92-01-02-31. Who may be reimbursed.

1. Treatment that falls within the scope and field of the treating allied health care professional's license to practice is reimbursable.

2. Paraprofessionals who are not independently licensed shall practice under the direct supervision of a licensed allied health care professional whose scope of practice and specialty training includes the service provided by the paraprofessional to be reimbursed.

3. Medical service providers may be refused reimbursement to treat cases under the jurisdiction of the organization.

4. An entity operating under the authority of the federal government and granted authority to receive direct reimbursement for payments made for medical treatment determined to be related to the workers' compensation injury may be reimbursed.

5. Reasons for holding a medical service provider ineligible for reimbursement include one or more of the following: a. Failure, neglect, or refusal to submit complete, adequate, and detailed reports. b. Failure, neglect, or refusal to respond to requests by the organization for additional reports. c. Failure, neglect, or refusal to respond to requests by the organization for drug testing.

1. d. Failure, neglect, or refusal to observe and comply with the organization's orders and medical service rules, including cooperation with the organization's managed care vendors.
2. e. Failure to notify the organization immediately and prior to burial in any death if the cause of death is not definitely known or if there is question of whether death resulted from a compensable injury.
3. f. Failure to recognize emotional and social factors impeding recovery of injured employees.
4. g. Unreasonable refusal to comply with the recommendations of board-certified or qualified specialists who have examined the injured employee.
5. h. Submission of false or misleading reports to the organization.
6. i. Collusion with other persons in submission of false or misleading information to the organization.
7. j. Pattern of submission of inaccurate or misleading bills.
8. k. Pattern of submission of false or erroneous diagnosis.
9. l. Billing the difference between the maximum allowable fee set forth in the organization's fee schedule and usual and customary charges, or billing the injured employee any other fee in addition to the fee paid, or to be paid, by the organization for individual treatments, equipment, and products.
10. m. Failure to include physical conditioning in the treatment plan. The medical service provider should determine the injured employee's activity level, ascertain barriers specific to the injured employee, and provide information on the role of physical activity in injury management.
11. n. Failure to include the injured employee's functional abilities in addressing return-to-work options during the recovery phase.
12. o. Treatment that is controversial, experimental, or investigative; which is contraindicated or hazardous; which is unreasonable or inappropriate for the work injury; or which yields unsatisfactory results.
13. p. Certifying disability in excess of the actual medical limitations of the injured employee.
14. q. Conviction in any court of any offense involving moral turpitude, in which case the record of the conviction is conclusive evidence.
15. r. The excessive use, or excessive or inappropriate prescription for use, of narcotic, addictive, habituating, or dependency inducing drugs.
16. s. Declaration of mental incompetence by a court of competent jurisdiction.
17. t. Disciplinary action by a licensing board resulting in suspension or revocation of the allied health care provider's license.

History: Effective January 1, 1994; amended effective October 1, 1998; January 1, 2000; July 1, 2010; July 1, 2017; January 1, 2018; April 1, 2020; January 1, 2026.

General Authority: NDCC 65-02-08, 65-02-20, 65-05-07

Law Implemented: NDCC 65-02-20, 65-05-07