A PUBLICATION BY THE LAW FIRM OF

Clifton, Mueller & Bovarnick, P.C.

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ATTORNEYS AT LAW

2006

APRIL & MAY

REQUESTING A DIME:

WHEN DOES THE CLOCK START TICKING?

This very issue lately confronted CMB.  Under the Workers’ Compensation Act, the authorized treating physician’s findings are binding on respondents unless they file a notice and proposal for the selection of a DIME within thirty days.  The time for selection of a DIME commences with the date on which the disputed findings or determination is mailed or physically delivered to the insurer or self insured

We have recently noticed an increase in demands for requests for prior authoriza-tion of medical treatment. It may be coincidental, but a review of new Workers’ Compensation Rules of Procedure 16-9 and 16-10 seems appropriate.

  Under these rules payers must respond to all requests for prior authorization within seven business days of the request.  If the request is contested, the payer must provide written notice of the reasons for the contest.  Recent case law holds that Rule 16-9 and 16-10 requirements apply to all requests for prior authorization, even though the request is not mandated by Rule 16.

  Prior authorization requests may be contested for: 1) a medical basis; or 2) non-medical reasons.  Medical contests have to be reviewed by a physician or certain licensed professionals (defined in Rule 16-5.A) before the notice of contest is sent.  The notice of contest must include:

employer.  These options raise the question: does the clock start ticking when the disputed findings are mailed or when they are physically delivered?

  The issue was decided in Irene M. Meszler, W.C. No. 4-488-976 (January 14, 2003).  Claimant mailed a copy of the treating physician’s MMI report to the respondent on March 7.  The respondent received the report on March 11 and filed a

notice and proposal to select a DIME on April 10.   At hearing, the claimant argued that the respondent was bound by the treat-ing physician’s rating because the respon-dent did not commence the DIME process within the Act’s time requirement.  The ALJ agreed and the ICAO affirmed.  The panel held that, “The thirty day period for

· an explanation of the medical reasons for the contest, including the name and credentials of the reviewing physician with a copy of his/her report;

· a cite to the Division’s Medical Treat-ment Guidelines (Rule 17), if appropriate;

· a list of the information most likely to influence a reconsideration; and

· a certificate of mailing.

Contests based on non-medical criteria must also include a certificate of mailing.

  Failure to comply with these provisions implicitly authorizes the requested treatment (unless a hearing is requested).  Penalties may be assessed if the Director or an Administrative Law Judge finds unreasonable delay occurred regarding a request for prior authorization.

  Handle all requests for prior authorization immediately upon receipt to avoid penal-ties. Keep deadlines in mind and don’t hesitate to contact CM&B with questions.

Requests For Prior Authorization –

Avoid Penalties

By Erica A. Weber

LEGISLATIVE UPDATE

On March 27, 2006, Governor Bill Owens signed HB06-1055, thereby amending C.R.S. § 8-41-301(2)(b).  The amended statute excludes all acts of violence, regardless of criminal intent, from the twelve week limitation on medical impairment benefits for mental impairment claims.

  The Senate Committee on Health and Human Services killed HB06-1291 on March 31, 2006.  The proposed legislation would have excluded certain persons who work for non-profit associations involved in youth sporting activities from the definition of employee.

  On April 13, 2006, Governor Bill Owens vetoed HB06-1174, which would have required every person working on a construction site, including independent contractors, to be covered by workers’ compensation insurance.