Oklahoma

Fee Schedule

January 20, 2012: Oklahoma News: PUBLIC
HEARING on the PHYSICIAN
GUIDELINES REGARDING THE SPINE
AND THE PROPOSED OKLAHOMA
TREATMENT GUIDELINES FOR THE
USE of SCHEDULE ll DRUGS

December 01, 2011: Oklahoma: News:
NOTICE OF PUBLIC HEARING on the
SCHEDULE OF MEDICAL and
HOSPITAL FEES

General Information

Publications

Work Comp News and Issues

Medical Control

The employer has the right to direct an injured employee's initial medical provider
for all non-emergency medical care as long as the treatment is provided within three
(3) days of the employer's actual knowledge of injury. Employers with Certified
Workplace Medical Plans will select a treating provider for the injured employee.
Injured employees not subject to a plan may select their own provider if that
provider has maintained an injured employee or the employee's family member's
medical records prior to the injury and can provide documentation to support the
prior 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.

State Fee Schedule

PURPOSE AND APPLICATION: Stop-loss is an independent reimbursement
methodology that will reimburse the hospital for unusually costly services rendered
during treatment to an injured worker. No charge attributable to implantables shall
be considered for purposes of determining eligibility for, and reimbursement under,
stop-loss.

b. COMPUTATION OF THE MAXIMUM ALLOWABLE
REIMBURSEMENT UNDER
STOP-LOSS: To be eligible for the stop-loss payment, the total audited charges for
the hospital in-patient stay, excluding charges attributable to implantables, must be
at least Seventy Thousand Dollars ($70,000.00), the minimum stop-loss threshold.
If the total audited charges for the hospital in-patient stay equal or exceed the
minimum stop-loss threshold, the total audited charges are then multiplied by
seventy percent (70%) to determine the maximum allowable reimbursement. For
purposes of this calculation, “audited charges” do not include any charges for
implantables since implantables are reimbursed separately under Ground Rule 4 of
these ground rules.

A good faith effort shall be made by the selfinsured employer or insurance carrier to
pay all
charges, or the portion of all charges which are in compliance with the Schedule of
Medical Fees. All medical charges which are in compliance with the Schedule of
Medical Fees should be paid within thirty (30) days after such charges are
submitted to the self-insured employer or insurance carrier. If such good faith
payment is not m ade within sixty (60) days of the charges being submitted, and the
issue of compensability of the injury, necessity of treatment, or other issues
requiring a judicial determination are not raised before a Judge of the Workers'
Compensation Court, the Schedule of Medical Fees will become applicable only if
ordered by a Judge of the
Workers' Compensation Court. Charges disputed due to conflicting interpretation of
the Schedule of Medical Fees may be submitted to the Administrator by the medical
provider to determine the proper amount due in accordance with the Schedule of
Medical Fees.

A request for Administrative Review of disputed medical charges may be made by
filing a Form 18, REQUEST FOR ADMINISTRATIVE REVIEW OF DISPUTED
MEDICAL CHARGES. A copy of the Form 18 and all supplemental materials
shall be sent by the medical provider to the self-insured employer or the insurance
carrier. A copy of the actual medical bill in dispute must include dates of service,
procedure codes, charges for services rendered and any payment received, and an
explanation of unusual services or circumstances. When a Form 18 is received by the
Administrator and it is determined that the Workers' Compensation Court lacks
jurisdiction in the matter,a Submission Form shall be forwarded to the selfinsured
employer or insurance carrier to be signed and returned by their authorized legal
representative before the Form 18 will be reviewed.
When the Form 18 is received by the Administrator and it is determined that the
Workers'
Compensation Court has jurisdiction over the cause of action, all parties will be
notified by mail.

All parties shall have thirty (30) days from the date of notificatio n to submit
further evidence,
documentation, or clarifications to the Administrator. After thirty (30) days, a
decision will be determined by the Administrator and an order will be issued. Prior
to this determination, the Administrator may request all parties to attend a hearing
on the matter. Any party feeling aggrieved by the order of the Administrator shall
have ten (10) days to appeal the ruling to a Judge of the Workers' Compensation
Court. A decision must be entered by the
Administrator before any appeal m ay be brought.

COMPUTATION OF MAXIMUM ALLOWABLE REIMBURSEMENT: The
maximum
allowable reimbursement per in-patient stay shall be computed as follows:
MAXIMUM ALLOWABLE REIMBURSEMENT = Medicare MS-DRG Relative
Weight
x $4,140.80.

OKLAHOMA WORKERS COMPENSATION
COMPREHENSIVE PUBLICATIONS AND INFORMATION
FOR INDUSTRIAL INJURIES