6.05: Utlization Reporting
(1) Providers must use, and insurers must accept, standard forms prescribed by the DIA, based on the most recent Center for Medicare and Medicaid Services forms.
(2) The Department may require utilization review agents to provide a sample of up to 100% of all billing records, both inpatient and outpatient, which sample shall be transmitted to the Department of Industrial Accidents so that the Department can implement appropriate utilization oversight. In addition to the standard billing file, for every outpatient service the Department may request information about the insurer, any procedures, and the employer's and provider's identification numbers. For inpatient services, the Department must receive all relevant diagnostic and procedure International Classification of Disease (ICD) codes, Current Procedural Terminology (CPT) and other codes, the length of stay and the cost of any ancillary services. The Department may require both counts of services as well as the amount reimbursed.