| Iowa WORKERS COMPENSATION COLLECTION PUBLICATIONS AND INFORMATION FOR MEDICAL PROVIDERS |
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Time limitations
Notice of injury (85.23)
The law provides that the employer must have notice or knowledge of an alleged injury within 90
days of its occurrence, if not, benefits may be denied. The 90-day period begins to run when the
employee knew, or should have known the injury arose out of and in the course of employment
.
Reporting of claims (86.11)
An Employer’s First Report of injury must be filed with the workers' compensation
commissioner when an employee alleges an injury arising out of and in the course of
employment, which results in time loss from work of more than three days, permanent injury or
death. The report is to be filed with the workers' compensation commissioner within four days
of notice or knowledge of such alleged injury.
Two-year Statute of Limitation (85.26)
If within two years from the occurrence of the injury the employee does not receive Iowa weekly
workers’ compensation benefits or file an application for arbitration, benefits may be denied.
Three-year Statute of Limitation (85.26)
If Iowa weekly workers’ compensation benefits have been paid, the employee has three years
from the last payment of weekly benefits to receive additional benefits or file an action before the
workers' compensation commissioner. If not filed within the three-year period, the benefits may
be denied. This statute of limitation does not apply to medical expenses reasonably necessary to
treat the injury.
The employer may direct an injured employee for all non-emergency medical care. 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.
Over the past several months the Workers’ Compensation Commission has received numerous
inquires regarding the resolution of medical fee disputes. As required by Iowa Code section 85.27
(3), and rules 876 IAC 10.3 and 876 IAC 4.46, insurers and providers who have a medical fee
dispute must take the following steps to resolve the dispute:
1. An insurer who disputes a charge must give a provider written notice of the disputed charge
within 60 days of receiving a bill. Charges not in dispute must be paid to the provider before
using the procedures in rule 876 IAC 10.3.
2. The notice should contain: names of employee and employer; date of injury; date of
disputed treatment; the amount of the charge the insurer agrees to pay; the amount of the charge
in dispute; the reason the charge is believed to be excessive or unnecessary, and the
documentation relied on; the address for directing correspondence; and the procedures available
through the Workers’ Compensation Commission to resolve the dispute.
3. If the provider does not accept the amount the insurer agrees to pay, the provider must give
written notice, and ask the disputed amount go to a reviewer for review.
4. The person chosen as the reviewer cannot be the Workers’ Compensation Commission. If
the parties cannot agree upon a reviewer, each shall submit a name to the commissioner, and the
commissioner shall decide who is to act as a reviewer.
5. The reviewer, as soon as practicable, is to determine in writing the amount of the charge that
is reasonable and necessary. Costs of the review are to be paid as agreed to by the parties.
6. A dispute over a charge can include the reasonableness of the charges. It may also include
the necessity of the charge.
7. A contested case proceeding may be commenced only after these steps for dispute
resolution have been followed, and good faith efforts to resolve the dispute have failed. Such a
proceeding must be commenced within 30 days after written determination is made by the
reviewer.
8. Rule 876 IAC 10.3 does not prevent providers and insurers from developing other
procedures to informally resolve their disputes, if those procedures aid in the resolution of a
medical fee dispute.
If the process, detailed in rule 876 IAC 10.3, does not resolve the dispute and the parties have
attempted resolution in good faith, a contest case may be initiated, pursuant to rule 876 IAC
4.46. The following applies to contested cases regarding medical fee disputes:
1. Evidence is filed at the time the contested case is initiated and is limited to that provided by
the reviewer, and the determination made by the reviewer.
2. The commissioner may request or allow additional evidence.
3. If a brief is to be filed, it needs to be filed at the time the matter is commenced.
4. The opposing party has 30 days from the date of service of the petition, to file a response
and optionally a brief. (8-4-08)
Notice of injury (85.23)
The law provides that the employer must have notice or knowledge of an alleged injury within 90
days of its occurrence, if not, benefits may be denied. The 90-day period begins to run when the
employee knew, or should have known the injury arose out of and in the course of employment
.
Reporting of claims (86.11)
An Employer’s First Report of injury must be filed with the workers' compensation
commissioner when an employee alleges an injury arising out of and in the course of
employment, which results in time loss from work of more than three days, permanent injury or
death. The report is to be filed with the workers' compensation commissioner within four days
of notice or knowledge of such alleged injury.
Two-year Statute of Limitation (85.26)
If within two years from the occurrence of the injury the employee does not receive Iowa weekly
workers’ compensation benefits or file an application for arbitration, benefits may be denied.
Three-year Statute of Limitation (85.26)
If Iowa weekly workers’ compensation benefits have been paid, the employee has three years
from the last payment of weekly benefits to receive additional benefits or file an action before the
workers' compensation commissioner. If not filed within the three-year period, the benefits may
be denied. This statute of limitation does not apply to medical expenses reasonably necessary to
treat the injury.
- Medical Control
The employer may direct an injured employee for all non-emergency medical care. 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.
- RESOLUTION OF MEDICAL FEE DISPUTES
Over the past several months the Workers’ Compensation Commission has received numerous
inquires regarding the resolution of medical fee disputes. As required by Iowa Code section 85.27
(3), and rules 876 IAC 10.3 and 876 IAC 4.46, insurers and providers who have a medical fee
dispute must take the following steps to resolve the dispute:
1. An insurer who disputes a charge must give a provider written notice of the disputed charge
within 60 days of receiving a bill. Charges not in dispute must be paid to the provider before
using the procedures in rule 876 IAC 10.3.
2. The notice should contain: names of employee and employer; date of injury; date of
disputed treatment; the amount of the charge the insurer agrees to pay; the amount of the charge
in dispute; the reason the charge is believed to be excessive or unnecessary, and the
documentation relied on; the address for directing correspondence; and the procedures available
through the Workers’ Compensation Commission to resolve the dispute.
3. If the provider does not accept the amount the insurer agrees to pay, the provider must give
written notice, and ask the disputed amount go to a reviewer for review.
4. The person chosen as the reviewer cannot be the Workers’ Compensation Commission. If
the parties cannot agree upon a reviewer, each shall submit a name to the commissioner, and the
commissioner shall decide who is to act as a reviewer.
5. The reviewer, as soon as practicable, is to determine in writing the amount of the charge that
is reasonable and necessary. Costs of the review are to be paid as agreed to by the parties.
6. A dispute over a charge can include the reasonableness of the charges. It may also include
the necessity of the charge.
7. A contested case proceeding may be commenced only after these steps for dispute
resolution have been followed, and good faith efforts to resolve the dispute have failed. Such a
proceeding must be commenced within 30 days after written determination is made by the
reviewer.
8. Rule 876 IAC 10.3 does not prevent providers and insurers from developing other
procedures to informally resolve their disputes, if those procedures aid in the resolution of a
medical fee dispute.
If the process, detailed in rule 876 IAC 10.3, does not resolve the dispute and the parties have
attempted resolution in good faith, a contest case may be initiated, pursuant to rule 876 IAC
4.46. The following applies to contested cases regarding medical fee disputes:
1. Evidence is filed at the time the contested case is initiated and is limited to that provided by
the reviewer, and the determination made by the reviewer.
2. The commissioner may request or allow additional evidence.
3. If a brief is to be filed, it needs to be filed at the time the matter is commenced.
4. The opposing party has 30 days from the date of service of the petition, to file a response
and optionally a brief. (8-4-08)
| General Information |
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| Work Comp News and Issues |
December 20, 2011:Iowa News: Workers'
Compensation Decisions // Iowa Supreme Court
Opinions // Iowa Court of Appeals Opinions //
Iowa State Bar Association
Compensation Decisions // Iowa Supreme Court
Opinions // Iowa Court of Appeals Opinions //
Iowa State Bar Association
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