Alabama Administrative Code

(Repealed). Author: Randy Richie, Workers' Compensation Director. Notes Ala. Admin. Code r. 480-5-3-.04 Effective February 16, 1993. Repealed: Filed October 9, 1997; effective November 13, 1997. Statutory Authority: Code of Ala. 1975, § 25-2-2(6).

(Repealed). Author: Randy Richie, Workers' Compensation Director. Notes Ala. Admin. Code r. 480-5-3-.05 Effective February 16, 1993. Repealed: Filed October 9, 1997; effective November 13, 1997. Statutory Authority: Code of Ala. 1975, § 25-2-2(6).

When used in these Rules and Regulations, the following words and phrases shall have the following meanings, respectively, unless the context clearly indicates a different meaning: (a) Actuarial Report - A document or other presentation prepared as a formal means of conveying pro…

(1) A proposed Fund shall file with the Director its application for a certificate of approval accompanied by a non-refundable filing fee in the amount of $2,000, which shall be deposited into the Workers' Compensation Administrative Trust Fund, at least 120 days prior to the pro…

(1) Administrator - The Trustees of a Fund shall appoint an Administrator. The Administrator shall perform duties as prescribed by the Trustees. The Administrator may be an employee of the Fund or the Sponsoring Association but shall not be an employee of the Fund's Service Compa…

The Director may involve the trustees in a Fund's day to day management if he/she determines that a Fund is in violation of the Law, these Rules, or is potentially impaired and that the Administrator is unwilling or unable to correct the deficiencies. This rule contemplates the n…

(1) Examination - The Director may examine and investigate the affairs of any Fund to determine whether the Fund is operating in accordance with these Rules and the Law. The Director may order an independent fiscal and actuarial examination. The Director may hire an independent a…

An individual, partnership, or corporation engaged in the business of servicing a fund shall have a full-time office in the State of Alabama which has full authority to investigate and pay claims under the provisions of the law. Service companies shall make application to the Dir…

(1) These rules are designed to cover permissive bill screening and permissive utilization review undertaken on behalf of an employer by a person or entity other than an employee of the employer and following a determination that an employee has suffered an injury by accident ari…

When used in these rules, the following words and phrases shall have the following meanings: (1) Accident - The term, as used in the phrases "personal injuries due to accident" or "injuries or death caused by accident," shall be construed to mean an unexpected or unforeseen event…

(1) 10 Percent (10%) Penalty: (a) Appropriate reimbursement pursuant to Rule 480-5-5-.04 for undisputed medical services reasonably performed and billed in accordance with Code of Ala. 1975, § 25-5-3 shall be paid to the provider within 25 working days of receipt of an approved s…

(1) A statement of medical services shall be made in accordance with standard coding methodology as established by the ICD-10-CM, HCPCS, and CPT-4 coding manuals and prevailing adjudication rules in Code of Ala. 1975, § 25-5-1(15). Unbundling, fragmenting charges, duplicating, ov…

(1) The following criteria shall be used by the Department of Industrial Relations to qualify an employer/agent who may perform the bill screening of medical services for workers' compensation claims. This entity shall be qualified by the Department as required in Rule 480-5-5-.0…

(1) Technical Reviewer: (a) It is the express intent of these rules that approval of medical services may be performed by the employer/agent or its designated employee who meets the requirements of Rule 480-5-5-.05. The technical reviewer shall not deny a medical service related …

(1) It is the express intent of these Rules that Utilization review may be performed by the insurance carrier, employer/agent, self-insured employer, or group self-insurance fund. There is no requirement that outside utilization review entity vendors be hired to perform utilizati…

(1) Application for pre-certification shall be made as early as possible by the provider prior to rendering of the medical services for a compensable illness or injury. If medical services are for treatment of a medical emergency, notification shall be made by the provider to the…

(1) Pre-certification review shall be conducted by telephone and/or facsimile during normal business hours (8:30 a.m. to 4:30 p.m. Central time, Monday through Friday, excluding legal holidays). Written requests may be processed by the RUE or employer/agent on a case-by case basi…

(1) The RUE or employer/agent is responsible for initiating the medical necessity review for continued hospitalization before the initial assigned length of stay expires. The responsibility to request an extension may be delegated to the hospital, if requested by the hospital and…

(1) Prior to a detailed medical review, a review of the claim shall be accomplished as a part of the initial bill screening process and shall include at least the following: (a) Identifying the job related illness/injury; (b) Identifying each service/item billed; (c) Identifying …

(1) The employer's authorized treating physician (other than emergency medical services) shall be the physician of record for attending or referral purposes. All referrals shall be pre-approved by the employer/agent. The employer/agent shall keep all interested parties involved i…

(1) Emergency Services - The provider who provides care under the "medical emergency" exception shall demonstrate that "emergency services" occurred as defined in Rule 480-5-5-.02. Author: Workers' Compensation Medical Services Board Notes Ala. Admin. Code r. 480-5-5-.13 New Rule…

(1) When elective surgery has been recommended by the treating physician, the employee, subject to the limitations of Code of Ala. 1975, § 25-5-77(b), or the employer/agent is entitled, but not required, to obtain a second professional opinion from a physician board certified in …

(1) Global Surgery Fees - Ongoing services prior to surgery shall be covered on a fee-for-services basis. The global surgery allowance shall encompass the actual surgery procedure and normal post-operative services. Post-operative visits after six weeks from the date of surgery s…

(1) All providers or payors performing or making referrals of workers' compensation cases to facilities in which the provider has an ownership interest, financial interest or fiduciary interest, shall notify the carrier, provider or their respective agent of such interest at the …

(1) Covered Expenses (a) Only services and products necessitated by an on-the-job injury or illness shall be covered. Such services and, or products shall be provided as a result of damage to the eye(s) due to a work injury or exposure. In addition, lenses and contact lenses not …

(1) Initial Evaluation (a) An evaluation shall be performed to determine if a patient will benefit from chiropractic services. (b) Where a chiropractor examines a patient and an evaluation for chiropractic services is performed, the billing of the office visit shall include the i…

(1) Applicability - The following shall apply to non-physician therapy providers (hospital outpatient, freestanding, and independent practicing facilities). Practicing physical therapists, physical therapist assistant, occupational therapists, occupational therapists assistants a…

(1) Covered Services - Reasonable and necessary hospital care medical services for an occupational illness or injury including acute-care hospital inpatient, outpatient, and rehabilitation facilities, shall be reimbursable as stated in Rule 480-5-5-.04(3), if the services rendere…

(1) Prescribed Medication Services (a) "Medicinal drugs" or "drugs" shall be defined as "legend" or "prescription" drugs that may only be dispensed when prescribed by a currently licensed provider authorized by law to prescribe drugs. (b) "Medicines" shall be defined as drugs pre…

(1) The following approved standardized reimbursement forms shall be used by providers as indicated below. Each form shall be completed in its entirety and shall comply with the Alabama Maximum Fee Schedule coding, if available. (a) Providers: physicians; optometrists; chiropract…

(1) Adverse decisions rendered under Rule 480-5-5-.08 or 480-5-5-.10 regarding medical necessity shall be subject to peer review and/or administrative appeal at the request of any party as follows: (a) Peer Clinical Review 1. All UREs or employers/agents shall have in place an ap…

(1) Discharge planning shall be the joint responsibility of the RUE or employer/agent and the facility. The RUE or the employer/agent shall work with the facility's discharge planning department to ensure continuity of care as directed by the physician from the facility to the al…

(1) Audit disputes between the RUE or employer/agent and billing party may be referred to the Workers' Compensation Ombudsman Program for medical dispute resolution in accordance with Code of Ala. 1975, § 25-5-77(i). (2) RUE or Employer/Agent Responsibilities (a) The services to …

(1) When medically appropriate, surgical procedures may be performed on an outpatient basis to reduce unnecessary hospitalization and to shift care to a less costly setting in accordance with Rule 480-5-5-.11(3). All freestanding Ambulatory Surgery Centers (ASCs) licensed in Alab…

(1) All nonelective acute care hospital admissions including emergencies, psychiatric admission, and all extended hospitalization shall be reviewed under generally accepted criteria. Author: Workers' Compensation Division Notes Ala. Admin. Code r. 480-5-5-.27 New Rule: Filed Augu…

(1) Basic Information - The Rules set out in this chapter apply to providers rendering dental and maxillofacial surgery services. Providers of these services shall also, when applicable, follow the rules and policies in these Rules pertaining to pre-certification, utilization rev…

(1) Medical case management determination shall be the responsibility of the employer/agent unless delegated. This service may be performed in conjunction with utilization management; however, it is differentiated by its designation to promote optimal recovery and physical rehabi…

(1) Prior to the provision of medical services, supplies or other non-medical services, the determination that the illness, injury or condition is work related must be made and shall be pre-certified as medically necessary and not for the convenience of the patient and/or family.…

(1) Pain management program services shall receive authorization from the employer/agent prior to providing services. No health care provider may refer the employee to another pain management program without prior authorization from the employer/agent. (2) Billing Information (a)…

(1) All services described in these rules, except those specifically noted, shall have prior authorization of the employer/agent before reimbursement shall be made. The authorized treating physician shall state that the condition was indeed work-related and that the durable medic…

(1) In accordance with Code of Ala. 1975, Section 25-5-77(h), the employer/agent shall process and pay all undisputed claims within 25 working days of receipt of an approved claim form. However, all authorized workers' compensation claims shall be filed to allow processing and re…

(1) All non-emergency ground and air ambulance service rendered to workers' compensation claimants shall be pre-certified. Emergency ground and air ambulance services shall be retro-certified within 24 hours of the service or on the next working day. (2) All ground and air ambula…

(1) The American Medical Association Guides to the Evaluation Of Permanent Impairment, Fourth Edition, shall be the recommended guide used by physicians in determining impairment and/or disability ratings. Author: Workers' Compensation Medical Services Board Notes Ala. Admin. Cod…

(1) In accordance with Code of Ala. 1975, Section 25-5-77(c), the employer shall pay reasonable charges for the employee's necessary board, lodging, and travel, if vocational rehabilitation requires residence at or near a facility away from the employee's customary residence. Cod…

(1) Occasionally an employee, whose injury falls under Alabama's jurisdiction, may require treatment by a medical provider in another state. Alabama's fee schedules are developed under the premise that treatment will be provided in this state. The hospital and ambulatory surgery …

When used in these rules, the following words and phrases shall have the following meanings: (1) Alcohol: Limits - less than 0.04 safety sensitive function, less than 0.08 non-safety sensitive function. Refusal: considered in excess of the permissible limits. (2) Confirmation Tes…

(1) Employers desiring a Drug-Free Workplace certification pursuant to Alabama Act 95-535 shall submit their request in writing on forms as approved by the Director, to the Department of Industrial Relations, Workers' Compensation Division, Drug-Free Workplace Certification Progr…

(1) The specimen collected for substance abuse testing may be tissue, blood, urine, breath, or other product of the human body that is capable of revealing the presence of drugs or their metabolites or of alcohol. However, the collection of any specimen constitutes a search under…

(1) Qualifications and Responsibilities: (a) The MRO shall not be an employee of the laboratory conducting the drug test unless the laboratory establishes a clear separation of functions to prevent any appearance of a conflict of interest. (b) The role of the MRO is to review and…

(1) Registration of Professional Employer Organizations in Alabama is authorized by Alabama Act No. 2006-229. The following rules and regulations are adopted pursuant to the authority contained therein. (2) Definitions as used herein:(a) Professional Employer Organization - a per…