RULE 19. DISPUTES BETWEEN PROVIDERS AND PAYORS
By virtue of the authority vested in the Commission pursuant to Idaho Code § § 72-508 and 72-707, the Industrial Commission of the State of Idaho hereby adopts this judicial rule of procedure governing the resolution of disputes between providers and payors.1 A "dispute" means a disagreement between a provider and a payor over whether any charge for medical services is acceptable pursuant to the provisions of the administrative regulation applicable at the time a charge was incurred.2 The definitions set forth in IDAPA 17.01.01.010 are incorporated by reference as if fully set forth herein.
B. Compliance Prerequisite.
In order to commence the dispute resolution process, a provider must have complied with the applicable procedures preliminary to dispute resolution set forth in IDAPA 17.01.01.803.06
Motions or responses by any party may be submitted in writing by hand delivery to the Boise Office at the Chinden Campus 11321 W. Chinden Blvd. (Bldg. #2), Boise, Idaho 83714, faxed to 208-334-2321, mailed via USPS to P.O. Box 83720, Boise, Idaho 83720-0041, or emailed to email@example.com. Email requests will be considered as an original document. Additional original documents are not required.
Required documents shall be served on parties by mail, fax, or personal delivery.
The Commission will use this dispute resolution process to determine whether the providerâ€™s charge is acceptable pursuant to the provisions of IDAPA 17.01.01.803.02 - .05.
E. Dispute Resolution Process.
a. Provider - If a provider has received from a payor a final objection to all or part of a provider's bill, or if 45 days have passed from the date provider sent the bill without response from payor, the provider may file with the Commission and serve on the payor a request for approval of the disputed charge. If a payor has finally objected to more than one charge in a single billing, the provider may seek approval of all such charges in a single motion.
(i) Form. The provider shall file such request on the form provided in Appendix 6A and attach thereto affidavits or other documents evidencing facts sufficient to show that the charge in dispute is acceptable pursuant to the applicable regulation. If the dispute is over a charge that does not have a CPT code or a conversion factor, the Provider will provide evidence of the provider's usual charge for that medical service to non-industrially injured patients.
(ii) Timing. Such request must be filed with the Commission and served on the payor within 30 calendar days of the date the provider receives the payor's final objection, or within 90 days from the date provider sent the bill to payor if payor has not responded. A provider's failure to timely file a request for the disputed charge shall forever bar the provider from seeking the Commission's approval of any charge as to which a final objection has been made.
b. Payor - A payor served with a request for the disputed charge shall file a response with the Commission, together with affidavits and/or other documents evidencing facts sufficient to show that the charge in dispute is not acceptable pursuant to the applicable regulation. The response and accompanying documents shall be served on the provider within 21 calendar days of the date it receives the provider's motion. If no response is filed and served within the time provided herein, the Commission shall enter a default in favor of the provider and the charges will be deemed acceptable.
2. Commission Staff Review.
When the time for filing a response has passed, the Commission shall refer all pleadings and supporting documents filed by the parties to a Commission staff member or members for administrative review and disposition.
a. Review. The Commission's staff shall review the pleadings and supporting documents as well as all other relevant information. The weight to be placed on any evidence considered by the Commission's staff shall be solely within the staff's independent judgment.
b. Administrative Order. The Commission staff will issue an administrative order ruling on the motion for disputed charge. The administrative order shall state the reasons therefor and shall be filed with the Commission and served on all parties
c. Compensation for Costs and Expenses. If Providerâ€™s motion disputing CPT or MS-DRG coded items prevails, an additional thirty percent (30%) shall be added to the amount found by the Commission to be owed as compensation for Providerâ€™s costs and expenses associated with using the dispute resolution process as set forth in IDAPA 17.01.01.803.06(i).
In the case of a prevailing motion disputing items without CPT or MS-DRG codes, the additional thirty percent (30%) shall be due only if the Payor does not pay the amount owed within thirty (30) days after the date of the Administrative Order.
The provider shall give written notice to the Commission that the Administrative Order remains unpaid after thirty (30) days. The written notice is to be copied to the in-state insurance adjuster and/or self-insured employer, whichever is appropriate.
The Commission will await a response from Payor for five business days to allow confirmation that payment was properly made. After such time has expired without payment confirmation, the Commission shall issue a Second Administrative Order to the Payor awarding the additional 30% penalty amount.
a. De Novo Review. Any party aggrieved by the administrative order issued by the Commission staff may, within 20 days of the date the administrative order is entered, file for reconsideration seeking de novo review by the Commission, stating with specificity the reason(s) therefor and shall serve a copy on the opposing party. The other party shall have 10 days to file a response to the motion, and the aggrieved party shall have 5 days to file a reply to the response. On filing for reconsideration, and where the Commission determines that the interests of justice will be served by further review, the Commission may conduct a de novo review of the record to determine whether the interests of justice have been served by the administrative order, or may remand the matter to Commission staff for de novo consideration and entry of an additional administrative order.
(i) Record. The record shall include all pleadings and exhibits filed with the Commission, any other information relied on by the Commission staff, and the administrative order.
b. Opportunity to Present Additional Evidence.
(i) Any party desiring to submit additional evidence must submit it with the reconsideration or response thereto. Additional evidence may not be submitted with a reply to a response. The party submitting the evidence must demonstrate good cause why the evidence was not submitted with the motion for disputed charge. Good cause will be based on whether the evidence was newly discovered or not available when the motion for a disputed charge was submitted, or excusable neglect. If the party fails to show good cause, the evidence will not be considered.
(ii) The Commission shall issue an order ruling on a request to augment the record. If the Commission grants such request, it shall establish a schedule and method whereby such additional evidence may be presented.
c. Order. After a de novo review of the record and, where applicable, review of additional evidence, the Commission shall issue an order on the reconsideration.
1. This Judicial Rule stands on its own and does not incorporate by reference any other Judicial Rule promulgated by this Commission.
2. This process shall be used solely for resolving disputes between providers and payors over whether any charge for medical services is acceptable pursuant to the provisions of the administrative regulation applicable at the time a charge was incurred. It shall not be used to resolve disputes regarding the reasonableness, necessity or appropriateness of medical treatment. Reasonableness of treatment includes such issues as whether the number, provider, type or style of treatments is appropriate. Those issues may be raised by means of a Complaint filed with the Commission.