DAR File No. 38036
This rule was published in the October 15, 2013, issue (Vol. 2013, No. 20) of the Utah State Bulletin.
Labor Commission, Industrial Accidents
Workers' Compensation Rules - Medical Care
Notice of Proposed Rule
(Repeal and Reenact)
DAR File No.: 38036
Filed: 09/30/2013 04:41:00 PM
Purpose of the rule or reason for the change:
The Labor Commission's regulations for medical care of injured workers are currently found in two locations: 1) rules set forth in Rule R612-300; and 2) a Medical Fee Schedule, which is incorporated by reference into the rules. Under this system, it has been necessary for those affected by the regulations to search both the rules and the Medical Fee Schedule. The difficulty of having to search in both places is compounded by the fact that the rules and the Medical Fee Schedule are redundant in some places, ambiguous in others, and also contain provisions that have become outmoded as a result of the Commission's adoption of the CPT/RBRVS methodology for calculating medical fees. To address these problems, the proposed rule repeals the existing rules and Medical Fee Schedule, but takes the provisions of those regulations that remain necessary and reenacts them in the new Rule R612-300, which is organized in a more logical manner. This will allow stakeholders to look to a single source--the reenacted Rule R612-300--for the standards regarding medical care of injured workers. It also allows the Commission to eliminate the redundant, ambiguous and archaic provisions that had been present in the old rules and Medical Fee Schedule.
Summary of the rule or change:
The proposed rule repeals the Labor Commission's existing Rule R612-300, governing medical care for injured workers. The proposed rule also eliminates the Commission's Medical Fee Schedule, which had been incorporated by reference into the former Rule R612-300. The proposed rule then combines the substantive provisions of both the old rule and Medical Fee Schedule into the new Rule R612-300. Because the enacted rule is a composite of existing standards found in either the old Rule R612-300 or the Medical Fee Standards, the enacted rule contains few substantive changes to the provisions of the old Rules and Fee Standards. The significant changes are as follows: Section R612-300-1 adds definitions of terms frequently used in the rule, updated CPT and RBRVS. Section R612-300-4 incorporates by reference the newest versions of the Optum CPT codes and the Optum RBRVS, to be used in computing fees for medical services to injured workers. Increased conversion factor for anesthesiology. As recommended by the Commission's Medical Advisory Committee and the Workers' Compensation Advisory Council, Subsection R612-300-4(1) increases the conversion factor for anesthesiology from $41 to $50. Elimination of provisions redundant with CPT/RBRVS methodology. For several years, the Labor Commission has adopted the standardized coding system of the CPT and the relative value system of the RBRVS to serve as the basis for computing medical fees. As this CPT/RBRVS methodology has expanded and matured, it has become unnecessary for the Commission to address particular medical fee and treatment issues. For that reason, some of the detailed discussion of fees for procedures such as radiology, electrophysiologic testing, needle procedures, somatosensory monitoring, restorative services, and anesthesiology have been condensed or eliminated in the proposed rule. Travel Reimbursement. Although the former Section R612-300-20 stated that injured workers' reimbursements for travel to obtain medical care are to be consistent with the State of Utah's travel reimbursement rates, the former rule also specified meal reimbursement rates that are lower than those allowed by the state. At Section R612-300-8, the new rule eliminates the specified meal reimbursement rates. This will allow the reimbursement rates for injured workers to mirror the state reimbursement rates. The immediate effect of this change is to increase the breakfast allowance from $6 to $10; the lunch allowance from $9 to $13; and the dinner allowance from $15 to $16.
State statutory or constitutional authorization for this rule:
- Section 34A-1-104
- Section 34A-2-201
This rule or change incorporates by reference the following material:
- Adds Optum 2013 The Essential RBRVS, published by Optum, 2013 1st Qtr Emr Upd
- Adds Optum 2013 Current Procedural Coding Expert, CPT codes, published by Optum, 2013 edition
- Adds Utah's 2006 Impairment Guides, published by Utah Labor Commission, 2006
Anticipated cost or savings to:
the state budget:
Repeal and reenactment of Rule R612-300 will not impose any additional administrative or enforcement costs on the state budget. Regarding the state's workers' compensation coverage costs, the rule's minor increases to injured worker travel allowances and anesthesiology payment rates are such a small part of overall workers' compensation costs factors as to be negligible. Likewise, the Commission does not anticipate that other nonsubstantive changes incorporated in Rule R612-300 will have any cost impact on the state budget.
Rule R612-300's minor increases to injured worker travel allowances and anesthesiology payment rates are such a minor part of overall workers' compensation cost facts as to be negligible with respect to local government�s workers' compensation expenses. Likewise, the Commission does not anticipate that other nonsubstantive changes incorporated in Rule 612-300 will have any cost impact on local governments.
Rule R612-300's minor increases to injured worker travel allowances and anesthesiology payment rates are such a negligible part of overall workers' compensation cost facts as to be negligible with respect to small business's workers' compensation expenses. Likewise, the Commission does not anticipate that other nonsubstantive changes incorporated in Rule R612-300 will have any cost impact on small business.
persons other than small businesses, businesses, or local governmental entities:
Rule R612-300 will require workers' compensation payors to pay slightly higher travel reimbursements to some injured workers, and also pay higher fees to anesthesiologists treating injured workers. In the context of the payors' overall workers' compensation expenses, the modest increases to these two payment categories will have negligible impact.
Compliance costs for affected persons:
Costs of compliance with the proposed Rule R612-300 are limited to workers' compensation payors, who will be required to pay slightly more for injured worker travel and anesthesiology. In the context of payors' overall workers' compensation expenses, the modest increases to these two minor payment categories are unlikely to appreciably increase payors' costs.
Comments by the department head on the fiscal impact the rule may have on businesses:
All workers' compensation stakeholders, including businesses, will benefit from the streamlining and updating of Rule R612-300. The proposed rule eliminates the need to search between two documents--the rule and the Medical Fee Schedule--to resolve issues arising from the medical care of injured workers. The slight increases to travel allowances and anesthesiology expenses provided by the rule are such small parts of overall workers' compensation costs that it is unlikely they will necessitate any appreciable cost in businesses' workers' compensation costs.
Sherrie Hayashi, Commissioner
The full text of this rule may be inspected, during regular business hours, at the Division of Administrative Rules, or at:Labor Commission
HEBER M WELLS BLDG
160 E 300 S
SALT LAKE CITY, UT 84111-2316
Direct questions regarding this rule to:
- Ron Dressler at the above address, by phone at 801-530-6841, by FAX at 801-530-6804, or by Internet E-mail at firstname.lastname@example.org
Interested persons may present their views on this rule by submitting written comments to the address above no later than 5:00 p.m. on:
This rule may become effective on:
Sherrie Hayashi, Commissioner
R612. Labor Commission, Industrial Accidents.
R612-300. Workers' Compensation Rules - Medical Care.
R612-300-1. Whom May Attend Industrial Patients.
A. The employer has first choice of physicians; but if
the employer fails or refuses to provide medical attention, the
employee has the choice of physicians.
B. An employee of an employer with an approved medical
program may procure the services of any qualified practitioner
for emergency treatment if a physician employed in the program is
not available for any reason.
R612-300-2. Injured Workers' Right to Privacy.
A. No agent of the employer or the employer's
insurance carrier shall be present during an injured worker's
visit with a medical provider, unless agreed upon by the
B. If an agent of the employer or the employer's
insurance carrier is excluded from the medical visit, the medical
provider and the injured worker shall meet with the agent at the
conclusion of the visit so as to communicate regarding medical
care and return to work issues.
R612-300-3. Changes of Doctors and Hospitals.
A. It shall be the responsibility of the insurance
carrier or self-insured employer to notify each claimant of the
change of doctor rules. Those rules are as follows:
1. If a company doctor, designated facility or PPO is
named, the employee must first treat with that designated
provider. The insurance carrier or self-insured employer shall be
responsible for payment for the initial visit, less any health
insurance copays and subject to any health insurance
reimbursement, if the employee was directed to and treated by the
employer's or insurance carrier's designated provider,
and liability for the claim is denied and if the treating
physician provided treatment in good faith and provided the
insurance carrier or self-insured employer a report necessary to
make a determination of liability. Diagnostic studies beyond
plain x-rays would need prior approval unless the claimed
industrial injury or occupational illness required emergency
diagnosis and treatment.
2. The employee may make one change of doctor without
requesting the permission of the carrier, so long as the carrier
is promptly notified of the change by the employee.
(a) Physician referrals for treatment or consultation
shall not be considered a change of doctor.
(b) Changes from emergency room facilities to private
physicians, unless the emergency room is named as the
"company doctor", shall not be considered a change of
doctor. However, once private physician care has begun, emergency
room visits are prohibited except in cases of:
(i) Private physician referral, or
(ii) Threat to life.
3. Regardless of prior changes, a change of doctor shall
be automatically approved if the treating physician fails or
refuses to rate permanent partial impairment.
B. Any changes beyond those listed above made without the
permission of the carrier/self-insurer may be at the
employee's own expense if:
1. The employee has received notification of rules,
2. A denial of request is made.
C. An injured employee who knowingly continues care after
denial of liability by the carrier may be individually
responsible for payment. It shall be the burden of the carrier to
prove that the patient was aware of the denial.
D. It shall be the responsibility of the employee to make
the proper filings with the division when changing locale and
doctor. Those forms can be obtained from the division.
E. Except in special cases where simultaneous attendance
by two or more medical care practitioners has been approved by
the carrier/employer or the division, or specialized services are
being provided the employee by another physician under the
supervision and/or by the direct referral of the treating
physician, the injured employee may be attended by only one
practitioner and fees will not be paid to two practitioners for
similar care during the same period of time.
F. The Director of the Division of Industrial Accidents
may authorize an injured worker to be examined by another
physician for the purpose of obtaining a further medical
examination or evaluation pertaining to the medical issues
involved, and to obtain a report addressing these medical issues
in all cases where:
1. The treating physician has failed or refused to give
an impairment rating, and/or
2. A substantial injustice may occur without such further
G. The Commission has jurisdiction to decide liability
for medical care allegedly related to an industrial
A. Within one week following the initial examination of
an industrial patient, nurse practicioners, physicians and
chiropractors shall file "Form 123 - Physicians' Initial
Report" with the carrier/self-insured employer, employee,
and the division. This form is to be completed in as much detail
as feasible. Special care should be used to make sure that the
employee's account of how the accident occurred is completely
and accurately reported. All questions are to be answered or
marked "N/A" if not applicable in each particular
instance. All addresses must include city, state, and zip code.
If modified employment in #29 is marked "yes," the
remarks in #29 must reflect the particular restrictions or
limitations that apply, whether as to activity or time per day or
both. Estimated time loss must also be given in #29. If
"Findings of Examination" (#17) do not correctly
reflect the coding used in billing, a reduction of payment may be
made to reflect the proper coding. A physician, chiropractor, or
nurse practitioner is to report every initial visit for which a
bill is generated, including first aid, when a worker reports
that an injury or illness is work related. All initial treatment,
beyond first aid, that is provided by any health care provider
other than a physician, chiropractor, or nurse practictioner must
be countersigned by the supervising physician and reported on
Form 123 to the Industrial Accidents Division and the insurance
carrier or self-insured employer.
B.1. Any medical provider billing under the restorative
services section of the Labor Commission's adopted
Resource-Based Relative Value Scale (RBRVS) or the Medical Fee
Guidelines shall file the Restorative Services Authorization
(RSA) form with the insurance carrier or self-insured employer
(payor) and the division within ten days of the initial
2. Upon receipt of the provider's RSA form, the payor
has ten days to respond, either authorizing a specified number of
visits or denying the request. No more than eight visits may be
incurred during the authorization process.
3. After the initial RSA form is filed with the payor and
the division, an updated RSA form must be filed for approval or
denial at least every six visits until a fixed state of recovery
has been achieved as evidenced by either subjective or objective
findings. If the medical provider has filed the RSA form per this
rule, the payor is responsible for payment, unless compensability
is denied by the payor. In the event the payor denies the entire
compensability of a claim, the payor shall so notify the
claimant, provider, and the division, after which the provider
may then bill the claimant.
4. Any denial of payment for treatment must be based on a
written medical opinion or medical information. The denial
notification shall include a copy of the written medical opinion
or information from which the denial was based. The payor is not
liable for payment of treatment after the provider, claimant, and
division have been notified in writing of the denial for
authorization to pay for treatment. The claimant may then become
responsible for payment.
5. Any dispute regarding authorization or denial for
treatment will be determined from the date the division received
the RSA form or notification of denial for payment of
6. The claimant may request a hearing before the Division
of Adjudication to resolve compensability or treatment
7. Subjective objective assessment plan/procedure (SOAP
notes) or progress notes are to be sent to the payor in addition
to the RSA form.
8. Any medical provider billing under the Restorative
Services Section of the RBRVS or the Commission's Medical Fee
Guidelines who fails to submit the required RSA form shall be
limited to payment of up to eight visits for a compensable claim.
The medical provider may not bill the patient or employer for any
C. S.O.A.P. notes or progress reports of each visit are
to be sent to the payor by all medical practitioners
substantiating the care given, the need for further treatment,
the date of the next treatment, the progress of the patient, and
the expected return-to-work date. These reports must be sent with
each bill for the examination and treatment given to receive
payment. S.O.A.P. notes are not to be sent to the division unless
D. "Form 110 - Release to Return to Work" must
be mailed by either the medical practitioner or carrier/employer
to the employee and the division within five calendar days of
E. The carrier/employer may request medical reports in
addition to regular progress reports. A charge may be made for
such additional reports, which charge should accurately reflect
the time and effort expended by the physician.
R612-300-5. Regulation of Medical Practitioner Fees.
Pursuant to Section 34A-2-407(9):
A. The Labor Commission of Utah:
1. Establishes and regulates fees and other charges for
medical provider services as required for the treatment of a
work-related injury or illness.
2. Adopts and by this reference incorporates the Optum
Essential RBRVS, 2012 1st Quarter Emergency Update,
1761/RBRCU/1766R/RBRC12?RBRC/U1766R ("RBRVS"), as the
method for calculating reimbursement and the 2012 American
Medical Association Current Procedural Terminology
a. The non-facility total unit value will apply in
calculating the reimbursement, except that procedures provided in
a facility setting shall be reimbursed at the facility total unit
value and the facility may bill a separate facility
b. The CPT and RBRVS, are subject to the Utah Labor
Commission's Medical Fee Guidelines and the following Labor
Commission conversion factors for medical care rendered for a
work-related injury or illness, effective December 1, 2012:
(Conversion Rates below EFFECTIVE December 1, 2012, to be used
with the RBRVS procedural Unit value as per specialty.)
Anesthesiology $41.00 (1 unit per 15 minutes of
Medicine, E and M $46.00;
Evaluation and Management codes 99201 - 99204 and 99211 -
Pathology and Laboratory $52.00;
Restorative Services $46.00;
All 20000 codes, codes 49505 thru 49525 and all 60000
codes of the CPT-4 coding guidelines $58.00.
3. Adopts and incorporates by this reference the Utah
Labor Commission's 2013 Medical Fee Guidelines, effective
December 1, 2012. The Utah Medical Fee Guidelines can be obtained
from the division for a fee sufficient to recover costs of
development, printing, and mailing or can be downloaded at the
Labor Commission's website.
4. Decides appropriate billing procedure codes when
disputes arise between the medical practitioner and the employer
or its insurance carrier. In no instance will the medical
practitioner bill both the employer and the insurance
B. Employees cannot be billed for treatment of their
work-related injuries or illnesses.
C. Discounting from the fees established by the Labor
Commission is allowed only through specific contracts between a
medical provider and a payor for treatment of work-related injury
D. Restocking fee 15%. Rule R612-2-16 covers the
E. Dental fees are not published. Rule R612-2-18 covers
F. Ambulance fees are not published. Rule R612-2-19
covers ambulance charges.
G. For procedures not covered by other provisions of this
rule, medical providers have three options.
1. Medical providers may request preauthorization for a
procedure from the insurance carrier.
2. Medical providers may present evidence to Medical Fee
Committee for incorporating a procedure into the Commission's
fee schedule. However, such incorporation will have prospective
3. Medical providers may apply for hearing before the
Commission's Adjudication Division pursuant to Subsection
34A-2-801(1)(c) to establish a reasonable fee for the
R612-300-6. Method of Rating.
A. For rating all impairments, which are not expressly
listed in Section 34A-2-412, the Commission incorporates by
reference "Utah's 2006 Impairment Guides" as
published by the Commission for all injuries rated on or after
July 11, 2006. For those conditions not found in "Utah's
2006 Impairment Guides," the American Medical
Association's "Guides to the Evaluation of Permanent
Impairment, Fifth Edition" are to be used.
R612-300-7. Adjusting Resource-Based Relative Value Scale
A. When adjusting any medical provider's bill who has
billed per the Commission's adopted RBRVS the adjusting
entity shall provide one or more of the following explanations as
applies to the down coding when payment is made to the medical
1. Code 99202, 99203, 99204 or 99205 - the submitted
documentation for a new patient did not meet the three key
components lacking in the level of history for the code
2. Code 99202, 99203, 99204 or 99205 - the submitted
documentation for a new patient did not meet the three key
components lacking in the level of examination for the code
3. Code 99202, 99203, 99204 or 99205 - the submitted
documentation for a new patient did not meet the three key
components lacking in the level of medical decision making for
the code billed.
4. Code 99202, 99203, 99204, or 99205 - the submitted
documentation for a new patient did not meet the three key
components lacking in the level of history and exam for the code
5. Code 99213, 99214 or 99215 - the submitted
documentation for an established patient did not meet the two key
components lacking in the level of history and exam that the code
6. Code 99213, 99214 or 99215 - the submitted
documentation for an established patient did not meet the two key
components lacking in the level of history and medical decision
making for the code billed.
7. Code 99213, 99214 or 99215 - the submitted
documentation for the established patient did not meet the two
key components lacking in the level of exam and medical decision
making for the code billed.
B. The above explanations may be abbreviated, with a
legend provided, to accommodate the space of computerized
R612-300-8. Fees in Cases Requiring Unusual Treatment.
The RBRVS scheduled fees are maximum fees except that
fees higher than RBRVS scheduled may be authorized by the
Commission when extraordinary difficulties encountered by the
physician justify increased charges and are documented by written
R612-300-9. Hospital or Surgery Pre-Authorization.
Any ambulatory surgery or impatient hospitalization other
than a life or limb threatening admission, allegedly related to
an industrial injury or occupational disease, shall require
pre-authorization by the employer/insurance carrier. Within two
working days of a telephone request for pre-authorization, the
employer/carrier shall notify the physician and employee of
approval or denial of the surgery or hospitalization, or that a
medical examination or review is going to be obtained. The
medical examination/review must be conducted without undue delay
which in most circumstances would be considered less than thirty
days. If the request for pre-authorization is made in writing,
the employer/carrier shall have four days from receipt of the
request to notify the physician and employee. If the employee
chooses to be hospitalized and/or to have the surgery prior to
such pre-authorization or medical examination/review, the
employee may be personally responsible for the bills incurred and
may not be reimbursed for the time lost unless a determination is
made in his/her favor.
R612-300-10. One Fee Only to be Paid in global Fee
In a global fee case which is transferred from one doctor
to another doctor, one fee only will be paid, apportioned at the
discretion of the Commission. Adequate remuneration shall also be
paid to the medical practitioner who renders first aid treatment
where the circumstances of the case require such
R612-300-11. Surgical Assistants' Fees.
Fees, in accordance with the Commission's adopted
Resource-Based Relative Value Scale (RBRVS), in addition to the
global fee for surgical services, will be paid surgical
assistants only when specifically authorized by the employer or
insurance carrier involved, or in hospitals where interns and
residents are not available and the complexity of the surgery
makes a surgical assistant necessary.
R612-300-12. Separate Bills.
Separate bills must be presented by each surgeon,
assistant, anesthetist, consultant, hospital, special nurse, or
other medical practitioner within 30 days of treatment on a HCFA
1500 billing form so that payment can be made to the medical
practitioner who rendered the service. All bills must contain the
federal ID number of the person submitting the bill.
R612-300-13. Hospital Fees Separate.
Fees covering hospital care shall be separate from those
for professional services and shall not extend beyond the actual
necessary hospital care. When it becomes evident that the patient
needs no further hospital treatment, he/she must be discharged.
All billings must be submitted on a UB92 form and be properly
itemized and coded and shall include all appropriate
documentation to support the billing. There shall not be a
separate fee charged for the necessary documentation in billing
for payment of hospital services. The documentation of hospital
services shall include at a minimum the discharge summary. The
insurance carrier may request further documentation if needed in
order to determine liability for the bill.
R612-300-14. Charges for Ordinary Supplies, Materials, or
Fees covering ordinary dressing materials or drugs used
in treatment shall not be charged separately but shall be
included in the amount allowed for office dressings or
R612-300-15. Charges for Special or Unusual Supplies,
Materials, or Drugs.
A. Charges for special or unusual supplies, materials, or
drugs not included as a normal and usual part of the service or
procedure shall, upon receipt of an itemized and coded billing,
be paid at cost plus 15% restocking fees.
B. For purposes of part A above, the amount to be paid
shall be calculated as follows:
1. Applicable shipping charges shall be added to the
purchase price of the product;
2. The 15% restocking fee shall then be added to the
amount determined in sub part 1;
3. The amount of taxes paid on the purchase of the
supplies, materials, or drugs shall then be added to the amount
determined in sub part 2, which sum shall constitute the total
amount to be paid.
R612-300-16. Fees for Unscheduled Procedures.
Fees for medical or surgical procedures not appearing in
the Commission's adopted RBRVS current fee schedule are
subject to the Commission's approval and should be submitted
to the Commission when the physician and employer or insurance
carrier do not agree on the value of the service. Such fees shall
be in proportion as nearly as practicable to fees for similar
services appearing in the RBRVS.
R612-300-17. Ambulance Charges.
Ambulance charges must not exceed the rates adopted by
the State Emergency Medical Service Commission for similar
R612-300-18. Dental Injuries.
A. This rule establishes procedures to obtain dental care
for work-related dental injuries and sets fees for such dental
B. Initial Treatment.
1. If an employer maintains a medical staff or designates
a company doctor, an injured worker seeking dental treatment for
work-related injuries shall report to such medical staff or
doctor and follow their instructions.
2. If an employer does not maintain a medical staff or
designate a company doctor, or if such staff or doctor are not
available, an injured worker may consult a dentist to obtain
immediate care dental for injuries caused by a work-related
accident. The insurer shall pay the dentist providing this
initial treatment at 70% of UCR for the services
C. Subsequent care by initial treatment
1. If additional treatment is necessary, the dentist who
provided initial treatment may submit to the insurer a request
for authorization to continue treatment. The transmission date of
the request must be verifiable. The request itself must include a
description of the injury, the additional treatment required, and
the cost of the additional treatment. If the dentist proceeds
with treatment without authorization, the dentist must accept 70%
of UCR as payment in full and may not charge any additional sum
to the injured worker.
2. The insurer shall respond to the request for
authorization within 10 working days of the request's
transmission. This 10-day period can be extended only with
written approval of the Industrial Accidents Division. If the
insurer does not respond to the dentist's request for
authorization within 10 working days, the insurer shall pay the
cost of treatment as contained in the request for
3. If the insurer approves the proposed treatment, the
insurer shall send written authorization to the dentist and
injured worker. This authorization shall include the anticipated
4. On receipt of the insurer's written authorization,
and if the dentist accepts the payment provisions therein, the
dentist may proceed to provide the approved services. The dentist
must accept the amount to be paid by the insurer as full payment
for those services and may not bill the injured worker for any
D. Subsequent care by other providers.
1. If the dentist who provided initial treatment does not
agree to the payment offered by the insurer, the insurer shall
within 20 calendar days direct the injured worker to a dentist
located within a reasonable travel distance who will accept the
insurer's payment offer.
2. If the insurer cannot locate another dentist to
provide the necessary services, the insurer shall attempt to
negotiate a satisfactory reimbursement with the dentist who
provided initial treatment. The negotiated reimbursement may not
include any balance billing to the claimant.
3. If the insurer is successful in arranging treatment
with another dentist, the insurer shall notify the injured
4. If, after having received notice that the insurer has
arranged the services of another dentist, the injured worker
chooses to obtain treatment from a different dentist, the insurer
shall only be responsible for payment at 70% of UCR. Under the
circumstances of this subsection (4), the treating dentist may
bill the injured worker for the difference between the
dentist's charges and the amount paid by the
E. Payment or treatment disputes that cannot be resolved
by the parties may be submitted to the Labor Commission's
Adjudication Division for decision, pursuant to the Adjudication
Division's established forms and procedures.
R612-300-19. HIV, Hepatitis B and C Testing and Reporting
for Emergency Medical Service Providers.
A. Authority - The HIV, Hepatitis B and C Testing and
Reporting for Emergency Medical Services Providers rule is
established under the authority of U.C.A. Section
B. Purpose - To establish procedures pursuant to U.C.A.
Section 78B-8-401 for source patient testing and reporting
following a significant exposure of an emergency medical services
1. Department means the Utah Labor Commission.
2. Contact means designated person(s) within the
emergency medical services agency or the employer of the
emergency medical services provider.
3. Disease means Human Immunodeficiency Virus, acute or
chronic Hepatitis B or Hepatitis C infections.
4. Emergency medical services provider means Emergency
Medical personnel as defined in Section 26-8a-102, a public
safety officer, local fire department personnel, or personnel
employed by the Department of Corrections or by a county jail,
who provide prehospital Emergency medical care for an emergency
medical services agency either as an employee or a
5. Emergency medical services (EMS) agency means an
agency, entity, or organization that employs or utilizes
emergency medical services providers as defined in (4) as
employees or volunteers.
6. Source Patient means any individual cared for by a
prehospital emergency medical services provider, including but
not limited to victims of accidents or injury, deceased persons,
and prisoners or persons in the custody of the Department of
7. Receiving facility means a hospital, health care or
other facility where the patient is delivered by the emergency
medical services provider for care.
8. "Significant Exposure" and
"Significantly Exposed" mean:
a. exposure of the body of one person to the blood or
body fluids visibly contaminated by blood of another person
1. percutaneous injury, including a needle stick or cut
with a sharp object or instrument; or
2. contact with an open wound, mucous membrane, or
nonintact skin because of a cut, abrasion, dermatitis, or other
b. exposure that occurs by any other method of
transmission defined by the Department of Health as a significant
D. Emergency Medical Services Provider
1. The EMS provider shall document and report all
significant exposures to the receiving facility and contact as
defined in (C) (2).
2. The reporting process is as follows:
a. The exposed EMS provider shall complete the Exposure
Report Form (ERF) at the time the patient is delivered to the
receiving facility and provide a copy to the person at the
receiving facility authorized by the facility to receive the
form. In the event the exposed EMS provider does not accompany
the source patient to the receiving facility, he/she may report
the exposure incident, with information requested on the ERF, by
telephone to a person authorized by the facility to receive the
form. In this event, the exposed EMS provider shall nevertheless
submit a written copy of the ERF within three days to an
authorized person of the receiving facility.
b. The exposed EMS provider shall, within three days of
the incident, submit a copy of the ERF to the contact as defined
in (C) (2).
E. Receiving Facility Responsibility:
1. The receiving facility shall establish a system to
receive ERFs as well as telephoned reports from exposed EMS
providers on a 24-hour per day basis. The facility shall also
have available or on call, trained pre-test counselors for the
purpose of obtaining consent and counseling of source patients
when HIV testing has been requested by EMS providers. The
receiving facility shall contact the source patient prior to
release from the facility to provide the individual with
counseling or, if unable to provide counseling, provide the
source patient with phone numbers for a trained counselor to
provide the counseling within 24 hours.
2. Upon notification of exposure, the receiving facility
shall request permission from the source patient to draw a blood
sample for disease testing, as defined in (C) (3). In conjunction
with this request, the source patient must be advised of his/her
right to refuse testing and be advised that if he/she refuses to
be tested that fact will be forwarded to the EMS agency or
employer of EMS provider. The source patient shall also be
advised that if he/she refuses to be tested, the EMS agency or
provider may seek a court order to compel the source patient to
submit to a blood draw for the disease testing.
Testing is authorized only when the source patient,
his/her next of kin or legal guardian consents to testing, with
the exception that consent is not required from an individual who
has been convicted of a crime and is in the custody or under the
jurisdiction of the Department of Corrections, or if the source
patient is dead. If consent is denied, the receiving facility
shall complete the ERF and send it to the EMS agency or employer
of the EMS provider. If consent is received, the receiving
facility shall draw a sample of the source patient's blood
and send it, along with the ERF, to a qualified laboratory for
3. The laboratory that the receiving facility has sent
source patient's blood draw to shall send the disease test
results, by Case ID number, to the EMS agency or employer of the
F. EMS Agency/Employer Responsibility:
1. The EMS agency/employer, upon receipt of the disease
tests, from the receiving facility laboratory, shall immediately
report the result, by case number, not name, to the exposed EMS
2. The EMS agency/employer, upon the receipt of refusal
of testing by the source, shall report that refusal to the EMS
3. The agency/employer or its insurance carrier shall pay
for the EMS provider and the source patient testing for the
covered diseases per the Labor Commission fee schedule.
4. The EMS agency/employer shall maintain the records of
any disease exposures contained in this rule per the OSHA Blood
Borne Pathogen standards.
R612-300-20. Travel Allowance and Per Diem.
A. An employee who, based upon his/her physician's
advice, requires hospital, medical, surgical, or consultant
services for injuries arising out of and in the course of
employment and who is authorized by the self-insurer, the
carrier, or the Commission to obtain such services from a
physician and/or hospital shall be entitled to:
1. Subsistence expenses of $6 per day for breakfast, $9
per day for lunch, $15 per day for dinner, and actual lodging
expenses as per the state of Utah's in-state travel policy
(a) The employee travels to a community other than
his/her own place of residence and the distance from said
community and the employee's home prohibits return by 10:00
(b) The absence from home is necessary at the normal hour
for the meal billed.
2. Reasonable travel expenses regardless of distance that
are consistent with the state of Utah's travel reimbursement
rates, or actual reasonable costs of practical transportation
modes above the state's travel reimbursement rates as may be
required due to the nature of the disability.
B. This rule applies to all travel to and from medical
care with the following restrictions:
1. The carrier is not required to reimburse the injured
employee more often than every three months, unless:
(a) More than $100 is involved, or
(b) The case is about to be closed.
2. All travel must be by the most direct route and to the
nearest location where adequate treatment is reasonably
3. Travel may not be required between the hours of 10:00
p.m. and 6:00 a.m., unless approved by the Commission.
4. Requests for travel reimbursement must be submitted to
the carrier for payment within one year of the authorized medical
5. Travel allowance shall not include picking up
prescriptions unless documentation is provided substantiating a
claim that prescriptions cannot be obtained locally within the
injured worker's community.
6. The Commission has jurisdiction to resolve all
R612-300-21. Interest for Medical Services.
A. All hospital and medical bills must be paid promptly
on an accepted liability claim. All bills which have been
submitted properly on an accepted liability claim are due and
payable within 45 days of being billed unless the bill or a
portion of the bill is in dispute. Any portion of the bill not in
dispute is payable within 45 days of the billing.
B. Per Section 34A-2-420, any award for medical treatment
made by the Commission shall include interest at 8% per annum
from the date of billing for the medical service.
R612-300-22. Medical Records.
A. Workers' compensation insurers, employers and the
Utah Labor Commission need access to health information of
individuals who are injured on the job or who have a work-related
illness in order to process or adjudicate claims, or to
coordinate care under Utah's workers' compensation
system. Generally, this health information is obtained from
health care providers who treat these individuals and who may be
covered by federal "HIPAA" privacy rules.
The HIPAA Privacy Rule specifically recognizes the
legitimate need of the workers' compensation system to have
access to individuals' health information to the extend
authorized by State law. See 45 CFR 164.512(1). The Privacy Rule
also recognizes the importance of permitting disclosures required
by other laws. See 45 CFR 164.512(a). Therefore, disclosures
permitted by this rule for workers' compensation purposes or
otherwise required by this rule do not conflict with and are not
prohibited by the HIPAA Privacy Rule.
B. A medical provider, without authorization from the
injured workers, shall:
1. For purposes of substantiating a bill submitted for
payment or filing required Labor Commission forms, such as the
"Physician's Initial Report of Injury/Illness" or
the "Restorative Services Authorization," disclose
medical records necessary to substantiate the billing, including
drug and alcohol testing, to:
a. An employer's workers' compensation insurance
carrier or third party administrator;
b. A self-insured employer who administers its own
workers' compensation claims;
c. The Uninsured Employers' Fund;
d. The Employers' Reinsurance Fund; or
e. The Labor Commission as required by Labor Commission
2. Disclose medical records pertaining to treatment of an
injured worker, who makes a claim for workers' compensation
benefits, to another physician for specialized treatment, to a
new treating physician chosen by the claimant, or for a
consultation regarding the claimed work related injury or
C.1. Except as limited in C(3), a medical provider, whose
medical records are relevant to a workers' compensation claim
shall, upon receipt of a Labor Commission medical records release
form, or an authorization form that conforms to HIPAA
requirements, disclose his/her medical records to:
a. An employer's insurance carrier or third party
b. A self-insured employer who administers its own
workers' compensation claims;
c. An agent of an entity listed in B(1)(a through e),
which includes, but is not limited to a case manager or reviewing
d. The Uninsured Employers Fund;
e. The Employers' Reinsurance Fund;
f. The Labor Commission;
g. The injured worker;
h. An injured workers' personal
i. An attorney representing any of the entities listed
above in an industrial injury or occupational disease
2. Medical records are relevant to a workers'
compensation claim if:
a. The records were created after the reported date of
the accident or onset of the illness for which workers'
compensation benefits have been claimed; or
b. The records were created in the past ten years (15
years if permanent total disability is claimed) and;
i. There is a specific reason to suspect that the medical
condition existed prior to the reported date of the claimed work
related injury or illness or
ii. The claim is being adjudicated by the Labor
3. Medical records related to care provided by a
psychiatrist, psychologist, obstetrician, or care related to the
reproductive organs may not be disclosed by a medical provider
unless a claim has been made for a mental condition, a condition
related to the reproductive organs, or the claimant has signed a
separate, specific release for these records.
D. A medical provider, who has treated an injured worker
for a work related injury or illness, shall disclose information
to an injured workers' employer as to when and what
restrictions an injured worker may return to work.
E. Requests for medical records beyond what sections B,
C, and D permit require a signed approval by the director, the
medical director, a designated person(s) within the Industrial
Accidents Division or an administrative law judge if the claim is
F. A party affected by the decision made by a person in
section E may appeal that decision to the Adjudication Division
of the Labor Commission.
G. Upon receipt and within the scope of this rule, an
injured worker shall provide those entities or person listed in
C(1) the names, address, and dates of medical treatment (if
known) of the medical providers who have provided medical care
within the past 10 years (15 years for permanent total disability
claim) except for those medical providers names in C(3). Labor
Commission form number 307 "Medical Treatment Provider
List" must be used for this purpose. Parties listed in C(1)
of this rule must provide each medical provider identified on
form 307 with a signed authorization for access to medical
records. A copy of the signed authorization may be sent to the
medical providers listed on form 307.
H. An injured worker may contest, for good reason, a
request for medical records created prior to the reported date of
the accident or illness for which the injured worker has made a
claim for benefits by filing a complaint with the Labor
Commission. Good reason is defined as the request has gone beyond
the scope of this rule or sensitive medical information is
contained in a particular medical record.
I.1. Any party obtaining medical records under authority
of this rule may not disclose those medical records, without a
valid authorization, except as required by law.
2. An employer may only use medical records obtained
under the authority of this rule to:
a. Pay or adjudicate workers' compensation claims if
the employer is self-insured;
b. To assess and facilitate an injured workers'
return to work;
c. As otherwise authorized by the injured
3. An employer obtaining medical records under authority
of this rule must maintain the medical records separately from
the employee's personnel file.
J. Any medical records obtained under the authority of
this rule to make a determination regarding the acceptance of
liability or for treatment of a condition related to a
workers' compensation claim shall only be used for
workers' compensation purposes and shall not be released,
without a signed release by the injured worker or his/her
personal representative, to any other party. An employer shall
make decisions related only to the workers' compensation
claim based on any medical information received under this
K. When any medical provider provides copies of medical
records, other than the records required when submitting a bill
for payment or as required by the Labor commission rules, the
following charges are presumed reasonable:
1. A search fee of $15 payable in advance of the
2. Copies at $.50 per page, including copies of
microfilm, payable after the records have been prepared
3. Actual costs of postage payable after the records have
been prepared an sent. Actual cost of postage are deemed to be
the cost of regular mail unless the requesting party has
requested the delivery of the records by special mail or
4. The Labor Commission will release its records per the
above charges to parties/entities with a signed and notarized
release from the injured worker unless the information is
classified and controlled under the Government Records Access and
Management Act (GRAMA).
L. No fee shall be charged when the RBRVS or the
Commission's Medical Fee Guidelines require specific
documentation for a procedure or when medical providers are
required to report by statute or rule.
M. An injured worker or his/her personal representative
may obtain one copy of each of the following records related to
the industrial injury or occupational disease claim, at no cost,
when the injured worker or his/her personal representative have
signed a form by the Industrial Accidents Division to
substantiate his/her industrial injury/illness claim;
1. History and physical;
2. Operative reports of surgery;
3. Hospital discharge summary;
4. Emergency room records;
5. Radiological reports;
6. Specialized test results; and
7. Physician SOAP notes, progress notes, or specialized
(a) Alternatively, a summary of the patients records may
be made available to the injured worker or his/her personal
representative at the discretion of the physician.
R612-300-23. Insurance Carrier's Privilege to
The employer or the employer's insurance carrier or a
self-insured employer shall have the privilege of medical
examination of an injured employee at any reasonable time. A copy
of the medical examination report shall be made available to the
Commission at any time upon request of the Commission.
R612-300-24. Notice to Health Care Providers.
Any notice from a carrier denying further liability must
be mailed to the Commission and the patient on the same day as it
is mailed to the health care provider. Where it can be shown, in
fact, that a medical care provider and the injured employee have
received a denial of further care by the insurance carrier or
self-insured employer, further treatment may be performed at the
expense of the employee. Any future ratification of the denial by
the Commission will not be considered a retroactive denial but
will serve to uphold the force and effect of the previous denial
R612-300-25. Review of Medical Payments.
A. Health care providers and payors are primarily
responsible to resolve disputes over fees for medical services
between themselves. However, in some cases it is necessary to
submit such disputes to the Division for resolution. The
Commission therefore establishes the following procedure for
submission and review of fees for medical services.
1. The provider shall submit a bill for services
rendered, with supporting documentation, to the payor within one
year of the date of service;
2. The payor shall evaluate the bill according to the
guidelines contained in the Commission's Medical Fee
Guidelines and RBRVS and shall pay the provider the appropriate
fee within 45 days as required by Rule R612-2-13.
3. If the provider believes that the payor has improperly
computed the fee under the RBRVS, the provider or designee shall
request the payor to re-evaluate the fee. The provider's
request for re-evaluation shall be in writing, shall describe the
specific areas of disagreement and shall include all appropriate
documentation. The provider shall submit all requests for
re-evaluation to the payor within one year of the date of the
4. Within 30 days of receipt of the written request for
re-evaluation, the payor shall either pay the additional fee due
the provider or respond with a specific written explanation of
the basis for its denial of additional fees. The payor shall
maintain proof of transmittal of its response.
B. If the provider continues to disagree with the
payor's determination of the appropriate fee, the provider
shall submit the matter to the Division by filing with the
Division a written explanation of the disagreement. The
provider's explanation shall include copies of:
1. The provider's original bill and supporting
2. The payor's initial payment of that bill;
3. The provider's request for re-evaluation and
supporting documentation; and
4. The payor's written explanation or its denial of
C. The Division will evaluate the dispute according to
the requirements of the Medical Fee Guidelines and RBRVS and, if
necessary, by consulting with the provider, payor, or medical
specialists. Within 45 days from the date the Division receives
the provider's request, the Division will mail its
determination to both parties.
D. Any party aggrieved by the Division's
determination may file an application for hearing with the
Division of Adjudication to obtain formal adjudication of the
E. A payor seeking reimbursement from a provider for
overpayment of a bill shall submit a written request to the
provider detailing the circumstances of the payment requested
within one year of submission of the bill.
1. Providers should make appropriate reimbursements, or
respond in writing detailing the reasons why repayment will not
be made, within 90 days or receipt of a written request from a
2. If a dispute as to reimbursement occurs, an aggrieved
party may request resolution of the dispute by the Labor
R612-300-26. Utilization Review Standards.
A. As used in this subsection:
1. "Payor" means a workers' compensation
insurance carrier, a self-insured employer, third-party
administrator, uninsured employer or the Uninsured Employers'
Fund, which is responsible for payment of the workers'
2. "Health Care Provider" means a provider of
medical services, including an individual provider, a
health-service plan, a health-care organization, or a
3. "Request for Authorization" means any
request by a physician for assurance that appropriate payment
will be made for a course of proposed medical treatment,
including surgery or hospitalization, or any diagnostic studies
beyond plain X-rays.
4. "Utilization Review," as authorized in
Section 34A-2-111, is a process used to manage medical costs,
improve patient care, and enhance decision-making. Utilization
review includes, but is not limited to, the review of requests
for authorization to treat, and the review of bills, for the
purpose of determining whether the medical services provided were
or would be necessary, to treat the effects of the
injury/illness. Utilization review does not include bill review
for the purpose of determining whether the medical services
rendered were accurately billed. Nor does it include any system,
program, or activity in connection with making decisions
concerning whether a person has sustained an injury or illness
which is compensable under Section 34A-2 or 34A-3.
5. "Reasonable Attempt" is defined as at least
two phone calls and a fax, or three phone calls, within five
business days from date of the payor's receipt of the
physician's request for review.
B. Any utilization review system shall establish an
appeals process which utilizes a physician(s) for a final
decision by the insurer, should an initial review decision be
contested. The payor may establish levels of review that meet the
1. Level I--Initial Request and Review. A payor may use
medical or non-medical personnel to initially apply
medically-based criteria to a request for authorization for
payment of a specific treatment. The treating physician must send
all the necessary documentation for the payor to make a decision
regarding the treatment recommended. The payor must then notify
the physician within five business days of the request for
authorization of payment for the treatment, by a method which
provides certification of transmission of the document, of either
an acceptance or a denial of the request. A denial for
authorization of payment for a recommended treatment utilizing
the Commission's form, Form 223, must be sent to the provider
with the criteria used in making the determination to deny
payment for the treatment. A copy of the denial must also be
mailed to the claimant. Level I--Request and Review does not
include authorization requests for services billed from the
Restorative section of the Resource-Based Relative Value Scale
(RBRVS). Requests for authorization for restorative services are
governed by rule R612-2-3(B).
2. Level II--Review. A physician, who has been denied
authorization of payment for treatment, or has received no
response within five business days from the request for
authorization for payment at Level I review, may request a
physician's review by sending the completed portion of the
Commission form 223 to the payor. Such a request for review may
be filed by any physician who has been denied authorization for
payment for restorative services beyond the initial eight visits
as authorized by Rule R612-2-3(B). The requesting physician must
include the times and days that he/she is available to discuss
the case with the reviewing physician, and must be reasonably
available during normal business hours. The payor's physician
representative must complete the review within five business days
of the treating physician's request for review. Before the
insurer's physician representative may issue a denial of an
authorization for payment to treat, a reasonable effort must have
made to contact the requesting treating physician to discuss the
differing aspects of the case. Failure by the payor to respond
within five business days, by a method which provides
certification of transmission, to a denial for authorization for
payment for treatment, shall constitute an authorization for
payment of the treatment. The payor's denial to pay for the
recommended treatment must be issued on Commission's form
223, and the denial must be accompanied by the criteria that was
used in making the decision to deny authorization, along with the
name and speciality of the reviewing physician. The denial to
authorize payment for treatment must then be sent to the
physician, the claimant, and the Commission. The payor shall
notify the Commission if an additional five days is needed in
order to contact the treating physician or to review the case. An
additional extension of time may be requested from the Commission
to accommodate highly unusual circumstances or particularly
C. Upon receipt of denial of authorization for payment
for medical treatment at Level II, the Commission will
facilitate, upon the request of the claimant, the final
disposition of the case. If the parties agree, the medical
dispute may be resolved by the Commission through binding
mediation or medical review. If there is not agreement among the
parties, the Commission will resolve the dispute through formal
adjudication. The payor shall be responsible for sending the
claimant the Commission appeals information when the denial for
authorization for payment for medical treatment is sent to the
D. If the medical treatment requested is not an
emergency, and treatment is rendered by the physician after,
receiving notice of the utilization standards encompassed in this
rule, the following shall apply:
1. The Commission shall, if the disputed medical
treatment is ultimately determined to be compensable as an
expense necessary to treat the industrial injury or occupational
disease, order that the physician be reimbursed at only 75% of
the of the amount otherwise payable had appropriate authorization
been timely obtained. The injured worker shall not be liable for
any additional payment to the physician above the 75%.
2. Neither the worker's employer or its workers'
compensation insurer shall be liable for any portion of the cost
of disputed medical treatment, if that treatment is ultimately
determined not to be compensable as an expense necessary to treat
an industrial injury or occupational disease.
3. A worker may become liable for the cost of the
disputed medical treatment, if that treatment is ultimately
determined not to be compensable as an expense necessary to treat
the industrial injury or occupational disease.
4. Except for any co-pays or deductibles under the
worker's health insurance plan, the penalty provision in D(1)
and D(3) shall not apply if the physician performs the medical
treatment in question, having been preauthorized in writing to do
the same by a health insurer or other non-worker's
compensation insurance payor.
5. The penalty provisions in D(1) shall not apply to
medical treatment rendered in emergency situations, which are
defined as a threat to life or limb.
6. The Commission shall notify a physician, in writing,
of reported violations of this rule. Repeated violations of this
rule by a physician may result in a report from the Commission to
the Department of Commerce, Division of Occupational/Professional
R612-300-27. Commission Approval of Health Care Treatment
A. Authority. Pursuant to authority granted by Section
34A-2-111(2)(c)(i)(B)(VII) of the Utah Workers' Compensation
Act, the Utah Labor Commission establishes the following
standards and procedures for Commission approval of medical
treatment and quality care guidelines.
1. Scientifically based: Section
34A-2-111(2)(c)(i)(B)(VII)(Aa) of the Act requires that
guidelines be scientifically based. The Commission will consider
a guideline to be "scientifically based" when it is
supported by medical studies and/or research.
2. Peer reviewed: Section 34A-2-111(2)(c)(i)(B)(VII)(Bb)
of the Act requires that guidelines be peer reviewed. The
Commission will consider a guideline to be "peer
reviewed" when the medical study's content, methodology,
and results have been reviewed and approved prior to publication
by an editorial board of qualified experts".
3. Other standards: Pursuant to its rulemaking authority
under Section 34A-2-111(2)(c)(i)(B)(VII), the Utah Labor
Commission establishes the following additional standards for
medical treatment and quality care guidelines.
a. The guidelines must be periodically updated and,
subject to Commission discretion, may not be approved for use
unless updated in whole or in part at least biannually;
b. Guideline sources must be identified;
c. The guidelines must be reasonably priced;
d. The guidelines must be easily accessible in print and
C. Procedure: Pursuant to Section
34A-2-111(2)(c)(i)(B)(VII) of the Utah Workers' Compensation
Act, a party seeking Commission action to approve or disapprove a
guideline shall file a petition for such action with the Labor
KEY: workers' compensation, fees, medical practitioners
Date of Enactment or Last Substantive Amendment: [
February 25, ]2013
Authorizing, and Implemented or Interpreted Law: 34A-1-104; 34A-2-201
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For questions regarding the content or application of this rule, please contact Ron Dressler at the above address, by phone at 801-530-6841, by FAX at 801-530-6804, or by Internet E-mail at email@example.com.