Compliance Corner
A central question that comes up throughout the life of a workers’ compensation claim is often “How are they getting paid?” Thanks to Simply Research, we highlight what holds true in Arizona.
Acceptance or Denial Determinations
An insurance carrier, self-insured employer or claims processing representative shall make a determination whether to deny or pay a medical bill on an accepted claim, in whole or in part, including the decision as to the amount to pay, within 30 days from the date the claim is accepted, if the billing is received before the date of acceptance, or within 30 days from the date of receipt of the billing if the billing is received after the date of acceptance.
All billing denials shall be based on reasonable justification. The insurance carrier, self-insured employer or claims processing representative shall pay the approved portion of the billing within thirty days after the determination for payment is made. If the billing is not paid within the applicable time period, the insurance carrier, self-insured employer, or claims processing representative shall pay interest to the health provider on the billing at a rate that is equal to the legal rate. Interest shall be calculated beginning on the date that the payment to the health care provider is due.
Billing Requirements
Any billing by a health care provider shall include all of the following:
(1) The correct demographic patient information and claim number, if known.
(2) The correct health care provider information, including name, address, telephone number, and federal taxpayer identification number.
(3) The appropriate medical coding with dollar amounts and units clearly stated with all descriptions.
(4) Clearly printed date or dates of service.
(5) Legible medical reports required for each date of service if the billing is for direct treatment of the injured worker.
Limitations Period
An insurance carrier, self-insured employer or claims processing representative is not responsible for payment of any billings for medical, surgical or hospital benefits provided unless the billings are received by the insurance carrier, self-insured employer, or claims processing representative and any court action for the payment of the billings is commenced within twenty-four months from the date on which the medical service was rendered or from the date on which the health care provider knew or should have known that service was rendered on an industrial claim, whichever occurs later. A subsequent billing or corrective billing does not restart the limitations period.
Do Workers have to Pay?
An injured worker is not responsible for payment of any portion of a medical bill for services rendered on an accepted claim and is not responsible for payment of any disputed amount between a health care provider and the insurance carrier, self-insured employer, or claims processing representative.
Workers’ Comp 101: Medical, Surgical, Hospital, and Burial Expenses in Arizona
A. A carrier, self-insured employer, or special fund division, shall pay bills for medical, surgical, and hospital benefits according to applicable medical and surgical fee schedules adopted by the Commission and in effect at the time the services are rendered. A physician or provider of nursing, hospital, drug or other medical services shall itemize and submit a bill for payment only to the responsible carrier, self-insured employer, or special fund division.
B. Medical treatment or services shall not be delayed or cancelled due to payment requirements or billing disputes with any carrier, self insured employer, or special fund division on any accepted workers’ compensation claim.
C. A medical provider, their agent or debt collector shall not seek payment from any claimant for any disputed or unpaid amounts that are the responsibility of the carrier, self-insured employer, or special fund division.
D. If a claimant pays a bill, the responsible carrier, self-insured employer, or special fund division shall reimburse the claimant the amount allowed by the fee schedules, provided that the claimant presents receipted vouchers or other proof of payment to support the claim for reimbursement.
E. If an insured employer pays a bill, the responsible carrier or self-insured employer shall reimburse the employer the amount allowed by the fee schedules, provided that the employer presents receipted vouchers or other proof of payment to support the claim for reimbursement.
F. A carrier, self-insured employer, or special fund division may pay any authorized burial expenses directly to the funeral service professional.
G. If an employee’s dependent pays burial expenses, the responsible carrier, self-insured employer, or special fund division shall reimburse the dependent provided that the dependent presents proof of payment to support the claim for reimbursement.
H. If an insured employer pays burial expenses, the responsible carrier or self-insured employer shall reimburse the employer provided that the employer presents proof of payment to support the claim for reimbursement.
Resolving Disputes
An insurance carrier, self-insured employer or claims processing representative may establish an internal system for resolving payment disputes and other contractual grievances with health care providers.
Contractual Arrangements
These rules does not apply to health care providers that enter into an express written contract with the insurance carrier, the self-insured employer or a claims processing representative that specifies the period in which approved bills shall be paid and that includes contractual remedies for untimely bill payment. If the contract does not include remedies for untimely payment, payment must be made according to the provisions of the contract but the interest penalty shall apply to any late payment. The commission does not have jurisdiction over disputes involving timely payment of billings under contracts between the insurance carrier, self-insured employer or claims processing representative and the health care provider.
Glossary Check
(1) “Accepted claim” means a claim for benefits that has been accepted by a final notice of claim status or final order or award of the commission.
(2) “Date of receipt” means the electronic acknowledgment date or, if a bill does not contain an electronic acknowledgment date, the date of receipt is presumed to occur five days after the bill was mailed to the recipient’s address.
