Sec.31-280-3. Practitioner fee schedule

(a) Definitions

For purposes of section 31-280-3 governing practitioner fee schedule, the following definitions apply:

(1) "Chairman" means the Chairman of the Workers' Compensation Commission.

(2) "CPT Code" means the descriptive terms and identifying codes used in reporting services and procedures performed by Practitioners as listed in the American Medical Association's Physician's Current Procedural Terminology (CPT).

(3) "Dispute Resolution Panels" means the three-member panels appointed by the Chairman pursuant to subsection (e) (2) of these regulations to consider and resolve disputes regarding CPT Code assignment or other claims and payment issues.

(4) "Employer" means any employer subject to the requirements of the Workers' Compensation system as further defined in Conn. Gen. Stat. 31-275 (10).

(5) "Annual Increase" means the annual percentage increase in the consumer price index for all urban workers which according to Public Act 93-228 shall be applied to the Practitioner Fee Schedule as a limit on the annual growth in total medical fees.

(6) "Payor" means any person, corporation, firm, partnership, other entity, or the State of Connecticut and any public corporation within the State that, based on statutory obligation or contract, makes payment to Practitioners for services provided to employees under the Workers' Compensation system, including but not limited to insurance companies, self-insured employers, and mutual insurance associations or trusts.

(7) "Practitioner" means any health care practitioner authorized by the Workers' Compensation Commission to provide services to eligible employees under the Workers' Compensation Act.

(8) "Practitioner Billing and Payment Guidelines" means the manual prepared and published by the Chairman in accordance with Public Act 93-228 to set guidelines for the billing, claims payment review, and payment process for Practitioners, Payors and Reviewers.

(9) "Practitioner Fee Schedule" means the schedule of payments to Practitioners which is established, published, and updated annually by the Chairman in accordance with these regulations.

(10) "Reviewer" means any person, corporation, firm, partnership or other entity, which may be a Payor or a third-party entity acting on behalf of a Payor, that reviews, examines, evaluates or makes recommendations for payment of any bills, claims or fees submitted by a Practitioner to a Payor under the Workers' Compensation system. The term "Reviewer" shall not apply to individual employees of a Reviewer company providing claims payment review services.

(b) Practitioner Fee Schedule

(1) The Chairman shall establish, publish and update annually in accordance with section 31-280-3 a Practitioner Fee Schedule.

(2) No later than sixty (60) days following the effective date of section 31-280-3, the Chairman shall establish a Practitioner Fee Schedule listing fees by CPT Codes. Such Practitioner Fee Schedule shall be calculated from a data base consisting of current charge data (collected within the past year). Such data may be broadly based and may include health and accident claims as well as Workers' Compensation claims. Such data base shall include representative data from the entire State of Connecticut. Practitioner fees shall be uniform throughout the State. Separate conversion factors may be established for surgical, medical, radiology; pathology, anesthesiology and other types of services or claims as determined by the chairman.

The Practitioner Fee Schedule for physicians shall be established as the 74th percentile level of the data base of statewide charges. The fee schedule for non-physician practitioners billing under the same CPT Code, except for physical medicine, shall be seventy percent (70%) numerically of the Practitioner Fee Schedule for physicians. The fee will be determined by the licensure of the practitioner providing the service, not the licensure of the practitioner billing for the services.

The Chairman may contract with a private data company (1) to obtain statistically valid and reliable charge data, conversion factors, unit values, and follow-up days; and (2) to consult in establishing and updating the Practitioner Fee Schedule.

(3) The Practitioner Fee Schedule shall be adjusted and published annually with respect to the factors listed in subsection (b) (2) of section 31-280-3, upon consultation with the Medical Advisory Board and subject to the Annual Increase limit established by Public Act 93-228.

(4) Except where the Practitioner and Payer have entered into a specific written agreement providing otherwise, Provider charges for medical services provided to employees under the Workers' Compensation System shall be recognized in accordance with these regulations and the Practitioner Billing and Payment Guidelines and payable up to the Practitioner Fee Schedule. Except as otherwise provided by contract, the Practitioner Fee Schedule shall be the maximum permissible payment amount.

(c) Medical Advisory Board

(1) The Medical Advisory Board shall advise the Chairman concerning the ongoing development and updating of the Practitioner Fee Schedule established and updated pursuant to these regulations. The Board shall review and assist the Chairman in the implementation of the Practitioner Fee Schedule, the management of disputes, issues concerning communications with Practitioners (including explanations of benefits), and any other issues that arise regarding payment review.

(2) The Medical Advisory Board shall annually review the Practitioner Billing and Payment Administration Guidelines and recommend any necessary changes.

(d) Practitioner Billing and Payment Guidelines

(1) Pursuant to Public Act 93-228, the Chairman shall publish Practitioner Billing and Payment Guidelines. Such guidelines shall govern the billing, claims payment review, and payment process for Practitioners, Reviewers and Payors. The Medical Advisory Board shall assist the Chairman in accordance with Subsection (c) (2) of section 31-280-1.

(2) Practitioners shall bill for Workers' Compensation services using CPT Codes and the Practitioner Billing and Payment Guidelines.

(3) The guidelines shall require that Practitioners submit all bills using the HCFA 1500 form or its current equivalent beginning no later than October 1, 1993.

(4) Practitioners shall use a system of global billing for surgery claims, combining office visits with surgical fees in accordance with the guidelines.

(5) Additional areas to be covered by the guidelines include but shall not be limited to procedures for billing and payment, assignment of CPT Codes, and retention of billing documentation by Reviewers and Payors.

(e) Dispute Resolution

(1) Each Payor shall establish an internal mechanism for resolving disputes regarding CPT Code assignment, claims payment review and other payment issues. A written description of such dispute resolution mechanism shall be filed with the Chairman not later than sixty (60) days following the effective date of these regulations and shall be provided by the Payors to Practitioners upon request. The dispute resolution mechanism shall provide for a Payor response no later than 60 days from the submission of the dispute by the Practitioner.

(2) Effective no later than sixty (60) days following the effective date of these regulations, the Chairman shall maintain a list of members to serve on the Dispute Resolution Panels. Such Dispute Resolution Panels shall resolve issues that cannot be resolved through the internal mechanisms established by Payors. Each panel shall consist of three members appointed by the Chairman: one Reviewer or Payor representative, one Practitioner representative, and one representative from the Commission. Payor representatives shall be appointed from lists of nominations provided by the Connecticut Business and Industry Association and the Insurance Association of Connecticut. Practitioner representatives shall be appointed from a list of nominations provided by the professional society that represents the Practitioner, i.e., the Connecticut State Medical Society, the Connecticut Chiropractic Association, or the Connecticut Physical Therapy Association.

(3) A Practitioner may request review of unresolved payment issue disputes by submitting a written request for review to the Chairman and the Payor. Within 21 days following receipt of such request, the Payor, or a Reviewer acting on behalf of the Payor, must forward all supporting documentation for the claim to the Dispute Resolution Panel.

(4) The Dispute Resolution Panel will consider the evidence previously submitted in the internal dispute resolution process and, at the discretion of the Panel, other relevant factors (which may include utilization). Any party may submit written argument with copies provided to other parties, but may not submit new evidence as part of such review unless permitted by the Panel.

(5) The Dispute Resolution Panel shall consider the matter and issue a written determination within 90 days following receipt of the request for review. The determination of the Dispute Resolution Panel shall be final and the only appeal shall be in accordance with section 31-301 of the Connecticut General Statutes.

(Effective January 31, 1994)