PURPOSE: This rule sets forth the Division of Workers’ Compensation administrative procedures available to employers, insurance carriers and health care providers to resolve disputes concerning charges for services, in accordance with section 287.140, RSMo.

1. (1) Procedures pertaining to applications for payment of additional reimbursements.

   1. (A) If an employer or insurer disputes the reasonableness of a medical fee or charge, the employer or insurer shall notify the health care provider in writing that the medical charge is being disputed and shall explain the basis for the dispute. The employer or insurer may tender partial payment and the health care provider may accept payment of the amount tendered without prejudice to the filing of an application for payment of additional reimbursements of medical fees. Upon receiving the written notice of the dispute, the health care provider shall contact the insurer or employer to attempt to resolve the dispute. If the negotiation is unsuccessful and more than ninety (90) days have elapsed since the date of first billing, the health care provider may file an application for payment of additional reimbursement of medical fees with the division.

   2. (B) The health care provider shall file with the division an original application for payment of additional reimbursements of medical fees. The application shall contain the following information:

      1. 1. The name, address and telephone

number of the health care provider and, if different, the address where the service was rendered;

1. 2. Name, address and telephone number

of the employer and insurer against whom the application is being filed;

1. 3. Name, address and Social Security

number of the employee for whom health care services were rendered, together with the date of injury, for all disputes;

1. 4. The amount in dispute;
2. 5. Any information the division deems

necessary to resolve the dispute.

1. (C) The health care provider shall serve through personal service or by certified mail, return receipt requested, a copy of the application on the person or corporation against whom the application has been filed. The health care provider shall file proof of service with the division.
2. (D) The application shall be filed on a form prescribed by the division and shall contain the required information. If the application does not include all the information required by this rule or proof of service is not filed with the division, the application will be rejected and will be returned for the additional information.
3. (E) If no report of injury or claim for compensation has been filed with the division for the injury for which the health care was provided the application may be returned for lack of jurisdiction.
4. (F) Upon receipt of the application, the division will assign a medical fee dispute number and confirm acceptance or rejection of the application to the health care provider.
5. (G) After the filing of an application for payment of additional reimbursement of medical fees, the parties shall again attempt to resolve their dispute without the assistance of the division.
6. (H) If the parties are unable to resolve their dispute after sixty (60) days have lapsed since the filing of the application for payment of additional reimbursement of medical fees, the health care provider may file a written application for an evidentiary hearing of the medical fee dispute. The health care provider shall forward a copy of the application for an evidentiary hearing to all parties. The employer or insurer shall file an answer to the application for an evidentiary hearing within thirty (30) days from the date of the application, unless good cause is found by the division to extend the filing of the answer. If the employer or insurer fails to file a timely answer the facts contained in the application are deemed admitted as true. An evidentiary hearing shall be scheduled in front of an administrative law judge or legal advisor. An application for an evidentiary hearing cannot be dismissed without prejudice after an evidentiary hearing has been scheduled, without approval of the administrative law judge or legal advisor.
7. (I) Either party may engage in discovery to the extent authorized by Chapter 287, RSMo.
8. (J) The hearing shall be held at a place and time to be set by the division. The division shall notify all parties as to the time and place of the hearing. The hearing shall be simple and informal and all parties shall be entitled to be heard and to introduce evidence, however, the rules of evidence in civil proceedings shall apply. The administrative law judge or legal advisor shall conduct the hearing and shall issue an award deciding the issues in dispute. The award should be completed within thirty (30) days of submission of the case.
9. (K) Either party may file an application for review with the Labor and Industrial Relations Commission within twenty (20) days from the date of the award of the administrative law judge or legal advisor. This review shall be subject to review and appeal in the 8 CSR 50-2

same manner as provided for other awards in Chapter 287, RSMo.

1. (L) The parties shall notify the division of the date and amount of any settlement of the application for payment of additional reimbursement of medical fees.
2. (M) The division, without a hearing, may reject an application for payment of additional reimbursements of medical fees without prejudice for failure to follow the procedures of this rule.
3. (N) Any settlement or award entered on the application for reimbursement of additional medical fees shall prohibit the health care provider from pursuing any additional fees for work-related medical treatment from the employee.
4. (O) If the health care provider filed an application for payment of additional reimbursement of medical fees prior to the underlying workers’ compensation case is dismissed or settlement is approved by the administrative law judge or legal advisor, or an award entered by the administrative law judge, or within the applicable period of limitations, the division retains jurisdiction to hear the dispute. If the parties file an application for payment of additional reimbursement of medical fees after the underlying workers’ compensation case is dismissed or settlement is approved by the administrative law judge or legal advisor, or an award is entered by the administrative law judge, or the applicable period of limitations has expired, the division does not have jurisdiction to accept the application. The division shall notify the parties regarding its lack of jurisdiction to hear the dispute.

1. (2) Procedures Pertaining to Applications for Direct Payments.

   1. (A) If an employer or insurer fails to make payment for services provided to an employee by a health care provider due to an injury covered under the Missouri Workers’ Compensation Law, and more than ninety (90) days have elapsed since the date of first billing, the health care provider may file an application for direct payment with the division.

   2. (B) The notice of services provided and request for direct payment shall contain the following information:

      1. 1. The name, address and telephone

number of the health care provider and, if different, the address where the service was rendered;

1. 2. Name, address and telephone number

of the employer and insurer against whom the application is being filed; INDUSTRIAL RELATIONS

1. 3. Name, address and Social Security

number of the employee for whom health care services were rendered, together with the date of injury, for all disputes;

1. 4. A brief description of the disputed

services rendered; the date services were provided; the amount of money claimed to be owed; and the name and title of the person from the insurer or employer giving authorization (if known);

1. 5. Any information the division deems

necessary.

1. (C) The health care provider shall serve the employer or insurer through personal service or by certified mail, return receipt requested, a copy of the application on the person or corporation against whom the application has been filed. The health care provider shall file proof of service in accordance with section

1. (4) of this rule with the division.

   1. (D) The application shall be filed on a form prescribed by the division and shall contain the required information. If the application does not include all the information required by paragraph (B)1. of this rule or proof of service is not filed with the division, the application will be returned for the additional information.
   2. (E) The division, without a hearing, may reject an application for direct payment without prejudice if the application does not pertain to a dispute relating to services for a compensable injury or for failure to follow the procedures of this rule.
   3. (F) If there is no report of injury or claim for compensation filed with the division for the injury for which the health care was provided, the application will be returned for lack of jurisdiction of the division.
   4. (G) Upon filing of the application, the division shall cause the application for direct payment to be made part of the underlying workers’ compensation case and shall notify the health care provider of all proceedings relating to the underlying workers’ compensation case. The division shall notify all parties to the case that the application has been made part of the underlying workers’ compensation case. The health care provider shall be granted standing to appear as a party in the underlying workers’ compensation case for the limited purpose of establishing that the health care provider is entitled to payment for services rendered. The health care provider shall have all rights accorded a party under Chapter 287, RSMo, as to this limited issue.
   5. (H) The health care provider is barred from pursuing the employee for any workrelated costs incurred in pursuing the medical fee dispute and any reduction in payment of a medical charge. This rule is not intended to prohibit the provider from pursuing the responsible party for payment of fees for medical treatment that is found by award or settlement not to be work-related.
   6. (I) The division shall lose jurisdiction to hear medical fee disputes relating to direct payments after the underlying workers’ compensation case is dismissed or settlement approved by the administrative law judge or legal advisor or an award is entered by the administrative law judge.
2. (3) In any dispute between a health care provider and a managed care organization regarding medical care services or payment of such services, the decision of the managed care organization is subject to review by the division according to section 287.135.5, RSMo.
3. (4) Except as otherwise provided in this rule, each party filing any document with the division shall mail or deliver to the opposing party a true and accurate copy of the document filed with the division and shall certify or state on the document being filed that such mailing or delivery has occurred.

AUTHORITY: section 287.650, RSMo Supp. 1999.* Emergency rule filed Feb. 3, 1993, effective Feb. 19, 1993, expired June 18, 1993. Emergency rule filed June 29, 1993, effective July 9, 1993, expired Nov. 5, 1993. Emergency rule filed Nov. 16, 1993, effective Nov. 26, 1993, expired March 25, 1994. Emergency rule filed June 28, 1994, effective July 8, 1994, expired Nov. 4, 1994. Emergency rule filed Oct. 20, 1994, effective Nov. 5, 1994, expired March 4, 1995. Emergency rule filed Aug. 18, 1995, effective Aug. 28, 1995, expired Feb. 23, 1996. Original rule filed Aug. 18, 1995, effective Feb. 24, 1996. Rescinded and readopted: Filed Jan. 21, 2000, effective Sept. 30, 2000. *Original authority: 287.650, RSMo 1939, amended 1949, 1961, 1980, 1993, 1995, 1998.