BARE NECESSITIES

Maine Workers’ Compensation Board Rules

STATUTORY REFERENCES• Title 39-A § 206

–Duties and rights of parties as to medical and other services; cost

• Title 39-A § 208–Medical Information

• Title 39-A § 209-A–Medical Fee Schedule

BOARD RULES CHAPTER 5• Outlines billing procedures and

reimbursement levels for health care providers who treat injured employees.

• Describes the dispute resolution process when there is a dispute regarding reimbursement and/or appropriateness of care.

• Sets standards for health care reporting.

AUTHORIZATION• Nothing in the Act or rules requires the

authorization of medical, surgical and hospital services, nursing, medicines, and mechanical, surgical aids provided pursuant to 39-A M.R.S.A. § 206. – The goal is to get the injured worker

treated and back to work as quickly as possible.

AUTHORIZATION• An employer/insurer is not permitted to

require pre-authorization of medical, surgical and hospital services, nursing, medicines, and mechanical, surgical aids provided pursuant to 39-A M.R.S.A. § 206 as a condition of payment unless you sign an agreement that requires such.– An employee retains the right to select

his/her health care providers regardless of any payment agreement.

DUTIES OF HEALTH CARE PROVIDERS• Health care providers must complete

diagnostic medical reports in accordance with Title 39-A M.R.S.A. § 208.– The employer/insurer may withhold the

payment of fees. No NOC is required.– The Board may assess penalties up

to $100 per violation.

M-1 FORM• The M-1 Form is the diagnostic

medical report prescribed by the Board.

• Failure to use the prescribed form:– The provider may not charge for completing

an initial diagnostic medical report.– The Board may assess penalties up

to $100 per violation.

M-1 FORM• Except for claims for medical benefits only, the

M-1 Form is required within 5 business days from the completion of a medical examination or within 5 business days from the date notice of injury is given to the employer, whichever is later.– Applies to all health care providers.– The Board may assess penalties up to

$500 per violation on health care providers who fail to comply with the 5 day requirement.

M-1 FORM• If ongoing medical treatment is

being provided, the M-1 Form is required every 30 days.–Applies to all health care providers

treating the employee.–The Board may assess penalties

up to $100 per violation.

M-1 FORM• A final M-1 Form is required within 5 working

days of the termination of treatment, except that only an initial report must be submitted if the provider treated the employee on a single occasion.– Applies to all health care providers

treating the employee.– The Board may assess penalties up to

$100 per violation.

OTHER REPORTS• Nothing in the Act or rules requires any

personal or telephonic contact between any health care provider and a representative of the employer/insurer.– If there is personal or telephonic contact, best

practice is to have the conversation transcribed and made part of the patient’s health care record so that all parties have access to the information.

OTHER REPORTS• An employer may request, at any time,

medical information concerning the condition of the employee for which compensation is sought. – The health care provider shall respond within 10

business days from receipt of the request.– A copy should be sent to the

employee/employee’s representative.

FEES FOR REPORTS• Health care providers may charge for

completing an initial M-1 Form or other supplemental report. The charge is to be identified by billing CPT® Code 99080. – Applies to each of the health care providers

treating the employee.– The maximum fee for completing an initial

M-1 Form or other supplemental report is: Each 10 minutes: $30.00.

TIMELY FILING• An insurance company cannot put a

time limit on the submission of workers’ compensation bills.–The time for filing petitions is

governed by 39-A M.R.S.A. § 306.

TIMELY FILING• A petition is barred unless filed

within 2 years after the date of injury or the date the employee's employer files a required first report of injury whichever is later.

TIMELY FILING• If an employer or insurer pays

benefits under the Act, with or without prejudice, within the 2 year period, the period during which an employee or other interested party must file a petition is 6 years from the date of the most recent payment.

BILLING PROCEDURES• Medical bills for insured employers must

be submitted to the insurance carrier or to the insurance carrier's agent.– Employers don’t have the choice to pay

medical bills themselves and not go through their carrier.

– Even if an employer has a policy with a deductible, the insurer is still responsible for payment from the first dollar.

BILLING PROCEDURES• To verify workers' compensation

coverage information for employers:–Review the list of authorized self-

insurers–Query the Board’s insurance

verification coverage tool–Contact the Board (Coverage,

OMRS, Troubleshooter)

BILLING PROCEDURES• While you can find out the name of

the insured employer's carrier online, there is no way to verify the claim administrator online.–A phone call should be made to the

employer/insurer to confirm where the bill, etc. should be sent.

BILLING PROCEDURES• Insurance carrier information should

appear in the carrier block located in the upper center and right margin of the HCFA 1500 Form.– Enter in the white, open carrier area the

name and address of the payer to whom the bill is being sent. The payer is the carrier or third-party administrator that will handle the claim.

BILLING PROCEDURES• Insurance carrier information

should appear in the form locator 38 of the UB-04 Form.–Enter in the white, open area the

name and mailing address of the party responsible for the bill.

BILLING PROCEDURES• Bills must specify the billing entity’s tax

id, the license number, registration number, certificate number, or NPI of the health care provider, the employer, the date of injury/occurrence, the date of service, the work-related injury or disease treated, the appropriate procedure code(s), and the charges for each procedure code.

BILLING PROCEDURES• Bills properly submitted on

standardized claim forms are sufficient to comply with this requirement. –Form 1450 instruction manual

available at NUBC.org–Form 1500 instruction manual

available at NUCC.org

BILLING PROCEDURES• Form 1450:

–Insured/Employer (FL 58/65)–Date of Injury/Occurrence

(FL 18-28 and 31-34)

BILLING PROCEDURES• Form 1500:

–Insured (Item #4)–Patient’s Condition (Item #10)

BILLING PROCEDURES

•Uncoded bills may be returned for coding.

•No NOC is required.

PAYMENT AGREEMENTS• A written payment agreement

directly between a health care provider and an employer/insurer supersedes the maximum allowable payment otherwise available.

PAYMENT AGREEMENTS• A written payment agreement between a

health care provider and an entity other than the employer/insurer seeking to invoke its terms supersedes the maximum allowable payment otherwise available only if the employer/insurer was a named beneficiary of the payment agreement at the time the health care provider signed the payment agreement.

PAYMENT AGREEMENTS• An employee retains the right to

select health care providers for the treatment of an injury or disease for which compensation is claimed regardless of any payment agreement.

MEDICAL RECORDS• A bill must be accompanied by health care

records to substantiate the services rendered. – The provider may charge for the records. The

charge should be identified on the billing form with CPT® Code S9981 (units equal total number of pages).

– The maximum fee for copies is $5 for the first page and 45¢ for each additional page, up to a maximum of $250.00.

MEDICAL RECORDS• Authorization from the employee for

release of medical information by health care providers is not required if the information pertains to treatment of an injury or disease that is claimed to be compensable under the Act regardless of whether the claimed injury or disease is denied by the employer/insurer.

MEDICAL RECORDS• Health care providers must at the written

request of the employer/insurer or the employer/insurer’s representative furnish copies of any written information authorized by the employee within 10 business days from receipt of a properly completed Form 220. – Applies to medical records and information,

pre-existing and subsequent to the workplace injury, for which claim is being made.

MEDICAL RECORDS• Health care providers must at the written

request of the employee/employee’s representative furnish copies of any written information pertaining to a claimed workers’ compensation injury or disease regardless of whether the claimed injury or disease is denied by the employer/insurer. Copies must be furnished within 10 business days from receipt of the request. – There is currently no mandated request

form for use by employees/employee’s representatives.

MEDICAL RECORDS• An itemized invoice must accompany the

copies requested.• The maximum fee for copies is $5 for the

first page and 45¢ for each additional page, up to a maximum of $250.00.

• The copying charge must be paid by the party requesting the records.

MEDICAL RECORDS• Health care providers shall not require

payment prior to responding to the request.

• Health care providers shall not charge a fee for postage/ shipping, sales tax, or a fee for researching a request that results in no records.

PROVISIONAL PAYMENTS• If additional amounts are due (because the

maximum allowable payment under the workers’ compensation MFS is greater than the health insurer’s payment), these amounts must be paid to the health care provider within 10 days after the receipt of notice of an approved agreement or within 10 days after any order or decision of the Board.• The Board may assess against the

employer or insurance carrier a fine of up to $200 for each day of noncompliance.

CONTACT INFORMATIONKimberlee.Barriere@

Maine.Gov