February 21, 2012: Colorado News: All About
Claims Newsletter Issue 32 Released
November 10, 2011:Colorado: Issues:
The Colorado fee schedule should govern
reimbursement for out-of-state providers.
October 13, 2011:
2012 Medical Fee Schedule Workshops
•Colorado Springs
•Denver
•Fort Collins
•Registration Form for all workshops
October 03, 2011: News: News and Alerts
Adoption of Rules 16 and 18
Rules 16 and 18 have now been officially
adopted.
2011 Workers' Compensation Act
Fee Schedule
Claims Newsletter Issue 32 Released
November 10, 2011:Colorado: Issues:
The Colorado fee schedule should govern
reimbursement for out-of-state providers.
October 13, 2011:
2012 Medical Fee Schedule Workshops
•Colorado Springs
•Denver
•Fort Collins
•Registration Form for all workshops
October 03, 2011: News: News and Alerts
Adoption of Rules 16 and 18
Rules 16 and 18 have now been officially
adopted.
2011 Workers' Compensation Act
Fee Schedule
| COLLECTION GUIDEBOOK AVAILABLE |
- Medical Control
The employer has the right to direct care to designated providers when a listing of at
least two providers is posted in the workplace. The providers listed must be
different physical locations and not share common ownership. An injured employee
may change his/her medical provider on a one-time basis to another provider on the
employer's designated provider list. If the employer did not direct care at the time of
injury, the injured employee may select a medical provider of his/her choice. The
employee may select his/her own pharmacy or select a pharmacy from the Express
Scripts pharmacy network. Emergency medical care does not require preapproval and
should be secured at the nearest location.
- Inpatient Facility Reimbursement:
(a) The following types of inpatient facilities are reimbursed at 100% of billed
inpatient charges:
(1) Children's hospital
(2) Veterans' Administration hospital
(3) State psychiatric hospital
(b) The following types of inpatient facilities are reimbursed at 80% of billed
inpatient charges:
(1) Medicare certified Critical Access Hospital (CAH) (listed in Exhibit 3 of
Rule 18)
(2) Medicare certified long-term care hospital
(3) Colorado Department of Public Health and Environment (CDPHE) licensed
rehabilitation facility, and,
(4) CDPHE licensed psychiatric facilities that are privately owned.
(5) CDPHE licensed skilled nursing facilities (SNF).
- SB 07-079
• Payor is a self insured employer for whom the “P or E” is acting as a TPA or
• Payor is affiliated with, or is receiving administrative services from the “P or
E”; or
• The contract expressly allows network leasing; and
• Members are given an ID Card with contacts for claims and questions; and
• Payors required to comply with terms of the contract between the Provider and
“P or E”.
The law may be enforced through litigation including injunctive relief, and arbitration.
Prevailing providers may recoup attorneys’ fees (except for claims for simple
nonpayment). Prior arbitration awards may be used as precedent in subsequent
proceedings and restrictions on their disclosure to “those who have a bona fide
interest in the arbitration” is prohibited.
- 8-43-205. Mediation. (1) Any party involved in a claim arising under articles
40 to 47 of this title may request mediation services by filing a request for
mediation services with the division. However, mediation shall be entirely
voluntary and shall not be conducted without the consent of all parties to the
claim. If a request for mediation services is
- made after an application for a hearing has been filed, the administrative law
judge hearing the dispute shall approve, on motion of the parties, the
submission of the dispute to mediation prior to hearing the matter. An
application for mediation services shall be filed on a form prescribed by the
director. Upon receiving the application for mediation services, the director
shall cause a mediation conference to occur within thirty days thereafter. At
a mediation conference, the claimant may be represented by the claimant,
counsel, or any other agent of the claimant's choice.
Mediators need not be attorneys. (2) Mediation proceedings conducted
pursuant to this section shall be considered to be settlement negotiations and
are confidential. No admission, representation, or statement made in the
course of such mediation proceedings that is not otherwise subject to
discovery or otherwise obtainable under the procedures established in
articles 40 to 47 of this title shall be admissible as evidence or subject to
discovery under said articles. No mediator who participates in mediation
proceedings conducted pursuant to this section shall be compelled or
permitted to testify about any matter discussed or revealed during such
proceedings in any other proceeding under articles 40 to 47 of this title.
| General Information |
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| Work Comp News and Issues |
Hospital
•Hospital ◦Inpatient Hospital Facility
Fees Rule 18-6(I) ■Provider restrictions
Rule 18-6(I)(1)
■Bills for Service Rule 18-6(I)(2) ■Use of
UB-04 Rule 18-6(I)(2)(a)
■Determining MS-DRG Rule 18-6(I)(2)(b)
■Maximum Length of Stay (LOS) Rule 18-
6(I)(2)(c)
■Acute care facility and its rehab facility
Rule 18-6(I)(2)(d)
◦Reimbursement, Inpatient Rule 18-6(I)
(3) ■80% billed charges, inpatient Rule
18-6(I)(3)(b)
■100% billed charges, inpatient Rule 18-6
(I)(3)(a)
■Children's hospital 100%, inpatient Rule
18-6(I)(3)(a)(1)
■Veterans' Administration 100%,
inpatient Rule 18-6(I)(3)(a)(2)
■State psychiatric hospital 100%,
inpatient Rule 18-6(I)(3)(a)(3)
■Medicare certified critical Access 80%
Rule 18-6(I)(3)(b)(1)
■Medicare certified long-term care Rule
18-6(I)(3)(b)(2)
■CDPHE licensed Rehabilitation Rule 18-6
(I)(3)(b)(3)
■CDPHE licensed, private psychiatric
Rule 18-6(I)(3)(b)(4)
■All other facilities, inpatient Rule 18-6(I)
(3)(c) ■Basic equation, inpatient Rule 18-
6(I)(3)(c)(1)
■Supply et al., inpatient Rule 18-6(I)(3)(c)
(2)
■Trauma Center Activation Rule 18-6(I)
(3)(c)(3)
■Determining outliers Rule 18-6(I)(3)(d)
■'Hospital Cost,' inpatient Rule 18-6(I)(3)
(d)(1)
■Cost to charge ratio, inpatient Rule 18-6
(I)(3)(d)(2)
■Base 'difference,' inpatient Rule 18-6(I)
(3)(d)(3)
■Outlier reimbursement, inpatient Rule 18-
6(I)(3)(d)(4)
■Inpatient with ERD Rule 18-6(I)(3)(e)(1)
■Inpatient with Trauma Center Rule 18-6
(I)(3)(e)(2)
■Transfers Rule 18-6(I)(3)(f)
■Compliance with Rule 16-6(B) & Final
Payment Rule18-6(I)(3)(g)
◦Outpatient, scheduled Rule 18-6(J)
■Provider restrictions, outpatient Rule 18-
6(J)(1) ■Prior authorization, outpatient
Rule 18-6(J)(1)(a)
■Separate facility restrictions, outpatient
Rule 18-6(J)(1)(b) ■Hospital affiliated,
outpatient Rule 18-6(J)(1)(b)(1)
■Ambulatory Surgery Center (ASC)
Rule18-6(J)(1)(b)(2)
◦Bills for Service, outpatient Rule 18-6(J)
(2) ■UB-04. outpatient Rule 18-6(J)(2)(a)
■Professional charges, outpatient Rule 18-
6(J)(2)(b)
■Surgical RVP codes, outpatient Rule 18-6
(J)(2)(c)
◦Reimbursement, outpatient Rule 18-6(J)
(3) ■Children's hospital 100%, outpatient
Rule 18-6(J)(3)(a)(1)
■Veterans' Administration 100%,
outpatient Rule 18-6(J)(3)(a)(2)
■State psychiatric hospital 100%,
outpatient Rule 18-6(J)(3)(a)(3)
■Critical Access Hospital, outpatient Rule
18-6(J)(3)(b)
■Additional reimbursement, outpatient
Rule 18-6(J)(3)(c)(5)
■Other facilities, outpatient
reimbursement Rule 18-6(J)(3)(c)
■Reimbursement, outpatient facility Rule
18-6(J)(3)(c)(1-5)
■Convalescence Rule 18-6(J)(3)(c)(4)
■Diagnostics, pre-operative, outpatient
Rule 18-6(J)(3)(c)(3)
■X-rays, pre-operative, outpatient Rule
18-6(J)(3)(c)(3)
■Ambulance service, outpatient Rule 18-6
(J)(3)(c)(5)
■Blood supplies, outpatient Rule 18-6(J)
(3)(c)(5)
■Observation Room, outpatient Rule 18-6
(J)(3)(c)(4)
■Supply et al., outpatient, Rule 18-6(J)(3)
(c)(2)
■Implants, outpatient Rule 18-6(J)(3)(c)
(2)
■Primary & multiple procedures,
outpatient Rule 18-6(J)(3)(c)(1)
■Diagnostic testing, outpatient Rule 18-6
(J)(3)(c)(3)
■Laboratory, outpatient Rule 18-6(J)(3)(c)
(3)
■Observation Room, outpatient Rule 18-6
(J)(3)(c)(4)
◦Prior authorization, outpatient Rule 18-6
(J)(1)(a)
◦APC Values include, outpatient Rule 18-6
(J)(3)(c) ■Nursing, outpatient Rule 18-6
(J)(3)(c)
■Technician and related services,
outpatient Rule 18-6(J)(3)(c)
■Facility use, outpatient Rule 18-6(J)(3)
(c)
■Equipment, surgical, outpatient Rule 18-6
(J)(3)(c)
■Fluoroscopy, outpatient Rule 18-6(J)(3)
(c)
■X-rays during surgery, outpatient Rule
18-6(J)(3)(c)
■Radiology during surgery, outpatient
Rule 18-6(J)(3)(c)
■Administrative costs, outpatient Rule 18-
6(J)(3)(c)
■Housekeeping costs, outpatient Rule 18-
6(J)(3)(c)
■Anesthesia, trained observer outpatient
Rule 18-6(J)(3)(c)
■Discontinued surgeries Rule 18-6(J)(3)(e)
■Multiple providers, single OR Rule 18-6
(J)(3)(e)
■No line-by-line comparison of charges
Rule 18-6(J)(3)(e)
•Outpatient Clinic Rule 18-6(K) ◦Bills for
Service, outpatient clinic Rule 18-6(K)(1)
■Modifiers, use on UB-94, Clinic Rule 18-
6(K)(1)
◦Reimbursement, Clinic Rule 18-6(K)(2)
■80% billed charges, clinic Rule 18-6(K)(2)
(b)
■100% billed charges, clinic Rule 18-6(K)
(2)(a)
■Children's hospital 100%, clinic Rule 18-
6(K)(2)(a)(1)
■Veterans' Administration 100%, Clinic
Rule 18-6(K)(2)(a)(2)
■State psychiatric hospital 100%, clinic
Rule 18-6(K)(2)(a)(3)
■Primary Rural Health Facility Clinic
Rule 18-6(K)(2)(b)
■All other clinic facilities Rule 18-6(K)(2)
(c)
■Clinic fees, none Rule 18-6(K)(2)(c)(1)
■Diagnostic testing, clinic fee, none Rule
18-6(K)(2)(c)(2)
■"Supply et al." Rule 18-6(K)(2)(c)(3)
■Pharmaceuticals Rule 18-6(K)(2)(d)
•Outpatient Urgent Care Facility Rule 18-6
(L)
•Urgent Care Facility, outpatient Rule 18-6
(L) ◦Provider restrictions, Urgent care
Rule 18-6(L)(1)
◦Prior authorization, urgent care Rule 18-6
(L)(1)(a)
◦Urgent Care Facility qualifications Rule
18-6(L)(1)(b)
◦Follow-up care, no facility fees, urgent
care Rule 18-6(L)(1)(c)
◦Employer designated provider
restrictions Rule 18-6(L)(1)(d)
◦Bills for Service, Urgent Care Facility
Rule 18-6(L)(2)
◦CMS 1500 (08-05)for facility fee, urgent
care Rule 18-6(L)(2)(a)
◦S9088, Urgent care facility fee Rule 18-6
(L)(2)(b)
◦Reimbursement, Urgent Care Rule 18-6(L)
(3) ■Maximum allowance, Urgent Care
Fee Rule 18-6(L)(3)(a)
■Supply et al., urgent care facility Rule 18-
6(L)(3)(b)
■Diagnostic testing, urgent care facility
Rule 18-6(L)(3)(c)
■Laboratory service, urgent care facility
Rule 18-6(L)(3)(c)
■Therapeutic Services, urgent care facility
Rule 18-6(L)(3)(c)
■Observation Room, Urgent Care facility
Rule 18-6(L)(3)(d)
■No line-by-line comparison for payment
Rule 18-6(L)(3)(e)
■Drug supply Rule 18-6(L)(4)
•Outpatient ' Emergency Room Rule 18-6
(M) ◦Provider Restrictions, Emergency
Room Rule 18-6(M)(1)
◦Bills for Service, Emergency Room Rule
18-6(M)(2) ■UB-94 Rule 18-6(M)(2)(a)
■Documentation, Emergency Room Rule
18-6(M)(2)(b)
•Reimbursement, Emergency Room Rule
18-6(M)(3)
◦80% billed charges, ER Rule 18-6(M)(3)
(b)
◦100% billed charges, ER Rule 18-6(M)(3)
(a)
◦Children's hospital 100%, ER Rule 18-6
(M)(3)(a)(1)
◦Veterans' Administration 100%, ER Rule
18-6(M)(3)(a)(2)
◦State psychiatric hospital 100%, ER Rule
18-6(M)(3)(a)(3)
◦Critical Access Hospital, ER, Rule 18-6
(M)(3)(b)
◦Level Care determination, ER Rule 18-6
(M)(3)(c)
◦Level of Care Points Rule 18-6(M)(3)(d)
◦No line-by-line comparison for lesser
value Rule 18-6(M)(3)(e)
◦No reimbursement, ER if admitted Rule
18-6(M)(3)(f)
◦Trauma Center, ER Rule 18-6(M)(3)(g)
◦No fees trauma alert, ER Rule 18-6(M)(3)
(g)
◦Trauma center in addition to ER Rule 18-6
(M)(3)(g)(1)
◦Trauma center activation vs. alert Rule 18-
6(M)(3)(g)(2)
633 17th Street, Suite 400, Denver, CO
80202-3660 • Phone: 303-318-8700 • Email
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