Employer/insurers may automatically conform charges according to the fee schedule adopted by the Board and the charges listed in the fee schedule shall be presumed usual, customary, and reasonable and

Requests for reimbursement of mileage expenses incurred by the employee shall be paid within 15 days after receipt of an itemized written request. Employer/insurers shall not unilaterally change any CPT-4 or CDT code of the provider. All automatically conformed charges according to the fee schedule adopted by the Board shall be for the CPT-4 or CDT code listed by the provider. In situations where charges have been reduced or payment of a bill denied, the carrier, self-insured employer, or third party administrator shall provide an Explanation of Benefits with payment information explaining why the charge has been reduced or disallowed, along with a narrative explanation of each Explanation of Benefits code used. In all claims, any health service provider whose fee is reduced to conform to the fee schedule and who Rule 203 APPENDIX Rule 203 disputes that fee, or employer/insurers who dispute the CPT-4 or CDT code used by the provider for services rendered shall, in the first instance, request peer review of the charges, and may thereafter request a mediation conference or an evidentiary hearing by filing Form WC-14 with the Board. For charges not contained in the fee schedule and which are disputed within 30 days as not being reasonable, usual and customary, the aggrieved party shall follow the procedures provided in subsection (c). (b)(1) A medical provider or an employee who has incurred expenses for healthcare goods and services or other medical expenses shall submit the charges to the employer or its workers’ compensation carrier for payment within one year of the date of service. In the event that the claim or the expense is controverted, the medical expenses or request for reimbursement must be submitted for payment within one year of the date of service or within one year of the date that the claim is accepted or established as compensable, whichever is later. Failure by the medical provider or employee to submit expenses within the time prescribed shall result in waiver of such expenses. (2) Any challenge by a medical provider to the amount of payment for goods, services, or expenses shall be submitted to the payer within 120 days of payment. Failure by a medical provider to challenge the amount of payment of such goods, services, or expenses within 120 days shall result in the waiver of additional payment. (c) Disputes (1) An employer or insurer shall pay when due all charges deemed reasonable, and follow the procedures set forth in subsection (2) for review of only those specified charges which are disputed. (2) For charges not contained in the fee schedule and which are disputed as not being the usual, customary and reasonable charges prevailing in the State of Georgia, the employer, insurer, or physician shall file a request for peer review with a peer review organization authorized by the Board within 30 days of the receipt of charges by the employer/insurer, and shall serve a copy of the request and supporting documentation upon all parties and counsel. A request for peer review of chiropractic charges or treatment shall attach to the application 10 copies of the charges and all of the reports dealing with the treatment of the injured employee. The peer review organizations approved by the Board are as follows: Georgia Psychological Association; Georgia Chiropractic Association, Inc.; Appropriate Utilization Group, LLC; and such other organizations as designated by the Board. (3) Unless peer review is requested as set forth in Rule 203 (c)(2), all reasonable charges for medical, surgical, hospital and pharmacy Rule 203 LABOR AND INDUSTRIAL RELATIONS Rule 203 goods and services shall be payable by the employer or its worker’s compensation insurer within 30 days from the date that the employer or the insurer receives the charges and the medical reports required by the Board or within 15 days after receipt of an itemized written request for mileage incurred by the employee. Failure of the health care provider to include with submission of charges the reports or other documents required by the Board, constitutes a defense for the employer or insurer’s failure to pay the submitted charges within 30 days of receipt or within 15 days of receipt of an itemized written request for mileage incurred by the employee; however, the employer or insurer must submit to the health care provider written notice indicating the need for further documentation within 30 days of receipt of the charges or within 15 days of an itemized written request for mileage incurred by the employee and failure to do so will be deemed a waiver of the right to defend a claim for failure to pay such charges in a timely fashion on the ground that the charges were not properly accompanied by required documentation. Such waiver shall not extend to any other defense the employer and insurer may have with respect to a claim of untimely payment. If any charges for health care goods or services are not paid when due, or any reimbursement for health care goods or services paid by the employee or any charges for mileage incurred by the employee are not paid when due, penalties shall be added to such charges and paid at the same time as, and in addition to, the charges claimed for the health care goods and services. For any payment of charges made more than 30 days after their due date, but paid within 60 days of such date, there shall be added to such charges an amount equal to 10 percent of the amount due. For any payment of charges made more than 60 days after the due date, but paid within 90 days of such date, there shall be added to such charges an amount equal to 20 percent of the amount due. For any charges not paid within 90 days of the due date, in addition to the 20 percent add-on penalty, the employer or insurer shall pay interest on the combined total in an amount equal to 12 percent per annum from the 91st day after the date the charges were due until full payment is made. All such penalties and interest shall be paid to the provider of the health care goods or services. (4) The employer, insurer, or physician requesting review must comply with the requirements of the statute, Board Rules, and rules of the appropriate peer review organization before the Board will rule on any disputed charges. (5) If there is no appropriate peer review organization, the party requesting review may request a mediation conference by filing Form WC-14 with the Board. The charges submitted which conform to the list as published by the Board shall be prima facie proof of the usual, customary, and reasonable charges for the medical services provided. Rule 203 APPENDIX Rule 203 (6) The employer/insurer shall, within 30 days from the date that a decision regarding the peer review of charges or treatment is issued by a peer review organization, make payment of disputed charges based upon the recommendations, or request a mediation conference or an evidentiary hearing. The peer review organization shall serve a copy of its decision upon the employee if unrepresented, or the employee’s attorney. A physician whose fee has been reduced by the peer review organization shall have 30 days from the date that the recommendation is mailed to request a mediation or hearing. In the event of a hearing or mediation conference, the recommendations of the peer review organization shall be evidence of the usual, customary, and reasonable charges. (7) In cases where the peer review organization recommends that the fee be reduced, the employer/insurer shall pay the physician the fee amount recommended by the peer review organization less the fee for peer review initially paid by the employer/insurer. In the event the peer review organization recommends the entire fee be disallowed, the employer/insurer may automatically deduct the fee for the peer review from future allowable expenses submitted by the physician for treatment or services rendered to the employee arising out of the same injury. (d) Medical expenses shall include the reasonable cost of attendant care that is directed by the treating physician, during travel or convalescence. (e) Medical expenses shall include but are not limited to the reasonable cost of travel between the employee’s home and the place of examination or treatment or physical therapy, or the pharmacy. When travel is by private vehicle the rate of mileage shall be 40 cents per mile. This rate is subject to change based upon changes in fuel costs. Reimbursement for any charges for mileage incurred by the employee shall be paid within 15 days from the date that the employer or the insurer receives the itemized written request required by the Board. Travel expenses beyond the employee’s home city shall include the actual cost of meals and lodging. Travel expenses shall further include the actual cost of meals when total elapsed time of the trip to obtain outpatient treatment exceeds four hours. Cost of meals shall not exceed $30 per day. Note as to revisions. — The revision effective July 1, 2007, designated the existing provisions of subsection (b) as paragraph (b)(1), and added the last sentence, and added paragraph (b)(2). The revision effective July 1, 2010, deleted the former last sentence of the second paragraph of paragraph (c)(2), which read: ‘‘A request for peer review of any other treatment or charges shall attach to the application two copies of the charges and all of the reports dealing with the treatment of the injured employee.’’ The revision effective July 1, 2011, deleted ‘‘Medical Directors Solutions, LLC;’’ preceding ‘‘Georgia Psychological AssociaRule 203 LABOR AND INDUSTRIAL RELATIONS tion’’ in the concluding paragraph of paragraph (c)(2). The revision effective July 1, 2013, added the third sentence in subsection (a); inserted ‘‘or employee’’ in the last sentence of paragraph (b)(1); substituted ‘‘payer’’ for ‘‘payor’’ in the first sentence of paragraph (a)(2); in paragraph (c)(3), inserted ‘‘or within 15 days of an itemized written request for mileage incurred by the employee’’ three times, and deleted ‘‘its’’ preceding ‘‘submission’’ in the second sentence; in the ending paragraph of subsection (c), inserted ‘‘or any reimbursement for health care goods or services paid by the employee or any charges for mileage incurred by the employee are not paid when due’’ in the first sentence, and substituted ‘‘percent’’ for ‘‘%’’ in the second, third, and fourth sentences; and added the fourth sentence in subsection (e). The revision effective July 1, 2014, substituted the present provisions of the undesignated paragraph of paragraph Rule 205 (c)(2) for the former provisions, which read: ‘‘The peer review committees approved by the Board are as follows: Georgia Psychological Association; Georgia Chiropractic Association, Inc.; Appropriate Utilization Group, LLC; and such other committees as the Board has posted as so designated at its Atlanta office.’’ The revision effective July 1, 2015, substituted ‘‘peer review organization’’ for ‘‘peer review committee’’ throughout; in paragraph (c)(2), deleted ‘‘; Exam Works’’ following ‘‘Dane Street’’, in paragraph (c)(7), substituted ‘‘fee for per review’’ for ‘‘filing costs’’, substituted ‘‘organization’’ for ‘‘committee’’ and substituted ‘‘fee’’ for ‘‘filing costs’’. The revision effective July 1, 2017, inserted ‘‘or CDT’’ in three places in subsection (a) and deleted ‘‘Dane Street’’ before ‘‘and such other organizations’’ near the end of the undesignated paragraph following paragraph (c)(2). Rule 204. Subsequent Non-Work Related Injury; Chain of Causation; Burden of Proof. The employer/insurer shall not suspend weekly benefits on the ground that a subsequent nonwork related injury has broken the chain of causation between the compensable injury and the employee’s disability except by the order of the Board. The burden of proving that the chain of causation has been broken shall be upon the employer/insurer. Rule 205. Necessity of Treatment; Disputes Regarding Authorized Treatment. (a) Reports required by the Board include State Board of Workers’ Compensation Form WC-20(a), 1500 Claim Form, UB-04, or American Dental Association Form 2012 and supporting narrative, if any, properly filled out and with supporting itemized hospital charges, discharge summary, and billings from other authorized providers of service and shall be furnished at no charge to the party responsible for payment. In addition, health care providers may submit and payers may receive and pay bills for medical services and products provided to the injured employee electronically in accordance with the Medical Billing and Reimbursement for Workers’ Compensation procedures outlined in an Appendix to the Georgia Fee Schedule. Medical services provided pursuant to the Workers’ Compensation Act are not confidential to the Rule 205 APPENDIX Rule 205 employer/insurer who by law are responsible for the payment of services. Hospitals and other medical providers who by their own rules require medical releases shall be responsible for obtaining same at the time of treatment. (b)(1) Medical treatment/tests prescribed by an authorized treating physician shall be paid, in accordance with the Act, where the treatment/tests are: (a) Related to the on the job injury; (b) Reasonably required and appear likely to accomplish any of the following: (1) Effect a cure; (2) Give relief; (3) Restore the employee to suitable employment; (4) Establish whether or not the medical condition of the employee is causally related to the compensable accident. (2) Advance authorization for the medical treatment or testing of an injured employee is not required by this Chapter as a condition for payment of services rendered. A Board certified WC/MCO may provide for pre-certification by contract with network providers pursuant to O.C.G.A. § 34-9-201(b)(3). (3)(a) An authorized medical provider may request advance authorization for treatment or testing by completing Sections 1 and 2 of Board Form WC-205 and faxing or emailing same to the insurer/ self-insurer, along with supporting medical documentation. The insurer/self-insurer shall respond by completing Section 3 of the WC-205 within five (5) business days of receipt of this form. The insurer/self-insurer’s response shall be by facsimile transmission or email to the requesting authorized medical provider. If the insurer/self-insurer fail to respond to the WC-205 request within the five business day period, the treatment or testing stands pre-approved. (b) In the event the insurer/self-insurer furnish an initial written refusal to authorize the requested treatment or testing within the five business day period, then within 21 days of the initial receipt of the WC-205, the insurer/self-insurer shall either: (a) authorize the requested treatment or testing in writing; or (b) file with the Board a Form WC-3 controverting the treatment or testing indicating the specific grounds for the controversion. (4) Where the employer fails to comply with Rule 205(b)(3), the employer shall pay for the treatment/test requested related to the compensable injury in accordance with the Chapter. Rule 205 LABOR AND INDUSTRIAL RELATIONS Rule 205 (c) Except where medical services are provided by the employer through a Board-certified WC/MCO pursuant to O.C.G.A. § 34-9-208; (1) When an authorized treating provider has recommended medical treatmentesting and the employer/insurer have been provided documentation of such recommendation for at least 5 business days, but have failed to authorize the treatment/testing, the employee or the employee’s attorney may file a petition to show cause why the medical treatment/testing that has been recommended should not be authorized. (Section B of WC-PMT). The Petition shall request the Board to issue a notice of a show cause telephonic conference before an Administrative Law Judge to be scheduled for a date and time not more than 5 business days from the date of the Petition. (2) Upon the filing of Section B of the WC-PMT, the Board shall issue a Notice of Telephonic Conference for a date and time not more than 5 business days from the date of the Petition. Postponements will be discouraged and granted only for good cause shown. Any party requesting a postponement must contact the Board and obtain an alternate date which is within 5 business days of the original conference date and certify that the date is agreeable to the opposing party. The parties may participate, telephonically only, in the show cause conference by calling the telephone number listed on the Notice. The purpose of the telephonic conference will be to show cause why the treatment or testing at issue has not been authorized. Failure of any party to participate in the conference does not preclude a ruling on the Petition. (3) In lieu of participation in the telephonic conference, the employer/insurer may authorize the treatment by completing Section C of the WC-PMT or controvert the treatment by completing Section D of the WC-PMT. If the treatment is authorized, written notice of the authorization shall be provided to the medical provider. The completion and filing of the Controvert in Section D with proper service of the WC-PMT shall constitute notice that the compensability of the medical treatment/testing at issue is being controverted for the specific reasons stated. No additional filing of a Notice to Controvert for the requested medical testing/treatment shall be required. Upon completion and filing of the Authorization in Section C or the Controvert in Section D of the WC-PMT, any scheduled telephonic conference is cancelled. (4) Following the telephonic conference, the Administrative Law Judge may issue an Interlocutory Order which exclusively addresses authorization of the treatment or testing at issue. If it is determined that the treatment/testing should be authorized, the Order shall require the employernsurer to provide written authorization to the medical provider. The Order will take effect absent timely objection. Rule 205 APPENDIX Rule 205 (5) Any party objecting to the Interlocutory Order may request a hearing within 20 days from the date of the Interlocutory Order. A Hearing Request will operate as a supersedeas of the order. Where treatmentesting has been ordered, the failure to request a hearing will be construed as consent to payment in accordance with the fee schedule for the requested medical treatment/testing. (d)(1) If medical treatment is controverted on the ground that the treatment is not reasonably necessary, the burden of proof shall be on the employer. If the treatment is controverted on the grounds that the treatment is either not authorized or is unrelated to the compensable injury, the burden of proof shall be upon the employee. (2) In the event of a dispute as to the necessity and/or reasonableness of services already rendered, the procedure listed in Board Rule 203(c) shall be followed. (e) If an employer or insurer utilizes a Board certified WC/MCO pursuant to O.C.G.A. § 34-9-201(b)(3), and a dispute arises regarding the treatment/test prescribed by the authorized treating physician and the dispute is not resolved within 30 days as outlined in Rule 208(f ), then the employer or insurer has 15 days from notification by the WC/MCO to authorize the treatment/test or controvert the treatment/ test. In no event will the employer or insurer utilizing a WC/MCO have more than 45 days from the receipt of the notice of a dispute as set forth in Rule 208(f ) to comply with this provision. Note as to revisions. — The revision effective July 1, 2007, inserted ‘‘UB-04’’ in the first sentence of subsection (a). The revision effective July 1, 2009, inserted ‘‘, along with supporting medical documentation’’ at the end of the first sentence in subparagraph (b)(3)(a). The revision effective July 1, 2010, added the second sentence in subsection (a). The revision effective July 1, 2011, in paragraph (b)(4), deleted ‘‘, in accordance with the Chapter,’’ following ‘‘shall pay’’ and added ‘‘related to the compensable injury in accordance with the Chapter’’ at the end. The revision effective July 1, 2014, substituted ‘‘1500 Claim Form’’ for ‘‘HCFA 1500’’ in the first sentence of subsection (a). The revision effective July 1, 2017, substituted ‘‘UB-04, or American Dental Association Form 2012’’ for ‘‘or UB-04’’ in the first sentence of subsection (a); added subsection (c); and redesignated former subsections (c) and (d) as present subsections (d) and (e), respectively.