing for an exemption or revocation of an exemption. (3-23-22)
03. Approval by Commission. The Commission must approve the exemption or revocation of exemption. The Commission may require verification of information submitted. Fraud or misrepresentation in the information provided will void the exemption or revocation. (3-23-22)
04. IC53 Form. If the employer is insured, it is the employer's responsibility to file a copy of the IC53 form with the employer's insurance company. (3-23-22)
202. -- 300. (RESERVED)
01. Insurance Carriers. In order to gain approval from the Industrial Commission to underwrite worker's compensation insurance under Section 72-301, Idaho Code, an insurance carrier shall comply with the additional following requirements: (7-1-25)
a. Deposit With State Treasurer. The carrier must receive approval from the Director of the Idaho
Department of Insurance to underwrite casualty and surety insurance under Sections 41-506 and 41-507, Idaho Code, and shall initially deposit security in the amount of two hundred fifty thousand dollars ($250,000) with the State Treasurer, under the provisions of Section 72-302, Idaho Code. (3-23-22)
b. Application. To receive approval from the Industrial Commission, an insurance carrier must submit a completed application, available from the Industrial Commission’s Fiscal Department, including: (7-1-25)
i. A recommendation from the Idaho Department of Insurance that the carrier be approved to transact worker’s compensation insurance in the State of Idaho; (7-1-25)
ii. The latest audited financial statement of said carrier; (3-23-22)
iii. A statement appointing the Director of the State of Idaho Department of Insurance as its agent to receive service of legal process; (7-1-25)
iv. The name and address of the carrier’s appointed Claims Administrator employing an Idaho licensed resident adjuster or the insurance carrier’s own in-house Idaho adjusting staff with authority to make compensation payments and adjustments of claims arising under the Act. Each Claims Administrator shall have only one (1) mailing address on record at the Commission for claims adjusting purposes. If more than one (1) Claims Administrator is utilized in Idaho, a list of every such Claims Administrator and all corresponding policyholders shall be provided; (7-1-25)
v. A statement that the carrier will distribute blank forms that are prescribed by the Commission to its insured; (3-23-22)
vi. A statement that all surety bonds covering the payment of compensation will be filed with the Idaho State Treasurer for all employers insured. All carriers will use the continuous bond form set out on the Commission’s website. (3-23-22)
vii. A statement that renewal certificates on said bonds will be issued and filed with the Industrial Commission immediately, when and if renewed; (3-23-22)
viii. A statement that all surety contract cancellations will be canceled in compliance with Section 72-311, Idaho Code; (3-23-22)
ix. A statement that said carrier will deposit, in addition to other security required by this rule, further security equal to all unpaid outstanding awards of compensation; (3-23-22)
x. A statement that said carrier will comply with the statutes of the state of Idaho and rules of the Industrial Commission and that payments of compensation shall be sure and certain and not unnecessarily delayed; (7-1-25)
xi. A statement that the carrier will make reports to the Commission as are required; and (7-1-25)
xii. A copy of the Certificate of Authority from the carrier’s State of Domicile. (7-1-25)
02. Self-Insured Employers. In order to gain written approval from the Industrial Commission to self-insure under Section 72-301, Idaho Code, an employer shall comply with the following requirements: (7-1-25)
a. Payroll. Have an average annual Idaho Payroll over the preceding three (3) years of at least seven million dollars ($7,000,000). (7-1-25)
b. Application. Submit a completed application, available from the Industrial Commission’s Fiscal Department, along with the application fee of two hundred fifty dollars ($250), to the Idaho Industrial Commission, Attention: Fiscal Department, including: (7-1-25)
i. Documentation demonstrating the sound financial condition of the employer, such as the most
recent CPA reviewed or, if available, audited, financial statement. (7-1-25)
ii. Written designation of a Claims Administrator employing an Idaho licensed resident adjuster including name and address. Each Claims Administrator shall have only one (1) mailing address on record at the Commission for claims adjusting purposes. (7-1-25)
iii. A claims history of all worker's compensation claims filed with the employer or the employer's worker's compensation carrier, as well as all compensation paid, during the previous five (5) calendar years. (7-1-25)
iv. A copy of an insurance plan that includes excess insurance coverage or copies of all proposed policies of excess worker's compensation insurance coverage. (7-1-25)
v. An actuarial study prepared by a qualified actuary determining adequate rates for the proposed self-funded worker's compensation plan based upon a fifty percent (50%) confidence level. (7-1-25)
vi. A self-insurance feasibility study that includes an analysis of the advantages and disadvantages of self insurance as compared to current coverage, and the related costs and benefits. (7-1-25)
vii. A custodial agreement with the State Treasurer for securities required to be deposited under Sections 72-301 and 72-302, Idaho Code. (7-1-25)
viii. Supplemental information as requested. (7-1-25)
ix. Prior to final approval, an initial security deposit must be made with the Idaho State Treasurer per Section 72-301, Idaho Code, or a self-insurer's bond in substantially the form as the Commission's self-insurer's compensation bond, available on the Commission's website, in the amount of one hundred fifty thousand dollars ($150,000), plus five percent (5%) of the first ten million dollars ($10,000,000) of the employer's average annual Payroll in the state of Idaho for the three (3) preceding years; along with such additional security as may be required by the Commission based on prior claims history. (7-1-25)
x. Where financial reports or other factors such as the high risk industry of the employer indicate the need, the Commission may require an employer that is organized as a joint venture or a wholly owned subsidiary to provide an initial guaranty agreement from each member of the joint venture or the parent company. This guaranty agreement confirms the continuing agreement of each of the joint venture members or the parent company to guarantee the payment of all Idaho worker's compensation claims of employees of that joint venture or subsidiary employer. The guaranty agreement shall be in substantially the same form as the Self-insured Indemnity and Guaranty Agreement and, as applicable, the companion Consent of the Board of Directors, both available on the Commission's website. (7-1-25)
xi. Idaho National Laboratory. An employer meeting the requirements of Section 72-301A, Idaho Code, does not have to comply with the requirements of Paragraphs 302.02.a., 02.f., 02.i., and 02.k., above. (3-23-22)
01. Insurance Carriers. An insurance carrier approved under IDAPA 17.01.01.301.01 shall comply with the following requirements: (3-23-22)
a. Maintain Statutory Security Deposits with the State Treasurer. (3-23-22)
i. Each insurance carrier shall maintain with the Idaho State Treasurer a security deposit in the amount of twenty-five thousand dollars ($25,000) if approved by the Commission prior to July 15, 1988, or two hundred and fifty thousand dollars ($250,000) if approved subsequently. (3-23-22)
ii. In addition to the security required in Subsection 01.a.i, of this rule, each insurance carrier shall deposit an amount equal to the total unpaid outstanding awards of said insurance carrier. Such deposit shall be in the
form permitted by Section 72-301, Idaho Code. Surety bonds shall be in the form available on the Commission's website. If a surety bond is deposited, the surety company shall be completely independent of the principal and authorized to transact such business in the state of Idaho. A partial release of security deposited hereunder must be requested in writing and approved by the Commission. (3-23-22)
b. Appoint Agent for Service of Process. Each insurance carrier shall appoint the Director of the Department of Insurance as its agent to receive service of legal process. (3-23-22)
c. Maintain Resident Idaho Office. Each insurance carrier shall maintain a Claims Administrator employing an Idaho licensed resident adjuster or the carrier's own adjusting offices or officers residing in Idaho. (3-23-22)
i. Each authorized insurance carrier shall notify the Commission in writing of any change to the primary claims administrator within fifteen (15) days of such change and report the designated claims administrator for every insured Idaho employer through proof of coverage (POC). (7-1-25)
ii. Each authorized insurance carrier will ensure that every in-state adjuster can classify and identify all claims adjusted on behalf of said insurance carrier, and that the in-state adjuster will provide such information to the Industrial Commission upon request. Further each in-state Adjuster must have full authority to: (3-23-22)
(1) Investigate and adjust all claims for compensation; (3-23-22)
(2) Pay all compensation benefits due; (3-23-22)
(3) Accept service of claims, applications for hearings, orders of the Commission, and all process which may be issued under the Worker's Compensation Law; (3-23-22)
(4) Enter into compensation agreements and SAs with Claimants; (7-1-25)
(5) Provide at the employer's expense necessary forms to any employee who wishes to file a Claim under the Worker's Compensation Law. (3-23-22)
d. Supply Forms. Each insurance carrier shall distribute the required forms prescribed by the Commission to all employers it insures. A list of required forms is available on the Commission's website. (3-23-22)
e. Comply with Industrial Commission Reporting Requirements. Each insurance carrier shall, within the time prescribed, file such reports and respond to such information requests as the Commission may require from time to time concerning matters under the Worker's Compensation Law. (3-23-22)
f. Report Proof of Coverage. (3-23-22)
i. Each insurance carrier shall report all proof of coverage to National Council on Compensation Insurance (NCCI). NCCI is the designated agent to receive, process, and forward the proof of coverage information required by these rules to the Commission. The address of the Commission's designated agent is available on the Commission's website. (7-1-25)
ii. The Industrial Commission adopts the IAIABC's electronic proof of coverage record layout and transaction standards as the required reporting mechanism for new policies, renewal policies, endorsements, cancellations, and non-renewals of policies. A copy of the record layout, data element requirements, and transaction standards is available on the Commission's website. Each insurance carrier shall report data for all mandatory elements in the current IAIABC proof of coverage record layout and transaction standards on each policy reported. (3-23-22)
iii. The most recent proof of coverage information contained in the Industrial Commission's database shall be presumed to be correct for the purpose of determining the insurance carrier providing coverage. (3-23-22)
g. Report New Policy, Renewal Policy, and Endorsement Information Within Thirty Days. Each
insurance carrier shall report the issuance of any new worker's compensation policy, renewal policy, or endorsement to the Industrial Commission or its designated agent within thirty (30) days of the effective date of the transaction. (3-23-22)
h. Report Cancellation and Non-Renewal of Policy Within Time Prescribed by Statute. Each insurance carrier shall report the cancellation and/or nonrenewal of any worker's compensation insurance policy to the Industrial Commission or its designated agent within the time frames prescribed by Section 72-311, Idaho Code. Receipt of cancellation or nonrenewal notices by the Commission's designated agent shall be deemed to have been received by the Commission. (3-23-22)
i. Report Election of Coverage on Form IC52 or Similar Format. Each insurance carrier shall report election of coverage or revocation of election of coverage on or in a format substantially the same as Form IC52, 'Election of Coverage,' available on the Commission's website. (3-23-22)
j. Report Deductible Policy. On or before March 3rd of each year, every insurance carrier shall submit a report of all deductible policies that were issued and in effect during the previous calendar year. That report shall be submitted in a form substantially similar to the current 'Deductible Policy Report' available on the Commission's website. The report shall include the following information: insured name, policy number, effective and expiration dates, deductible amount, the premium charged for the policy before credit for the deductible, and the final premium after credit for the deductible. (3-23-22)
k. Report Outstanding Awards. Each insurance carrier shall report to the Industrial Commission at the end of each calendar quarter, or more often as required by the Commission, any outstanding award. (3-23-22)
i. The report of outstanding awards shall be filed with the Industrial Commission by the end of the month following the end of each calendar quarter. (3-23-22)
ii. The report shall be filed even if there are no outstanding awards. In that event, the carrier shall certify the fact that there are no outstanding awards to be reported. (3-23-22)
iii. The report shall be submitted in a manner as prescribed by the Industrial Commission or in a format that is substantially the same as the current Form IC36A, 'Report of Outstanding Awards - Insurance Carriers' available on the Commission's website. The report may be produced as a computerized spreadsheet or database printout. (7-1-25)
iv. Reports submitted in a format other than online filing, such as hard copy or email attachment, shall be signed and certified to be correct by a corporate officer. If an insurance carrier has designated more than one adjuster for worker's compensation claims in Idaho, a corporate officer of the insurance carrier shall prepare, certify, and file a consolidated report of outstanding awards. (7-1-25)
v. The report shall list all outstanding awards, commencing with the calendar quarter during which the award is made or benefits are first paid, whichever occurs earlier. (3-23-22)
02. Self-Insured Employers. A self-insured employer approved under Subsection 301.02 shall comply with the following requirements: (3-23-22)
a. Payroll Requirements. Maintain an average annual Idaho Payroll over the preceding three (3) years of at least seven million dollars ($7,000,000), if such employer was originally approved by the Commission subsequent to June 30, 2025, and four million dollars ($4,000,000), if such employer was originally approved by the Commission prior to July 1, 2025. Any self-insured employer that does not meet the Payroll requirement of this rule for two consecutive semi-annual premium tax reporting periods shall be allowed to maintain their self-insured status for six (6) months from the end of the last reporting period in order to permit them time to increase their Payroll or obtain worker's compensation coverage with an insurance carrier authorized to write worker's compensation insurance in the state of Idaho. (7-1-25)
b. Security Deposit with Treasurer. (3-23-22)
i. Maintain a primary security deposit with the Idaho State Treasurer in the form permitted by Section 72-301, Idaho Code, a self-insurer's bond form available on the Commission's website, or in substantially the same form, or in such other form approved by the Commission, in the amount of one hundred fifty thousand dollars ($150,000), plus five percent (5%) of the employers' average annual Payroll in the state of Idaho for the three (3) preceding years, not in excess of ten million dollars ($10,000,000). If a surety bond is deposited, the surety company shall be completely independent of the principal and authorized to transact such business in the state of Idaho. In addition thereto, the self-insured employer shall deposit additional security in such amount as the Commission determines is necessary to secure the self-insured employer's total unpaid liability for compensation under the Worker's Compensation Law. No approved security shall be accepted for deposit above its par value. Additional deposits of approved security may be required semi-annually if the market value of an approved investment falls below its par value or if the total value of the employer's security deposit falls below the total security required to be maintained on deposit when calculated in accordance with this rule. (3-23-22)
ii. Self-insured employers shall receive a credit for the primary security deposit against the self-insured employer's obligation to post the additional security required by Subparagraph 302.02.b.i. of this rule. (3-23-22)
iii. Excess insurance coverage approved by the Commission may apply as a credit against the self-insured employer's obligation to post the additional security required by Subparagraph 302.02.b.i. of this rule. The Commission must be provided with thirty (30) days advance written notice of any change or cancellation of an approved excess insurance policy. No credit will be given for any excess insurance coverage provided by a surplus lines carrier, as described in Chapter 12, Title 41, Idaho Code. (3-23-22)
iv. Any withdrawal or partial release of security deposited hereunder must be requested in writing and approved by the Commission. Only one (1) request may be made per calendar year. (7-1-25)
c. Continue or Provide Guaranty Agreement. (3-23-22)
i. A self-insured employer that is organized as a joint venture or a wholly owned subsidiary shall continue in effect any guaranty agreement that the Commission has previously allowed or required, until termination is permitted by the Commission. (3-23-22)
ii. Where an adverse change in financial condition or other relevant factors such as claims history or industry risk indicates the need, a self-insured employer that is organized as a joint venture or a wholly owned subsidiary may be allowed to, or shall upon request, provide a guaranty agreement from each member of the joint venture or the parent company. This guaranty agreement confirms the continuing agreement of each of the joint venture members or the parent company to guarantee the payment of all Idaho worker's compensation claims of employees of that joint venture or subsidiary self-insured employer. The guaranty agreement shall be in substantially the same form as the current sample Indemnity and Guaranty Agreement, and as applicable, the companion Consent of the Board of Directors, available on the Commission's website. (3-23-22)
d. Maintain a Licensed Resident Adjuster. Maintain an Idaho licensed, resident claims adjuster located within the state of Idaho who shall have full authority to make decisions and to authorize the payment of all compensation on said claims on behalf of the employer including, but not limited to, the following: (3-23-22)
i. Investigate and adjust all claims for compensation; (3-23-22)
ii. Pay all compensation benefits due; (3-23-22)
iii. Accept service of claims, applications for hearings, orders of the Commission, and all process which may be issued under the Worker's Compensation Law; (3-23-22)
iv. Enter into compensation agreements and SAs with Claimants; (7-1-25)
v. Provide at the employer's expense necessary forms to any employee who wishes to file a Claim under the Worker's Compensation Law. (3-23-22)
e. File Reports. Report to the Industrial Commission semi-annually, or more often as required by the Commission, total unpaid liability on all open claims. (3-23-22)
i. The semi-annual report of total unpaid liability shall be filed with the Industrial Commission by the end of the months of January and July. (3-23-22)
ii. The report shall provide the aggregate number of open claims, including indemnity with medical and Medical Only Claims, along with the amount of any compensation paid on open claims, as of the end of each June and December. (3-23-22)
iii. The report shall be filed even if there are no open claims. In that event, the employer shall certify the fact that there are no open claims to be reported. (3-23-22)
iv. The report shall be submitted on or in a manner as prescribed by the Industrial Commission or in a format that is substantially the same as the current Form IC-211, “Self-Insured Employer Report of Total Unpaid Liability,” available on the Commission’s website. The report may be produced as a computerized spreadsheet or database printout. (7-1-25)
v. Reports submitted in a format other than online filing, such as hard copy or email attachment, shall be signed and certified to be correct by a corporate officer. If an employer has designated more than one adjuster for worker’s compensation claims in Idaho, a corporate officer of the employer shall prepare, certify, and file a consolidated report of all unpaid liability. (7-1-25)
vi. A self-insured employer shall also make, within the time prescribed, such other reports and respond to such information requests as the Commission may require from time to time concerning matters under the Worker’s Compensation Law. (3-23-22)
f. Submit to Audits by Industrial Commission. Each year a self-insured employer shall provide the Industrial Commission with a copy of its annual financial statements, or other acceptable documentation. Each self-insured employer shall submit to audit by the Commission or its designee at any time and as often as it requires to verify the amount of premium such self-insured employer would be required to pay as premium to the State Insurance Fund, and to verify compliance with the provisions of these rules and the Idaho Worker’s Compensation Law. For the purpose of determining such premium for uninsured contractors of a self-insured employer, the most recent proof of coverage information contained in the Industrial Commission’s database shall be presumed to be correct for the purpose of determining such coverage. (3-23-22)
g. Idaho National Laboratory. An employer meeting the requirements of Section 72-301A, Idaho Code, does not have to comply with Paragraph 303.02.a. and 302.02.b., above. (3-23-22)
01. Procedure for Submitting Premium Tax Forms. The form IC 4008, to be filed in the manner prescribed by the Commission, shall be used to report numbers of policies and the total gross premiums written. A copy must be attached to the reporting entity’s annual premium tax statement that is filed with the Idaho Department of Insurance. Forms submitted in a format other than online filing, such as hard copy or email attachment, shall be signed and certified to be correct by a corporate officer. This form is due to the Commission by July 31 for the reporting period of January 1 through June 30; it is due by March 3 for the reporting period of July 1 through December 31. (7-1-25)
01. Payroll Reports. Self-insured employers shall file in the manner prescribed by the Commission a form IC 4010, along with the accompanying computation form IC 4010a. Forms submitted in a format other than online filing, such as hard copy or email attachment, shall be signed and certified to be correct by a corporate officer. The premium tax payment due shall be based upon the manual premium calculated for each reporting period, as modified by an experience modification factor calculated by NCCI and submitted to the Commission in accordance
with Subsection 304.02 of this rule. No other rating factor shall be allowed. If the self-insured employer elects to not provide such experience modification factor, the premium tax will be computed based upon the manual premium only. (7-1-25)
02. Experience Modification. A self-insured employer that elects to use an experience modification factor in computing premium tax shall make an annual application to NCCI for an experience modification factor using the NCCI form ERM-6 and paying to NCCI any fees charged for providing that calculation. An NCCI experience modification factor may only be based on the employer's Idaho operations for which self-insured status is authorized. In order to have an experience modification factor considered for any reporting period, an employer must timely submit to the Commission's Fiscal Department: (3-23-22)
a. A copy of the completed form ERM-6 filed with NCCI; (3-23-22) b. The resulting experience modification factor received from NCCI; and (3-23-22) c. The completed IC 4010 Semi-Annual Premium Tax Form for Self-Insurers and IC 4010a Computation Form. (3-23-22)
305. REQUIREMENTS FOR MAINTAINING IDAHO WORKER'S COMPENSATION CLAIMS FILES.
01. Idaho Office. (3-23-22)
a. The insurance carrier or self-insured employer shall authorize and require a member of its in-state staff or an Idaho licensed resident adjuster to service and make decisions regarding claims pursuant to Section 72-305, Idaho Code. (3-23-22)
b. As staffing changes occur and, at least annually, the insurance carrier, self-insured employer, or licensed adjuster shall submit to the Commission Secretary the names of those authorized to make decisions regarding claims pursuant to Section 72-305, Idaho Code. Each authorized insurance carrier shall designate only one (1) Claims Administrator for each policy of worker's compensation insurance. (3-23-22)
02. Claim Files. All Idaho worker's compensation claim files shall be maintained within the state of Idaho in either hard copy or immediately accessible electronic format. Claim files shall include all documents relevant to the claim file: (7-1-25)
a. FROI and Claim for Benefits; (3-23-22) b. Copies of bills for medical care; (3-23-22) c. Copy of lost-time computations, if applicable; (3-23-22) d. Correspondence reflecting reasons for any delays in payments, the resolution of such delays, and acceptance or denial of compensability; (3-23-22) e. Employer's return-to-work communications; and (3-23-22) f. Medical reports. (3-23-22)
03. Correspondence. All original correspondence involving adjusting decisions regarding Idaho worker's compensation claims shall be authorized and accessible through electronic reproduction by the resident Idaho adjuster. (7-1-25)
04. Date Stamp. Each of the documents listed in Subsections 305.02 and 305.03, above, shall be date-stamped with the name of the receiving office on the day received, and by each receiving agent or vendor acting on behalf of the claims office. (3-23-22)
05. Notice and Claim. All First Reports of Injury, Claims for Benefits, notices of occupational illnesses, and fatalities shall be sent directly to the in-state adjuster for the insurance carrier or self-insured employer. An EDI Filing of the FROI, Claim for Benefits, and notices of occupational illness and fatality shall be sent electronically to the Industrial Commission. (7-1-25)
a. All compensation, as defined by Section 72-102, Idaho Code, must be issued from the in-state office. (3-23-22)
b. Except as ordered otherwise by the Commission, the insurance carrier or self-insured employer may make compensation payments by either: (3-23-22)
i. Check or other readily negotiable instrument; (3-23-22)
ii. Upon the Claimant’s written request, through an electronic payment transfer to an account designated by the Claimant. The Claimant or Claimant’s attorney may discontinue receiving the electronic transfer payment and revert to receiving compensation payments via check by written notification; or (7-1-25)
iii. An insurance carrier or a self-insured employer may pay compensation through either: (1) an automated teller machine (ATM) card, (2) debit card, or (3) access card (hereinafter, collectively referred to as an “access card”) to a Claimant if there is a signed agreement between the insurance carrier or self-insured employer and the Claimant. An insurance carrier or self-insured employer shall not reduce compensation payments paid to a Claimant through an access card for any fees, surcharges, and adjustments unless they are for direct costs in replacing an access card through an expedited mail service, international transaction fees, or out-of-network ATM fees. The Claimant or Claimant’s attorney may discontinue receiving payment via access card by written notification. (7-1-25)
c. Notwithstanding subsection (ii) and (iii) above if the Claimant is represented by an attorney who may have an attorney’s lien for fees due on such compensation payments, the attorney must agree to payment by electronic transfer to Claimant’s account or payment through an access card before such compensation may be paid other than by a check made payable to the Claimant and the attorney. Upon request, updated electronic payment history shall be provided by written notification to represented parties. (7-1-25)
07. Checks and Drafts. Checks must be signed and issued within the state of Idaho; drafts are prohibited. (3-23-22)
a. The Commission may, upon receipt of a written Application for Waiver, grant a waiver from the provisions of Subsections 305.06 and this subsection of this rule to permit an insurance carrier or a self-insured employer to sign and issue checks outside the state of Idaho. (7-1-25)
b. An Application for Waiver must be accompanied by an affidavit signed by an officer or principal of the insurance carrier or self-insured employer, attesting to the fact that the insurance carrier or self-insured employer is prepared to comply with all statutes and rules pertaining to prompt payments of compensation. (3-23-22)
c. All waivers shall be effective from the date the Commission issues the order granting the waiver. A waiver shall remain in effect until revoked by the Industrial Commission. At least annually, staff of the Industrial Commission may review the performance of any insurance carrier or self-insured employer for which a waiver under this rule has been granted to assure that the insurance carrier or self-insured employer is complying with all statutes and rules pertaining to prompt payments of compensation. (3-23-22)
d. If at any time after the Commission has granted a waiver, the Commission receives information permitting the inference that the insurance carrier or self-insured employer has failed to provide timely benefits to any Claimant, the Commission may issue an order to show cause why the Commission should not revoke the waiver; and, after affording the insurance carrier or self-insured employer an opportunity to be heard, may revoke the waiver and order the insurance carrier or self-insured employer to comply with the requirements of Subsections 305.06 and this subsection of this rule. (7-1-25)
08. Copies of Checks. Copies of checks and/or electronically reproducible copies of the information contained on the checks must be maintained in the in-state files for Industrial Commission audit purposes. Notice of the first income benefit check shall be sent to the Industrial Commission electronically on the same day of issuance. (7-1-25)
09. Prompt Claim Servicing. Prompt claim servicing includes, but is not limited to: (3-23-22)
a. Making an initial decision to accept or deny a Claim for an injury or occupational disease within thirty (30) days of the date the Claims Administrator receives knowledge of the same. The worker shall be given notice of that initial decision in accordance with Section 72-806, Idaho Code. Nothing in this rule shall be construed as amending the requirement to start payment of income benefits no later than four (4) weeks or twenty-eight (28) days from the date of disability under the provisions of Section 72-402, Idaho Code. (3-23-22)
b. Payment of medical bills in accordance with the provisions of Section 803 of these rules. (3-23-22)
c. Payment of income benefits on a weekly basis, unless otherwise approved by the Commission. (3-23-22)
i. The first payment of income benefits under Section 72-408, Idaho Code, shall constitute application by the insurance carrier or self-insured employer for a waiver to pay Temporary Total Disability (TPD) benefits on a bi-weekly basis, Temporary Partial Disability (TPD) benefits on other than a weekly basis, Permanent Partial Disability (PPD) benefits based on permanent impairment and Permanent Total Disability (PTD) benefits every twenty-eight (28) days, rather than on a weekly basis. (3-23-22)
ii. Such waiver application shall be granted upon receipt and remain in effect unless revoked by the Industrial Commission in accordance with Subparagraph 305.11.c.iii. (3-23-22)
iii. If at any time after a waiver has been granted pursuant to this section the Commission receives information permitting the inference that the insurance carrier or self-insured employer has failed to service claims in accordance with Idaho law, or that such waiver has created an undue hardship on a Claimant, the Commission may issue an order to show cause why the Commission should not revoke that waiver, and after affording the insurance carrier or employer an opportunity to be heard, may revoke the waiver with respect to all or certain Claimants and order the insurance carrier or self-insured employer to comply with the requirements of Subsection 305.11.c. of this rule. (3-23-22)
d. Payment of the first Permanent Partial Disability (PPD) benefit based on permanent impairment no later than fourteen (14) days after receipt of the Medical Report providing the impairment rating. The first payment shall include payment of benefits retroactive to the date of medical stability. (3-23-22)
e. Temporary Partial Disability (TPD) payments may be calculated using the employee's pay period, whether weekly, bi-weekly, or semi-monthly. TPD payments owed for a particular pay period shall issue no later than seven (7) days following the date on which employee is ordinarily paid for that pay period. (7-1-25)
10. Audits. The Industrial Commission may perform audits to ensure compliance with the above requirements. (7-1-25)
11. Non-Compliance. Non-compliance with the above requirements may result in the revocation of the authority of an insurance carrier to write worker's compensation insurance or self-insured employer to self-insure its worker's compensation insurance obligations in the state of Idaho, or such lesser sanctions as the Industrial Commission may impose. (3-23-22)
01. Employee Not Required to Take Sick Leave in Lieu of Compensation. No employer obligated to pay worker's compensation benefits to an employee as provided by the Worker's Compensation Law may require an employee to accept 'sick leave' or other comparable benefit in lieu of the worker's compensation benefits provided by law. (7-1-25)
02. Election of Sick Leave or Alternative Compensation Prohibited. Further, an employee may not elect to accept “sick leave” or other comparable benefit from an employer in lieu of worker’s compensation benefits to which the employee is entitled under the Worker’s Compensation Law. (3-23-22)
Pursuant to Section 72-327, Idaho Code, the state insurance fund, every authorized insurance carrier, and self-insured employer in Idaho shall report annually to the Industrial Commission the total gross amount of medical only and Indemnity Benefits paid on Idaho worker’s compensation claims during the applicable reporting period. The reported indemnity payments only are used to calculate the pro rata share of the annual assessment for the ISIF, under Section 72-327, Idaho Code. (7-1-25)
01. Filing. The report of indemnity and medical payments shall be filed with the Industrial Commission simultaneously with the first Semi-Annual Premium Tax Report; which, pursuant to Section 72-523, Idaho Code, is due each year on March 3rd. (3-23-22)
02. Form. The report of indemnity and medical payments shall be submitted on Form IC2-327 in the manner prescribed by the Industrial Commission. (7-1-25)
03. Report Required When No Indemnity Paid. If an entity required to report under this rule has no claims against which indemnity or medical payments have been made during the reporting period, a report shall be filed so indicating. (3-23-22)
04. Penalty for Late Filing. A penalty shall be assessed by the Commission for filing the report of indemnity and medical payments later than March 3rd each year. (3-23-22)
a. A penalty of two hundred dollars ($200) for late filing of seven (7) days or less. (3-23-22)
b. A penalty of one hundred dollars ($100) per day for late filing of more than seven (7) days. (3-23-22)
c. A penalty assessed by the Commission shall be payable to the Industrial Commission and be submitted with the April 1 payment of the ISIF assessment, following notice by the Commission of the penalty assessment. (3-23-22)
05. Estimating Indemnity Payments for Entities That Fail to Report Timely. If an entity required to report indemnity payments under these rules fails to report within the time allowed in these rules, the Commission will estimate the indemnity payments for that entity by using the indemnity amount reported for the preceding reporting period and adding twenty percent (20%). (3-23-22)
06. Adjustment for Overpayments or Underpayments. Overpayments or underpayments, including those resulting from estimating the indemnity payments of entities that fail to report timely, will be adjusted on the billing for the subsequent period. (3-23-22)
308. – 400. (RESERVED)
01. Amounts Paid over Base Rate. Sums paid by an employer to an employee, over and above the base rate of compensation agreed upon by the employer and the employee in a contract of hire, which are contingent and dependent upon the employee’s increased physical exertion and/or efficiency shall be included in computing the employee’s average weekly wage pursuant to Section 72-419(4)(a), Idaho Code. Said sums shall not be considered premium pay. (3-23-22)
02. Fringe Benefits. Also, in computing the average weekly wage, it shall be presumed that wages include, but are not limited to, cost of living increases, vacation pay, holiday pay, and sick leave. (3-23-22)
03. Premium Pay. Further, in computing the average weekly wage, it shall be presumed that premium pay includes, but is not limited to, shift differential pay and overtime pay. (3-23-22)
04. Examples Not Exclusive. The above-listed examples are not exclusive in computing the average weekly wage. (7-1-25)
01. Averaging Multiple Ratings. Where more than one (1) evaluating physician has given ratings, these shall be converted to the statutory percentage of the whole man, and averaged for the applicable rating. (3-23-22)
02. Correcting Manifest Injustice. The Commission may take steps to correct a manifest injustice resulting from averaging multiple ratings. (7-1-25)
01. Compensation for Disability. A Claimant under the Worker's Compensation Law shall be entitled to compensation for permanent disability for the loss of each tooth other than wisdom teeth at the rate of one tenth of one percent (1%) of the whole man. The loss of wisdom teeth shall not constitute any permanent disability. Compensation hereunder shall be in addition to payments for medical services including dental appliances and bridgework necessitated by the injury and any income benefits during the period of Claimant's recovery to which the Claimant be entitled. (3-23-22)
02. Prima Facie Evidence. This rule and schedule shall be prima facie evidence of the percentage of permanent disability to be attributed to the loss of teeth. (3-23-22)
01. Procedure. In all cases in which a particular injury or occupational disease results in a worker's compensation Claim, the Provider shall submit written Medical Reports for each medical visit to the Payor. A medical authorization for release of records signed by Claimant shall remain in effect until revoked. Payors and Providers may contract with one another to identify specific records that will be provided in support of billings. The Provider shall also submit the same written Medical Reports to the Claimant upon request. These reports shall be submitted within fourteen (14) days following each evaluation, examination, and/or treatment. The first copy of any such reports shall be provided to the Payor and the Claimant, or their attorney, at no charge. If duplicate copies of reports already provided are requested by either the Payor or the Claimant, the Provider may charge the requesting party a reasonable charge to provide the additional reports. Whenever possible, billing information shall be coded using CPT. In the case of Hospitals, reports shall include a Uniform Billing Form 04. In the case of physicians and other Providers supplying outpatient services, this reporting requirement shall include a CMS 1500 form. (7-1-25)
a. If an injury or occupational disease results in a Claim, the Employer/Surety or Provider shall submit written reports to the Commission upon request. Such request may either be in writing or telephonic. If a Claim is referred to the Rehabilitation Division, Medical Reports shall be furnished by the Payor or Provider directly to the office that requests such reports. The Payor or Provider shall consider this an on-going request until notice is received that the reports are no longer required. (3-23-22)
b. If the injury or occupational disease results in a time-loss Claim, the Payor shall submit copies of medical records containing information regarding the beginning and ending of disability, releases to work whether light duty or regular duty, impairment ratings, physical restrictions to the Commission. Other Medical Reports shall be submitted to the Commission only upon request. (3-23-22)
c. ISIF shall receive all copies of Medical Reports, without charge, from either the Claimant or the Payor, depending upon who seeks to join it as a party to a worker's compensation Claim. (3-23-22)
d. If the Commission requests Medical Reports from the Payor or Provider, the information shall be
provided within a reasonable time period without charge. If information is received for which the Commission has no need, the information may be discarded or destroyed. (3-23-22)
02. Report Form and Content. Upon approval of the Commission, Medical Reports may be submitted in electronic or other machine-readable form usable to all parties. (3-23-22)
03. Timely Response Requirement. When the Commission requests a Medical Report from a Payor or Provider for use in monitoring a worker's compensation Claim, the Payor or Provider shall provide the requested information promptly. (3-23-22)
04. Forfeiture of Payment. If a Provider fails to give records to the Payor or Claimant, the Payor or Claimant may petition the Commission for an order requiring the Provider to provide the requested information. The petition shall set forth the Petitioner's efforts to obtain the information, the responses to those efforts, and why the Petitioner believes that the Provider has the information. In response to the petition, the Commission may enter an order requiring the Provider to furnish the requested records or demonstrate that the records are not available. If a Provider fails to provide records when ordered by the Commission, the Commission may enter an Order of Forfeiture. In the event such an order is entered, the Provider will forfeit its right to payment from both the Payor and Claimant, until such time as the records are provided. (3-23-22)
01. Commercial Transportation. If Claimant has no vehicle, or has access to a vehicle and is reasonably unable to utilize the vehicle for transportation covered by Sections 72-432(13) or 72-433(3), Idaho Code, Claimant's employer shall reimburse Claimant the actual cost of commercial transportation as evidenced by actual receipts. (7-1-25)
02. Request for Reimbursement. It shall be Claimant's responsibility to submit a travel reimbursement request to the employer. Such request shall be made on a form substantially the same as Industrial Commission Form IC 432(1), posted on the Commission's website. The Claimant must attach to the form a copy of a bill or receipt showing that the visit occurred. The employer shall furnish the Claimant with copies of this form. (3-23-22)
03. Frequency of Requests. Claimant shall not request transportation reimbursement more frequently than once every thirty (30) days. However, notwithstanding this provision, should a Claimant request transportation reimbursement more frequently than every thirty (30) days, employer need not issue more than one reimbursement check in any thirty-day (30) period. (3-23-22)
01. Requests from Other Agencies. If records are in the possession of the Rehabilitation Division by reason of an agreement to comply with valid confidentiality regulations of any agency of the state of Idaho, or agency of the United States, then disclosure shall be requested from the source agency, and not from the Rehabilitation Division. (3-23-22)
502. RULE GOVERNING REPORTS OF ATTORNEY COSTS AND FEES IN LITIGATED CASES. When requested by the Commission, parties to a Litigated Case shall provide the Commission the information required by Section 72-528, Idaho Code. The form for Sureties is Form 1022 and the form for Claimant's attorneys is Form 1023; both are available on the Commission's website. (3-23-22)
01. EDI Reporting. The Commission adopts the IAIABC's electronic claims record layout and
transaction standards as the required reporting mechanism for all initial claim filings and subsequent reports from any employer not otherwise exempt by these rules. The Commission’s EDI Claims Guides and Tables are available on the website. (7-1-25)
02. Trading Partner Agreements. Before commencing electronic reporting, Trading Partners shall electronically submit a Trading Partner Agreement, which the Commission must approve prior to submitting reports. This agreement will identify the insurance carrier, the Claims Administrator, the sender of the electronic files, and the electronic filing method. To ensure the accuracy of reported data, the Trading Partner must maintain their profile to reflect changes as they occur and the Commission may make periodic audits of Trading Partner files. If a Trading Partner Agreement is entered into by a Claims Administrator, notice to the Trading Partner of a FROI shall be deemed to be notice to the underlying insurance carrier or self-insured employer. (7-1-25)
a. Individual claimants, claimant’s legal counsel, and employers that are not insured are not required to comply with EDI requirements for FROIs and SROIs. (7-1-25)
b. Parties exempt from EDI requirements must submit FROIs on a form 1A-1 and SROIs on a form IC-8, or in a format substantially similar. Both forms are available on the Commission’s website. (3-23-22)
04. Retaining Claims Files. Upon request of the Commission, insurance carriers, Claims Administrators, or employers shall provide to the Commission, in whole or in part according to the request, a copy of the claim file at no cost to the Commission. All insurance carriers, Claims Administrators, or employers shall retain complete copies of claims files for the life of the Claim and a minimum of five (5) years from the date of closure. (3-23-22)
05. Filing Not an Admission. Filing a FROI is not an admission of liability and is not conclusive evidence of any fact stated therein. (7-1-25)
06. Filing Considered Authorization. Filing of a Claim shall be considered an authorization for the release of medical records that are relevant to or bearing upon the particular injury or occupational disease for which the Claimant is seeking compensation. (3-23-22)
07. Timely Response Requirement. When the Commission requests additional information to process the Claim, the surety or self-insured employer shall respond within seven (7) days. The Commission’s request may be in writing or telephonic. (7-1-25)
01. Report Requirements. An electronic filing of the Final Report as prescribed by Commission EDI requirements shall be filed for all indemnity claims or any claims resolved by settlement agreement within thirty (30) days from the date the surety or self-insured employer closes the claim file. In the case of medical-only claims, no Final Report need be filed. For death claims and permanent total disability claims, Annual Reports shall be filed within the first quarter of each calendar year. A Final Report shall be filed within thirty (30) days from the date the surety or self-insured employer closes the death or permanent total disability claim file. In the event the Commission is unable to reconcile the Annual Report or Final Report, a written request for additional information may be made, and the surety or self-insured employer shall submit the requested information within fifteen (15) working days of the request. If the surety or self-insured employer is unable to furnish the requested information, the surety or self-insured employer shall notify the Commission, in writing, of its inability to respond and the reasons therefor within fifteen (15) working days of the request. (7-1-25)
02. Change in Status of Employer. In case of any default by the Employer or in the event the Employer fails to pay any final award or awards, by reason of insolvency or because a receiver has been appointed, the receiver or successor shall continue to report to the Commission, including the submission of Annual Reports, Final Reports and schedules of outstanding awards. (7-1-25)
01. Notice of Change of Status. Pursuant to Section 72-806, Idaho Code, a worker shall receive written notice within fifteen (15) days of any change of status or condition, including, but not limited to, whenever there is an acceptance, commencement, denial, reduction, or cessation of medical or monetary compensation benefits to which the worker might presently or ultimately be entitled. Pursuant to Section 72-316, Idaho Code, such notice is required when benefits are curtailed to recoup any overpayment of benefits. (7-1-25)
02. By Whom Given. Notice of Change of Status shall be given by: the surety if the employer has secured Worker's Compensation Insurance; or the employer if the employer is self-insured; or the employer if the employer carries no Worker's Compensation Insurance. (7-1-25)
03. Form of Notice. Notice of Change of Status shall be mailed within ten (10) days by regular United States Mail to the last known address of the worker, as shown in the records of the party required to give notice as set forth above. If the worker has elected to receive electronic correspondence, notice may be emailed to the worker within fifteen (15) days. The Notice shall be given in a format substantially similar to IC Form 8, available on the Commission's website. (7-1-25)
04. Copies of Notice. The party giving notice pursuant to Section 72-806, Idaho Code, shall send a copy of any such notice to the employer, and the worker's attorney, if the worker is represented, at the same time notice is sent to the worker. The party will provide notice to the Commission consistent with its policy on electronic submission of the FROI and SROI. In the case of an overpayment recovery request made pursuant to I.C. 72-316, notice shall be contemporaneously submitted to the Commission by email or in paper format. (7-1-25)
a. In a case in which no hearing on the merits has been held, twenty-five percent (25%) of Available Funds shall be presumed reasonable; or (3-23-22)
b. In a case in which a hearing has been held and briefs submitted (or waived) under Judicial Rules of Practice and Procedure (JRP), Rules X and XI, thirty percent (30%) of Available Funds shall be presumed reasonable; or (3-23-22)
c. In any case in which compensation is paid for total permanent disability, fifteen percent (15%) of such disability compensation after ten (10) years from date such total permanent disability payments commenced. (3-23-22)
a. All requests for approval of fees shall be deemed requests for approval of a Charging Lien. (3-23-22)
b. An attorney representing a Claimant in a Worker's Compensation matter shall, within thirty (30) days of the Commission's dismissal of any Settlement Agreement or upon request of the Commission, file with the Commission, and serve the Claimant with a copy of the Fee Agreement, and an affidavit or memorandum containing: (7-1-25)
i. The date upon which the attorney became involved in the matter; (3-23-22)
ii. Any issues which were undisputed at the time the attorney became involved; (3-23-22)
iii. The total dollar value of all compensation paid or admitted as owed by employer immediately prior to the attorney's involvement; (3-23-22)
iv. Disputed issues that arose subsequent to the date the attorney was hired; (3-23-22) v. Counsel's itemization of compensation that constitutes Available Funds; (3-23-22) vi. Counsel's itemization of costs and calculation of fees; and (3-23-22) vii. The statement of the attorney identifying with reasonable detail his or her fulfillment of each element of the Charging Lien. (3-23-22)
c. Upon receipt and a determination of compliance with this Rule by the Commission by reference to its staff, the Commission may issue an Order Approving Fees without a hearing. The thirty (30) day-time period for counsel to submit the affidavit or memorandum may be waived for good cause shown. (7-1-25)
03. Procedure if Fees Are Determined Not to Be Reasonable. (3-23-22)
a. Upon receipt of the affidavit or memorandum, the Commission staff will notify counsel in writing of the Commission's informal determination, which shall state the reasons for the determination that the requested fee is not reasonable. Omission of any information required by Paragraph 802.02.b. may constitute grounds for an informal determination that the fee requested is not reasonable. (7-1-25)
b. If counsel disagrees with the Commission staff's informal determination, counsel may file, within fourteen (14) days of the date of the determination, a Request for Hearing for the purpose of presenting evidence and argument on the matter. Upon receipt of the Request for Hearing, the Commission shall schedule a hearing on the matter. A Request for Hearing shall be treated as a motion under Rule III(e), JRP. (3-23-22)
c. The Commission shall order an employer to release any Available Funds in excess of those subject to the requested Charging Lien and may order payment of fees subject to the Charging Lien which have been determined to be reasonable. (3-23-22)
d. The proponent of a fee which is greater than the percentage of recovery stated in Subsection 802.02 shall have the burden of establishing by clear and convincing evidence entitlement to the greater fee. The attorney shall always bear the burden of proving by a preponderance of the evidence his or her assertion of a Charging Lien and reasonableness of his or her fee. (3-23-22)
04. Disclosure Statement. Upon retention, the attorney shall provide to Claimant a copy of a disclosure statement. No fee may be taken from a Claimant by an attorney on a contingency fee basis unless the Claimant acknowledges receipt of the disclosure by signing it. Upon request by the Commission, an attorney shall provide a copy of the signed disclosure statement to the Commission. The terms of the disclosure may be contained in the Fee Agreement, so long as it contains the following text: (3-23-22)
a. In worker's compensation matters, attorney's fees normally do not exceed twenty-five percent (25%) of the benefits your attorney obtains for you in a case in which no hearing on the merits has been completed. In a case in which a hearing on the merits has been completed, attorney's fees normally do not exceed thirty percent (30%) of the benefits your attorney obtains for you. (3-23-22)
b. Depending upon the circumstances of your case, you and your attorney may agree to a higher or lower percentage which would be subject to Commission approval. Further, if you and your attorney have a dispute regarding attorney fees, either of you may petition the Industrial Commission, PO Box 83720, Boise, ID 83720-0041, to resolve the dispute. (3-23-22)
803. MEDICAL FEES.
01. General Provisions for Medical Fees. The following provisions shall apply to Commission approval of claims for medical benefits. (3-23-22)
a. Acceptable Charge. Payors shall pay Providers the acceptable charge for medical services. (3-23-22)
b. Coding. The Commission will generally follow the coding guidelines published by CMS and by the American Medical Association (AMA), including the use of modifiers and payment status indicators unless otherwise specified in Section 803 of this rule. (7-1-25)
c. Disputes. Disputes between Providers and Payors are governed by Subsection 803.06 of this rule and JRP 19. (3-23-22)
d. Outside of Idaho. Reimbursement for medical services provided outside the state of Idaho may be based upon the agreement of the parties. If there is no agreement, services shall be paid in accordance with the worker's compensation fee schedule in effect in the state in which services are rendered. If there is no fee schedule in effect in such state, or if the fee schedule in that state does not allow reimbursement for the services rendered, reimbursement shall be paid in accordance with these rules. (3-23-22)
a. The Commission adopts the Resource-Based Relative Value Scale (RBRVS), published by CMS, as amended, as the standard to be used to determine acceptable charges by physicians. (3-23-22)
b. Modifiers. Modifiers for physicians will be reimbursed as follows: (3-23-22)
i. Modifier 50: Additional fifty percent (50%) for bilateral procedure. (3-23-22)
ii. Modifier 51: Fifty percent (50%) of secondary procedure. This modifier will be applied to each medical or surgical procedure rendered during the same session as the primary procedure. (3-23-22)
iii. Modifier 80: Twenty-five percent (25%) of coded procedure. (3-23-22)
iv. Modifier 81: Fifteen percent (15%) of coded procedure. This modifier applies to MD and non-MD assistants. (3-23-22)
c. Conversion Factors. The standard for determining the acceptable charge for a medical service, identified by a code assigned to that service in the latest edition of the Physician's CPT, published by the American Medical Association, as amended, is calculated by the application of the total facility or non-facility Relative Value Unit (RVU) for services as determined by place of service in the latest RBRVS in effect on the first day of January of the current calendar year, to the following corresponding conversion factors. The procedure with the largest RVU will be the primary procedure and will be listed first on the claim form. (7-1-25)
| MEDICAL FEE SCHEDULE | |||
|---|---|---|---|
| SERVICE CATEGORY | CODE RANGE(S) | DESCRIPTION | CONVERSION FACTOR |
| Anesthesia | 00000 - 09999 | Anesthesia | $60.33 |
| Surgery - Group One | 22000 - 22999 | Spine | $135.00 |
| 23000 - 24999 | Shoulder, Upper Arm, & Elbow | ||
| 25000 - 27299 | Forearm, Wrist, Hand, Pelvis & Hip | ||
| 27300 - 27999 | Leg, Knee, & Ankle | ||
| 29800 - 29999 | Endoscopy & Arthroscopy | ||
| 61000 - 61999 | Skull, Meninges & Brain | ||
| 62000 - 62259 | Repair, Neuroendoscopy & Shunts | ||
| 63000 - 63999 | Spine & Spinal Cord | ||
| Surgery - Group Two | 28000 - 28999 | Foot & Toes | $124.00 |
| 64550 - 64999 | Nerves & Nervous System |
| MEDICAL FEE SCHEDULE | |||
|---|---|---|---|
| SERVICE CATEGORY | CODE RANGE(S) | DESCRIPTION | CONVERSION FACTOR |
| Surgery - Group Three | 10000 - 19999 | Integumentary System | $88.54 |
| 20000 - 21999 | Musculoskeletal System | ||
| 29000 - 29799 | Casts & Strapping | ||
| 30000 - 39999 | Respiratory & Cardiovascular | ||
| 40000 - 49999 | Digestive System | ||
| 50000 - 59999 | Urinary System | ||
| 60000 - 60999 | Endocrine System | ||
| 62260 - 62999 | Spine & Spinal Cord | ||
| 64000 - 64549 | Nerves & Nervous System | ||
| 65000 - 69999 | Eye & Ear | ||
| Radiology | 70000 - 79999 | Radiology | $88.54 |
| Pathology & Laboratory | 80000 - 89999 | Pathology & Laboratory | To Be Determined |
| Medicine - Group One | 90000 - 90749 | Immunization, Injections, & Infusions | $49.00 |
| 94000 - 94999 | Pulmonary / Pulse Oximetry | ||
| 97000 - 97799 | Physical Medicine & Rehabilitation | ||
| 97800 - 98999 | Acupuncture, Osteopathy, & Chiropractic | ||
| Medicine - Group Two | 90750 - 92999 | Psychiatry & Medicine | $70.00 |
| 93000 - 93999 | Cardiography, Catheterization, Vascular Studies | ||
| 95000 - 96020 | Allergy / Neuromuscular Procedures | ||
| 96040 - 96999 | Assessments & Special Procedures | ||
| 99000 - 99607 | E / M & Miscellaneous Services |
(3-23-22)
d. Anesthesiology. The Conversion Factor for the Anesthesiology CPT Codes shall be multiplied by the current Anesthesia Base Units assigned to that CPT Code by CMS, plus the allowable time units reported for the procedure. Time units are computed by dividing reported time by fifteen (15) minutes. Time units will not be used for CPT Code 01996. (3-23-22)
e. Services Without CPT Code, RVU or Conversion Factor. The acceptable charge for medical services that do not have a current CPT code, a currently assigned RVU, or a conversion factor will be the reasonable charge for that service, based upon the usual and customary charge and other relevant evidence, as determined by the Commission. Where a service with a CPT Code, RVU, and conversion factor is, nonetheless, claimed to be exceptional or unusual, the Commission may, notwithstanding the conversion factor for that service set out in Paragraph 02.c, above, determine the acceptable charge for that service, based on all relevant evidence in accordance with the procedures set out in Subsection 06, below. (3-23-22)
f. Medicine Dispensed by Physicians. Reimbursement to physicians for any drug or topical agent, including over-the-counter (OTC), shall not exceed the lesser of the acceptable charge calculated for that medicine as if provided by a Pharmacy under Subsection 04 of this rule, or one hundred thirty percent (130%) of the AWP for the lowest-cost therapeutic equivalent drug. Reimbursement to physicians for repackaged medicine shall be lesser of the AWP for the medicine prior to repackaging, identified by the National Drug Code (NDC) reported by the original manufacturer, or one hundred thirty percent (130%) of the AWP for the lowest-cost therapeutic equivalent drug. Reimbursement may be withheld until the original manufacturer's NDC is provided by the physician. Physicians who dispense medications shall not receive a dispense or compounding fee. (7-1-25)
g. Adjustment of Conversion Factors. The conversion factors set out in this rule may be adjusted each
fiscal year (FY) by the Commission to reflect changes in inflation or market conditions in accordance with Section 72-803, Idaho Code. (3-23-22)
03. Acceptable Charges For Medical Services Provided By Hospitals And Ambulatory Surgery Centers Under The Idaho Worker’s Compensation Law. The following standards shall be used to determine the acceptable charge for Hospitals and ASCs. (3-23-22)
a. Critical Access Hospitals. The standard for determining the acceptable charge for inpatient and outpatient services provided by a Critical Access Hospital is ninety percent (90%) of the reasonable charge. Implantable hardware charges shall be reimbursed at the rate of the actual cost plus fifty percent (50%). (3-23-22)
b. Hospital Inpatient Services. The standard for determining the acceptable charge for inpatient services provided by Hospitals, other than Critical Access Hospitals, is calculated by multiplying the base rate by the current MS-DRG weight for that service. The base rate for inpatient services is ten thousand two hundred dollars ($10,200). Inpatient services that do not have a relative weight shall be paid at eighty-five percent (85%) of the reasonable charge; however, Implantable Hardware charges billed for services without an MS-DRG weight shall be reimbursed at the rate of actual cost plus fifty percent (50%). (3-23-22)
c. Hospital Outpatient and ASC Services. The standard for determining the acceptable charge for outpatient services provided by Hospitals (other than Critical Access Hospitals) and for services provided by ASCs is calculated by multiplying the base rate by the Medicare Hospital Outpatient Prospective Payment System APC weight in effect on the first day of January of the current calendar year. The base rate for Hospital outpatient services is one hundred forty dollars and seventy-five cents ($140.75). The base rate for ASC services is ninety-one dollars fifty cents ($91.50). (3-23-22)
i. Medical services for which there is no APC weight listed shall be reimbursed at seventy-five percent (75%) of the reasonable charge, except when bundled with another service appearing on the same bill or is a service defined in 803.03.c.ii. - iv. of this rule. (7-1-25)
ii. Status indicator N codes or items with no CPT or HCPCS code shall receive no payment except as provided in Subparagraph 803.03.c.ii.(1) of this rule. (7-1-25)
(1) Implantable Hardware may be eligible for separate payment under Subparagraph 03.d.iii. of this rule. (3-23-22)
iii. Outpatient physical, occupational, and speech therapy services will be reimbursed according to the allowable professional charge under Subsection 803.02 of this rule. (7-1-25)
iv. Status indicator Q codes are not subject to composite APC packaging standards. (7-1-25)
d. Additional Hospital Payments. When the charge for a medical service provided by a Hospital (other than a Critical Access Hospital) meets the following standards, additional payment shall be made for that service, as indicated. (3-23-22)
i. Inpatient Threshold Exceeded. When the charge for a Hospital inpatient MS-DRG coded service exceeds the sum of thirty thousand dollars ($30,000) plus the payment calculated under the provisions of Paragraph 03.b. of this rule, then the total payment for that service shall be the sum of the MS-DRG payment and the amount charged above that threshold multiplied by seventy-five percent (75%). Implantable charges shall be excluded from the calculation for an additional inpatient payment under this Subparagraph. (3-23-22)
ii. Inpatient Implantable Hardware. Hospitals may seek additional reimbursement beyond the MSDRG payment for invoiced Implantable Hardware where the aggregate invoice cost is greater than ten thousand dollars ($10,000). Additional reimbursement shall be the invoice cost plus an amount which is equal to ten percent (10%) of the invoice cost, but which does not exceed three thousand dollars ($3,000). Handling and freight charges shall be included in invoice cost. (3-23-22)
iii. Outpatient Implantable Hardware. Hospitals and ASCs may seek additional reimbursement beyond
the APC payment for invoiced Implantable Hardware where the aggregate invoice cost is greater than five hundred dollars ($500). Additional reimbursement shall be the invoice cost plus an amount which is equal to ten percent (10%) of the invoice cost, but which does not exceed one thousand dollars ($1,000). Handling and freight charges shall be included in invoice cost. (3-23-22)
e. Adjustment of Hospital and ASC Base Rates. The Commission may periodically adjust the base rates set out in Paragraphs 803.03.b. and 803.03.c. of this rule to reflect changes in inflation or market conditions. (3-23-22)
04. Acceptable Charges For Medicine Provided By Pharmacies. The following standards shall be used to determine the acceptable charge for medicine provided by pharmacies. (3-23-22)
a. Brand/Trade Name Medicine. The standard for determining the acceptable charge for brand/trade name medicine shall be the AWP, plus a five dollar ($5) dispensing fee. (3-23-22)
b. Generic Medicine. The standard for determining the acceptable charge for generic medicine shall be the AWP, plus an eight dollar ($8) dispensing fee. (3-23-22)
c. Compound Medicine. The standard for determining the acceptable charge for compound medicine shall be the sum of the AWP for each drug included in the compound medicine, plus a five dollar ($5) dispensing fee and a two dollar ($2) compounding fee. All components of the compound medicine shall be identified by their original manufacturer's NDC when submitted for reimbursement. Payors may withhold reimbursement until the original manufacturer's NDC assigned to each component of the compound medicine is provided by the Pharmacy. Components of a compound medicine without an NDC may require medical necessity confirmation by the treating physician prior to reimbursement. (3-23-22)
d. Prescribed Over-the Counter Medicine. The standard for determining the acceptable charge for prescribed over-the-counter medicine filled by a Pharmacy shall be the reasonable charge plus a two dollar ($2) dispensing fee. (3-23-22)
05. Acceptable Charges For Medical Services Provided By Other Providers Under The Idaho Worker's Compensation Law. The standard for determining the acceptable charge for Providers other than physicians, Hospitals or ASCs shall be the reasonable charge. (3-23-22)
a. Durable Medical Equipment (DME) Providers. Within the first thirty (30) days of equipment use, the Payor shall be given the option to rent or purchase DME. Rented equipment shall be considered purchased once the rental charges exceed the purchase price, which may not exceed ten percent (10%) of the invoice cost. If purchased, the DME shall become the property of the Claimant. (7-1-25)
06. Billing And Payment Requirements For Medical Services And Procedures Preliminary To Dispute Resolution. This rule governs billing and payment requirements for medical services provided under the Worker's Compensation Law and the procedures for resolving disputes between Payors and Providers over those bills or payments. (3-23-22)
a. Time Periods. None of the periods herein shall begin to run before the Notice of Injury/Claim for Benefits has been filed with the Employer as required by law. (3-23-22)
b. Provider to Furnish Information. A Provider, when submitting a bill to a Payor, shall inform the Payor of the nature and extent of medical services furnished and for which the bill is submitted. This information shall include, but is not limited to, the patient's name, the employer's name, the date the medical service was provided, the diagnosis, if any, and the amount of the charge or charges. Except for the circumstances listed below, payment is forfeited when the charges are not billed within twelve (12) months from the date of service and may not be balance billed as defined in Section 72-102(2), Idaho Code: (7-1-25)
i. The industrial nature of the injury is initially unknown to the Provider; (7-1-25)
ii. A change in Employer's coverage or designated claims administrator is unknown to the Provider.
(7-1-25)
iii. This list is not exhaustive, and the Commission has discretion to address disputes regarding timeliness of the billing in the dispute resolution procedures of the Commission set out in Paragraph 803.06.iv. of this rule. (7-1-25)
iv. A Provider's bill shall, whenever possible, describe the Medical Service provided, using the American Medical Association's appropriate CPT coding, including modifiers, the appropriate HCPCS code, the diagnostic and procedure code set version required by CMS and the original NDC for the year in which the service was performed. (3-23-22)
v. The bill shall also contain the name, address and telephone number of the individual the Payor may contact in the event the Payor seeks additional information regarding the Provider's bill. (3-23-22)
vi. If requested by the Payor, the bill shall be accompanied by a written report as defined by Subsection 010.31 and required by Section 404 of these rules. Where a bill is not accompanied by such Report, the periods expressed in Paragraphs 803.06.c. and 803.06.e. of this rule, shall not begin to run until the Payor receives the Report. (3-23-22)
c. Prompt Payment. Unless the Payor denies liability for the Claim or, pursuant to Paragraph 803.06.e. of this rule, sends a Preliminary Objection, a Request for Clarification, or both, as to any charge, the Payor shall pay the charge within thirty (30) calendar days of receipt of the bill or upon acceptance of liability, if made after bill is received from Provider. (3-23-22)
d. Partial Payment. If the Payor acknowledges liability for the Claim and, pursuant to Paragraph 803.06.e. of this rule, sends a Preliminary Objection, a Request for Clarification, or both, as to only part of a Provider's bill, the Payor must pay the charge or charges, or portion thereof, as to which no Preliminary Objection or Request for Clarification has been made, within thirty (30) calendar days of receipt of the bill. (3-23-22)
e. Preliminary Objections and Requests for Clarification. (3-23-22)
i. Whenever a Payor objects to all or any part of a Provider's bill on the ground that such bill contains a charge or charges that do not comport with the applicable administrative rule, the Payor shall send a written Preliminary Objection to the Provider within thirty (30) calendar days of the Payor's receipt of the bill explaining the basis for each of the Payor's objections. (3-23-22)
ii. Where the Payor requires additional information, the Payor shall send a written Request for Clarification to the Provider within thirty (30) calendar days of the Payor's receipt of the bill, and shall specifically describe the information sought. (3-23-22)
iii. Each Preliminary Objection and Request for Clarification shall contain the name, address, and phone number of the Claims Administrator located within the state of Idaho that the Provider may contact regarding the Preliminary Objection or Request for Clarification. (7-1-25)
iv. Where a Payor does not send a Preliminary Objection to a charge set forth in a bill or a Request for Clarification within thirty (30) calendar days of receipt of the bill, or provide an in-state contact in accord with Subparagraph 06.e.iii., it shall be precluded from objecting to such charge as failing to comport with the applicable administrative rule. (3-23-22)
f. Provider Reply to Preliminary Objection or Request for Clarification. (3-23-22)
i. Where a Payor has timely sent a Preliminary Objection, Request for Clarification, or both, the Provider shall send to the Payor a written Reply, if any it has, within thirty (30) calendar days of the Provider's receipt of each Preliminary Objection or Request for Clarification. (3-23-22)
ii. If a Provider fails to timely reply to a Preliminary Objection, the Provider shall be deemed to have acquiesced in the Payor's objection. (3-23-22)
iii. If a Provider fails to timely reply to a Request for Clarification, the period in which the Payor shall pay or issue a Final Objection shall not begin to run until such clarification is received. (3-23-22)
g. Payor Shall Pay or Issue Final Objection. The Payor shall pay the Provider's bill in whole or in part or send to the Provider a written Final Objection, if any it has, to all or part of the bill within thirty (30) calendar days of the Payor's receipt of the Reply. (3-23-22)
h. Failure of Payor to Finally Object. Where the Payor does not timely send a Final Objection to any charge or portion thereof to which it continues to have an objection, it shall be precluded from further objecting to such charge as unacceptable. (3-23-22)
i. Dispute Resolution Process. If, after completing the applicable steps set forth above, a Payor and Provider are unable to agree on the appropriate charge for any Medical Service, a Provider which has complied with the applicable requirements of this rule may move the Commission to resolve the dispute as provided in the Judicial Rule Re: Disputes Between Providers and Payors, as referenced in Paragraph 803.01.c. of this rule. If Provider's motion disputing CPT or MS-DRG coded items prevails, Payor shall pay the amount found by the Commission to be owed, plus an additional thirty percent (30%) of that amount to compensate Provider for costs and expenses associated with using the dispute resolution process. For motions filed by a Provider disputing items without CPT or MS-DRG codes, the additional thirty percent (30%) shall be due only if the Payor does not pay the amount found due within thirty (30) days of the administrative order. (3-23-22)
804. – 999. (RESERVED)