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, services or aids in accordance with section 287.140, RSMo.

1. (1) If an employer or insurer disputes the reasonableness of a medical fee or charge, that employer or insurer shall notify the health care provider in writing that the medical bill 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 by the employer or insurer without prejudice to the filing of an application for payment of additional reimbursements of medical fees. Upon receiving the written notice of 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
2. (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.

3. (2) The application for payment of additional reimbursements of medical fees shall contain the following information:

   1. (A) The name, address and telephone number of the health care provider and, if different, the address where the service was rendered;
   2. (B) Name, address and telephone number of the employer and insurer against whom the claim is being filed;
   3. (C) Name, address and Social Security number of the patient (employee) for whom health care services were rendered, together with the date of injury, for all disputes;
   4. (D) An explanation as to why the health care provider believes the medical fee charged is fair and reasonable, taking into consideration the usual and customary fees charged in the community for similar treatment of other similarly injured persons; and
   5. (E) The relief requested.
4. (3) If the application does not include all the information required by section (2) of the rule, it will be returned for the additional information. If there is no report of injury or claim for compensation filed with the division for the alleged injury for which the health care was provided, the application will be returned for lack of jurisdiction of the division for the injury for which medical treatment was provided.
5. (4) The division, without a hearing, may reject an application for payment of additional reimbursements of medical fees without prejudice if the application does not contain a brief explanation of the dispute relating to the reasonableness of the bill.
6. (5) Upon the filing of an application for payment of additional reimbursements of medical fees, the health care provider shall file with the division an original and two (2) copies of the application, with a self-addressed stamped envelope. The division shall create and assign a medical fee dispute number to a file, and return to the health care provider two (2) file stamped copies. Thereafter, the health care provider shall serve through personal service or by certified mail, return receipt requested, a file stamped copy of the application upon the person or corporation against whom the application has been filed.
7. (6) The parties shall again attempt to resolve their dispute without the assistance of the division.
8. (7) If the parties are unable to resolve their dispute, either party may file a written application for evidentiary hearing of the medical fee dispute. An evidentiary hearing shall be scheduled in front of an administrative law judge or legal advisor. The employer or insurer shall file an answer to the application within twenty (20) days of the date of notice for setting of evidentiary hearing. If the employer or insurer fails to file a timely answer, the health care provider’s allegations are deemed admitted unless good cause is found by the division to extend the filing date of the answer. An application cannot be dismissed without prejudice after an evidentiary hearing has been scheduled without approval of the administrative law judge or legal advisor.
9. (8) Either party may engage in discovery to the extent authorized by Chapter 287, RSMo, upon approval by the administrative law judge or legal advisor.
10. (9) The parties shall notify the division of the date and amount of any settlement of the application for payment of additional reimbursements of medical fees.
11. (10) The division shall notify all parties as to the time and place of any hearing and at the hearing all parties shall be entitled to be heard and to introduce evidence. The administrative law judge or legal advisor shall conduct the hearing and shall issue an award deciding the dispute. The award should be completed within thirty (30) days of submission of the case.
12. (11) Either party may file an application for review with the Labor and Industrial Relations Commission within twenty (20) days from the date of the ruling or order of the administrative law judge or legal advisor. This review shall be subject to review and appeal in the same manner as provided for other awards in Chapter 287, RSMo.
13. (12) 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.
14. (13) Venue for the proceedings established in sections (1)–(12) shall be in Jefferson City, except that proceedings on the application may be held in other locations as determined by the division.
15. (14) If an employer or insurer fails to make payment for authorized 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 date of first billing, the health care provider may file with the division an application for payment and request for direct payment, and 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 a proof of service with the division.

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

    1. (A) Name, address, signature and telephone number of the health care provider and, if different, the address where the service was rendered;
    2. (B) Name, address and telephone number of the employer and insurer against whom the claim is being filed;
    3. (C) Name, address and Social Security number of the patient (employee) for whom health care services were rendered, together with the date of injury and, if known, the Division Injury Number; and
    4. (D) A brief description of the disputed services rendered; the date the services were provided; the amount of money claimed owed; and the name and title of the person giving authorization (if known).
17. (16) If the application does not include all the information required by section (15), it will be returned for the additional information. If there is no report of injury or claim for compensation filed with the division for the alleged injury for which the health care was provided, the application will be returned for lack of jurisdiction of the division for the injury for which medical treatment was provided.
18. (17) The division, without a hearing, may reject an application for payment and request 8 CSR 50-2

for direct payment without prejudice, if the application does not pertain to a dispute relating to authorized services.

1. (18) Upon the filing of the application, the division shall cause the notice 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 services were authorized by the employer or insurer, and 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, and rule 8 CSR 50- 2.010 as to these limited issues.
2. (19) In any dispute between a health care provider and a managed care organization regarding medical care services or payment for such services, the decision of the managed care organization is subject to review by the division according to section 287.135.5, RSMo.

AUTHORITY: section 287.650, RSMo 1994.* 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. *Original authority 1939, amended 1949, 1961, 1980, 1993.