This rule has been repealed.

This rule has been repealed.

This rule has been repealed.

This rule has been repealed.

This rule has been repealed.

(2) An order may be issued without a hearing:

(a) as a result of action initiated by the department;

(b) as part of the department's response to inquiries from the public and which leads to a department investigation;

(c) as a result of department investigation, mandated statutorily; or

(d) as a result of the receipt of a petition requesting an order.

(3) Any department order issued pursuant to this rule without a hearing may be appealed in the manner provided by law. Appeals can be made to the workers' compensation court after prior statutory remedies have been exhausted (see ARM 24.5.101) .

(a) Before a party may request a contested case hearing on an order which is issued by the uninsured employers' fund without a hearing and establishes only the amount of penalty owed and no other issue, the party must first obtain an administrative review of that order pursuant to ARM 24.29.206.

(b) Department determinations rendered by the independent contractor central unit regarding employment status issues are not considered department orders for purposes of these rules. These determinations are issued pursuant to ARM Title 24, chapter 35, subchapters 2 and 3.

(a) receipt of a petition for administrative review which must contain:

(i) the name and address of the petitioner;

(ii) a short, plain statement of the petitioner's contentions; and

(iii) a statement of the resolution the petitioner is seeking; or

(b) receipt of a written mutual request by all of the parties to the dispute to agree to waive the formal contested case proceedings until an administrative review is conducted in accordance with 2-4-603 , MCA.

(2) An administrative review caused by a petition pursuant to ARM 24.29.206(1) (a) includes:

(a) at the discretion of the petitioner, an informal conference with the department by telephone or in person at the department office in Helena; and

(b) a review by the department of all relevant facts and applicable laws involved in the action by the department. Such a review is not subject to the Rules of Civil Procedure or the Rules of Evidence.

(c) Upon completion of the informal conference and review, the department shall issue a notice to the parties in a timely manner.

(3) An administrative review caused by a petition and waiver of formal proceedings pursuant to ARM 24.29.206(1) (b) must be conducted as an informal proceeding in accordance with the provisions of 2-4-604 , MCA.

(4) The department may rescind, alter or amend any action at any time during the administrative review, in which case a contested case hearing will not be held unless a party does not concur with the notice and requests the hearing be held.

(1) Except as provided in (2), parties having a dispute involving legal rights, duties, or privileges, where the dispute is one over which the department has jurisdiction to hold a hearing, must bring the dispute to the department for a contested case hearing.

(2) The following disputes are required to follow the administrative rules on mediation before proceeding as provided by statute to either a contested case hearing before the department or a case in the workers' compensation court:

(a) disputes over benefits available directly to a claimant under Title 39, chapter 71, MCA;

(b) disputes between an insurer and a medical service provider regarding medical services provided; and

(c) disputes involving a determination of the independent contractor central unit regarding the issue of whether a worker is an independent contractor or an employee.

(3) A contested case concerning employment classifications assigned to an employer by a Plan 2 or Plan 3 insurer is administered by the classification review committee in accordance with 33-16-1012, MCA.

(4) A contested case held by the department under Title 39, chapters 71 or 73, MCA, is administered by the department in accordance with ARM 24.2.101 and 24.29.201(2).

This rule has been repealed.

This rule has been repealed.

This rule has been repealed.

(2) The test for determining whether an individual is acting as an independent contractor for workers' compensation purposes is that found at ARM 24.35.301 through 24.35.303.

(3) Notwithstanding the provisions of ARM 24.29.213(1) , an individual may apply to the department for an exemption from the Workers' Compensation Act pursuant to the provisions contained in ARM Title 24, chapter 35, subchapter 1.

(2) A party seeking a contested case hearing under ARM 24.29.207 must make a written request to the department for a contested case hearing within 10 days of notice of the results of an administrative review or within 30 days of notice of adverse action.

(3) A party seeking judicial review of a final order of the department after a contested case hearing must file a petition with the workers' compensation court within 30 days after notice of the final order.

(4) A party is considered to have been given notice on the date a written notice is personally delivered or 3 days after a written notice is mailed. A request for administrative review, contested case hearing or judicial review must be received in the department or court within the time limits set forth above. The time limits for request for administrative review or contested case hearing may be extended by the department for good cause.

(1) For purposes of Title 39, chapter 71, MCA, except those which require a signature under oath, the department accepts electronic signatures as follows:

(a) an electronic scan or photocopy of a manual signature for documents transmitted to the department by fax or attached to electronic mail or File Transfer Service in portable document format; or

(b) a signature properly authenticated and verified by an electronic signature for which appropriate auditable records are available. Audit reports or records supporting the signature must be produced to the department upon request.  

(2) An insurer may, at its discretion, require a document being submitted directly to it to bear an original manual signature.

For the purposes of ARM Title 24, chapter 29, subchapter 6, the following definitions apply:

(1) "Ability to pay" means sufficient financial strength and stability to:

(a) pay debts as they mature;

(b) pay benefits and all liabilities which are likely to be incurred under the Workers' Compensation Act, and the Occupational Disease Act for occupational diseases that occurred prior to July 1, 2005; and

(c) have sufficient cash or cash equivalents, security deposit, and excess insurance to pay benefits as they come due.

(2) "Applicant" means an employer or employer group that makes an election to self-insure under compensation plan no. 1, regardless of whether the election is a new election or a renewal of a prior election.

(3) "Audited financial statements" means a set of documents that includes the applicant's: income statement, balance sheet, statement of cash flow, notes to the financial statements, and a signed, dated independent certified public accountant's independent audit report.

(4) "Benefits" means wage loss, legal, medical, rehabilitation, and all other benefits that are payable under the Workers' Compensation Act and the Occupational Disease Act (Title 39, chapter 72, MCA) for occupational diseases that occurred prior to July 1, 2005, including assessments or financial obligations.

(5) "Claims summary" means a compilation of information relating to prior and existing claims made under the Workers' Compensation Act and the Occupational Disease Act for occupational diseases that occurred prior to July 1, 2005, by showing by policy year, the total number of medical and indemnity claims, total benefits paid, and the total amount reserved for future liabilities.

(6) "Department" means the Montana Department of Labor and Industry.

(7) "Employer" means an "employer" as defined in 39-71-117(1), MCA, except those state agencies that are excluded from the definition pursuant to 39-71-403, MCA.

(8) "Employer group" means employers engaged in the same trades, businesses, occupations or professions who are members of an association which was formed for purposes other than becoming a self-insurer and has existed for a period of at least two years.

(9) "Guaranty fund" means the Montana self-insurers guaranty fund, established pursuant to 39-71-2609, MCA.

(10) "Occupational Disease Act" means Title 39, chapter 72, MCA, as it existed prior to July 1, 2005.

(11) "Public employer" means a city, county, city and county, school district, irrigation district, all other districts established by law, and all public corporations and quasi-public corporations and public agencies therein.

(12) "Reviewed financial statements" means a set of documents that includes the applicant's:

(a) income statement;

(b) balance sheet;

(c) statement of cash flow;

(d) notes to the financial statements; and

(e) a signed, dated statement from an independent certified public accountant expressing limited assurance that there are no material modifications that should be made to the statements, in order for them to be in conformity with generally accepted accounting principles.

(13) "Workers' Compensation Act" means Title 39, chapter 71, MCA.

(1) The department's approval of requests from private applicants to self-insure is contingent upon the acceptance of membership in the guaranty fund in accordance with 39-71-2609, MCA. Public employers and groups of public employers are not eligible for membership in the guaranty fund, and the guaranty fund has no role in the approval of decisions regarding the eligibility of public employers or groups of employers to self-insure, or in the amount of security required.

(2) The department will exchange information with the guaranty fund regarding financial statements, security deposit requirements, excess insurance requirements and any other information pertinent to the department's review of the application.

(3) The guaranty fund shall demonstrate its concurrence or nonconcurrence with department approval of a private plan no. 1 applicant by submitting in writing to the department, a formal acceptance or denial of the plan no. 1 applicant.

(4) If the department does not approve an applicant to self-insure, or if the guaranty fund does not accept the applicant as a member, then the applicant may not be granted permission to self-insure under plan no. 1.

(1) The provisions of ARM Title 24, chapter 29, subchapter 6 apply to public employers and public employer groups, other than state agencies as defined in 39-71-403, MCA, except that the guaranty fund has no involvement in department decisions regarding public employers or public employer groups.

(1) Employers or employer groups electing to be self-insured shall demonstrate ability to pay benefits as required by the Workers' Compensation Act. The determination of the ability to pay is determined based on an analysis by the department, with the concurrence of the guaranty fund as provided by law. The employer or group shall provide the department with:

(a) audited financial statements;

(b) evidence of excess insurance, if required;

(c) a security deposit, if required;

(d) an agreement (or parental agreement) of assumption and guarantee of workers' compensation and occupational disease liabilities, on forms prescribed by the department, if required; and

(e) other documentation as required by the department.

(2) An employer electing to self-insure that does not have audited statements prepared as a normal business practice may, with the prior approval of the department, and the concurrence of the guaranty fund, substitute reviewed financial statements for audited financial statements if the employer furnishes an increased security deposit.

(3) The department will analyze the information provided by the employer or employer group. The analysis will include review of excess insurance, security deposit and financial conditions, current and historical, related to their ability to pay compensation benefits.

(1) A security deposit must be deposited with the department by the applicant on order of the department, with the concurrence of the guaranty fund.

(2) The security deposit requirement may be waived in whole or in part by the department, with the concurrence of the guaranty fund, for applicants who provide substantive evidence that the statutory amount of the security deposit is not needed. This evidence must reflect the applicant's ability to pay the benefits provided for in the Workers' Compensation Act, and the Occupational Disease Act for occupational diseases that occurred before July 1, 2005.

(3) A self-insurer that does not have sufficient securities on deposit with the department, with which to pay benefits, shall be required to furnish additional security.

(1) When a security deposit is required under ARM 24.29.610, it may be a surety bond, government bond, letter of credit, or certificate of deposit acceptable to the department and the guaranty fund. When a security deposit is required, the following criteria apply:

(a) The department shall accept a surety bond only from companies certified by the United States Department of Treasury as "Companies Holding Certificates of Authority as Acceptable Sureties on Federal Bonds and as Acceptable Reinsuring Companies," as published in the most recent Federal Register.

(i) A surety bond issued by a company that has a Best's rating of "A" or better and a financial size rating of X or greater will be approved.

(ii) A surety bond issued by a company that is rated by Best's, but does not meet the criteria specified in (1)(a)(i) will be considered for approval at the discretion of the department, with the concurrence of the guaranty fund.

(iii) A surety bond issued by a company not rated by Best's will be considered for approval at the discretion of the department, with the concurrence of the guaranty fund.

(b) The security deposit must name the department as obligee and must be held by the department as security for payment of all liabilities likely to be incurred under the Workers' Compensation Act, or the Occupational Disease Act for occupational diseases that occurred before July 1, 2005. The department, with the concurrence of the guaranty fund, shall retain a security deposit until all liabilities have been paid. In the event liabilities have not been met by the self-insurer, the department shall proceed pursuant to 39-71-2108, MCA. If the self-insurer has placed multiple forms of security deposits, the department shall, at its discretion, convert the deposits needed to pay claims.

(c) A security deposit in the form of a surety bond or letter of credit must include a statement that the grantor of the security deposit is required to give to the principal, the department and the guaranty fund, 60 days notice of its intent to terminate future liability. The grantor of the security deposit is not relieved of liability for injuries occurring prior to the effective date of termination.

(d) The security deposit must be issued on the forms prescribed by the department.

(e) A security deposit in the form of a certificate of deposit must be issued by a financial institution located within the United States and must be fully insured by a federally chartered insurance corporation.

(f) Letters of credit must be issued by a financial institution located within the United States with investment grade ratings issued by Moody's Investors Service, Standard & Poor's, or Fitch Ratings. If ratings from those rating entities are not available, the approval of the financial institution will be made at the discretion of the department, with the concurrence of the guaranty fund.

(1) Specific excess insurance is required of an employer or an employer group electing coverage under plan No. 1.

(2) Aggregate excess insurance is required by the department, with the concurrence of the guaranty fund, for an employer or an employer group unless substantive evidence is provided that it is not warranted. This evidence must include diversification of risk, industry type, financial resources, self-insured retention levels, policy limits of the specific excess policy, safety program, loss experience and other appropriate factors as determined relevant by the department, with the concurrence of the guaranty fund.

(3) The contract or policy of specific excess insurance and aggregate excess insurance must comply with the following:

(a) It is issued by a carrier admitted and licensed in Montana with a Best's Rating of A- or better and a financial size rating of VI or greater. Excess coverage issued by a carrier not rated by Best's will be considered for approval at the discretion of the department, with the concurrence of the guaranty fund.

(b) A self-insurer that anticipates that it may have material changes to the provisions or coverage of its excess insurance policy must notify the department of that possibility at least 30 days before the effective date of the changes.

(i) If there is a change in the provisions or coverage, the department has the authority to evaluate the changes related to the terms of the authorization to self-insure, and the department may, with the concurrence of the guaranty fund, make adjustments in the terms of that authorization accordingly.

(ii) In the event of a temporary extension of authority, the department may condition the renewal of self-insurance authority upon a suitable change in the amount of security required from the self-insurer.

(c) It may be canceled or its renewal denied only upon written notice by registered or certified mail to the other party to the policy and to the department and the guaranty fund, not less than 60 days before termination by the party desiring to cancel or not renew the policy. A carrier is liable for payment of all claims that occur from the date of inception of the policy to the cancellation date of the policy.

(d) Any contract or policy containing a commutation clause must provide that any commutation effected thereunder will not relieve the underwriter or underwriters of further liability in respect to claims and expenses unknown at the time of such commutation or in regard to any claim apparently closed at the time of initial commutation which is subsequently reopened by the department or a court. If the underwriter proposes to settle the liability as provided in the commutation clause of the policy for future compensation benefits payable for accidents or occupational diseases occurring during the term of the policy by the payment of a lump sum to the self-insurer, then not less than 60 days prior notice to such commutation must be given by the underwriter(s) or agent(s) by registered or certified mail to the department and the guaranty fund. If any commutation is effected, the department with the concurrence of the guaranty fund, shall have the right to direct such sum be placed in trust for payment of benefits of the injured employee(s) entitled to such future payments.

(e) If a self-insurer becomes insolvent and, or, fails to make benefit payments, the excess carrier, after it has been determined the retention level has been reached on the excess insurance policy, shall make payments to the entity making payments on behalf of the insolvent self-insured in the same manner as payments would have been made by the excess carrier to the self-insured.

(f) It must include an endorsement regarding late claim reporting penalty waiver.

(g) All of the following will be applied toward the retention level in the excess insurance contract:

(i) payments made by the self-insurer;

(ii) payments made on behalf of the self-insurer from the proceeds of any security deposit as ordered by the department; and

(iii) payments made on behalf of the insolvent self-insurer by the guaranty fund.

(h) Copies of the certificates and policies of the excess insurance must be filed with the department for a determination that such certificates and policies fully comply with the provisions of the Workers' Compensation Act, the Occupational Disease Act, and ARM Title 24, chapter 29, subchapter 6. 

(1) An employer initially electing to be bound as a self-insurer shall provide the following:

(a) a completed application on forms provided by the department;

(b) audited financial statements for the last two years, or, an employer that does not have audited financial statements prepared as a normal business practice may, with the prior approval of the department and the concurrence of the guaranty fund, substitute reviewed financial statements if the employer furnishes an increased security deposit approved by the department with the concurrence of the guaranty fund;

(c) proof that it has been in business for a period of not less than three years; however, at the discretion of the department, with the concurrence of the guaranty fund:

(i) a new employer created from the reorganization of a self-insured employer may elect to self-insure even though it has not been in existence for a period of three years. Such election must be made on the effective date of creation of the new employer;

(ii) an employer in business less than three years may be considered if its liability is guaranteed by a parent corporation which has been in business for a period of not less than three years. The department, with the concurrence of the guaranty fund, may accept a guarantee from an employer in lieu of a parental guarantee;

(iii) an employer whose liability is guaranteed by a parent corporation or an employer shall provide a resolution and an agreement of assumption and guarantee of workers' compensation liabilities on forms prescribed by the department and submit two years of audited financial statements demonstrating the ability to pay compensation benefits;

(d) evidence that it has obtained an insurance policy of specific excess and if required, aggregate excess insurance with policy limits, nature of coverage, and retention amounts acceptable to the department, with the concurrence of the guaranty fund, as required in ARM 24.29.616;

(e) a claims summary of claims incurred in Montana from insurance companies who provided coverage for the preceding three years;

(f) evidence that its internal or contracted claims adjustment service is in compliance with ARM 24.29.804;

(g) evidence that it has a written safety and loss control program;

(h) a security deposit in an amount required by the department with the concurrence of the guaranty fund;

(i) certification that the self-insurance plan is not funded by a regulated or unregulated insurance company;

(j) evidence that internal policies and procedures are satisfactory to administer a self-insurance program; and

(k) evidence of permission to self-insure in other states, if applicable.

(1) An employer group applicant shall provide the following:

(a) a completed application on forms provided by the department;

(b) a list of individual employers making up the employer group;

(c) a signed copy of the by-laws adopted by the employer group, and all documents pertaining to formation, operation and contractual arrangements, including amendments and addenda;

(d) a copy of an agreement signed by each individual employer showing:

(i) each employer's agreement to accept joint and several liability for all workers' compensation and occupational disease liabilities incurred by the employer group;

(ii) provisions for addition of a new member to the self-insured employer group;

(iii) provisions for withdrawal and expulsion of a member from the self-insured employer group;

(iv) provision for power of attorney between the individual employers and the self-insured employer group;

(v) agreement to be bound by the by-laws and by the employer group's decisions; and

(vi) provisions for assessment for deficits;

(e) a copy of at least the most recent year's audited financial statements, or reviewed financial statements, if audited statements are not prepared as part of the employer's normal business practice, from each member of the employer group. The total premiums payable to the group from employers having reviewed financial statements shall not constitute more than 10 percent of the group's total premium. The department or the guaranty fund may require copies of additional years' audited or reviewed financial statements from the applicant. Upon request of the applicant, and when approved by the department and the guaranty fund, the submission of these financial statements may be to an independent certified public accountant (CPA). The department will advise the CPA of the nature and format of the information to be provided to the department. The applicant shall pay the cost of such a submission and review;

(f) evidence that each private employer in the group has been in business for a period of not less than three years;

(g) a claims summary from insurance carriers who provided coverage for claims incurred in Montana for each member of the employer group for the preceding three years;

(h) evidence of specific excess and if required, aggregate excess insurance with policy limits and retention amounts acceptable to the department and guaranty fund;

(i) a security deposit in an amount as required by the department, with the concurrence of the guaranty fund;

(j) evidence of its internal or contracted claims adjustment service in compliance with ARM 24.29.804;

(k) identification of the financial institution the employer group will use to deposit and withdraw funds for purposes of paying workers' compensation and occupational disease liabilities;

(l) an explanation of how claims reserves will be established on each case and the method of review to assure accuracy and adequacy of the amount of the reserves;

(m) the estimated annual premium to be paid by each member of the employer group;

(n) a projection of annual administrative expenses;

(o) evidence that the employer group has an effective written safety and loss control program;

(p) evidence that internal policies and procedures are satisfactory to operate a group self-insurance program;

(q) resolution by each member authorizing participation in the program;

(r) resolution designating authorized signatures for participation in the program;

(s) a feasibility study conducted by a certified actuary to include an actuarial forecasting of losses and recommended premium levels;

(t) a business plan for the employer group;

(u) pro forma financial statements for each of the first five years of the employer group's operation, to include any assumptions made; and

(v) copies of any contracts including, but not limited to, contracts with an administrative service company, claims examiner, and fiscal agent.

(a) a completed application on forms provided by the department;

(b) resolution designating authorized signatures for participation in the program;

(c) a copy of a signed agreement showing:

(i) agreement to accept joint and several liability for all workers' compensation benefits and occupational disease obligations incurred by the employer group;

(ii) provision for power of attorney between the new applicant and the employer group; and

(iii) agreement to be bound by the by-laws and by the employer group's decisions;

(d) copies of additional years audited or reviewed financial statements may be required from each new applicant by the department or the guaranty fund. Upon request of the applicant, and when approved by the department and the guaranty fund, the submission of these financial statements may be to an independent certified public accountant. The department will advise the CPA of the nature and format of the information to be provided to the department. The applicant shall pay the cost of such a submission and review;

(e) the employer group may accept a new applicant who provides reviewed financial statements, provided the total premiums payable to the group from individual members having reviewed financial statements, including the new applicant, shall not exceed 25% of the employer group's total normal premium for the year the applicant joins the employer group;

(f) a claims summary from insurance carriers who provided coverage for claims incurred in Montana during the preceding 3 years;

(g) evidence that the applicant has been accepted for coverage by the employer group's excess insurance carrier; and

(h) evidence that the private employer has been in business for a period of not less than 3 years; however, a new entity created from the reorganization of one or more self-nsured entities may elect to self-insure individually or as a member of a employer group even though the new entity has not been in existence for a period of 3 years. Such election shall be made on the effective date of the new employer entity.

(1) An employer who has been self-insured may renew the election each ensuing year, by meeting all the requirements of these rules, except that the claims summary required in ARM 24.29.617(1)(e) must be a claims summary for the preceding year(s) for claims incurred as a self-insurer in Montana. Application for renewal must be made 60 days prior to the renewal date, or on such other date as determined by the department and the guaranty fund.

(a) In addition to the other information required in ARM 24.29.617, except as provided by (1)(b), the employer shall submit an independent actuarial analysis for the preceding year, completed by a qualified actuary as defined by the American Academy of Actuaries. The analysis must include, but is not limited to, a reserve analysis that includes all self-insured periods in Montana, through the most recent calendar year. Except as provided by (1)(c), the results of the analysis must be summarized at the low level, middle (or expected) level, and high level, with the corresponding confidence level expressly stated for each.

(b) The department may waive the requirement of (1)(a) with the concurrence of the guaranty fund.

(c) If the self-insurer believes a different actuarial methodology other than that of confidence level is better for its business needs, the self-insurer in association with its independent actuary must present facts to the department that substantiate its position before it receives approval from the department, with the concurrence of the guaranty fund, to use that different methodology.

(2) An employer group which has elected to be bound by plan no. 1 may renew the election for each ensuing year by meeting all the requirements of these rules, except ARM 24.29.618(1)(c), (1)(d), (1)(e), (1)(f), (1)(g), (1)(l), (1)(m), (1)(q), (1)(r), (1)(s), (1)(t), (1)(u), and (1)(v). Application for renewal must be made at least 60 days prior to the renewal date or on such other date as determined by the department and the guaranty fund. In addition to the information required in ARM 24.29.618, the employer group shall submit:

(a) a copy of the preceding year's audited financial statements for the self-insured group;

(b) a claims summary for the preceding years for claims incurred as a self-insurer in Montana; and

(c) an independent actuarial analysis for the preceding year, completed by a qualified actuary, as defined by the American Academy of Actuaries. Except as provided by (2)(d), the results of the analysis must be summarized at the low level, middle (or expected) level, and high level, with the corresponding confidence level expressly stated for each. The analysis must include, but is not limited to:

(i) a reserve analysis that includes all self-insured periods in Montana, through the most recent calendar year; and

(ii) a premium/rate analysis that projects the total premium need and average rate for the upcoming year which is adequate to cover:

(A) all expected workers' compensation liability costs, whether past, present, or future, with respect to claims previously incurred or claims expected to be incurred in the upcoming year; and

(B) administrative expenses.

(d) If the self-insured group believes a different actuarial methodology other than that of confidence level is better for its business needs, the self-insured group in association with its independent actuary must present facts to the department that substantiate its position before it receives approval from the department, with the concurrence of the guaranty fund, to use that different methodology.

(3) If a self-insurer does not renew its election, the employer(s) shall elect to be bound by compensation plan no. 1, plan no. 2, or plan no. 3 on the effective date of the termination of permission to self-insure.

(2) Suspension or termination of membership in the Montana self-insurers guaranty fund or failure to pay the department's annual assessment may result in automatic and immediate termination of the department's permission to self-insure in accordance with 39-71-2609 and 39-71-2105 , MCA.

(3) An employer or employer group which is self-insured under plan no. 1 which intends to withdraw as a self-insurer or withdraw the self-insurance status of any subsidiaries, or members, shall notify the department and the guaranty fund, in writing, of its intent at least 60 days in advance of the change in status. Until all liabilities have been paid, the employer or employer group remains subject to these rules.

(a) 60 days prior to implementing changes that may affect its self-insurance status including but not limited to:

(i) name, controlling ownership, legal status, change in proposed employer group membership, or permanent employment location;

(ii) permanent increase or decrease of more than 25% in the number of employees in Montana; or

(iii) changes in the policies, procedures or administration of its self insurance program; and

(b) within 30 days subsequent to:

(i) adverse material change in financial status;

(ii) adverse material change in liabilities;

(iii) permanent reductions, shutdowns, suspensions, or closures of Montana operations; or

(iv) new or additional location of employment in Montana as a result of a significant change of operations.

(a) make application for the transfer of the claims; and

(b) provide an actuarial analysis of the claims to be transferred.

(2) The transfer application and approval process and guidelines will be consistent with the application and approval process for all new or proposed self-insured entities as provided by part 21 of the Workers' Compensation Act and ARM Title 24, chapter 29, subchapter 6.

(3) The independent actuarial analysis of the employer's or group's claim liabilities must be made using the preceding year's data, including all years of self-insurance liabilities. The actuarial report must be completed by a qualified actuary as defined by the American Academy of Actuaries.

(4) After the transfer of claims liabilities is complete, the new owner of the claims liabilities will have the same reporting requirements as all other prior self-insureds in Montana.

This rule has been repealed.

This rule has been repealed.

This rule has been repealed.

This rule has been repealed.

This rule has been repealed.

This rule has been repealed.

This rule has been repealed.

This rule has been repealed.

This rule has been repealed.

This rule has been repealed.

This rule has been repealed.

This rule has been repealed.

This rule has been repealed.

This rule has been repealed.

This rule has been repealed.

This rule has been repealed.

This rule has been repealed.

(1) Any employer, except state agencies specified in 39-71-403, MCA, may elect coverage under plan No. 2 by owning an insurance policy that is in force, sold by a private insurance carrier authorized by the insurance commissioner's office to sell workers' compensation insurance in Montana.

(2) Any employer may elect coverage under plan No. 3 by owning an insurance policy that is in force, sold by the state compensation insurance fund.

(3) Insurance policies as required by (1) and (2) must include section 3A, on the Insurance Declaration page, evidencing Montana coverage.

(4) In order to meet the requirements of this rule:

(a) the insurance policy must list Montana as a state under whose laws coverage is provided; or

(b) section 3A of the coverage declarations page must expressly list Montana as a state under whose laws coverage is provided.

This rule has been repealed.

This rule has been repealed.

This rule has been repealed.

This rule has been repealed.

(a) Periodic review by the department of an insurer's future claims liabilities may result in an increase in deposit requirements pursuant to 39-71-2215, MCA.

(b) Upon proof from the insurer that its liabilities have been reduced, a reduction of the amount held on deposit by the department may be granted at the department's discretion. Requests for reduction in deposit may be submitted in writing to the department no more frequently than once every 12 months.

(c) The department may require 30 days advance written notice by the insurer of the insurer's intent to exchange one form of securities for another.

(d) Securities must remain on deposit until the department is satisfied all liabilities of the insurer arising under Title 39, chapter 71, MCA, have been met.

(2) A plan number two insurer may deposit one or more of the following securities to meet its obligation to make a security deposit as required by 39-71-2215, MCA:

(a) a United States Treasury note;

(b) a certificate of deposit; or

(c) an irrevocable letter of credit.

(3) The security deposit must be issued in the form prescribed by the department and must include a statement that the grantor of the security deposit is required to give the department 60 days advance notice of its intent to terminate future liability. The grantor of the security deposit is not relieved of the liability for claims arising under Title 39, chapter 71, MCA, prior to the effective date of the termination. Notice must be sent to the department via certified or registered mail.

(a) A security deposit in the form of a certificate of deposit must be issued by a financial institution located within the United States and must be fully insured by a federally chartered insurance corporation.

(b) A security deposit in the form of an irrevocable letter of credit must be issued by a financial institution located within the United States that is acceptable to the department, based on its financial ratings.

(4) The security deposit must name the department as obligee and must be held by the department.

(a) A safekeeping or custodial arrangement with a bank or trust company located in the city of Helena, Montana, may be authorized if:

(i) the department is satisfied such securities are held under the same conditions of security as if the securities had been deposited with the department; and

(ii) the department is satisfied the hours of business do not hinder department access to or ability to sell and/or collect on the securities.

(b) If the deposit of securities with the department will result in the need to handle the securities for exchange or remittance of coupons for collection of interest then the department, at its discretion, may require the securities be held in the safekeeping or custodial arrangement described above at the insurer's direct expense.

(5) The insurer is required to submit the following reports:

(a) a copy of the "Exhibit of Premium and Losses-Business in the State of Montana During the Year," from the insurer's annual statement of the preceding calendar year, as filed with the Montana insurance commissioner;

(b) a total summary of experience claim losses including, but not limited to, compensation and medical benefits and reserves for future liability as of May 1 of each year; and

(c) other reports and information as required by the department.

(6) The reports required by (5) must be filed with the department:

(a) upon the insurer's initial authorization by the Montana insurance commissioner's office to write workers' compensation insurance;

(b) by May 1 of each following year; and

(c) upon request of the department.

(a) the personal assistant is providing services to the disabled person pursuant to 53-6-145 , MCA, and rules adopted by the department of public health and human services implementing that statute; and

(b) the personal assistant is the employee of another person or entity that has the right to exercise an employer's control over the personal assistant, including the right to discipline and terminate employment.

(1) Effective January 1, 1993, payments made to an employee to reimburse the employee for ordinary and necessary expenses incurred in the course and scope of employment are not wages if all of the following are met:

(a) the amount of each employee's reimbursement is entered separately in the employer's records;

(b) the employee could reasonably be expected to incur the expenses while traveling on the business of the employer;

(c) the reimbursement is not based on a percentage of the employee's wages nor is it deducted from wages; and

(d) the reimbursement does not replace the customary wage for the occupation.

(2) Reimbursement for expenses may be based on any of the following methods that apply:

(a) for actual expenses incurred by the employee, to the extent that they are supported by receipts;

(b) for meals and lodging, at a flat rate no greater than the amount allowed to employees of the state of Montana pursuant to 2-18-501 (1) (b) and (2) (b) , MCA for meals, and 2-18-501 (5) , MCA for lodging, unless, through documentation, the employer can substantiate a higher rate;

(c) for mileage, at a rate no greater than that allowed by the United States internal revenue service for that year, provided that the individual actually furnishes the vehicle;

(d) for equipment other than vehicles, the reasonable rental value for that equipment, which for individuals involved in timber falling may not exceed $22.50 per working day for chain saw and related timber falling expenses;

(e) for heavy equipment, including but not limited to semi-tractors or bulldozers, the reasonable rental value may not exceed 75% of the employee's gross remuneration;

(f) for drivers utilized or employed by a motor carrier with intrastate operating authority, meal and lodging expenses may be reimbursed by either of the methods provided in (2) (a) or (b) for each calendar day the driver is on travel status; or

(g) for drivers utilized or employed by a motor carrier with interstate operating authority, meal and lodging expenses may be reimbursed by the methods provided in (2) (a) or (b) , or by a flat rate not to exceed $30.00 for each calendar day the driver is on travel status.

(1) For the purposes of this rule, the following definitions apply:

(a) "Agricultural employer" means an employer whose operations are assigned to an agricultural classification code for workers' compensation purposes. The term is intended to be consistent with the definition of agriculture provided by 15-1-101, MCA.

(b) "Bedroom" means a room in a dwelling that is primarily used for sleeping.

(c) "Dwelling" means a building equipped for human habitation.

(d) "Zero bedrooms" means a dwelling that is an efficiency, dormitory, or a bunkhouse.

(2) For the purposes of calculating wages pursuant to 39-71-123, MCA, the monthly fair rental value, in U.S. dollars, for housing is established for each county in Montana as specified in the publication entitled "Montana Workers Compensation Housing, Rent or Lodging Monthly Rates."

(a) The publication is available online via the department's web site, http://erd.dli.mt.gov.

(b) A printed copy of the publication is available to the public at no cost, upon request to the department's Employment Relations Division.

(3) In recognition of Montana's rural nature and expansive landscape, and the fact that housing supplied by an agricultural employer is likely to be remotely situated and distant from communities with an established rental housing market, housing furnished by an agricultural employer is discounted by 50 percent of the fair rental value for housing established in (2) of this rule, for the county in which the dwelling is located.

(4) If an individual is not currently using the room for sleeping, it is not considered a bedroom for the purpose of this rule.

(5) The provisions of this rule apply to housing furnished any worker.

(1) Upon notice of an accident, injury, or occupational disease an employer shall, within six days of such notice, submit to the employer's workers' compensation insurer or to the department, a completed form known as the first report of occupational injury/occupational disease.

This rule has been repealed.

This rule has been repealed.

(1) All workers' compensation and occupational disease claims filed pursuant to the Montana Workers' Compensation and Occupational Disease Acts must be adjusted by a certified claims examiner in Montana. For the purposes of this rule a certified claims examiner must maintain an office that is located in Montana and adjust Montana claims from that office. The office may be in the examiner's personal residence located in Montana. The sole use of a mail box or mail drop located in Montana does not constitute maintaining an office in Montana.

(2) An insurer must maintain the documents related to each claim filed with the insurer under the Montana Workers' Compensation and Occupational Disease Acts at the office of the person adjusting the claim in Montana until the claim is settled. The documents may either be original documents, or duplicates of the original documents, and must be maintained in a manner which allows the documents to be retrieved from that office and copied at the request of the claimant or the department. Settled claim files stored outside of the certified claims examiner's office must be made available by the insurer within 48 hours of a request for a file. Electronic or optically imaged documents are permitted by this rule.

(3) For purposes of (2), a "settled claim" means a department-approved compromise of benefits between a claimant and an insurer. The term "settled claim" does not include a claim where there has only been a lump sum advance of benefits.

(4) At least 14 days in advance of a change in a third-party administrator responsible for workers' compensation claim examination services, the insurer must notify the department in writing, using the department's current Third-Party Administrator Change Form or by another format preapproved by the department. The written notification must be mailed, faxed, or e-mailed to the department's designated contact person.

(5) The insurer may delegate the duty to notify the department to a third-party administrator.

(6) Failure to timely notify the department of a change in a third-party administrator may result in the imposition of an administrative penalty against the insurer, pursuant to 39-71-107, MCA.

This rule has been repealed.

This rule has been repealed.

This rule has been repealed.

This rule has been repealed.

This rule has been repealed.

For purposes of this subchapter, the following definitions apply:

(1) "Approved continuing education course" or "course" means any course, seminar, or program of instruction that has been approved by the department for presentation as part of the continuing education requirements for claims examiner certification and that relates to the state workers' compensation system or to interactions among injured workers, medical providers, and employers.

(2) "Certificate of completion" means a document issued by the sponsoring organization to the claims examiner signifying satisfactory completion of a course and reflecting credit hours earned by the claims examiner.

(3) "Certified claims examiner" means a claims examiner who is in compliance with the requirements of 39-71-320, MCA.

(4) "Claims examiner" means a claims examiner as defined under 39-71-116, MCA.

(5) "Credit hours" means the value assigned to a course by the department, upon review and approval of course materials and content outline.

(6) "Hour," for the purposes of continuing education credits, means a 50-minute period.

(7) "Instructor" means an individual who meets the requirements set forth in ARM 24.29.844, is identified by a sponsoring organization in a course submission, participates in course presentations, activities and discussions, and who may monitor the attendance and conduct of course participants, or administer examinations.

(8) "New hire" means a person who has:

(a) not been previously employed by the insurer or third-party administrator as a claims examiner;

(b) been separated from employment with the insurer or third-party administrator for at least 60 days and is required to complete new hire paperwork such as a Form I-9 or Form W-4; or

(c) received an internal promotion or transfer to a claims examiner position. The term includes a temporary employee.

(9) "Proctor" means a person who monitors the attendance, conduct, and the examination process for course participants, but who does not participate in course presentations, activities or discussions, or complete any required examinations.

(10) "Remote training" means a course format in which a body of students attend a training session using a web meeting tool and/or conference telephone service with a method approved by the department to ensure full participation of each student.

(11) "Self-study" means those independent study methods taught outside the classroom setting through approved text or prerecorded audio or video content, or another method of information exchange where both the means and content are approved by the department.

(12) "Significant change" means a change in two or more of the following course elements:

(a) course goals or objectives;

(b) major course topic(s);

(c) course length;

(d) syllabus or course outline;

(e) teaching method; or

(f) examination method.

(13) "Sponsoring organization" means any group(s) or organization(s) and their agent(s) that submit courses for department review and offer or provide approved courses for continuing education credit to allow claims examiner certification and are responsible for those course offerings.

(14) "Trainee" means an employee who has no prior claims examiner experience and is participating in a program by which the employer prepares the trainee to carry out the essential functions of a certified claims examiner.

(1) Except as provided by ARM 24.29.818 and this rule, only a certified claims examiner may perform the tasks identified by 39-71-116, MCA, as being the responsibility of a claims examiner. As provided by 39-71-116, MCA, those tasks are to:

(a) determine liability;

(b) apply the requirements of the Workers' Compensation Act;

(c) settle workers' compensation or occupational disease claims; and

(d) determine survivor benefits.

(2) After an insurer or its agent has accepted liability for the claim or has begun paying benefits under a reservation of rights (including pursuant to 39-71-608, MCA), a certified claims examiner is responsible for making any decision that denies, reduces, or changes the type or level of benefits being provided to an injured worker or the survivors of an injured worker.

(3) Examples of decisions made under (2) include, but are not necessarily limited to:

(a) changing the disability status of a worker; and

(b) denying medical benefits.

(4) A person does not violate this rule if under the following circumstances, a person not certified as a claims examiner denies initial liability on a new claim, when the first report of injury clearly shows that the alleged incident has not resulted in:

(a) professional medical evaluation or treatment;

(b) loss of work exceeding the shift during which the accident occurred; or

(c) anything other than mere notice of a possible exposure to a potentially harmful substance or condition.

(5) A claim denied under the circumstances described in (4) must identify in the denial letter the certified claims examiner who is accountable for the decision to deny the claim.

This rule has been repealed.

(1) A new hire or claims examiner trainee may, for a period of not more than 180 days, perform tasks otherwise required to be performed by a certified claims examiner, if the employer has designated a certified claims examiner as being accountable for the decisions made by the new hire or claims examiner trainee.

(2) The employer of a new hire or claims examiner trainee must maintain documentation for each claim being handled by a new hire or claims examiner trainee, of the certified claims examiner who is accountable for the decisions made by that new hire or claims examiner trainee.

(a) The employer may change the certified claims examiner designated as being accountable for decisions on a claim being handled by a new hire or claims examiner trainee at any time, so long as that change is appropriately documented within the insurer's records.

(b) The documentation required by this section must be promptly made available to the department, the injured worker, or the attorney of an injured worker, if that information is requested in writing.

(3) A person who is a new hire or claims examiner trainee that does not timely become a certified claims examiner is not allowed to perform tasks that are required to be performed by a certified claims examiner.

(1) Claims examiners must be certified by the department upon the following:

(a) completion of the application form provided by the department;

(b) meeting the minimum qualifications for certification in (2);

(c) payment of the required fees; and

(d) satisfactory completion of an examination.

(2) To meet the minimum qualifications, the applicant for certification shall be:

(a) at least 18 years of age; and

(b) have a high school diploma or equivalent certificate.

(3) Certification is for a two-year period. The certification date is the date of the successfully completed examination.

(1) Each applicant for certification as a workers' compensation claims examiner shall, prior to the issuance of such certification, personally take and pass an examination given by the department or a department-approved agent as a test of qualifications and competency.

(2) Satisfactory completion of an examination demonstrates the individual's:

(a) familiarity with Montana's workers' compensation statutes;

(b) ability to navigate the administrative rules found in this chapter;

(c) knowledge of workers' compensation definitions and concepts.

(3) Any person taking an examination may use a copy of Title 39, chapter 71, MCA, during the test procedure.

(4) A passing score on an examination is at least 80 percent.

(a) An applicant for claims examiner certification may take the examination up to three times in a 180-day period. If an applicant does not pass the examination within that 180-day period, the applicant must wait 60 days before taking the examination again.

(b) The examination fee must be paid for each examination taken.

(5) Any examination completed through dishonest or fraudulent means is given a score of 0. 

(1) A certified claims examiner must report to the department, within 20 days of the event:

(a) the name and address of an insurer or third-party administrator who has hired the person to be employed as a certified claims examiner, and the date of hire;

(b) the date of separation of employment from that employer; and

(c) a change of address or other contact information for the certified claims examiner.

(2) An insurer or third-party administrator must report to the department, within 20 days of the event, the name and date of hire of any person who will be working as a claims examiner for the employer as either a:

(a) new hire; or

(b) claims examiner trainee.

This rule has been repealed.

(1) If a certification has lapsed but application for renewal is received within 24 months from the renewal date, the claims examiner must pay the application fee and provide evidence of sufficient continuing education credits received during the lapsed period.

(2) If a certification has lapsed greater than 24 months from the renewal date, the claims examiner shall submit an initial application for certification, pay the required fees, and successfully pass an examination to become a certified claims examiner. The continuing education credit requirement for renewal starts over with the new certification period.

(3) A person may not perform the functions of a certified claims examiner with a lapsed certification. 

(1) Certification shall be renewed upon:

(a) payment of the applicable fee;

(b) completion of the renewal form provided by the department at any time during the certification period, but no later than the expiration of the certification period;

(c) verification of completion of 24 hours of approved continuing education courses during the current certification period, to include at least:

(i) four hours of training on workers' compensation statutes, administrative rules, and case law since the last certification; and

(ii) one hour of training on appropriate and ethical communication; and

(iii) other approved continuing education courses which may include but are not limited to mediation/negotiation; medical terminology; human anatomy; interpreting medical records; injured worker's rights and responsibilities; insurers' rights and responsibilities; prevention of injuries; stay-at-work/return-to-work training; and medical fee schedule reimbursements.

(2) The department may accept workers' compensation continuing education courses approved by the Office of Public Instruction, the state bar of Montana or the Montana insurance commissioner for the adjuster license requirements which meet the course criteria specified in these rules toward the 24 hours of approved courses required for the claims examiner certification renewal.

(3) No more than six hours of approved continuing education courses may be carried over to the next certification period. The request for approved continuing education courses to be carried over must be submitted with the renewal application for which the courses were taken. 

(1) Any sponsoring organization that requests continuing education credits be approved by the department for training must complete and submit a request on a form provided by the department.

(2) The department shall review the course submission and determine the number of credit hours to be awarded for completion of the course.

(3) Courses subject to an award of continuing education credits may include but are not limited to:

(a) classroom setting or seminars;

(b) self-study, electronic media;

(c) correspondence course;

(d) computer-based training; or

(e) remote training. 

(a) the practical and academic experience of each faculty member is sufficient to teach the subject assigned;

(b) the course enhances the ability of a claims examiner to provide claims handling services to the public effectively;

(c) the subject matter relates to professional ethics, where practicable.

(2) Submissions for approval of courses must include at least the following information:

(a) the name of the sponsoring organization;

(b) the title of the course;

(c) the proposed date(s) of offering or the dates the course was held;

(d) course goals and objectives;

(e) major course topic(s);

(f) course length;

(g) a list of other states, if any, that have approved the course and the credits granted the course in those states;

(h) a syllabus or course outline;

(i) a summary of each course outline element;

(j) method of instruction, such as classroom, self-study, videotape, audiotape, teleconference, etc.;

(k) method of administering examinations, if any;

(l) method of attendance verification;

(m) method of student record maintenance;

(n) instructors, if any;

(o) a designated contact person;

(p) a written explanation of examination security measures and examination administration methods; and

(q) written notification of additional dates of course offering to the department three days in advance of presentation of any course.

(3) Requests for advance approval of courses must be received by the department no less than 30 days prior to the anticipated starting date of the course.

(4) Requests for approval of courses already held must be received prior to December 31 of the calendar year in which the activity was presented.

(5) Approved accredited university or college courses will be allowed 15 continuing education credits for each semester credit and ten continuing education credits for each quarter credit.

(6) Charges for courses must be clearly disclosed to students before enrollment:

(a) if a course is canceled for any reason, all charges are refundable in full, unless the refund policy is clearly defined in the enrollment application;

(b) in instances requiring refunds under (6)(a), the charges must be refunded within 45 days of cancellation;

(c) in the event that a continuing education provider postpones a course for any reason, the provider must give the students a choice of attending a course at a later date or having their charges refunded in full. The provider must refund the charges within 45 days of the postponement unless the student notifies the provider that the student has chosen to attend a later course;

(d) a sponsoring organization may have a refund policy addressing a student's cancellation or failure to complete a course, as long as that policy is made clear to potential students.

(7) A sponsoring organization must provide proof of course completion to each course participant who successfully completes the approved course of study within one month of course completion or prior to the end of the calendar year during which the participant completed the course. The department may grant the sponsoring organizations up to two months to provide such proof of course completion, if the sponsoring organization notifies the course participants in writing, in advance of the course.

(8) Sponsoring organizations who add qualified course instructors after a course is approved must submit the names of those instructors to the department at least three days prior to the course offering.

(9) Course approval is for a period of two years following the course approval date.

(10) Sponsoring organizations must resubmit courses for new review and certification whenever significant changes in course content are made. 

(11) The minimum number of credits that the department may award is one credit.

(12) No course may be advertised as having been approved for credit by the department until the sponsoring organization receives written approval from the department.

(a) a high school diploma or equivalent certificate;

(b) experience in at least one of the following:

(i) three or more years of managerial, supervisory, technical, or teaching experience as a subject matter expert;

(ii) appropriate national designations; or

(iii) approval on an exception basis by the department.

(2) An instructor may be disqualified if that person has:

(a) intentionally falsified documents filed with the department; or

(b) intentionally misrepresented course approval, credit hour assignment, curriculum, or course content to students or prospective students.

(3) Certified claims examiners teaching or lecturing approved courses will be credited with two times the number of approved credit hours of courses they instruct.

(4) Proctors will not earn continuing education credit for their services.

(1) The following fees apply to the certified claims examiner program:

(a) initial application for certification $100

(b) examination 75

(c) renewal application 75

(d) renewal application for lapsed certification 100

(e) approval of a continuing education course 75

(2) All fees are payable in advance.

(3) All fees are nonrefundable. 

This rule has been repealed.

For the purpose of this subchapter, the following definitions apply, unless the context of the rule clearly indicates otherwise:

(1) "Administration fund assessment" means the Workers' Compensation Administration Fund assessment provided for by 39-71-201, MCA.

(2) "Advisory organization" means the workers' compensation advisory organization designated by the insurance commissioner as defined by 33-16-1023, MCA. The current advisory organization is the national council on compensation insurance.

(3) "Insurer" has the same meaning as provided by 39-71-116, MCA. The term does not include the Uninsured Employers' Fund as provided for by 39-71-503, MCA, or the subsequent injury fund as provided for by 39-71-901, MCA.

(4) "New fund claims" means claims administered by the plan No. 3 insurer, where the claims arise from an injury or occupational disease that occurred on or after July 1, 1990.

(5) "Old fund claims" means claims administered by the plan No. 3 insurer, where the claims arose from an injury or occupational disease that occurred before July 1, 1990.

(6) "Other income" means any revenue account that has an offsetting cash deposit or withdrawal which includes, but is not limited to, revenue accounts such as long term bond income, short term investment pool (STIP) participant earnings, or STIP security lending items, but expressly does not include any surcharge or assessment amounts.

(7) "Payment" means the tender of funds to the department for a monetary obligation due directly from an insurer. In the context of this subchapter, the term is used when an insurer is directly liable for the underlying obligation.

(8) "Remittance" means the tender of funds to the department, where the funds are collected by an insurer from a policyholder. In the context of this subchapter, the term is used to refer to an insurer's tender to the department of surcharges collected by an insurer from its policyholders, where the underlying obligation rests on a policyholder, not the insurer.

(9) "SAW/RTW" means stay-at-work/return-to-work assistance as defined in 39-71-1011, MCA.

(10) "Safety fund assessment" means the assessment for the occupational safety and health administration fund as defined in 50-71-128, MCA.

(11) "SIF" means the subsequent injury fund as defined by 39-71-901, MCA.

This rule has been repealed.

This rule has been repealed.

(a) deduct any outstanding credits a plan No. 1 insurer may have to arrive at the final amount due from that insurer;

(b) deduct any outstanding credits the plan No. 3 insurer may have for old fund claims to arrive at the final amount due with respect to old fund claims; or

(c) deduct the aggregate of any outstanding credits that plan No. 2 insurers and that the plan No. 3 insurer (with respect to plan No. 3 new fund claims) may have to arrive at the final amount due via the administration fund assessment premium surcharge.

(1) Any assessment payment, surcharge remittance, summary report, or quarterly expenditure report received by the department more than five days past the due date is considered to be late.

This rule has been repealed.

This rule has been repealed.

This rule has been repealed.

This rule has been repealed.

This rule has been repealed.

This rule has been repealed.

This rule has been repealed.

This rule has been repealed.

This rule has been repealed.

This rule has been repealed.

This rule has been repealed.

This rule has been repealed.

This rule has been repealed.

This rule has been repealed.

This rule has been repealed.

This rule has been repealed.

(1) The department may combine the assessments for the administration fund, SIF, SAW/RTW, and safety fund into one bill. 

This rule has been repealed.

This rule has been repealed.

(1) The administration fund assessment is calculated on the total amount of paid losses as described at 39-71-201, MCA.

(2) Compensation benefits paid include periodic and lump-sum payments for:

(a) permanent total disability;

(b) permanent partial disability;

(c) temporary total disability;

(d) temporary partial disability;

(e) loss of hearing, whether under the Workers' Compensation or Occupational Disease Act for occupational diseases that occurred prior to July 1, 2005;

(f) rehabilitation benefits (biweekly compensation paid to claimants);

(g) death benefits;

(h) disfigurement payments;

(i) SIF cases, to the extent paid by the insurer and not reimbursed by the SIF;

(j) settlement amounts paid pursuant to 39-71-741, MCA, except to the extent any portion of the settlement is reported as being medical benefits paid;

(k) benefits paid pursuant to 39-71-608, MCA; and

(l) settlement amounts paid pursuant to 39-72-405, MCA.

(3) Medical benefits paid include payments for:

(a) medical and dental treatment;

(b) prescription drugs;

(c) prosthetics and orthotics;

(d) other durable medical goods;

(e) hospital care;

(f) domiciliary care;

(g) diagnostic examinations for the purpose of determining what treatment is necessary;

(h) medical benefits paid pursuant to 39-71-615, MCA; and

(i) hearing loss treatment, whether under the Workers' Compensation or Occupational Disease Act for occupational diseases that occurred prior to July 1, 2005.

(4) With respect to medical benefits, the amount actually paid by the insurer, rather than the amount billed by the provider, is the basis for computation of benefits paid.

(5) Benefits paid include any amount paid by the insurer or the employer, regardless of any deductible paid by the employer or reimbursements to the insurer from reinsurance or excess insurance other than by the claimant. Co-payments actually made by the claimant are not considered to be "benefits paid" for the purposes of this rule.

(6) Each insurer must report in the format required by the department, the compensation paid and the medical benefits paid in the preceding year no later than March 1 of each year.

(a) The plan No. 3 insurer must report the amount of compensation benefits and medical benefits paid on old fund claims separately from those amounts expended on new fund claims.

(7) The administration fund assessment is payable directly to the department by the following entities:

(a) all plan No. 1 insurers;

(b) a plan No. 2 insurer that has paid compensation or medical benefits in the prior year, and has reported no premium earned in that prior year, must pay directly to the department an administration fund assessment pursuant to 39-71-201, MCA; and

(c) the plan No. 3 insurer for old fund claims.

(8) The minimum amount of the administration fund assessment for an insurer is calculated as outlined in 39-71-201, MCA.

(9) Miscellaneous expense costs are not included in the calculation of the administration fund assessment. Miscellaneous expense costs are all workers' compensation or occupational disease costs incurred by an insurer other than compensation or medical benefits paid. These costs include, but are not limited to:

(a) rehabilitation services provided by a licensed rehabilitation provider or the department of public health and human services;

(b) rehabilitation expenses, such as books and tuition, or auxiliary rehabilitation benefits, such as relocation expenses;

(c) administrative costs for the processing of claims, such as the costs of investigating or adjusting the claim;

(d) independent medical examinations requested by the insurer, where the purpose of the examination(s) is not for the diagnosis or treatment of the claimant's condition;

(e) matching payments to a catastrophically injured worker's family; and

(f) various other miscellaneous costs that do not constitute a compensation benefit or medical benefit provided to the claimant or beneficiary.

(10) In the event an insurer submits an amended report identifying compensation paid and medical benefits paid after the time specified in (6), the department will compare the amended report with the initial report and:

(a) if the amended report results in a change in the amount of administration fund assessment owed by the insurers identified in (7) of $100.00 or more, the department will bill each affected insurer for the additional amount owed;

(b) if the amended report indicates the insurers identified in (7) have overpaid their administration fund assessment by more than $100.00, the department may credit the overpayment to each affected insurer's following year's assessment period; or

(c) if the amended report results in a change in the amount of the administration fund assessment surcharge, the department will adjust the following year's administration fund assessment surcharge to reflect that change.

(11) The department may inspect the insurer's records to determine whether the insurer is properly reporting compensation paid and medical benefits paid.

(12) In determining the amount to be collected through the administration fund assessment, after considering the adjustments made in ARM 24.29.956, the department shall compare the amount actually collected for the administration fund in a given fiscal year to the actual amounts expended from the workers' compensation administration fund for that fiscal year.

(a) As described in 39-71-201, MCA, the "amount collected for a given fiscal year" includes monies intended to cover that fiscal year's assessment, which include:

(i) payment or remittance received by July 1 of the prior fiscal year;

(ii) payment, remittance, or other income received during the current fiscal year; and

(iii) payment or remittance received in the following fiscal year which arrives after the due date but prior to the calculation of the following year's assessment.

(b) The comparison must be done after the due date for the final premium surcharge payments applicable to that fiscal year to be received by the department.

(c) Any amount that is greater than the actual expenditures for the given fiscal year must be allocated to each plan on a proportionate basis toward the following year's calculation of the administration assessment.

(d) Any monies received after the following year's assessment surcharge has been calculated will be credited for the year in which those monies were received.

(e) In making the adjustments for the assessment calculations for FY05, the department shall compare the collections and expenditures for both FY02 and FY03 and make the appropriate adjustments. Beginning with the assessment calculations for FY06, the department will look back to the most recent completed fiscal year.

This rule has been repealed.

(1) The department will compute the premium surcharge to be paid by all employers insured by plan No. 2 insurers and by the plan No. 3 insurer in the manner provided by 39-71-201 and 50-71-128, MCA.

(a) In calculating the total administration fund and safety fund assessment premium surcharge rate, the department will use previous calendar year direct premium earned data reported to the department by plan No. 2 insurers and the plan No. 3 insurer.

(b) For the purpose of calculating the surcharge, late payments and remittances will not be considered if received after the new surcharge rate has been calculated. Instead, the payments and remittances will be considered for the purpose of surcharge calculation as if made for the fiscal year in which they were received.

(2) The administration fund and safety fund assessment premium surcharge rate is effective for policies written or renewed on or after July 1 of each year. For policies written or renewed during the fiscal year, the current surcharge rate will apply to all payments made during the policy year regardless of any changes in the surcharge rate effective as of the next fiscal year.

(3) Insurers may address over-collections or overpayments in the following manner:

(a) Any over-collection of the administration fund assessment premium surcharge from a policyholder by the insurer may be refunded by the insurer, or applied to premium or future surcharge payments due from the policyholder to the insurer. An accounting of the payment shall be provided by the insurer to the policyholder.

(b) If a surcharge remittance from an insurer to the department is later determined to include an overpayment, the insurer may deduct the amount overpaid from the next surcharge remittance due from the insurer to the department. The insurer shall maintain records documenting any surcharge amounts refunded to its policyholders.

(4) Each plan No. 2 insurer and the plan No. 3 insurer is responsible for correctly calculating the amount of the authorized premium surcharge for the administration fund and safety fund assessment that the insurer is to collect from each of its insured employers using the rate established by the department. Because the insurer, not the department, calculates the amount of premium due from the employer, disputes between the insurer and the insured regarding the amount of the premium surcharge are not disputes over which the department has jurisdiction.

(5) Each plan No. 2 insurer and the plan No. 3 insurer shall maintain reasonable records showing the total amount of premium surcharge billed for each policyholder and the total amount of premium surcharge actually collected from each policyholder. The department may inspect those records.

(6) All uninsured employers may be assessed a penalty surcharge based on what would have been charged had the employer been enrolled by the plan No. 3 insurer.

This rule has been repealed.

(2) The requirements for remittance of the SIF assessment premium surcharge are the same as for the administration fund assessment premium surcharge. Payment of the SIF assessment is due July 1 of each year.

(1) The total amount paid by SIF from April 1 of the previous year through March 31 of the current year includes commitments for payments by SIF on individual reimbursements or settlements.

This rule has been repealed.

(1) In the event an insurer fails to timely and accurately report its paid losses for the previous year by the following March 1, the department may base the insurers' paid losses using the quarterly information submitted by the insurer pursuant to 39-71-306, MCA. If the insurer has not filed all of the quarterly reports as required by 39-71-306, MCA, the department may consult with the advisory organization or other sources regarding the appropriate amount to estimate as those paid losses. The department may also use that estimate as the basis for the SIF, SAW/RTW, and safety fund assessment as well.

(2) The estimate will be used to calculate the administration fund assessments for those insurers who must pay their assessment directly to the department. For those insurers who are responsible to collect the administration fund assessment surcharge from its policyholders, the estimate will be used in the computation of the percentage rate of premium surcharge.

(3) An annual paid loss report received after March 1, but received by or before March 31, may be considered pursuant to ARM 24.29.954 for assessment calculation purposes.

(4) The department may, in its sole discretion, recalculate the assessment and surcharge rates if the insurer makes a late report as provided by (3).

(5) Pursuant to 39-71-306, MCA, a penalty of up to $1,000 may be assessed against the insurer for an annual report received after March 1.

(1) The department may approve a petition for a lump-sum settlement between an insurer and an injured worker or the worker's beneficiary, which converts permanent disability biweekly payments to a lump-sum payment, in accordance with the provisions of 39-71-741, MCA.

(2) No department approval is required for a lump-sum payment of:

(a) accrued indemnity benefits;

(b) advance indemnity benefits; or

(c) an impairment award for a claim with a date of injury on or after July 1, 2005.

(3) The department presumes that biweekly benefit payments are in the best interests of the worker. Department approval of a petition for lump-sum conversion may be given only if the worker demonstrates that the worker's ability to become financially self-sustaining is more probable with a whole or partial lump-sum payment than with the biweekly payments and the worker's other resources, as outlined by ARM 24.29.1202.

(4) Conversion of biweekly permanent partial disability benefits to a lump sum must meet the requirements of (3) only when the claimant's date of injury was prior to July 1, 1991.

(5) Conversion of biweekly permanent total disability benefits to a lump sum must meet the test of (3) for all dates of injury.

(6) The workers' compensation court has jurisdiction over disputes between claimants and insurers regarding conversion of biweekly disability payments to a lump sum and disputes arising from the department's denial of approval of a petition for conversion. A dispute between an insurer and claimant is subject to mediation. A dispute arising from department denial of a petition for conversion is not subject to mandatory mediation.

(1) A petition to the department for lump-sum conversion of biweekly permanent total disability benefits for all dates of injury must include a description of the lump-sum proposal, including but not limited to:

(a) analysis of current financial conditions as described in (3);

(b) analysis of financial condition under the proposed lump-sum conversion, that includes a description of the use of the lump-sum and how this use will contribute to financially sustaining the worker over the same period biweekly payments would have been paid;

(c) analysis of financial condition that would be reasonably expected had the worker not been injured as described in (6); and

(d) an affidavit signed by the worker attesting to the validity of information provided in the written petition.

(2) A petition to the department for conversion of biweekly permanent partial disability benefits to a lump-sum payment must include an analysis of current financial conditions as described in (3) only for a claim with a date of injury prior to July 1, 1991.

(3) "Analysis of current financial condition" for purposes of (1) shall include a list of all the worker's income, assets, and liabilities, as well as other available resources, including but not limited to:

(a) periodic income (specify periods reported):

(i) social security disability income,

(ii) social security retirement income,

(iii) retirement or pension income,

(iv) other disability insurance,

(v) health insurance benefits,

(vi) mortgage insurance benefits,

(vii) spousal or other family income,

(viii) life insurance proceeds,

(ix) credit disability benefits,

(x) interest or dividend income,

(xi) workers' compensation benefits,

(xii) third party recovery (actual or potential);

(b) monetary assets:

(i) cash on hand,

(ii) checking account,

(iii) savings account,

(iv) accounts and notes receivable,

(v) savings bonds,

(vi) stocks and bonds,

(vii) mutual funds,

(viii) cash value of life insurance,

(ix) cash value of annuities,

(x) cash value of retirement fund;

(c) fixed assets:

(i) home and property,

(ii) other real estate,

(iii) retirement fund,

(iv) motor vehicles,

(v) personal property;

(d) liabilities:

(i) all monthly living expenses,

(ii) existing delinquent or outstanding debts,

(iii) periodic payments on debts,

(iv) long-term liabilities,

(v) attorney fees and costs.

(4) If a petition for lump-sum conversion of permanent total benefits involves the partial or total elimination of existing delinquent or outstanding debts, a debt management plan must be described and include:

(a) plan of management, through applying the proposed lump-sum payment, of all existing delinquent or outstanding debts, both short- and long-term; and

(b) description of how the worker will be sustained financially through use of the lump-sum payment and other available resources, including cash available throughout the life of the debt management plan, to manage delinquent or outstanding debts.

(5) If a permanent total benefit lump-sum proposal involves a business venture, a business plan must be described and include:

(a) Information indicating the worker's capability in proposed business venture, including:

(i) relevant educational and work history,

(ii) knowledge of the proposed business,

(iii) if managerial, managerial capability,

(iv) role to be assumed in the proposed business.

(b) If the venture is a new business, information about the proposed business venture including, but not limited to:

(i) description of the proposed business venture,

(ii) estimate of the purchase price of the business,

(iii) work sheets showing: total source of dollars, start-up costs, projected expenses and net income forecast,

(iv) feasibility study of the market conditions in the intended market area, showing that the business is a feasible venture.

(c) If the venture is an existing business, information about the proposed business including, but not limited to:

(i) description of proposed business venture,

(ii) legal agreement showing intent to sell the existing business, purchase price of the business, and any conditions placed upon such sale,

(iii) income tax statements and balance sheets for the two consecutive years prior to the agreement to sell the business,

(iv) work sheets showing total source of dollars, start-up costs, projected expenses and net income forecast,

(v) market analysis showing market conditions in the intended market area.

(d) A statement of cash that will be available to the worker as income on a biweekly basis after start-up costs and other business expenses are considered throughout the life of the venture.

(6) "Analysis of financial condition that would be reasonably expected had the worker not been injured" for purposes of (1) must include a description of the income the worker would have received and the basis upon which the estimate is derived. The analysis must include:

(a) evidence of education and work experience, including:

(i) work history, dates and descriptions of employment or unemployment, names and locations of employers;

(ii) highest level of formal education attained, degrees received, dates of attendance, names and locations of schools; and

(iii) special training, professional licenses, registrations, or certifications, certifications received; dates of attendance, names and locations of institutions providing training, licenses, registrations or certifications.

(b) evidence of probable job promotions and pay increases, including:

(i) supportive documentation from employers, union contracts, or other reasonable substantiation of probable job promotions,

(ii) wage history,

(iii) statement from employer at the date of the accident of last wage rate paid; and

(iv) supportive documentation estimating wage rates from the date of the accident up to age 65.

(7) A request for lump-sum settlement of medical benefits must include the following information:

(a) copy of medical reports documenting maximum medical improvement, current diagnosis, and recommendations for future treatment, if any;

(b) specific dollar amount of the settlement allocated to medical benefits;

(c) statement from the claimant and insurer as to why it is in the best interest of the parties to settle medical benefits;

(d) statement signed by the claimant to acknowledge the claimant understands which specific medical benefits will terminate upon settlement;

(e) statement signed by the claimant to acknowledge the claimant is on notice and understands that the future medical benefits settled under the agreement may not be covered by secondary healthcare payers such as Medicare, Medicaid, or other health insurers; and

(f) submission of the following completed forms to the department:

(i) "Summary of Settlement of Medical Benefits" form with original signatures by the claimant and the insurer or the insurer's authorized representative; and

(ii) "Petition for Settlement Injury/Occupational Disease Medical Benefits Closed On An Accepted Claim" form with original signatures by the claimant, a witness, and the insurer or the insurer's authorized representative.

(8) The total value of the workers' compensation benefits may be discounted at the current rate established by the department when an insurer calculates a conversion to a lump-sum payment. Only for claims with dates of injury between April 15, 1985 and June 30, 1987, the lump-sum payment may be discounted by 7%, compounded annually.

(1) The department shall deny a petition for a lump-sum conversion of permanent total disability unless the worker demonstrates that the worker's ability to become financially self-sustaining is more probable with a whole or partial lump-sum payment than with biweekly payments and the worker's other resources.

(2) The department shall approve a petition for lump-sum conversion of permanent total disability benefits when:

(a) The worker demonstrates that the worker's financial condition under the lump-sum proposal will not be greater than could have reasonably been expected had the worker not been injured and the lump sum is limited to the unpaid biweekly benefits; and

(b) The worker demonstrates that the lump-sum proposal will improve the worker's financial condition over what could have been reasonably expected had the worker not been injured and the lump sum is limited to the purchase price to the insurer of an annuity that would yield an amount equal to the biweekly benefits payable over the estimated duration of the compensation period.

(3) For claims with date of injury between April 15, 1985 and June 30, 1987, all requirements of (2) must be met and the proposed lump-sum amount of unpaid biweekly benefits may be discounted at a rate of 7% per year, compounded annually.

(4) If the claimant does not meet the requirements of 39-71-710, MCA, and the estimated duration of the compensation period is the remaining life expectancy of the worker, the insurer shall determine the remaining life expectancy in accordance with the most recent Life Table: Expectation of Life at Single Years of Age, by Race and Sex: United States, all races, both sexes column, in Vital Statistics of the United States, Volume II-Mortality, Part A, U.S. Department of Health and Human Services, Public Health Service, National Center for Health Statistics.

(5) If the difference between the present discounted value of a permanent total disability lump-sum payment and the future value of the biweekly payments is the only justification provided for the lump-sum conversion, the department shall deny the petition.

(6) The department shall deny or approve a lump-sum petition within 14 days of receipt. If additional information is required to enable a determination on a petition, the department shall request the information within the 14-day review period. If additional information is not received within the 14-day review period, the department shall deny the petition on the basis of lack of information.

This rule has been repealed.

(2) After determination that the claim is covered under the Workers' Compensation or Occupational Disease acts, the liability for payment of the claim is the responsibility of the appropriate workers' compensation insurer.

(3) Pursuant to 39-71-743 , MCA, when a claim is covered under the Workers' Compensation or Occupational Disease acts, providers may not bill the injured worker for the difference between the initial amount billed and the amount reimbursed to the provider by the insurer as set by applicable statutes and rules, except for the co-pay provided by 39-71-704 , MCA.

(a) For injured workers who are receiving benefits from the Uninsured Employers' Fund pursuant to 39-71-503 , MCA, the provisions of this rule are subject to 39-71-510 , MCA.

(4) The injured worker is responsible for charges incurred for treatment of conditions which were not the result of the injury or for treatment when medical benefits have terminated according to 39-71-704 , MCA.

As used in subchapters 14 and 15, the following definitions apply:

(1) "Acute care hospital" or "hospital" means a health care facility appropriately licensed by the Department of Public Health and Human Services that provides inpatient and outpatient medical services to injured workers experiencing acute illness or trauma. Acute care hospitals are sometimes referred to as regulated hospitals.

(2) "Ambulatory Payment Classification (APC)" means the reimbursement system adopted by the department for outpatient services.

(3) "Ambulatory surgery center (ASC)" means a health care facility that operates primarily for the purpose of furnishing outpatient surgical services to patients.

(4) "Base rate" means the dollar value which is multiplied by the relative weight of the MS-DRG or APC to determine payment.

(5) "Bundling" means the practice of grouping multiple services, procedures, and supplies into one charge item instead of billing each separately.

(6) "CMS" means the Centers for Medicare and Medicaid Services.

(7) "Correct Coding Initiative (CCI)" means the code edits adopted by the department that are used to correct contradictory billing information.

(8) "Current Procedural Terminology (CPT)" codes means codes and descriptors of procedures owned, copyrighted, and published by the American Medical Association.

(9) "Department" means the Montana Department of Labor and Industry.

(10) "Designated Treating Physician" means a provider who is designated or formally approved by the insurer as the physician who will be coordinating the injured worker's care, according to the criteria in 39-71-1101, MCA.

(11) "Documentation" means written information that is complete, clear, and legible, which describes the service provided and substantiates the charge for the service.

(12) "Durable medical equipment (DME)" means durable medical appliances or devices used in the treatment or management of a condition or complaint, along with associated nondurable materials and supplies required for use in conjunction with the appliance or device. The term does not include an implantable object or device.

(13) "Evidence-based" means use of the best evidence available in making decisions about the care of the individual patient, gained from the scientific method of medical decision-making and includes use of techniques from science, engineering, and statistics, such as randomized controlled trials (RCTs), meta-analysis of medical literature, integration of individual clinical expertise with the best available external clinical evidence from systematic research, and a risk-benefit analysis of treatment (including lack of treatment).

(14) "Facility" or "health care facility" means all or a portion of an institution, building, or agency, private or public, excluding federal facilities, whether organized for profit or not, that is used, operated, or designed to provide health services, medical treatment, or nursing, rehabilitative, or preventive care to any individual. The term includes chemical dependency facilities, critical access hospitals, end-stage renal dialysis facilities, home health agencies, home infusion therapy agencies, hospices, hospitals, long-term care facilities, intermediate care facilities for the developmentally disabled, medical assistance facilities, mental health centers, outpatient centers for surgical services, rehabilitation facilities, residential care facilities, and residential treatment facilities. The above facilities are defined in 50-5-101, MCA. The term does not include outpatient centers for primary care, infirmaries, provider-based clinics, offices of private physicians, dentists or other physical or mental health care workers, including licensed addiction counselors.

(15) "Functional status" means written information that is complete, clear, and legible, that identifies objective findings indicating the claimant's physical capabilities and provides information about the change in the status as a result of treatment.

(16) "Healthcare Common Procedure Coding System (HCPCS)" means the identification system for health care matters developed by the federal government, and includes level one codes, known as CPT codes, and level two codes that were developed to use for supplies, procedures, or services that do not have a CPT code. These codes also include successor codes for CPT and HCPCS established by the American Medical Association and CMS.

(17) "Implantable" means a system of objects or devices that is made either to replace and act as a missing biological structure, to repair or support a biological structure, or to manage chronic disease processes and that is surgically implanted, embedded, inserted, or otherwise applied. The term also includes any related equipment necessary to install, operate, program, and recharge the implantable.

(18) "Improvement status" means written information that is complete, clear, and legible, which identifies objective medical findings of the claimant's medical status with respect to the treatment plan.

(19) "Inpatient services" means services rendered to a person who has been admitted to a hospital for bed occupancy for purposes of receiving inpatient hospital services. Generally, a patient is considered an inpatient if formally admitted as inpatient with the expectation that the patient will remain at least overnight and occupy a bed even though it later develops that the patient can be discharged or transferred to another hospital and not actually use the hospital bed overnight. The physician or other practitioner responsible for a patient's care at the hospital is also responsible for deciding whether the patient should be admitted as an inpatient.

(20) "Insurer" has the same meaning as provided by 39-71-116, MCA.

(21) "Interested party" means:

(a) the "physician" or "provider" as defined by this rule;

(b) the "claimant" or "injured worker"; or

(c) the representative of the injured worker.

(22) "Maintenance care" has the same meaning as provided by 39-71-116.htm">39 -71-116, MCA.

(23) "Medical director" means a person who is an employee of, or contractor to, the department, and who is responsible for the independent medical review of requests for treatment(s) or procedure(s), when those requests are denied, and whose responsibility will also include other areas to be determined by the department. A person serving as a medical director must be a physician licensed by the state of Montana under Title 37, chapter 3, MCA.

(24) "Medical stability", "maximum medical improvement", "maximum healing", or "maximum medical healing" has the same meaning as provided by 39-71-116, MCA.

(25) "Medicare-Severity Diagnosis Related Group (MS-DRG or DRG)" means the inpatient diagnosis classifications of circumstances where patients demonstrate similar resource consumption, length of stay patterns, and medical severity status that are adopted by the department and are used for billing purposes.

(26) "Nonfacility" means any place not included in this rule's definition of "facility".

(27) "Objective medical findings" means medical evidence that is substantiated by clinical findings. Clinical findings include, but are not limited to, range of motion, atrophy, muscle strength, muscle spasm, and diagnostic evidence. Complaints of pain in the absence of clinical findings are not considered objective medical findings.

(28) "Outpatient" means a patient who is not admitted for inpatient or residential care.

(29) "Palliative care" has the same meaning as provided by 39-71-116, MCA.

(30) "Physician" means those persons identified by 33-22-111, MCA, practicing within the scope of the providers' license.

(31) "Primary medical services" has the same meaning as provided by 39-71-116, MCA.

(32) "Prior authorization" means:

(a) with respect to services provided on or before June 30, 2011, that for those matters identified by ARM 24.29.1517 the provider receives (either verbally or in writing) authorization from the insurer to perform a specific procedure or series of related procedures, prior to performing that procedure; and

(b) with respect to services provided on or after July 1, 2011, the interested party receives prior authorization (either verbally or in writing) from the insurer to perform treatment for those cases identified by ARM 24.29.1593.

(33) "Provider" means any health care provider, unless the context in another rule clearly indicates otherwise. "Provider" does not include pharmacists nor does it include a supplier of medical equipment who is not a health care provider.

(34) "Ratio of cost to charges (RCC)" means the computed ratio using charges and the hospital's Medicare cost report.

(35) "Rebuttable presumption" means that the Montana Guidelines, as adopted in ARM 24.29.1591, are presumed to be compensable medical treatment for an injured worker. The presumption can be rebutted by a preponderance of credible medical evidenced-based material and medical reasons to justify that the medical treatment(s) or procedure(s) that require prior authorization are reasonable and necessary care for the injured worker.

(36) "Relative Value Unit" or "RVU" represents a unit of measure for medical services, procedures, or supplies. RVU is used in the fee schedule formulas to calculate reimbursement fees and is expressed in numeric units. Those services that have greater costs or value have higher RVUs than those services with lower costs or value.

(37) "Resource-Based Relative Value Scale" or "RBRVS" means the publication titled "Essential RBRVS", published by Ingenix, Inc.

(38) "Secondary medical services" has the same meaning as provided by 39-71-116, MCA.

(39) "Service or services" means treatment including procedures and supplies provided in a facility or nonfacility that is billable under these rules.

(40) "Status indicator (SI)" codes mean CPT codes treated in the same fashion or category, such as packaged services, and apply to outpatient services only.

(41) "Treating physician" means:

(a) with respect to claims arising before July 1, 1993, the meaning provided by ARM 24.29.1511;

(b) with respect to claims arising on or after July 1, 1993, the meaning provided by 39-71-116, MCA.

(42) "Treatment plan" means a written outline of how the provider intends to treat a specific condition or complaint.

(a) With respect to services provided on or before June 30, 2011, the treatment plan must include a diagnosis of the condition, the specific type(s) of treatment, procedure, or modalities that will be employed, a timetable for the implementation and duration of the treatment, and the goal(s) or expected outcome of the treatment. Treatment, as used in this definition, may consist of diagnostic procedures that are reasonably necessary to refine or confirm a diagnosis. The treating physician may indicate that treatment is to be performed by a provider in a different field or specialty, and defer to the professional judgment of that provider in the selection of the most appropriate method of treatment; however, the treating physician must identify the scope of the referral in the treatment plan and provide guidance to the provider concerning the nature of the injury or occupational disease.

(b) With respect to services provided on or after July 1, 2011, a treatment plan must be made in accordance with the Montana Guidelines adopted in ARM 24.29.1591 and made in accordance with any insurer authorized treatments or procedures.

As used in subchapters 14 and 15, the following definitions apply:

(1) "Acute care hospital" or "hospital" means a health care facility appropriately licensed by the Department of Public Health and Human Services that provides inpatient and outpatient medical services to injured workers experiencing acute illness or trauma. Acute care hospitals are sometimes referred to as regulated hospitals.

(2) "Ambulatory Payment Classification (APC)" means the reimbursement system adopted by the department for outpatient services.

(3) "Ambulatory surgery center (ASC)" means a health care facility that operates primarily for the purpose of furnishing outpatient surgical services to patients.

(4) "Base rate" means the dollar value which is multiplied by the relative weight of the MS-DRG or APC to determine payment.

(5) "Bundling" means the practice of grouping multiple services, procedures, and supplies into one charge item instead of billing each separately.

(6) "CCR," formerly known as "RCC," means the cost-to-charge ratio computed by using the hospital's Medicare cost report and charges.

(7) "CMS" means the Centers for Medicare and Medicaid Services.

(8) "Correct Coding Initiative (CCI)" means the code edits adopted by the department that are used to correct contradictory billing information.

(9) "Current Procedural Terminology (CPT)" codes means codes and descriptors of procedures owned, copyrighted, and published by the American Medical Association.

(10) "Department" means the Montana Department of Labor and Industry.

(11) "Designated Treating Physician" means a provider who is designated or formally approved by the insurer as the physician who will be coordinating the injured worker's care, according to the criteria in 39-71-1101, MCA.

(12) "Documentation" means written information that is complete, clear, and legible, which describes the service provided and substantiates the charge for the service.

(13) "Durable medical equipment (DME)" means durable medical appliances or devices used in the treatment or management of a condition or complaint, along with associated nondurable materials and supplies required for use in conjunction with the appliance or device. The term does not include an implantable object or device.

(14) "Evidence-based" means use of the best evidence available in making decisions about the care of the individual patient, gained from the scientific method of medical decision-making and includes use of techniques from science, engineering, and statistics, such as randomized controlled trials (RCTs), meta-analysis of medical literature, integration of individual clinical expertise with the best available external clinical evidence from systematic research, and a risk-benefit analysis of treatment (including lack of treatment).

(15) "Facility" or "health care facility" means all or a portion of an institution, building, or agency, private or public, excluding federal facilities, whether organized for profit or not, that is used, operated, or designed to provide health services, medical treatment, or nursing, rehabilitative, or preventive care to any individual. The term includes chemical dependency facilities, critical access hospitals, end-stage renal dialysis facilities, home health agencies, home infusion therapy agencies, hospices, hospitals, long-term care facilities, intermediate care facilities for the developmentally disabled, medical assistance facilities, mental health centers, outpatient centers for surgical services, rehabilitation facilities, residential care facilities, and residential treatment facilities. The above facilities are defined in 50-5-101, MCA. The term does not include outpatient centers for primary care, infirmaries, provider-based clinics, offices of private physicians, dentists or other physical or mental health care workers, including licensed addiction counselors.

(16) "Functional status" means written information that is complete, clear, and legible, that identifies objective findings indicating the claimant's physical capabilities and provides information about the change in the status as a result of treatment.

(17) "Healthcare Common Procedure Coding System (HCPCS)" means the identification system for health care matters developed by the federal government, and includes level one codes, known as CPT codes, and level two codes that were developed to use for supplies, procedures, or services that do not have a CPT code. These codes also include successor codes for CPT and HCPCS established by the American Medical Association and CMS.

(18) "Implantable" means a system of objects or devices that is made either to replace and act as a missing biological structure, to repair or support a biological structure, or to manage chronic disease processes and that is surgically implanted, embedded, inserted, or otherwise applied. The term also includes any related equipment necessary to install, operate, program, and recharge the implantable.

(19) "Improvement status" means written information that is complete, clear, and legible, which identifies objective medical findings of the claimant's medical status with respect to the treatment plan.

(20) "Inpatient services" means services rendered to a person who has been admitted to a hospital for bed occupancy for purposes of receiving inpatient hospital services. Generally, a patient is considered an inpatient if formally admitted as inpatient with the expectation that the patient will remain at least overnight and occupy a bed even though it later develops that the patient can be discharged or transferred to another hospital and not actually use the hospital bed overnight. The physician or other practitioner responsible for a patient's care at the hospital is also responsible for deciding whether the patient should be admitted as an inpatient.

(21) "Insurer" has the same meaning as provided by 39-71-116, MCA.

(22) "Interested party" means:

(a) the "physician" or "provider" as defined by this rule;

(b) the "claimant" or "injured worker"; or

(c) the representative of the injured worker.

(23) "Maintenance care" has the same meaning as provided by 39 -71-116, MCA.

(24) "Medical stability", "maximum medical improvement", "maximum healing", or "maximum medical healing" has the same meaning as provided by 39-71-116, MCA.

(25) "Medicare-Severity Diagnosis Related Group (MS-DRG or DRG)" means the inpatient diagnosis classifications of circumstances where patients demonstrate similar resource consumption, length of stay patterns, and medical severity status that are adopted by the department and are used for billing purposes.

(26) "Nonfacility" means any place not included in this rule's definition of "facility".

(27) "Objective medical findings" means medical evidence that is substantiated by clinical findings. Clinical findings include, but are not limited to, range of motion, atrophy, muscle strength, muscle spasm, and diagnostic evidence. Complaints of pain in the absence of clinical findings are not considered objective medical findings.

(28) "Outpatient" means a patient who is not admitted for inpatient or residential care.

(29) "Palliative care" has the same meaning as provided by 39-71-116, MCA.

(30) "Physician" means those persons identified by 33-22-111, MCA, practicing within the scope of the providers' license.

(31) "Primary medical services" has the same meaning as provided by 39-71-116, MCA.

(32) "Prior authorization" means that for those matters identified by ARM 24.29.1517 the provider receives (either verbally or in writing) authorization from the insurer to perform a specific procedure or series of related procedures, prior to performing that procedure.

(33) "Provider" means any health care provider, unless the context in another rule clearly indicates otherwise. "Provider" does not include pharmacists nor does it include a supplier of medical equipment who is not a health care provider.

(34) "Relative Value Unit" or "RVU" represents a unit of measure for medical services, procedures, or supplies. RVU is used in the fee schedule formulas to calculate reimbursement fees and is expressed in numeric units. Those services that have greater costs or value have higher RVUs than those services with lower costs or value.

(35) "Resource-Based Relative Value Scale" or "RBRVS" means the publication titled "Essential RBRVS," published by OptumInsight, Inc.

(36) "Secondary medical services" has the same meaning as provided by 39-71-116, MCA.

(37) "Service or services" means treatment including procedures and supplies provided in a facility or nonfacility that is billable under these rules.

(38) "Status indicator (SI)" codes mean CPT codes treated in the same fashion or category, such as packaged services, and apply to outpatient services only.

(39) "Treating physician" means:

(a) with respect to claims arising before July 1, 1993, the meaning provided by ARM 24.29.1511;

(b) with respect to claims arising on or after July 1, 1993, the meaning provided by 39-71-116, MCA.

(40) "Treatment plan" means a written outline of how the provider intends to treat a specific condition or complaint. The treatment plan must include a diagnosis of the condition, the specific type(s) of treatment, procedure, or modalities that will be employed, a timetable for the implementation and duration of the treatment, and the goal(s) or expected outcome of the treatment. Treatment, as used in this definition, may consist of diagnostic procedures that are reasonably necessary to refine or confirm a diagnosis. The treating physician may indicate that treatment is to be performed by a provider in a different field or specialty, and defer to the professional judgment of that provider in the selection of the most appropriate method of treatment; however, the treating physician must identify the scope of the referral in the treatment plan and provide guidance to the provider concerning the nature of the injury or occupational disease.

(1) As required by 39-71-704, MCA, charges submitted by providers must be the usual and customary charge billed for nonworkers' compensation patients. Payment of medical claims must be made in accordance with the schedule of facility and professional medical fees adopted by the department.

(a) For services provided on or after July 1, 2011, payment of medical claims must also be made in accordance with the utilization and treatment guidelines adopted by the department in ARM Title 24, chapter 29, subchapter 16.

(b) For services provided on or after July 1, 2013, the department may assess a penalty on insurers for neglect or failure to use the correct fee schedule. It is the insurer's responsibility to ensure that the correct fee schedule is used by a third-party agent.

(i) If the insurer does not properly process the entire medical bill using the correct fee schedule within 60 days of the receipt, the department may assess a $200.00 penalty for each occurrence. Each medical bill is an occurrence.

(ii) This fine may be increased $100.00 per subsequent occurrence up to a maximum of $1,000.00.

(iii) The department will not assess any penalty unless the provider submits adequate documentation that they attempted to resolve the bill with the insurer. If the insurer does not correct the error, the provider may forward the billing, explanation of benefits, if any, and documentation of contact and responses to the department.

(iv) The insurer has the burden of proof to notify the department either by e-mail, facsimile, or letter that the bill(s) in question have been processed using the correct Montana fee schedule.

(v) The amounts collected from the insurer must be deposited with the department to be used in the Workers' Compensation Administration Fund.

(vi) An insurer may contest a penalty assessed pursuant to 39-71-107(5)(b), MCA, in a hearing conducted according to department rules. A party may appeal the final agency order to the workers' compensation court. The court shall review the order pursuant to the requirements of 2-4-704, MCA.

(c)  A provider of medical treatment or services shall only be paid for services under this chapter if the bill for medical treatment or services is timely received by the employer or appropriate payer.  Absent a showing of good cause, a bill for treatment or services is timely received by the employer or appropriate payer when it is actually received within 365 days of the later of:

(i)  the date of service; or

(ii)  the date the provider of medical treatment or services knew the treatment or services was related to a claim for benefits under this chapter.

(2) The insurer shall make timely payments of all medical bills for which liability is accepted. For services provided on or after July 1, 2013, the department may assess a penalty on an insurer that without good cause neglects or fails to pay undisputed medical bills on an accepted liability claim within 60 days of receipt of the bill(s). The insurer must document receipt date of the bill(s) or the receipt date will be three days after the bill(s) was sent by the provider.

(a) If the insurer does not pay the undisputed portions of a medical bill within 60 days of receipt, the department may assess a $200.00 penalty for each occurrence. Each medical bill is an occurrence.

(b) This fine may be increased $100.00 per subsequent occurrence up to a maximum of $1,000.00.

(c) The department will not assess any penalty unless the provider submits adequate documentation that they attempted to resolve the bill with the insurer. If the insurer does not pay the undisputed bill(s), the provider may forward the billing, explanation of benefits, if any, and documentation of contact and responses to the department.

(d) The insurer has the burden of proof to notify the department either by e-mail, facsimile, or letter that the bill(s) in question have been paid.

(e) The amounts collected from the insurer must be deposited with the department to be used in the Workers' Compensation Administration Fund.

(f) An insurer may contest a penalty assessed pursuant to 39-71-107(5)(c), MCA, in a hearing conducted according to department rules. A party may appeal the final agency order to the workers' compensation court.

(3) For services provided on or after July 1, 2013, the provider may charge 1 percent per month simple interest for unpaid balances on an undisputed medical bill on a claim pursuant to 39-71-704, MCA. The interest will start accruing on the 31st day after receipt of the bill by the insurer. The insurer must document receipt date of the bill or the receipt date will be three days after the bill was sent by the provider. If there is no payment within 30 days, the provider may bill the insurer 1 percent per month on the unpaid balance. For purposes of coding billed amounts, the Montana unique code MT005 is established by this rule and must be used by the provider to bill the interest amount.

(4) For services provided on or after July 1, 2013, the insurer may charge a 1 percent per month simple interest for overpayment made to a provider pursuant to 39-71-704, MCA. The interest will start accruing on the 31st day after receipt by the provider of the reimbursement request. The provider must document the receipt date of the reimbursement request or the receipt date will be three days after the request was sent by the insurer. If there is no payment within 30 days of the provider's receipt of a reimbursement request or if the provider has not made alternative arrangements for repaying the overpayment within 30 days, the insurer may charge the provider 1 percent per month simple interest on the balance.

(5) Payment of private room charges shall be made only if ordered by the treating physician.

(6) Special nurses shall be paid only if ordered by the treating physician.

(7) For claims arising before July 1, 1993, no fee or charge is payable by the injured worker for treatment of injuries sustained if liability is accepted by the insurer.

(8) For claims arising on or after July 1, 1993, no fee or charge is payable by the injured worker for treatment of injuries sustained if liability is accepted by the insurer, other than:

(a) the co-payment provided by 39-71-704, MCA. The decision whether to require a co-payment rests with the insurer, not the medical provider. If the insurer does not require a co-payment by the worker, the provider may not charge or bill the worker any fee. The insurer must give enough advance notice to known medical providers that it will require co-payments from a worker so that the provider can make arrangements with the worker to collect the co-payment;

(b) the charges for a nonpreferred provider, after notice is given as provided in 39-71-1102, MCA;

(c) the charges for medical services obtained from other than a managed care organization, once an organization is designated by the insurer as provided in 39-71-1101, MCA; or

(d) the charges for medical services denied by the insurer on the basis that the services meet both of the following criteria:

(i) the medical services do not return the injured worker to employment; and

(ii) the medical services do not sustain medical stability.

(9) For compensable services provided on or after July 1, 2013, if the injured worker pays for the initial medical service prior to acceptance of the claim by the insurer, the injured worker must be reimbursed the entire amount they paid out-of-pocket within 30 days of acceptance.

(a) If the insurer pays the provider, the provider must reimburse the injured worker.

(b) Otherwise, the insurer must reimburse the injured worker.

(10) For injured workers who are receiving benefits from the Uninsured Employers' Fund pursuant to 39-71-503, MCA, the provisions of this rule are subject to 39-71-510, MCA.

This rule has been repealed.

(1) After mediation, disputes between an insurer and a medical service provider arising over the amount of a fee for medical services are resolved by a hearing before the department upon written application of a party to the dispute or the injured worker. The following issues are considered to be disputes arising over the amount of a fee for medical services:

(a) amounts payable to medical providers, when benefits available directly to claimants are not an issue;

(b) access to medical records;

(c) timeliness of payments to medical providers; or

(d) requirements for documentation submitted by a provider to an insurer pursuant to ARM 24.29.1513 as a condition of the payment of medical fees.

(2) All other disputes arising over medical claims, including travel expense reimbursement to injured workers, shall be brought before a department mediator as provided in part 24 of the Workers' Compensation Act.

(3) Facility records must be furnished to the insurer upon request. Facilities must obtain the necessary release by their administrative procedures.

(4) The rule of privileged communication is waived by the injured worker seeking benefits under the Workers' Compensation or Occupational Disease acts.

This rule has been repealed.

(1) Facility bills must be submitted on a UB04 when the injured worker is discharged from the facility or every 30 days.

(2) The providers and payers shall use, when possible, electronic billing for the billing and reimbursement process in order to facilitate rapid transmission of data, lessen the opportunity for errors, and lessen system costs.

(3) It is the responsibility of the facility to use the proper service codes on any bills submitted for payment. The failure of a provider to do so, however, does not relieve the insurer's obligation to pay the bill, but it may justify delays in payment until proper coding of the services provided is received by the insurer.

(4) Except as provided in (3), insurers must make timely payments of facility bills. In cases where there is no dispute over liability for the condition, the insurer must, within 30 days of receipt of a facility's charges, pay the charges according to the rates established by these rules.

(5) Insurer-initiated medical necessity review, bill audits, and other administrative review procedures may only be conducted on a post-payment basis.

(1) Claims for furnishing replacement or repair of prosthetic appliances shall be paid to orthotists or prosthetists, who have been certified by the American Board for Certification in Orthotics or Prosthetics, and whose services are performed in a certified facility.

(2) For services provided on or after July 1, 2011, claims must be paid in accordance with the utilization and treatment guidelines adopted by the department in ARM 24.29.1591.

(a) the insurer submits to the department a detailed written statement indicating that the insurer is having difficulty in receiving medical information relating to a claimant's condition; and

(b) the department approves a suspension of compensation payments for not more than 30 days pending the receipt of medical information; and

(c) after the department approves the suspension of payments, the insurer notifies the claimant in writing that biweekly payments are being suspended pending the receipt of medical information. A copy of the notification shall be furnished to the department.

(a) Personal automobile and private airplane mileage expenses shall be reimbursed at the current rates specified for state employees. Prior authorization from the insurer is required for the use of a private airplane. Total reimbursable automobile miles shall be determined according to the most direct highway route between the injured worker's residence and the provider.

(b) Expenses for eligible meals shall be reimbursed at the meal rates established for state employees.

(c) Actual out-of-pocket receipted lodging expenses incurred by injured workers shall be reimbursed up to the maximum amounts established for state employees. Lodging in those areas specifically designated as high cost cities shall be reimbursed at actual cost. Any claim for receipted or high cost lodging reimbursement must be accompanied by an original receipt from a licensed lodging facility. If the injured worker stays in a nonreceiptable facility, or fails to obtain a receipt, the reimbursement is the amount set for state employees for nonreceipted lodging.

(d) Miscellaneous transportation expenses, such as taxi fares or parking fees, are reimbursable and must be supported by paid receipts.

(e) Requests for travel reimbursement must be made within a reasonable time following the date(s) the travel was incurred.

(2) For claims arising during the period July 1, 1989, through June 30, 1993, reimbursement for travel expenses shall be determined as follows:

(a) Personal automobile and private airplane mileage expenses shall be reimbursed at the current rates specified for state employees. Prior authorization from the insurer is required for the use of a private airplane. Total reimbursable automobile miles shall be determined according to the most direct highway route between the injured worker's residence and the provider. When the travel coincides in whole or in part with the injured worker's regular travel to or from the worker's employment, the coincident mileage may be subtracted from the reimbursable mileage. For each calendar month, the first 50 miles of automobile mileage is not reimbursable.

(b) Expenses for eligible meals shall be reimbursed at the meal rates established for state employees.

(c) Actual out-of-pocket receipted lodging expenses incurred by injured workers shall be reimbursed up to the maximum amounts established for state employees. Lodging in those areas specifically designated as high cost cities shall be reimbursed at actual cost. Any claim for receipted or high cost lodging reimbursement must be accompanied by an original receipt from a licensed lodging facility. If the injured worker stays in a nonreceiptable facility, or fails to obtain a receipt, the reimbursement is the amount set for state employees for nonreceipted lodging.

(d) Miscellaneous transportation expenses, such as taxi fares or parking fees, are reimbursable and must be supported by paid receipts.

(e) Claims for reimbursement of travel expenses must be submitted within 90 days of the date the expenses are incurred, on a form furnished by the insurer. Claims for reimbursement that are not submitted within 90 days may be denied by the insurer.

(3) For claims arising from July 1, 1993, through June 30, 2001, travel expenses are not reimbursed unless the travel is at the request of the insurer. Travel is "at the request of the insurer" when the insurer directs the claimant to: change treating physician; attend an independent medical examination; use a preferred provider; or be treated by a managed care organization. If travel expenses are to be reimbursed, then reimbursement shall be determined as follows:

(a) Personal automobile and private airplane mileage expenses shall be reimbursed at the current rates specified for state employees. Prior authorization from the insurer is required for the use of a private airplane. Total reimbursable automobile miles shall be determined according to the most direct highway route between the injured worker's residence and the provider. For each calendar month, the first 50 miles of automobile mileage is not reimbursable. In addition, travel within the community in which the worker resides shall not be reimbursed.

(b) Expenses for eligible meals shall be reimbursed at the meal rates established for state employees.

(c) Actual out-of-pocket receipted lodging expenses incurred by injured workers shall be reimbursed up to the maximum amounts established for state employees. Lodging in those areas specifically designated as high cost cities shall be reimbursed at actual cost. Any claim for receipted or high cost lodging reimbursement must be accompanied by an original receipt from a licensed lodging facility. If the injured worker stays in a nonreceiptable facility, or fails to obtain a receipt, the reimbursement is the amount set for state employees for nonreceipted lodging.

(d) Miscellaneous transportation expenses, such as taxi fares or parking fees, are reimbursable and must be supported by paid receipts.

(e) Claims for reimbursement of travel expenses must be submitted within 90 days of the date the expenses are incurred, on a form furnished by the insurer. Claims for reimbursement that are not submitted within 90 days may be denied by the insurer.

(4) For claims arising on or after July 1, 2001, payment of travel expense is subject to the following:

(a) Claims for reimbursement of travel expenses must be submitted within 90 days of the date the expenses are incurred, on a form furnished by the insurer. Claims for travel expense reimbursement that are not submitted within 90 days may be denied by the insurer. The insurer must notify the injured worker in writing that the request for travel expense reimbursement must be submitted within 90 days from the date the expense was incurred in order to be reimbursed. If the insurer fails to notify the claimant of the claimant's entitlement to travel expenses and 90 days have passed since the expense was incurred, the insurer must pay the travel.

(b) The type of travel selected must be the least costly form of travel unless the travel is not suitable for the claimant's medical condition, as certified by the claimant's physician.

(c) Reimbursement of travel is excluded under the following conditions:

(i) The first 100 miles of automobile travel are excluded each month unless the insurer requested the travel pursuant to 39-71-605 , MCA.

(ii) Travel to a medical provider within the claimant's community is excluded.

(iii) Travel outside the claimant's community is excluded if comparable treatment is available within the community, unless the insurer requests the claimant to travel to another community.

(iv) Travel is excluded when it is incurred while traveling to unauthorized or disallowed treatment or procedures.

(d) For purposes of this rule, "community" means the area within a 15 mile radius of the claimant's residence as determined by the most direct automobile route between the claimant's residence and the provider.

(e) The insurer is not liable for injuries that result from an accident that occurs during travel for treatment of the claim as provided in 39-71-704 , MCA.

(f) Reimbursement for travel expenses shall be determined as follows:

(i) Personal automobile and private airplane mileage expenses shall be reimbursed at the current rates specified for state employees. Prior authorization from the insurer is required for the use of a private airplane. Total reimbursable automobile miles shall be determined according to the most direct highway route between the claimant's residence and the provider.

(ii) Expenses for eligible meals shall be reimbursed at the meal rates established for state employees.

(iii) Actual out-of-pocket receipted lodging expenses incurred by the claimant shall be reimbursed up to the maximum amounts established for state employees. Lodging in those areas specifically designated as high cost cities shall be reimbursed at actual cost. Any claim for receipted or high cost lodging reimbursement must be accompanied by an original receipt from a licensed lodging facility. If the claimant stays in a nonreceiptable facility, or fails to obtain a receipt, the reimbursement is the amount set for state employees for nonreceipted lodging.

(iv) Miscellaneous transportation expenses, such as taxi fares or parking fees, are reimbursable and must be supported by paid receipts.

(5) Preauthorized expenses incurred for direct commercial transportation by air or ground, including rental vehicles, shall be reimbursed when no other less costly form of travel is available to the claimant, or when less costly forms of travel are not suitable to the claimant's medical condition, as certified by the claimant's physician.

(a) If a claimant chooses to use commercial transportation when a less costly form of travel suitable to the claimant's medical condition is available, as certified by the claimant's physician, reimbursement shall be made according to the rates associated with the least costly form of travel.

(6) For occupational disease claims arising prior to July 1, 2005, if liability has not been accepted on the claim and the department schedules a medical examination as provided in 39-72-602 , MCA, the insurer shall reimburse the claimant for the travel expenses incurred for the examination pursuant to this rule.

(7) The department shall make available to interested parties the specific information referenced in this rule concerning rates for transportation, meals, and lodging; meal time ranges; and designations of high cost cities. The department shall inform interested parties in a timely manner of all applicable updates to this information.

(2) The department shall arrange evaluations as close to the claimant's residence as reasonably possible.

(3) The department shall give written notice to the parties of the time and place of the examination. If the claimant fails to give 48 hours notice of the claimant's inability to attend the examination, the claimant is liable for payment of the evaluator's charges.

(4) The department may request a party to submit all pertinent medical documents including any previous impairment evaluations to the selected evaluator.

(5) Any party wanting to provide information to an evaluator or inquire about the status of an evaluation shall do so only through the department.

(6) The impairment evaluators shall operate according to the following procedures:

(a) The evaluator shall submit a report of the evaluator's findings to the department, claimant, and insurer within 15 days of the date of the examination.

(b) If another evaluation is requested within 15 days after the first evaluator mailed the first report, the department shall select a second evaluator who shall render an impairment evaluation of the claimant.

(c) The second evaluator shall submit a report of the second evaluator's findings to the department, claimant, and insurer, within 15 days of the date of the examination.

(d) The department shall submit both reports to the third evaluator, who shall then submit a final report to the department, claimant, and insurer within 30 days of the date of the examination or, if no examination is conducted, within 30 days of receipt of the first and second evaluation reports from the department. The final report must certify that the other two evaluators have been consulted.

(e) If neither party disputes the rating in the final report, the insurer shall begin paying the impairment award, if any, within 45 days of the third evaluator's mailing of the report.

(f) Either party may dispute the final impairment rating by filing a petition with the workers' compensation court within 15 days of the third evaluator's mailing of the report.

(1) The amounts of the following types of payments are determined according to the specific department rates in effect on the date the medical service or services are provided, regardless of the date of injury:

(a) medical fees;

(b) facility charges;

(c) prescription drugs; and

(d) DME.

(2) When services, procedures, or supplies are bundled for purposes of billing and the bundling covers more than one day, the date of discharge must be used as the date the services are provided for purposes of this rule.

This rule has been repealed.

This rule has been repealed.

This rule has been repealed.

This rule has been repealed.

This rule has been repealed.

This rule has been repealed.

This rule has been repealed.

(1) The department adopts the fee schedules provided by this rule to determine the reimbursement amounts for medical services provided at a facility when a person is discharged on or after December 1, 2008. An insurer is obligated to pay the fee provided by the fee schedules for a service, even if the billed charges are less, unless the facility and insurer have a managed care organization (MCO) or preferred provider organization (PPO) arrangement that provides for a different payment amount. The fee schedules, available online via the Internet at�http://erd.dli.mt.gov/workers-comp-claims-assistance/medical-regulations/montana-facility-fee-schedule/7-erd/workers-comp-regulations/267-montana-facility-fee-schedule.html, are comprised of the following elements:

(a) The Montana Hospital Inpatient Services MS-DRG Reimbursement Fee Schedule, based on CMS version 26;

(b) The Montana Hospital Outpatient and ASC Fee Schedule Organized by APC;

(c) The Montana Hospital Outpatient and ASC Fee Schedule Organized by CPT/HCPCS;

(d) The Montana Ambulance Fee Schedule;

(e) The Montana CCI Code Edits Listing;

(f) The Montana RCC and other Montana RCC-based Calculations;

(g) The Montana Status Indicator (SI) Codes; and

(h) The base rates and conversion formulas established by the department.

(2) The application of the base rate depends on the date the medical services are provided.

(3) Critical access hospitals and medical assistance facilities are reimbursed at 100 percent of that facility's usual and customary charges.

(4) Any services provided by a type of facility not explicitly addressed by this rule must be paid at 75 percent of its usual and customary charges.

(5) Any inpatient rehabilitation services, including services provided at a long term inpatient rehabilitation facility must be paid at 75 percent of that facility's usual and customary charges. All CMS rehabilitation MS-DRGs are excluded from the Montana MS-DRG payment system and instead are paid at 75 percent of the facility's usual and customary charges regardless of the place of service.

(6) DME, prosthetics, and orthotics, excluding implantables, will be paid at 75 percent of a facility's usual and customary charges.

(7) Facility billing must be submitted on a CMS Uniform Billing (UB-04) form or CMS 1500 form, including the 837-l and 837-P form when submitting electronically.

(8) Hospitals and ASCs must, on an annual basis, submit to the department data reporting Medicare, Medicaid, commercial, unrecovered, and workers' compensation claims reimbursement in a standard form supplied by the department. The department may in its discretion conduct audits of any facility's financial records to confirm the accuracy of submitted information.

(9) Individual medical providers who furnish professional services in a hospital, ASC, or other facility setting must bill insurers separately and must be reimbursed using the nonfacility fee schedule. Those reimbursements are excluded from any calculation of outlier payments.

(10) Facility pharmacy reimbursements are made as follows:

(a) If a facility pharmacy dispenses prescription drugs to an individual during the course of treatment in the facility, reimbursement is part of the MS-DRG or APC reimbursement.

(b) If a patient's medications are not included in the MS-DRG or APC service bundle, the reimbursement will be 75 percent of the facility's usual and customary charges.

(11)�The following applies to inpatient services provided at an acute care hospital:

(a)�The department may establish the base rate annually.

(i)�Effective December 1, 2008, the base rate is $7,735.

(b)�Payments for inpatient acute care hospital services must be calculated using the base rate multiplied by the Montana MS-DRG weight.�For example, if the MS-DRG weight is 0.5, the amount payable is $3,867.50, which is the base rate of $7,735 multiplied by 0.5.

(c)�If a service falls outside of the scope of the MS-DRG and is not otherwise listed on a Montana fee schedule, reimbursement for that service must be 75 percent of that facility's usual and customary charges.

(d)�The threshold for outlier payments is three times the Montana MS-DRG payment amount.�If the outlier threshold is met, the outlier payment must be the MS-DRG reimbursement amount plus an amount that is determined by multiplying the charges above the threshold by the sum of 15 percent and the individual hospital's Montana operating RCC.

(i)�For example, if the hospital submits total charges of $100,000, the MS-DRG reimbursement amount is $25,000, and the RCC is 0.50, then the resultant calculation for reimbursement is as follows:�The DRG reimbursement amount ($25,000) is multiplied by 3 to set the threshold trigger ($75,000). �The threshold trigger ($75,000) is subtracted from the total charges ($100,000) resulting in the amount above the trigger ($25,000).�The amount above the trigger ($25,000) is then multiplied by .65 (which is the RCC of .5 plus .15) to obtain the outlier payment ($16,250).�The total payment to the hospital in this example would be the DRG reimbursement amount ($25,000) plus the outlier payment ($16,250) = $41,250.

(ii)�The department may establish the inpatient outlier amount annually.

(e)�Where an implantable exceeds $10,000 in cost, hospitals may seek additional reimbursement beyond the normal MS-DRG payment.�Any implantable that costs less than $10,000 is bundled in the implantable charge included in the MS-DRG payment.

(i)�Any reimbursement for implantables pursuant to this subsection must be documented by a copy of the invoice for the implantable.�Insurers are subject to privacy laws concerning disclosure of health or proprietary information.

(ii)�Reimbursement is set at a total amount that is determined by adding the actual amount paid for the implantable on the invoice, plus the handling and freight cost for the implantable, plus 15 percent of the actual amount paid for the implantable.�Handling and freight charges must be included in the implantable reimbursement and are not to be reimbursed separately.

(iii)�When a hospital seeks additional reimbursement pursuant to this subsection, the implantable charge is excluded from any calculation for an outlier payment.

(iv)�Because the decision regarding an implantable is a complex medical analysis, this rule defers to the judgment of the individual physician and facility to determine the appropriate implantable.�A payer may not reduce the reimbursement when the medical decision is to use a higher cost implantable.

(f)�All facility services provided during an uninterrupted patient encounter leading to an inpatient admission must be included in the inpatient stay, except air and ground ambulance services which are paid separately pursuant to the Montana Ambulance Fee schedule.

(g)�The following applies to facility transfers when a patient is transferred for continuation of medical treatment between two acute care hospitals:

(i)�A hospital transferring a patient is paid as follows:�The MS-DRG reimbursement amount is divided by the geometric mean number of days duration listed for the MS-DRG; the resultant per diem amount is then multiplied by two for the first day of stay at the transferring hospital; the per diem amount is multiplied by one for each subsequent geometric mean day of stay at the transferring hospital; and the amounts for each day of stay at the transferring hospital are totaled.�If the result is greater than the MS-DRG reimbursement amount, the transferring hospital is paid the MS-DRG reimbursement amount.�Associated outliers and add-ons are then added to the payment.

(ii)�A hospital receiving a patient is paid the full MS-DRG payment plus any appropriate outliers and add-ons.

(iii)�Facility transfers do not include costs related to transportation of a patient to initially obtain medical care.�Such reimbursements are covered by ARM 24.29.1409.

(12)�The following applies to outpatient services provided at an acute care hospital or an ASC:

(a)�The department may establish the base rate for outpatient service at acute care hospitals annually.

(i)�Effective December 1, 2008, the base rate for hospital outpatient services is $105.

(b)�The department may establish the base rate for ASCs annually.

(i)�Effective December 1, 2008, the base rate for ASCs is $79, which is 75 percent of the hospital base rate.

(c)�Payments for outpatient services in a hospital or an ASC are based on the Montana APC system.�A single outpatient visit may result in more than one APC for that claim.�The payment must be calculated by multiplying the base rate times the APC weight.�If the APC weight is not listed or if the APC weight is listed as null, reimbursement for that service must be paid at 75 percent of the facility's usual and customary charges.�Examples of such services include but are not limited to laboratory tests, radiology, and therapies.�If a service falls outside of the scope of the APC and is not otherwise listed on a Montana fee schedule, reimbursement for that service must be 75 percent of that facility's usual and customary charges.

(d) CCI code edits must be used to determine bundling and unbundling of charges. No other clinical editing is allowed to determine bundling and unbundling of charges.

(e) Outpatient medical services include observation in an outpatient status.

(f) Where an outpatient implantable exceeds $500 in cost, hospitals or ASCs may seek additional reimbursement beyond the normal APC payment. In such an instance, the provider may bill CPT code L 8699, and the status indicator code "N" may not be used by a payer to determine the amount of the payment. Any implantable that costs less than $500 is bundled in the APC payment.

(i) Any reimbursement for implantables pursuant to this subsection must be documented by a copy of the invoice for the implantable. Insurers are subject to privacy laws concerning disclosure of health or proprietary information.

(ii) Reimbursement is set at a total amount that is determined by adding the actual amount paid for the implantable on the invoice, plus the handling and freight cost for the implantable, plus 15 percent of the actual amount paid for the implantable. Handling and freight charges must be included in the implantable reimbursement and are not to be reimbursed separately.

(g) The following applies to patient transfers from an ASC to an acute care hospital:

(i) An ASC transferring a patient is paid the APC reimbursement.

(ii) The acute care hospital is paid the MS-DRG or the APC reimbursement, whichever is applicable.

(iii) Facility transfers do not include costs related to transportation of a patient to initially obtain medical care. Such reimbursements are covered by ARM 24.29.1409.

(1) The department adopts the fee schedules provided by this rule to determine the reimbursement for medical services provided by a facility when a person is discharged on or after July 1, 2013. An insurer is obligated to pay the fee provided by the fee schedules for a service, even if the billed charge is less, unless the facility and insurer have a managed care organization (MCO) or preferred provider organization (PPO) arrangement that provides for a different payment amount. The fee schedules are available online at the Employment Relations Division web site and are updated as soon as is reasonably feasible relative to the effective dates of the medical codes as described below. The fee schedules are comprised of the elements listed in 39-71-704, MCA, and the following:

(a) The Montana Status Indicator (SI) Codes;

(b) The Montana unique code, MT003, described in (11)(e) and (12)(f); and

(c) The base rates and conversion formulas are established by the department.

(d) All current and prior instruction sets for services provided starting July 1, 2013, are available on the department's website. A copy of any instruction set for services provided starting July 1, 2013, through the present may be requested by email at DLIERDBP&[email protected]; phone at 406-444-6543; or by mail at P.O. Box 8011 Helena, MT 59604.

(2) The application of the base rate depends on the date the medical services are provided.

(3) Critical access hospitals (CAH) are reimbursed at 100 percent of that facility's usual and customary charges. CAH is a designation for a facility only. The reimbursement rate for CAH set by this rule applies to facility charges.

(a) Regarding professional services provided at a physical therapy (PT), occupational therapy (OT), and speech therapy (ST) services provided on an outpatient basis must be billed on a UB04 and reimbursed 100 percent of usual and customary. PT, OT, and ST outpatient services may not be billed on the CMS 1500.

(b) All other professional services provided at a CAH must be billed on a CMS 1500 and reimbursed according to the professional fee schedule pursuant to ARM 24.29.1534.

(4) Any services provided by a type of facility not explicitly addressed by this rule or any services using new codes not yet adopted by this rule must be paid at 75 percent of the facility's usual and customary charges.

(5) Any inpatient rehabilitation services, including services provided at a long- term inpatient rehabilitation facility must be paid at 75 percent of that facility's usual and customary charges. All CMS rehabilitation MS-DRGs are excluded from the Montana MS-DRG payment system and instead are paid at 75 percent of the facility's usual and customary charges regardless of the place of service.

(6) DME, prosthetics, and orthotics, excluding implantables, will be paid according to the professional fee schedule pursuant to ARM 24.29.1534 or, if no reimbursement value, ARM 24.29.1523.

(7) Facility billing must be submitted on a CMS Uniform Billing (UB04) form, including the 837-l form when submitting electronically.

(8) Hospitals and ASCs must, on an annual basis, submit to the department data reporting Medicare, Medicaid, commercial, unrecovered, and workers' compensation claims reimbursement in a standard form supplied by the department. The department may in its discretion conduct audits of any facility's financial records to confirm the accuracy of submitted information.

(9) Medical provider services furnished in an acute care hospital, ASC, or other facility setting, whether those professional services are furnished as an employee or as an independent professional, must be billed separately using the CMS 1500 and must be reimbursed using the professional fee schedule pursuant to ARM 24.29.1534, except as provided in (a).

(a) PT, OT, and ST services provided on an outpatient basis must be billed on a UB04 and reimbursed according to the facility fee schedule. These reimbursements are excluded from any calculation of outlier payments. PT, OT, and ST outpatient services may not be billed on the CMS 1500.

(10) Facility pharmacy reimbursements are made as follows:

(a) If a facility pharmacy dispenses prescription drugs to an individual during the course of treatment in the facility, reimbursement is part of the MS-DRG or APC reimbursement.

(b) If a patient's medications are not included in the MS-DRG or APC service bundle, the reimbursement will be according to ARM 24.29.1529.

(11) The following applies to inpatient services provided at an acute care hospital:

(a) The department may establish the base rate annually.

(i) The base rate effective July 1, 2023, is $10,011.

(ii) All prior base rates for services provided starting July 1, 2013, are available on the department's website. A copy of the base rates for services provided starting July 1, 2013, may be requested by email at DLIERDBP&[email protected]; phone at 406-444-6543; or by mail at P.O. Box 8011 Helena, MT 59604.

(b) Payments for inpatient acute care hospital services must be calculated using the base rate multiplied by the Montana MS-DRG weight. 

(c) If a service falls outside of the scope of the MS-DRG and is not otherwise listed on a Montana fee schedule, including new codes not yet adopted, reimbursement for that service must be 75 percent of that facility's usual and customary charges.

(d) The threshold for outlier payments is three times the Montana MS-DRG payment amount. If the outlier threshold is met, the outlier payment must be the MS-DRG reimbursement amount plus an amount that is determined by multiplying the charges above the threshold by the sum of 15 percent and the individual hospital's Montana CCR.

(i) For example, if the hospital submits total charges of $100,000, the MS-DRG reimbursement amount is $25,000, and the CCR is 0.50, then the resultant calculation for reimbursement is as follows: The DRG reimbursement amount ($25,000) is multiplied by 3 to set the threshold trigger ($75,000). The threshold trigger ($75,000) is subtracted from the total charges ($100,000) resulting in the amount above the trigger ($25,000). The amount above the trigger ($25,000) is then multiplied by .65 (which is the CCR of .5 plus .15) to obtain the outlier payment ($16,250). The total payment to the hospital in this example would be the DRG reimbursement amount ($25,000) plus the outlier payment ($16,250) = $41,250.

(ii) The department may establish the inpatient outlier amount annually.

(e) Where an implantable exceeds $10,000 in cost, hospitals may seek additional reimbursement beyond the normal MS-DRG payment. Hospitals may seek additional reimbursement by using Montana unique code MT003. Any implantable that costs less than $10,000 is bundled in the implantable charge included in the MS-DRG payment.

(i) Any reimbursement for implantables pursuant to this subsection must be documented by a copy of the invoice for the implantable (or purchase order if it lists the number of items, the wholesale price, and the shipping costs) and the operative report. Insurers are subject to privacy laws concerning disclosure of health or proprietary information.

(ii) Reimbursement is set at a total amount that is determined by adding the actual amount paid for the implantable on the invoice or purchase order for the implantable, plus 15 percent of the actual amount paid for the implantable, plus the handling and freight cost for the implantable. Handling and freight charges must be included in the implantable reimbursement and are not to be reimbursed separately.

(iii) When a hospital seeks additional reimbursement pursuant to this subsection, the implantable charge is excluded from any calculation for an outlier payment.

(iv) Because the decision regarding an implantable is a complex medical analysis, this rule defers to the judgment of the individual physician and facility to determine the appropriate implantable. A payer may not reduce the reimbursement when the medical decision is to use a higher cost implantable.

(f) All facility services provided during an uninterrupted patient encounter leading to an inpatient admission must be included in the inpatient stay, except air and ground ambulance services which are paid separately pursuant to the Montana Ambulance Fee schedule. Air ambulances whose charter and certification is through the federal Department of Transportation will be paid at 100 percent of their usual and customary charges pursuant to federal law.

(g) The following applies to facility transfers when a patient is transferred for continuation of medical treatment between two acute care hospitals:

(i) A hospital receiving a patient is paid the full MS-DRG payment plus any appropriate outliers and add-ons.

(ii) Facility transfers do not include costs related to transportation of a patient to initially obtain medical care. Such reimbursements are covered by ARM 24.29.1409.

(12) The following applies to outpatient services provided at an acute care hospital or an ASC:

(a) The department may establish a base rate annually.

(i) The base rate effective July 1, 2023, is $130.

(ii) All prior base rates for services provided starting July 1, 2013, are available on the department's website. A copy of the base rates for services provided starting July 1, 2013, may be requested by email at DLIERDBP&[email protected]; phone at 406-444-6543; or by mail at P.O. Box 8011 Helena, MT 59604.

(b) The department may establish a base rate annually for ASCs at 75 percent of the hospital outpatient base rate.

(i) The base rate effective July 1, 2023, is $98.

(ii) All prior base rates for services provided starting July 1, 2013, are available on the department's website. A copy of the base rates for services provided starting July 1, 2013, may be requested by email at DLIERDBP&[email protected]; phone at 406-444-6543; or by mail at P.O. Box 8011 Helena, MT 59604.

(c) Payments for outpatient services in a hospital or an ASC are based on the Montana APC system. A single outpatient visit may result in more than one APC for that claim. The payment must be calculated by multiplying the base rate times the APC weight. If an APC code is available, the services must be billed using the APC code. If the APC weight is not listed or if the APC weight is listed as null, reimbursement for that service must be paid at 75 percent of the facility's usual and customary charges. Examples of such services include but are not limited to laboratory tests and radiology. If a service falls outside of the scope of the APC and is not otherwise listed on a Montana fee schedule, reimbursement for that service must be 75 percent of that facility's usual and customary charges.

(d) CCI and MUE code edits must be used to determine bundling and unbundling of charges.

(e) Outpatient medical services include observation in an outpatient status.

(f) Where an outpatient implantable exceeds $500 in cost, hospitals or ASCs may seek additional reimbursement beyond the normal APC payment. In such an instance, the provider may bill using Montana unique code MT003. Any implantable that costs less than $500 is bundled in the APC payment.

(i) Any reimbursement for implantables pursuant to this subsection must be documented by a copy of the invoice for the implantable (or purchase order if it lists the number of items, the wholesale price, and the shipping cost) and the operative report. Insurers are subject to privacy laws concerning disclosure of health or proprietary information.

(ii) Reimbursement is set at a total amount that is determined by adding the actual amount paid for the implantable on the invoice or purchase order for the implantable, plus 15 percent of the actual amount paid for the implantable, plus the handling and freight cost for the implantable. Handling and freight charges must be included in the implantable reimbursement and are not to be reimbursed separately.

(g) The following applies to patient transfers from an ASC to an acute care hospital:

(i) An ASC transferring a patient is paid the APC reimbursement.

(ii) The acute care hospital is paid the MS-DRG or the APC reimbursement, whichever is applicable.

(iii) Facility transfers do not include costs related to transportation of a patient to initially obtain medical care. Such reimbursements are covered by ARM 24.29.1409.

(1) The purpose in developing utilization rules is to assure that appropriate quality and cost effective medical services are available to individuals injured on the job. Health care programs outside the workers' compensation arena such as the federal Medicare and Medicaid programs, as well as private health insurers, have had medical cost containment measures in place for some time. While reimbursement for medical services will continue to be based on fee schedules, the need for cost containment measures similar to those implemented in the nonworkers' compensation area has been recognized.

(2) The purpose of evidence-based utilization and treatment guidelines is to assist injured workers in receiving prompt and appropriate care, assist injured workers in stay-at-work/return-to-work options, assist clinicians in making decisions for specific conditions, and help insurers make reimbursement determinations. Although the primary purpose of the guidelines is advisory and educational, the guidelines are enforceable for payment purposes. The department recognizes that acceptable medical practice may include deviations from these guidelines, as individual cases dictate. Therefore, these guidelines are not relevant as evidence of a provider's legal standard of professional care.

This rule has been transferred.

(1) For claims arising on or after July 1, 1993, "treating physician" has the meaning provided by 39-71-116, MCA.

(2) The worker has a duty to select a treating physician. Initial treatment in an emergency room or urgent care facility is not selection of a treating physician. The selection of a treating physician must be made as soon as practicable. A worker may not avoid selection of a treating physician by repeatedly seeking care in an emergency room or urgent care facility. The worker should select a treating physician with due consideration for the type of injury or occupational disease suffered, as well as practical considerations such as the proximity and the availability of the physician to the worker.

(3) Selection of the treating physician, referrals made by the treating physician, and changes of treating physician must all be made in accordance with the provisions of 39-71-1101, MCA. Treatment from a physician's assistant or an advanced practice nurse, when the treatment is under the direction of the treating physician, does not constitute a change of physician and does not require prior authorization pursuant to ARM 24.29.1517.

(4) Subject to 39-71-1101, MCA, ARM 24.29.1517, and any other applicable rule or statute, nothing in this rule prohibits the claimant from receiving treatment from more than one physician if required by the claimant's injury or occupational disease.

This rule has been repealed.

(1) For claims arising on or after July 1, 2013, "treating physician" has the meaning provided by 39-71-116, MCA.

(2) The worker may select a treating physician. Initial treatment in an emergency room or urgent care facility is not selection of a treating physician. The selection of a treating physician should be made as soon as practicable. A worker may not avoid selection of a treating physician by repeatedly seeking care in an emergency room or urgent care facility. The worker should select a treating physician with due consideration for the type of injury or occupational disease suffered, as well as practical considerations such as the proximity and the availability of the physician to the worker.

(3) Any time after an insurer accepts liability for an injury or occupational disease, the insurer may recognize a treating physician selected by the injured worker. The treating physician is compensated at 100 percent of the fee schedule.

(4) After acceptance of liability, the insurer may formally approve the treating physician selected by the injured worker as a designated treating physician or may choose a different physician to be the designated treating physician. The designated treating physician is compensated at 110 percent of the fee schedule.

(a) The designated treating physician is responsible for coordination of all medical care, pursuant to 39-71-1101(2), MCA. The designated treating physician must agree to accept these responsibilities.

(b) The insurer must provide formal notification of the designated treating physician by e-mail, facsimile, or letter to:

(i) the injured worker;

(ii) the current treating physician; and

(iii) the designated treating physician. The effective date of the designation of treating physician is the date the insurer sends the notice of designation unless the physician declines within ten working days.

(c) A health care provider who is referred by the designated treating physician is compensated at 90 percent of the fee schedule. These providers are not responsible for coordinating care or providing determinations as required by the designated treating physician.

(5) Treatment from a physician's assistant or an advanced practice nurse, when the treatment is under the direction of the treating physician, does not constitute a change of physician and does not require prior authorization pursuant to ARM 24.29.1517.

(6) Subject to 39-71-1101, MCA, ARM 24.29.1517, and any other applicable rule or statute, nothing in this rule prohibits the claimant from receiving treatment from more than one physician if required by the claimant's injury or occupational disease.

(1) When a treating physician, emergency room or similar urgent care facility sees the claimant for the first time (related to the claim), the provider must furnish to the insurer the initial report, the Medical Status Form (MSF), and the treatment bill (CMS 1500) within seven business days of the visit.

(2) As soon as possible, upon completion of the initial diagnostic process, the treating physician must prepare a treatment plan and promptly furnish a copy to the insurer. Subsequent changes in the treatment plan must be documented and a copy of the amended treatment plan must be promptly furnished to the insurer.

(3) To be eligible for payment for subsequent visits, the provider must furnish to the insurer:

(a) the treatment bill (CMS 1500);

(b) improvement status with respect to the treatment plan; and

(c) applicable treatment notes with the bill.

(4) Certain treatment plans may require services be obtained from a vendor that is outside the tradition of being a professional health care provider. Under that circumstance, the treating physician has the obligation to include the medical necessity for the service in the treatment plan and furnish functional improvement status as appropriate. The vendor, however, is responsible for furnishing documentation.

(a) The following are examples of services that are contemplated as falling within the meaning of this subsection:

(i) health club membership; and

(ii) home health care services.

(5) Documentation is considered to be a service to the injured worker and no charge is allowed for the documentation required by this rule.

(6) The treating physician must report immediately to the insurer the date total disability ends or the date the injured worker is released to return to work.

(1) Functional improvement status must identify objective medical findings of the claimant's medical status, and note the effect of the medical services (positive, neutral, or negative), with respect to the goals of the treatment plan. The functional improvement status can be sufficiently documented on the Medical Status Form. The Montana Utilization and Treatment Guidelines outline the standards for functional improvement.

(2) If there are any significant changes in the treatment plan, that fact must be noted and described.

(1) This rule applies to:

(a) services provided on or before June 30, 2011; and

(b) body parts not covered by the Montana Guidelines, as described in ARM 24.29.1593.

(2) When prior authorization is required, the provider must request the authorization a reasonable amount of time in advance of the time the procedure is scheduled to be performed. The request must contain enough information to allow the insurer to make an informed decision regarding authorization. The insurer may not unreasonably withhold its authorization. An insurer's denial must contain an explanation of the reasons for its denial. Reasonableness will be judged in light of the circumstances surrounding the medical procedure and the claim.

(3) If a provider makes a written request for prior authorization at least 14 days prior to the date the service is scheduled to be performed, authorization is presumed to be given by the insurer if there is no written denial sent by the insurer to the provider within 14 days of the date the written request was mailed. If the written denial is made within three days of the expiration of the 14 day response period, the insurer must also notify the provider of the denial by telephone or facsimile ("fax").

(4) If a provider makes a verbal request for prior authorization, the burden of proof for showing that authorization was granted by the insurer rests with the provider. The provider should promptly send to the insurer a written confirmation of any verbal authorization made by the insurer. Such written confirmation should refer not only to the name of the claimant, the claim number, and the procedure authorized, but also the name of the person giving the authorization and the date the authorization was given.

(5) Prior authorization is required when:

(a) the provider to whom the referral is made is a consulting specialist; or

(b) there is a request for change of treating physician; or

(c) the claimant has not been treated for the injury (or occupational disease) within the past six months; or

(d) the claimant has been identified as having reached maximum medical improvement; or

(e) any of the following is proposed:

(i) nonemergency surgery;

(ii) an MRI or CT, if the same body part has been imaged within the last 12 months;

(iii) psychological counseling, other than provided by the treating physician;

(iv) membership in a health club;

(v) any pain clinic program;

(vi) pain medication is being prescribed for a period of six months or longer;

(vii) medical equipment and supplies if over $300.00;

(viii) a permanent change from one provider's specialty practice to the specialty practice of a different provider, for treatment of the same injury. The occasional and temporary change of provider due to illness, vacation, or emergency, does not require prior authorization; or

(ix) for any other procedure that by rule specifically requires prior authorization.

(6) For any service identified in (4)(e), additional authorization is required if the duration or extent of the service is later modified because of a change in the treatment plan.

(7) Prior authorization is not required for emergency procedures.

(8) If medical services related to the injury or occupational disease are denied pursuant to this rule because a provider failed to try to obtain prior authorization, an injured worker cannot be billed for those denied medical services pursuant to 39-71-743, MCA.

(9) When an insurer denies liability for an injury or occupational disease, and the insurer then later assumes liability for a particular condition, the insurer may not deny payment for the medical services provided for that condition during the period of denial based solely on failure to obtain prior authorization.

This rule has been repealed.

This rule has been repealed.

(1) This rule applies to DME provided by a nonfacility on or after January 1, 2008.

(2) Except for prescription medicines as provided by ARM 24.29.1529, reimbursement for DME dispensed through a medical provider is calculated by using the RVU listed in the RBRVS times the conversion factor established in ARM 24.29.1538 in effect on the date of service. If a RVU is not listed or if the RVU is listed as null, reimbursement is limited to a total amount that is determined by adding the cost of the item plus the freight cost plus the lesser of either $30.00 or 30 percent of the cost of the item. An invoice documenting the cost of the equipment or supply must be sent to the insurer upon the insurer's request.

(a) Copies of the instructions are available on the department web site at

(3) If a provider adds value to DME (such as by complex assembly, modification, or special fabrication), then the provider may charge a reasonable fee for those services. Merely unpacking an item is not a "value-added" service. While extensive fitting of devices may be billed for, simple fitting (such as adjusting the height of crutches) is not billable.

(4) This rule does not apply to:

(a) health care facilities;

(b) pharmacies; or

(c) equipment supply houses that are not also health care providers.

(1) For both facility and professional services, reimbursement for DME dispensed through a medical provider is determined by the professional fee schedule in effect on the date of service, except for prescription medicines as provided by ARM 24.29.1529. On March 31 of each year, or as soon thereafter as is reasonably feasible, the professional fee schedule with updated HCPCS will be posted on the web site. If a RVU is not listed or if the RVU is listed as null, reimbursement is limited to a total amount that is determined by adding the cost of the item plus the lesser of either $30.00 or 30 percent of the cost of the item plus the freight cost. An invoice documenting the cost of the equipment or supply must be sent to the insurer upon the insurer's request.

(a) Copies of the instructions are available on the department web site or may be obtained at no charge from the Montana Department of Labor and Industry, P.O. Box 8011, Helena, Montana 59604-8011.

(2) If a provider adds value to DME (such as by complex assembly, modification, or special fabrication), then the provider may charge a reasonable fee for those services. Merely unpacking an item is not a "value-added" service. While extensive fitting of devices may be billed for, simple fitting (such as adjusting the height of crutches) is not billable.

(1) Only reasonable and necessary medical expenses are payable. Procedures that are not generally accepted by the medical community may be determined not to be "reasonable" or "necessary". Providers are encouraged to seek prior approval from the insurer for experimental or controversial procedures.

(2) Disputes arising over payment of medical services may be appealed pursuant to 39-71-704, MCA and, when applicable ARM 24.29.1404.

(3) Medical services which are not payable include, but are not limited to, the following:

(a) disc nucleoplasty;

(b) extreme lateral interbody fusion (XLIA);

(c) freezeframer;

(d) frequency specific microcurrent;

(e) HEALOS/leopard cage;

(f) inter X therapy;

(g) kinesis myofascial integration;

(h) lidoderm patch;

(i) percutaneous disc nucleoplasty; and

(j) medical marijuana.

(1) In addition to the limitations on the payments for and dispensing of prescription drugs as set out by 39-71-727, MCA, the following apply:

(a) The reimbursement rate for prescription drugs is based upon the rate in effect on the date the drug is dispensed.

(b) Reimbursement rates to retail pharmacies for brand-name drugs are limited to the lesser of:

(i) the price charged for the prescription drug at the time of dispensing; or

(ii) the average wholesale price (AWP), minus 10 percent, at the time of dispensing, plus a dispensing fee, not to exceed $3.00 per prescription drug.

(c) Reimbursement rates to retail pharmacies for generic-name drugs are limited to the lesser of:

(i) the price charged for the prescription drug at the time of dispensing; or

(ii) the AWP, minus 25 percent, at the time of dispensing, plus a dispensing fee, not to exceed $3.00 per prescription drug.

(d) For the purposes of this rule, average wholesale prices must be updated monthly.

(2) If, prior to liability for a claim being accepted by the insurer, an injured worker has personally paid for prescription drugs, prescribed for a condition for which liability is subsequently accepted, the injured worker is entitled to a refund of the price paid by the injured worker for the prescription drug.

(a) The insurer, when accepting liability for a condition for which a prescription drug has been prescribed, must, upon receiving a proper receipt, reimburse the injured worker the retail price paid.

(b) After the injured worker has been reimbursed by the insurer, the pharmacy must, upon request by the insurer, reimburse the insurer for the difference in the amount paid by the injured worker and the amount provided by the fee schedule.

This rule has been repealed.

This rule has been repealed.

(1) The department adopts the fee schedule provided by this rule to determine the reimbursement amounts for medical services provided by an individual provider at a nonfacility or facility furnished on or after January 1, 2008. An insurer is not obligated to pay more than the fee provided by the fee schedule for a service provided within the state of Montana. The fee schedule is comprised of the following elements:

(a) the HCPCS codes, including CPT codes, which are incorporated by reference. Unless a special code or description is otherwise provided by rule, pursuant to 39-71-704, MCA, the edition of the CPT publication in effect at the time the medical service is furnished must be used to determine the proper procedure code;

(b) the RVU given in the RBRVS incorporated by reference. Unless a special code or description is otherwise provided by rule, pursuant to 39-71-704, MCA, the edition of the RBRVS in effect at the time the medical service is furnished must be used to determine the proper procedure code. For example, the 2010 version of the RBRVS applies to services provided from January 1, 2010, through December 31, 2010;

(i) Because this rule was previously adopted before the 2008 and 2009 versions of the RBRVS were issued, the 2009 version of the RBRVS does not apply to services in any year. The 2008 version of the RBRVS applies to services provided from January 1, 2009, through December 31, 2009 and the 2007 edition of the RBRVS applies to services provided from January 1, 2008, through December 31, 2008;

(c) the publication "Montana Workers' Compensation Nonfacility Fee Schedule Instruction Set for Services Provided on or after January 1, 2010", November 2009 edition, incorporated by reference;

(i) The "Montana Workers' Compensation Nonfacility Fee Schedule Instruction Set for 2009", applies to services provided from January 1, 2009, through December 31, 2009.

The "Montana Workers' Compensation Nonfacility Fee Schedule Instruction Set for 2008", September 2007 edition, applies to services provided from January 1, 2008, through December 31, 2008;

(d) the conversion factors established by the department in ARM 24.29.1538;

(e) modifiers, as found in the instructions; and

(f) the Montana unique code, MT001, described in greater detail in (7).

(2) The conversion factors, the CPT codes, and the RVU used depends on the date the medical service, procedure, or supply is provided. The reimbursement amount is generally determined by finding the proper CPT code in the RBRVS then multiplying the RVU for that code by the conversion factor. For example, if the conversion factor is $5.00, and a procedure code has a unit value of 3.0, the most that the insurer is required to pay the provider for that procedure is $15.00.

(3) Instructions for the fee schedule are available on the department's web site, along with already calculated reimbursement amounts by CPT code. All the definitions, guidelines, RVUs, procedure codes, modifiers, and other explanations provided in the instructions affecting the determination of individual fees apply. A copy of the instructions is available on the department web site at�http://erd.dli.mt.gov/work-comp-claims/medical-regulations or may be obtained at no charge from the Montana Department of Labor and Industry, P.O. Box 8011, Helena, Montana 59604-8011.

(4) The maximum fee that an insurer is required to pay for a particular procedure is listed on the department web site and was computed using the RVU in the total facility or nonfacility column of the RBRVS times the conversion factor, except as otherwise provided for in these rules.

(5) Each provider is to limit services to those which can be performed within the limits and restrictions of the provider's professional licensure. For nonlicensed providers, the insurer is not required to reimburse above the related CPT codes for appropriate services.

(6) RVUs have not been established in the RBRVS for CPT codes 99455 and 99456. The RVU established by the department for:

(a) code 99455 is 2.5 RVU; and

(b) code 99456 is 2.8 RVU.

(7) When billing the services listed below, the Montana unique code, MT001, must be used and a separate written report is required describing the services provided. The reimbursement rate for this code is 0.5 RVUs per 15 minutes. These requirements apply to the following services:

(a) face-to-face conferences with payor representative(s) to update the status of a patient upon request of the payor;

(b) a report associated with nonphysician conferences required by the payor; or

(c) completion of a job description or job analysis form requested by the payor.

(8) Where a procedure is not covered by these rules, the insurer must pay a reasonable fee, not to exceed the usual and customary fee charged by the provider to nonworkers' compensation patients unless the procedure is not allowed by these rules.

(9) Where a service is listed as "by report", the fee charged may not exceed the usual and customary fee charged by the provider to nonworkers' compensation patients.

(10) It is the responsibility of the provider to use the proper procedure, service, and supply codes on any bills submitted for payment. The failure of a provider to do so, however, does not relieve the insurer's obligation to pay the bill, but it may justify delays in payment until proper coding of the services provided is received by the insurer.

(11) Copies of the RBRVS are available from the publisher. Ordering information may be obtained from the department at the address listed in (3).

(1) An insurer must pay the fee schedule or the billed charge, whichever is less, for a service provided within the state of Montana. The fee schedules are available online at the department's web site and are updated as soon as is reasonably feasible relative to the effective dates of the medical codes as described below. All current and prior instruction sets for services provided starting July 1, 2013, are available on the department's website. The fee schedules are comprised of the elements listed in 39-71-704, MCA, and the following:

(a) the conversion factors established by the department in ARM 24.29.1538;

(b) modifiers, listed on the department's web site;

(c) the Montana unique code, MT001, described in (7);

(d) the Montana unique code, MT003, adopted and described in ARM 24.29.1433; and

(e) the Montana unique code, MT009, for referral to a CRC for on-site job evaluation with the injured worker to assist in returning him/her to work either to his/her time of injury job or a new job/position.

(2) The conversion factors, the Current Procedural Terminology (CPT) codes, and the relative value units (RVU) used depend on the date the medical service, procedure, or supply is provided. The reimbursement amount is generally determined by finding the proper CPT code in the Resource-Based Relative Value Scale (RBRVS) then multiplying the RVU for that code by the conversion factor.

(3) Where a permitted procedure is not covered by these rules or uses a new code, the insurer must pay 75 percent of the usual and customary fee charged by the provider to nonworkers' compensation patients.

(4) The maximum fee that an insurer is required to pay for a particular procedure is listed on the department web site and was computed using the RVU in the total facility or nonfacility column of the RBRVS times the conversion factor, except as otherwise provided for in these rules.

(5) Professionals, including those who furnish services in a hospital, critical access hospital, ambulatory surgery center, or other facility setting must bill insurers using the CMS 1500, with the exception of physical therapy, occupational therapy, and speech therapy services provided on an outpatient basis and billed on a UB04.

(6) Each provider is to limit services to those which can be performed within the provider's scope of license. For nonlicensed providers, the insurer is not required to reimburse above the related CPT codes for appropriate services.

(7) When billing the services listed below, the Montana unique code, MT001, must be used and a separate written report is required describing the services provided. The reimbursement rate for this code is 0.54 RVUs per 15 minutes with time documented by the provider. These requirements apply to the following services:

(a) face-to-face conferences with payor representative(s) to update the status of a patient upon request of the payor;

(b) a report associated with nonphysician conferences required by the payor;

(c) completion of a job description or job analysis form requested by the payor; or

(d) written questions that require a written response from the provider, excluding the Medical Status Form.

(8) Where a service is listed as "by report", the fee charged may not exceed the usual and customary fee charged by the provider to nonworkers' compensation patients.

(9) It is the responsibility of the provider to use the proper procedure, service, and supply codes on any bills submitted for payment. The failure of a provider to do so, however, does not relieve the insurer's obligation to pay the bill, but it may justify delays in payment until proper coding of the services provided is received by the insurer.

(10) Copies of the RBRVS are available from the publisher. Ordering information may be obtained from the department.

This rule has been repealed.

This rule has been repealed.

(1) The conversion factors established by the department for goods and services, other than anesthesia services are:

(a) $60.47 on or after July 1, 2023.

(b) All prior conversion factors for services provided starting July 1, 2013, are available on the department's website. 

(2) The conversion factors established by the department for anesthesia services are:

(a) $65.73 on or after July 1, 2023.

(b) All prior conversion factors for services provided starting July 1, 2013, are available on the department's website.

(3) The department will annually survey up to the top five insurers or third-party administrators providing group health plan coverage in Montana to collect information on the conversion factors paid during the current year for professional health care services in Montana. The term group health plan has the same meaning as provided in 33-22-140, MCA.

This rule has been repealed.

This rule has been repealed.

This rule has been repealed.

This rule has been repealed.

This rule has been repealed.

This rule has been repealed.

This rule has been repealed.

This rule has been repealed.

This rule has been repealed.

This rule has been repealed.

This rule has been repealed.

This rule has been repealed.

This rule has been repealed.

This rule has been repealed.

This rule has been repealed.

This rule has been transferred.

This rule has been transferred.

This rule has been transferred.

This rule has been transferred.

This rule has been transferred.

As used in this subchapter, the following definitions apply:

(1) "Claim" means an injury or occupational disease where:

(a) liability has been accepted by the insurer; or

(b) payment has been made by the insurer pursuant to:

(i) 39-71-608, MCA;

(ii) 39-71-615, MCA; or

(iii) any other reservation of rights.

(2) "Department" means the Department of Labor and Industry, Employment Relations Division.

(3) "Evidence-based" means use of the best evidence available in making decisions about the care of the individual patient, gained from the scientific method of medical decision-making and includes use of techniques from science, engineering, and statistics, such as randomized controlled trials (RCTs), meta-analysis of medical literature, integration of individual clinical expertise with the best available external clinical evidence from systematic research, and a risk-benefit analysis of treatment (including lack of treatment).

(4) " Formulary" means the list of drugs for which prior authorization is generally not needed, as adopted and automatically updated pursuant to ARM 24.29.1616.

(5) "Formulary rules" means:

(a) ARM 24.29.1601;

(b) ARM 24.29.1607;

(c) ARM 24.29.1616;

(d) ARM 24.29.1624;

(e) ARM 24.29.1631;

(f) ARM 24.29.1645; and

(g) ARM 24.29.1648.

(6) "Insurer" means compensation plan No. 1, plan No. 2, and plan No. 3.

(7) "Legacy claim" means a workers' compensation or occupational disease claim with an occurrence date before April 1, 2019.

(8) "Medical director" means a person who is an employee of, or contractor to, the department, and who is responsible for the independent medical review of requests for treatment(s) or procedure(s), when those requests are denied, and whose responsibility will also include other areas to be determined by the department. A person serving as a medical director must be a physician licensed by the state of Montana under Title 37, chapter 3, MCA.

(9) "Montana Guidelines" are the Montana utilization and treatment guidelines adopted by the department in ARM 24.29.1611.

(10) "ODG drug formulary" means the ODG Workers' Compensation Drug Formulary published by MCG Health, LLC.

(11) "PBM" mean the pharmacy benefits manager used by an insurer to help the insurer implement the formulary's use in the insurer's claims handling processes.

(12) "Primary medical services" has the same meaning as provided by 39-71-116, MCA.

(13) "Prior authorization" means the interested party receives prior authorization (either verbally or in writing) from the insurer:

(a) to perform treatment for those cases identified by ARM 24.29.1621; or

(b) to obtain medications for those cases identified in the formulary rules as requiring prior authorization.

(14) "Rebuttable presumption" means that the Montana Guidelines, as adopted in ARM 24.29.1611, are presumed to be compensable medical treatment for an injured worker. The presumption can be rebutted by a preponderance of credible medical evidenced-based material and medical reasons to justify that the medical treatment(s) or procedure(s) that require prior authorization are reasonable and necessary care for the injured worker.

(15) "Refill" means the dispensing of additional medications after the initial number of doses authorized by a written prescription have been dispensed, where the prescription expressly indicates that a certain number of refills are allowed without the need for another written prescription.

(16) "Supportive services" means those treatments, therapies, and related services that are designed to safely, effectively, and compassionately assist an injured worker transition from an existing medication regimen.

(17) "Treating physician" has the same meaning as provided by ARM 24.29.1401A.

(18) "Treatment" has the same meaning as provided by ARM 24.29.1401A.

(19) "Treatment plan" means a written outline of how the provider intends to treat a specific condition or complaint. A treatment plan includes a transition plan provided for in ARM 24.29.1631. A treatment plan must be made in accordance with the Montana Guidelines adopted in ARM 24.29.1611 and made in accordance with any insurer authorized treatments or procedures.

(1) The following rules are subject to the applicability provisions of this rule:

(a) ARM 24.29.1611;

(b) ARM 24.29.1621;

(c) ARM 24.29.1641; and

(d) ARM 24.29.1609.

(2) The rules identified in (1) apply to:

(a) injuries that occurred on or before June 30, 2007, for any treatment rendered on or after July 1, 2011, except that the provisions of (3) apply; and

(b) injuries that occurred on or after July 1, 2007, for any treatment rendered on or after July 1, 2011.

(3) The presumption of compensability in the Montana utilization and treatment guidelines adopted by ARM 24.29.1611 does not apply to injuries occurring on or before June 30, 2007. However, treatment for these injuries made in accordance with the guidelines constitutes reasonable primary or secondary medical treatment, pursuant to 39-71-704, MCA, for any condition or diagnosis identified in the guidelines. Therefore, prior authorization is not required for treatment within the guidelines for these injuries unless prior authorization would otherwise be required under these rules.

(4) As used in this subchapter, the term "injuries" includes occupational diseases which were diagnosed as an occupational disease, or should have been diagnosed as an occupational disease, during the time period specified.

(1) The provisions of these formulary rules apply to all claims arising on or after April 1, 2019, but only with respect to outpatient services.

(2) For claims arising before April 1, 2019, which are referred to as "legacy claims," the rules in this subchapter will apply to prescriptions written on or after April 1, 2020, or 90 days after the insurer gives notice as provided in ARM 24.29.1631, whichever is later.

(3) The provisions of this subchapter, including the formulary adopted and automatically updated as provided in ARM 24.29.1616 apply as they are in effect on the date the prescription is written.

(4) Nothing in this subchapter excuses an insurer from providing medications that constitute primary medical services required to be furnished by 39-71-704, MCA.

(5) Nothing in this subchapter requires an insurer to use the services of a PBM.

(1) Managed care organizations or preferred provider organizations providing any treatment for primary and secondary medical services to an injured worker shall use the Montana Guidelines. This rule does not alter or change how managed care organizations or preferred provider organizations are paid pursuant to 39-71-704, MCA.

(2) The provisions of this rule apply to medical services provided, or proposed to be provided, on or after July 1, 2011.

(1) The department adopts the utilization and treatment guidelines provided by this rule to set forth the level and type of care for primary and secondary medical services. As provided by 39-71-704, MCA, there is a rebuttable presumption that the Montana Guidelines establish compensable medical treatment for primary and secondary medical services for the injured worker. The applicable utilization and treatment guidelines are available electronically at the web site: http://www.mtguidelines.com; or a printed copy may be obtained for the cost of reproduction from the Employment Relations Division, Department of Labor and Industry, P.O. Box 8011, Helena, MT 59601-8011. The Montana Guidelines incorporated by reference apply as follows:

(a) for medical services provided on or after July 1, 2023: "Montana Utilization and Treatment Guidelines, 8th edition, 2023"; and

(b) all prior Utilization and Treatment Guidelines starting July 1, 2011, are available on the department's website or by contacting the department to request a copy. 

(2) The Montana Guidelines consist of the following ten chapters and General Guideline Principles which are included at the beginning of each chapter:

(a) Low Back Pain;

(b) Shoulder Injury;

(c) Thoracic Outlet Syndrome;

(d) Lower Extremity;

(e) Chronic Pain Disorder;

(f) Cervical Spine Injury;

(g) Complex Regional Pain Syndrome;

(h) Mild Traumatic Brain Injury;

(i) Moderate/Severe Traumatic Brain Injury; and

(j) Cumulative Trauma Conditions.

(3) The utilization and treatment guidelines adopted in (1) are to be read in conjunction with the Centers for Disease Control publications:

(a) "CDC Guideline for Prescribing Opioids for Chronic Pain – United States, 2016"; and

(b) 2018 edition of "Implementing the CDC Guideline for Prescribing Opioids for Chronic Pain."

(4) When providing treatment for primary and secondary medical services to an injured worker, all health care providers shall use the Montana Guidelines adopted by reference in (1).

(a) In cases where treatment(s) or procedure(s) are recommended by the Montana Guidelines, and treatment is provided in accordance with the guidelines, prior authorization is unnecessary unless the Montana Guidelines specify otherwise.

(b) The department recognizes that medical treatment may include deviations from the Montana Guidelines as individual cases dictate. The provider or interested party shall follow the procedure for prior authorization under ARM 24.29.1621 for cases in which treatments or procedures are requested that are:

(i) not specifically addressed or recommended by the Montana Guidelines for a body part that is covered by a guideline;

(ii) after maximum medical improvement; or

(iii) beyond the duration and frequency limits set out in the guidelines.

(c) An insurer is not responsible or liable for treatment(s) or procedure(s) as set out in (3)(b) unless:

(i) prior authorization is obtained from the insurer pursuant to 39-71-704, MCA, and in accordance with ARM 24.29.1621; or

(ii) the treatment(s) or procedure(s) were provided in a medical emergency.

(d) For those body parts not included in one of the guideline chapters, providers must apply and follow the general guideline principles that are found at the beginning of each chapter, and an insurer is liable for reasonable medical treatment.

(5) All insurers shall routinely and regularly review claims to ensure that care is consistent with the Montana Guidelines adopted by reference in (1) and (7).

(6) The provisions of this rule apply to medical services provided on or after July 1, 2011.

(7) Effective April 1, 2019, the formulary adopted in ARM 24.29.1616 is considered to be a part of the Montana Guidelines.

(1) The department will annually undertake formal rulemaking to select a formulary. The formulary may be any one of the following:

(a) a formulary published by a commercial vendor;

(b) a formulary published by another state for use in workers' compensation and occupational disease claims; or

(c) a formulary specially developed by the department.

(2) The department adopts and incorporates by reference its formulary as follows:

(a) for prescriptions written on or after July 1, 2023, the April 2023 edition of the ODG Drug formulary; and

(b) all prior ODG drug formulary lists starting January 2019, are available on the department's website or by contacting the department to request a copy. 

(3) Pursuant to 2-4-307, MCA, the automatic monthly updates of the annually adopted edition of the formulary are incorporated by reference without additional rulemaking, and are applicable as of the date the update is posted on the department's web site.

(4) The formulary is available on the department's website and from the vendor, via electronic access, at a subscription rate charged by the vendor, which may include supplemental information or materials that are not incorporated by reference. The vendor may be contacted at www.mcg.com/odg, and at ODG by MCG Health, 3006 Bee Caves Road, Suite A250, Austin, TX 78746.

(5) Archived versions of the formulary will be maintained by the department for five years from the date of the adoption of the formulary. 

(1) Prior authorization must be obtained in cases where treatment(s) or procedure(s) are requested that:

(a) are not specifically addressed or recommended by the Montana Guidelines for a body part that is covered by a guideline;

(b) are after maximum medical improvement;

(c) are beyond the duration and frequency limits set out in the guidelines; or

(d) the guidelines require prior authorization before proceeding with the treatment.

(2) For those body parts not covered by a guideline, the rule for prior authorization set out at ARM 24.29.1517 applies.

(3) When the guidelines explicitly require prior authorization for a treatment or modality, documentation need only include the clinical indications outlined in the guidelines to support that the treatment or modality is appropriate for the injured worker.

(4) When prior authorization is required because an interested party wishes to rebut the presumption of the guidelines, the interested party must submit to the insurer documentation to support the request and justification that the medical treatment(s) or procedure(s) are reasonable and necessary care for the injured worker. Documentation must consist of a preponderance of credible medical evidenced-based material and medical reasons to rebut the Montana Guidelines. Documentation submitted to rebut the guidelines may include any information from the following list. However, nothing in this list is intended to imply that any given information is sufficient to rebut the guidelines. Rather, whether the presumption of the guidelines is rebutted can only be determined on a case-by-case basis. Submitted information may include:

(a) an explanation or documentation of how the patient's medical condition is different from the medical indications used in the Montana Guidelines that may have resulted in a negative recommendation or exclusion;

(b) an explanation or documentation of objective findings and functional improvements that would be the expected result of the treatment(s) or procedure(s), either from past experience or from an explanation about the mechanism of injury and the effect of the treatment(s) or procedure(s), and where improvement can be measured;

(c) an explanation or documentation of objective signs of functional restoration for treatment conducted thus far;

(d) an explanation or documentation of measurable goals and progress points expected from additional treatment;

(e) a statement of how the request will benefit both a short-term and long-term treatment plan; or

(f) any additional evidence-based utilization and treatment guidelines or studies that support the interested party's case.

(5) All prior authorization requests, whether in written, e-mail, or facsimile (fax) form, must be made at least 14 days prior to the date the service is scheduled to be performed.

(a) Authorization is presumed to be given by the insurer if there is no written denial sent by the insurer to the interested party within 14 days of the date the written prior authorization request was made.

(b) An insurer may notify the interested party of authorization by written confirmation, e-mail, or facsimile (fax).

(c) Nothing in this rule precludes verbal communication. However, all deadlines in this rule must be satisfied in written form.

(6) If the insurer denies the prior authorization request, the denial must be in writing and must contain an explanation of why the justification is not sufficient.

(a) The denial must not be based solely on the fact that the medical treatment(s) or procedure(s) are not specifically addressed or recommended by the Montana Guidelines.

(b) If the written denial is five or fewer days before the expiration of the 14- day response period, the insurer must also notify the interested party of the denial by e-mail or facsimile (fax).

(7) When an insurer denies liability for an injury or occupational disease, and the insurer then later assumes liability for a particular condition, the insurer may not deny payment for the medical services provided for that condition during the period of denial based solely on failure to obtain prior authorization.

(8) The provisions of this rule apply to medical services provided, or proposed to be provided, on or after July 1, 2011.

(1) The formulary is considered to be a part of the Montana Guidelines established by the department. 

(2) A medical provider is expected to write a prescription for medication in accordance with the Montana Guidelines, as adopted by ARM 24.29.1611, and in accordance with the formulary adopted by ARM 24.29.1616.

(3) Because the formulary is part of the Montana Guidelines, medical providers are required to prescribe in accordance with the provisions of the formulary unless the provider can sufficiently articulate sound medical reasoning to vary from the formulary.

(4) Insurers shall pay for medications that are prescribed in a manner consistent with the formulary, subject to the medical provider furnishing documentation as required by ARM 24.29.1621. Payments for medications are subject to the provisions of 39-71-727, MCA.

(5) Pursuant to the formulary, prior authorization for an injury appropriate medication is not required as follows:

(a) the medication is listed as "Y" on the formulary; or

(b) the medication is listed as "N" on the formulary, and the prescription is:

(i) written within seven days of the occurrence of the workplace injury; and

(ii) limited to a maximum of a seven-day supply of the medication.

(6) Pursuant to the formulary, prior authorization for a medication is required as follows:

(a) except as provided by (5)(b), the medication is listed as "N" on the formulary;

(b) the medication is not listed on the formulary;

(c) the medication is experimental or investigational; or

(d) the medication is a compound, even if all the components of the compound are listed as "Y" medications on the formulary.

(7) The prior authorization process described in ARM 24.29.1621 applies to formulary matters, except that:

(a) the insurer shall respond within three business days of the receipt of a request for prior authorization being made to the insurer or the insurer's designee, by either approving or denying the request; and

(b) if the insurer fails to respond within three business days to a request for prior authorization, the prescription is deemed to be approved. An approval for a prescription medication made due to the lack of a timely response by the insurer does not apply to any refill that may be ordered.

(8) An insurer may delegate prior authorization decisions pertaining to the formulary to a PBM or other agent with which it contracts. An insurer has the legal responsibility for the decisions made by the PBM on behalf of the insurer.

(9) The delegation by an insurer of prior authorization decisions pertaining to the formulary to a PBM or other agent does not, in and of itself, violate the requirement of 39-71-107, MCA, that all claims be examined by a claims examiner in Montana.

(1) The insurer shall notify in writing the injured worker and the treating physician (who, for the purposes of this rule, also includes any other prescribing medical provider) that a claim constitutes a legacy claim in which the insurer will enforce the applicability of these formulary rules. 

(2) The notification required by (1) must include at least the following information:

(a) the name of the injured worker;

(b) the name of the treating physician or other prescribing medical provider;

(c) the name of each medication that is affected by the notice;

(d) the name and contact information of the claims examiner responsible for the injured worker's claim; and

(e) the date upon which the insurer will enforce the applicability of these formulary rules.

(3) This rule applies to a legacy claim on the latter of:

(a) April 1, 2020; or

(b) 90 days after the insurer provides notice as provided by (1).

(4) By not later than the applicability date of this rule pursuant to (3), the treating physician shall determine whether a transition plan is needed for an injured worker who is receiving:

(a) one or more drugs for which prior authorization is otherwise required; or

(b) drugs at a dosage level greater than recommended by the Montana Guidelines.

(5) The treating physician must state in writing whether the injured worker:

(a) should transition to "Y" status drugs or to medication dosages which are consistent with the recommendations of the Montana Guidelines; or

(b) should not undergo a transition from the existing medications because a transition is not medically appropriate.

(6) The treating physician must provide the basis for the medical provider's decision as required by ARM 24.29.1621. The explanation, and development of a transition plan as appropriate, constitutes a "by report" service (CPT code 99080).

(7) If the treating physician fails to provide the determination required in (5), by the date this rule becomes applicable to the claim pursuant to (3), these formulary rules will apply to prescriptions written for the injured worker.

(8) If the treating physician determines a transition from one or more drugs for which prior authorization required to a "Y" status drug is appropriate, or that a reduction in dosage is appropriate, the treating physician shall include in the worker's treatment plan a specific plan, including a projected time table or schedule, for transitioning the injured worker to care that is consistent with the Montana Guidelines.

(9) The treatment plan may, when determined by the treating physician to be medically necessary, include the provision of supportive services to the injured worker during the transition.

(10) Supportive services may be delivered in an out-patient or an in-patient setting, as appropriate, based upon the treating provider's transition plan. Supportive services that are reasonable and medically necessary constitute part of the primary medical services to which an injured worker with a legacy claim is entitled.

(11) Nothing in this rule prohibits the treating physician from proposing a treatment plan for transition prior to an insurer's authorization as provided in (1).

(1) An interested party who has requested and been denied authorization by the insurer for treatment, or an insurer, may request an independent medical review by the medical director designated by the department prior to mediation under 39-71-2401, MCA. If the independent medical review process is requested prior to mediation, the mediation process shall not proceed until completion of the independent medical review process.

(2) The interested party or insurer must submit its request for review to the department and must notify the other party of its request for review. Upon notice of a request for review, the insurer must submit a copy of the request for prior authorization, the denial, and any other relevant medical information to the department. The interested party and the insurer may also submit additional information to the department, if the information falls within the categories outlined in ARM 24.29.1621. Any new information submitted to the department must also be submitted to the other party.

(3) The medical director will review the medical records of the injured worker and other information relevant to the denial and issue a recommendation. For purposes of this rule, the medical director is the specific individual designated by the department to serve as the medical director with respect to a given set of disputed treatments or procedures. The medical director may seek consultation from other providers with specialties as would typically manage the medical condition at issue. If a consultation is sought and received, that provider's recommendation is also subject to the provisions of this rule.

(4) The medical director shall, within five days of receipt of the request for review, issue a written recommendation to the interested party and the insurer by mail, facsimile, or e-mail, or issue a notice that additional information or time is required to tender a recommendation along with an approximate date the recommendation will be issued, not to exceed 14 days from the date of receipt of the review request. If the medical director does not issue a recommendation within 14 days, the request for review is deemed denied and the parties may proceed to mediation.

(5) The medical director's review and recommendation is an informal alternative dispute resolution process without administrative or judicial authority and is not binding on the parties.

(a) The medical director's files and records are closed to all persons but the parties.

(b) The medical director may not be called to testify in any proceeding concerning the issues discussed in the independent medical review process.

(c) The medical director's recommendation and any information contained in the recommendation that is solely from the medical director are not admissible as evidence in any action subsequently brought in any court of law.

(d) The medical director's recommendation, including information contained in the recommendation, may be considered in mediation conducted under 39-71-2401, MCA.

(6) The insurer shall, within five days of receipt of the recommendation, notify the interested party if the previously denied treatment(s) or procedure(s) is authorized based on the medical director's recommendation.

(7) If the insurer does not authorize treatment after issuance of the medical director's recommendation, the interested party may file for mediation with the department pursuant to 39-71-2401, MCA.

(8) The provisions of this rule apply to medical services provided, or proposed to be provided, on or after July 1, 2011.

(9) An expedited case review for medications is provided by ARM 24.29.1645.

(1) Expedited case review is available only when insurer declines to authorize further dispensing of an already prescribed medication and halting the supply of that medication appears likely to result in a medical emergency. 

(2) A medical emergency occurs when all three of the following circumstances are present:

(a) the medical condition has a sudden onset;

(b) the medical condition manifests itself by acute symptoms of sufficient severity, including severe pain; and

(c) in the absence of immediate medical attention, the medical condition could reasonably be expected to result in:

(i) placing the injured worker's health or bodily functions in serious jeopardy; or

(ii) a serious dysfunction of any body organ or part of the injured worker.

(3) An expedited case review may be requested concurrently with a demand for mediation on the dispute concerning the medication.

(4) An expedited case review may only be requested within 14 days of the insurer's denial of, or refusal to authorize further dispensing of an already prescribed medication.

(5) A request for an expedited case review must be supported by such written information as the treating physician considers pertinent to the treating physician's opinion that a medical emergency is likely to occur as a result of the denial of the medication.

(6) The expedited medical review will be conducted within three business days of receipt by the department of a written request for an expedited medical review. The findings of the expedited medical review must be in writing and be based on the information provided by the treating physician, along with the reasoning given by the insurer or its agent for the denial.

(7) The findings of the medical director regarding whether or not a medical emergency is likely to occur as the result of not providing the further dispensing of medication as prescribed by the treating physician may be offered in evidence in mediation or the Workers' Compensation Court.

(8) If the findings of the medical director are that no medical emergency is likely to occur as a result of the insurer's denial, then the medical director shall further consider the matter of the denial under the independent medical review procedures provided for by ARM 24.29.1641.

(1) Disputes between the treating physician and the insurer regarding the formulary are subject to the same process available for other disputes regarding the Montana Guidelines, except as provided in ARM 24.29.1645.

(2) A dispute between the injured worker and the insurer regarding the use or application of the formulary constitutes a dispute concerning benefits, and may be resolved as provided by 39-71-2905, MCA.

(1) Prior to or upon termination of temporary total disability benefits to a disabled worker, a rehabilitation provider must be designated by the insurer or the division will require them to do so. If maximum healing has been reached by a disabled worker and the insurer has not designated a rehabilitation provider, the insurer will pay total rehabilitation benefits to the disabled worker and the 26-week period will not start until the rehabilitation provider is designated.

This rule has been repealed.

(2) Travel and relocation expenses may be paid to a worker on the same schedule as reimbursed to state employees in the course of state business.

(3) Mileage and per diem expenses may be paid for up to five round trips in searching for new employment.

(4) Relocation expenses include actual expenses of moving by a commercial mover, or actual charges for rental of a truck or trailer by a commercial rental company and receipted fuel expenses.

(5) Auxiliary rehabilitation benefits do not include the expenses of long term commuting.

(6) The division may order the insurer to pay such other reasonable and necessary auxiliary rehabilitation benefits as it deems appropriate.

This rule has been repealed.

This rule has been repealed.

the following information:

(a) plan objectives that summarize the type and duration of the training agreed to by the parties. It should include where the claimant will receive the training and identify any prerequisites and/or contingencies;

(b) the beginning and completion dates of the rehabilitation plan;

(c) a projection of expenditures to be made pursuant to the plan. The plan should include an estimate of the amount of tuition, fees, books, and other reasonable retraining expenses needed to successfully complete the plan. The plan should also include the date the funds are needed and to whom the funds should be paid;

(d) a description of the claimant's responsibilities under the plan. The plan should identify the responsibilities the claimant has agreed to undertake for successful completion of the plan. For example, the claimant agrees to attend classes and maintain a 2.0 grade point average, or the claimant agrees to timely register for classes, etc.;

(e) a description of the insurer's responsibilities under the plan. The plan should identify the responsibilities the insurer has agreed to undertake for successful completion of the plan. For example, the insurer will pay rehabilitation benefits for a period of 70 weeks to begin on a specific date, etc.;

(f) a description of the vocational rehabilitation provider's responsibilities. The plan should identify and list what actions or understandings the provider has agreed to undertake for successful completion of the plan. For example, the provider will continue to monitor the claimant's progress and provide further vocational rehabilitation services necessary to successfully complete the plan, etc.; and

(g) the signatures of both the claimant and the authorized insurer's representative.

This rule has been repealed.

This rule has been repealed.

This rule has been repealed.

This rule has been repealed.

This rule has been repealed.

(2) The insurer and claimant must agree to payment of tuition, fees, books and other reasonable and necessary retraining expenses. The expenses must be specified in the rehabilitation plan agreed upon between the insurer and claimant. The expenses must be paid directly by the insurer.

(3) The insurer must pay for tuition required for the agreed upon rehabilitation plan. The insurer must pay for fees, books, supplies and equipment which are a prerequisite for the retraining and required by the provider of the training. Unless otherwise agreed upon by the insurer and the claimant, the insurer is not responsible for fees, books, supplies and/or equipment which are optional, not required to complete the retraining plan. For example, the purchase of student health insurance at a Montana university is an optional fee not required for enrollment, unless the claimant does not have health care insurance. If the claimant does not have health care insurance, the purchase of student health insurance is required. The payment of parking fees is required for enrollment at Montana universities.

(a) Supplies include, but are not limited to, pens, paper, notebooks, etc. and are limited to $25 for each term of training. For example, a term of training is a semester, quarter, etc.

(b) Equipment includes, but is not limited to, calculators, computer hardware and/or software, ergonomic furniture, tools, etc. The insurer may choose to rent or lease rather than purchase the equipment, if the insurer determines it is more cost effective to do so.

(4) The insurer is not liable for tuition, fees, books or equipment costs incurred if the claimant fails to complete registration requirements or fails to properly withdraw from the agreed upon training program. The insurer is entitled to any refund of tuition or fees that may be paid by the retraining entity upon the early withdrawal of the claimant from the training program. In addition, the insurer is entitled to possession of books, tools or other equipment previously paid for by the insurer upon the pre-graduation withdrawal of the claimant from the agreed upon training program.

(1) Disputes between claimants and insurers over the entitlement to or payment of rehabilitation expenses must first be mediated and then may proceed to the workers' compensation court.

As used in this subchapter, the following definitions apply:

(1) "Injured worker" means an individual who has filed a claim for a workers' compensation injury or occupational disease and who does not meet the definition of a disabled worker.

(2) "Insurer" means an employer bound by compensation plan No. 1, an insurance company transacting business under compensation plan No. 2, or the state fund under compensation plan No. 3, as defined in 39-71-116, MCA.

(3) "Medical status form" means the department reporting form completed by an injured worker's treating physician or designee, which documents an injured worker's medically necessary work restrictions and work abilities.

(4) "Outcome report form" means the department reporting form completed by an insurer or vocational rehabilitation counselor, which documents the results for the injured worker of SAW/RTW assistance.

(5) "Request" means a request for SAW/RTW assistance by letter, e-mail, or telephone call to the department or insurer. A request must include, at a minimum, the name of the injured worker, the requestor's name and requestor's telephone number. A note in a medical record does not constitute a request.

(6) "SAW/RTW" means stay at work/return to work.

(7) "Time-of-injury employer" means the employer under whose employment a worker was injured or developed an occupational disease.

(8) "Transitional employment" means work for the injured worker with the time-of-injury employer offered by the employer for a temporary period of time, and may include a reduction in hours, workplace modifications, and alternative job duties.

(9) "Vocational rehabilitation counselor" means a rehabilitation provider who possesses current certification from the Commission on Rehabilitation Counselor Certification, as defined in 39-71-1011, MCA.

(2) The insurer shall designate a single point of contact with authority to coordinate all department requests for SAW/RTW assistance for injured workers and shall provide the department with written notice of the contact person's name or position title, telephone number, email address, and mailing address. When contact information changes, the insurer shall update the department a minimum of ten business days in advance of the change.

(3) When a request for SAW/RTW assistance is made directly to the insurer prior to the insurer's acceptance of liability for a claim, the insurer may elect to provide SAW/RTW assistance to the injured worker or it may refer the injured worker to the department for assistance.

(4) When a request for SAW/RTW assistance is made directly to the insurer and the insurer declines to provide SAW/RTW assistance the insurer shall notify the injured worker and the department in writing within three business days of a request for assistance.

(5) After the department has initiated SAW/RTW assistance to an injured worker, the insurer shall notify the department in writing within three business days of the insurer's acceptance or denial of liability for an injured worker's claim.

(6) For notice purposes, the department's contact information is:

(a) via email, [email protected];

(b) via fax machine, (406) 444-4140;

(c) via U.S. mail, SAW/RTW Assistance Program, P.O. Box 8011, Helena, MT 59604-8011; or

(d) via the street address is Employment Relations Division, Beck Building, 1805 Prospect Avenue, Helena, Montana.

(7) Notice sent by U.S. mail must be postmarked within the three business days required by this rule.

(8) The insurer shall report the outcome of SAW/RTW assistance to the department, using the department outcome reporting form, within 30 business days of the earliest of:

(a) the return to work start date;

(b) the termination of SAW/RTW services; or

(c) the injured worker's attainment of maximum medical improvement.

(2) When the department is unable to identify the insurer within three business days of receiving a request for SAW/RTW assistance, the department shall provide assistance to the injured worker. When the department identifies the at-risk insurer after the department has initiated assistance, the department shall continue to provide SAW/RTW services to the injured worker when the insurer declines to provide SAW/RTW assistance or fails to respond to department notice of the initiation of services. The department shall provide services until it:

(a) terminates SAW/RTW services to the injured worker upon notice of insurer denial of liability for the claim;

(b) terminates SAW/RTW services to the injured worker upon exhaustion of the maximum allowed provider fees, as provided in ARM 24.29.1815; or

(c) transfers responsibility for the delivery of SAW/RTW assistance to the insurer upon notice of the insurer's acceptance of liability for the claim.

(3) When the department provides SAW/RTW assistance, the department shall assign a vocational rehabilitation counselor to each eligible injured worker to provide services which may include, but are not limited to, the following:

(a) personal contact with injured worker to assess the worker's commitment and ability to stay at or return to work;

(b) identification of barriers to the injured worker staying at or returning to work;

(c) review of the injured worker's medical status form to ensure worker's understanding of work abilities and restrictions;

(d) personal contact with injured worker's employer to establish employer's ability to provide transitional employment that meets injured worker's abilities, as outlined by the medical status form;

(e) facilitation of communication between injured worker and employer regarding offer and acceptance of transitional employment;

(f) communication with injured worker's treating physician or designee regarding the assessment and approval of transitional employment when approval is not explicitly provided by medical status form;

(g) verification that duties assigned by employer to injured worker during transitional employment conform with abilities outlined by the medical status form;

(h) identification of concerns of the injured worker and employer and problem-solving throughout the process of establishing transitional employment; and

(i) monitoring injured worker's readiness and ability to return to time of injury job and providing appropriate interventions as needed.

(4) The department shall provide written notice to the injured worker, employer and insurer, if identified, when a vocational rehabilitation counselor is assigned by the department to provide SAW/RTW services to an injured worker. The notice shall be mailed within three business days of the assignment of a vocational rehabilitation counselor.

(5) The department shall provide written notice to the injured worker, employer and insurer of the completion of department-provided SAW/RTW assistance within three business days of the completion of services.

(a) a maximum of $90 per hour for services provided, billed in 1/10 hour increments;

(b) travel time of four (4) hours or less at one-half the hourly rate;

(c) travel time over four (4) hours at two-thirds the hourly rate; and

(d) mileage, lodging and meals at the State of Montana per diem rate established pursuant to Title 2, chapter 18, part 5, MCA.

(2) The department shall pay a maximum of $2,000.00 per claim to a certified vocational rehabilitation counselor for SAW/RTW services, not including mileage, lodging and meals.

(3) When the department provides the assistance, the department may pay up to $2,000.00 to assist an employer in modifying the workplace or purchasing equipment required for the employer to provide transitional employment. Any such equipment or workplace modifications become the property of the employer. To apply for financial assistance, the employer must submit a written application to the department that includes, at a minimum, the following:

(a) a written recommendation from the department-designated vocational rehabilitation counselor, which specifically describes the required workplace modification or equipment;

(b) the estimated cost of the recommended workplace modification; and

(c) the estimated cost of the recommended equipment.

(4) The department may deny an employer's application for financial assistance when the department determines the application is incomplete or the request for assistance is unreasonable. The department will notify the employer as to whether the application is accepted or rejected, and the reasons for the action.

(1) When the department provides SAW/RTW assistance, the department shall assign a vocational rehabilitation counselor to provide services to each eligible injured worker. 

(2) The department shall select an appropriate vocational rehabilitation counselor for each injured worker, using the following criteria:

(a) geographical proximity to the injured worker's residence;

(b) ability to accept and promptly provide services to an injured worker; and

(c) specialized expertise and pertinent experience with the type of injury or challenges to returning to work faced by the injured worker.

(3) The vocational rehabilitation counselor shall notify the department of the services provided, the progress toward transitional employment, and assistance outcomes, as directed by the department. 

This rule has been repealed.

(1) In keeping with the accepted standards for diagnosis, use of the chiropractic term "subluxation" on reports to the division is valid only in objective findings or descriptions. "Subluxation" is not a diagnosis in itself. It can be used within a diagnosis to clarify the description of a condition.

(2) Initial diagnosis represents a conclusion reached as the result of the initial examination and prior to initiation of treatment.

(3) Therapeutic or working diagnosis represents the conclusions upon which the treating chiropractor bases his treatment and therapy.

(4) Final diagnosis represents the final conclusion of the attending chiropractor. It is based on a total assessment of all factors consistent with academic training, scientific knowledge and clinical experience.

(5) This rule applies to services provided on or before June 30, 2011.

(1) For "therapeutics" defined as: any treatment considered necessary to return the patient to a preclinical status or establish a stationary status.

(2) Rehabilitation procedures necessary for reeducation or functional restoration of a disabled body system or part.

(3) This rule applies to services provided on or before June 30, 2011.

This rule has been repealed.

(2) A MCO may be formed by a single health care provider, a hospital, a consortium of medical service providers, or other groups or entities that provide the services required by these rules. In order to expand the areas served by a MCO, the use of satellite office locations providing medical services to injured workers is encouraged.

(3) Although these rules do not regulate preferred provider organizations (PPOs) , insurers are encouraged to use PPOs in addition to or in conjunction with the use of MCOs.

(4) The certification procedure contained in these rules consists of a two step process of a preliminary application and a final application. The department anticipates that preliminary applications may have to be revised or modified, and emphasizes that applicants are engaged in a process of certification. Certification of a MCO by the department, however, does not obligate insurers to contract with any MCO.

(1) "Applicant" means an individual, partnership, corporation or other legal entity seeking original certification as a MCO.

(2) "Certification" means authorization from the department to provide managed care services pursuant to the provisions of the Workers' Compensation Act.

(3) "Community" means the area within a 30 mile radius of the injured worker's residence, if there is a MCO (which has contracted with the injured workers' insurer) within that area.

(4) "Department" means the department of labor and industry.

(5) "Dispute" means a written complaint about how the MCO provides services to the injured worker or about a decision the MCO has made that affects the injured worker. A complaint that is not written is not a dispute within the meaning of these rules.

(6) "Injured worker" means a person who has suffered an occupational injury or disease for which an insurer:

(a) has accepted liability pursuant to the terms of the Workers' Compensation or Occupational Disease Acts; or

(b) is making compensation payments to the worker pursuant to 39-71-608 , MCA, or any other reservation of rights, and the insurer agrees to pay for all of the services provided by the MCO to that injured person.

(7) "Member" means an individual health care provider, (including, but not limited to a physician, osteopath, chiropractor, dentist, physician assistant, podiatrist, optometrist, physical therapist or occupational therapist) other than a personal doctor, who regularly provides services for or on behalf of a MCO, whether as an employee of the MCO or pursuant to contract. Ancillary personnel providing service, but who do not have direct responsibility for management of an injured worker's care are not included in this definition.

(8) "Miles" means air miles ("as the crow flies") from the point referenced, without regard to the availability of a convenient or direct roadway.

(9) "MCO" means a managed care organization that is certified under these rules.

(10) "Personal doctor" means a person who:

(a) is qualified to be a treating physician;

(b) has a documented history of providing treatment to the injured worker prior to the injury, for any condition;

(c) maintains the injured worker's medical records; and

(d) is one of the following types of practitioners:

(i) family practitioner;

(ii) general practitioner;

(iii) internal medicine practitioner; or

(iv) chiropractor.

(11) "Plan" means the written statement that details how a managed care organization will deliver medical and other services to claimants and insurers, unless the context clearly indicates otherwise.

(12) "Primary medical services" has the same meaning as provided by section 39-71-116 , MCA.

(13) "Secondary medical services" has the same meaning as provided by section 39-71-116 , MCA.

(14) "Service contract" means an agreement between an insurer and a MCO whereby the insurer may direct claimants to the MCO for medical and other services.

(15) "Treating physician" has the same meaning as provided by section 39-71-116 , MCA.

(2) The MCO will designate a treating physician for the injured worker in accordance with the plan, taking into consideration the nature of the injury and the injured worker's preference of treating physician. Within 7 days after the injured worker's initial visit to a medical provider within a MCO as directed by the insurer, the worker may select a personal doctor as the worker's treating physician, provided the personal doctor agrees to comply with all the rules, terms, and conditions regarding services performed by the MCO. The injured worker will be responsible for co-payments if the injured worker is treated by a personal doctor pursuant to this rule.

(3) If the injured worker indicates the desire to be treated by a personal doctor, the insurer has the responsibility of contacting the personal doctor to see if the doctor will comply with the MCO rules, terms, and conditions. The insurer has the responsibility to monitor the personal doctor's compliance with the rules, terms and conditions of the MCO. The insurer may contract with the MCO to perform some or all of these functions.

(4) Once an injured worker has entered a MCO and a treating physician has been designated or a personal doctor has been selected pursuant to this rule as the treating physician, the injured worker may not change either the MCO or treating physician without approval from the insurer.

(2) A preliminary application consists of the following elements:

(a) a statement describing the time, place and manner in which services will be provided to claimants (see 24.29.2323) ;

(b) a map showing the areas served by the MCO (see 24.29.2326) ;

(c) information describing the organizational structure of the MCO (see 24.29.2329) ;

(d) the plan for providing managed care (see 24.29.2331) ; and

(e) information concerning the ability of the MCO to meet its financial obligations (see 24.29.2336) .

(3) An applicant must furnish with the preliminary application the name, address and telephone number of a knowledgeable contact person who is familiar with the contents of the preliminary application.

(4) A preliminary application must be accompanied by a non-refundable application fee of $1,500.00. No fee will be required for final applications.

(5) An applicant must furnish an original and three copies of the preliminary application to the department. In lieu of the copies, an applicant may submit the information in an electronic form or on computer readable media that meets the requirements of the department. Applicants should contact the department to determine the format for supplying that information in electronic form or media. The map of the service areas need not be reproduced in electronic form.

(6) Any portion of the preliminary application that the applicant believes in good faith to be a trade secret, protected by the Uniform Trade Secrets Act (Title 30, chapter 14, part 4, MCA) , must be clearly identified as such by the applicant. Any portion of the preliminary application which is not specifically identified as a trade secret is subject to public inspection and disclosure. In the event that a person seeks disclosure of information that is identified as a trade secret, the department will determine whether the individual right to privacy is outweighed by the public right to know, and whether an appropriate protective order can be fashioned to permit disclosure in a way that does not injure the property rights of the applicant.

(1) An applicant must state in the preliminary application how it intends to serve the medical and medical rehabilitative needs of claimants and identify the times, places and manners in which those services will be provided.

(2) The statement required by this rule must be written to clearly inform claimants and interested parties of the following:

(a) the nature of the primary medical services that are available from the MCO;

(b) the specific location(s) where primary medical services are available and the hours and days on which those services are available;

(c) what other services (if any) are provided by the MCO to claimants, and where those services will be available;

(d) how persons may obtain further information about the MCO, including a telephone number for obtaining such information; and

(e) any other general information which the MCO believes would be useful in describing the operations of the MCO and the services offered.

(2) A claimant may be served by any MCO that offers primary medical services by an appropriate treating physician within 30 miles of the claimant's residence. If no MCO exists within 30 miles of the claimant's residence, then the claimant may be directed to any MCO that is within 100 miles of the place of residence. If no MCO exists within 100 miles of the place of residence of the claimant, then the claimant may be directed to the nearest MCO. If the claimant requires specialty medical services that are not available within the stated mileage restrictions, the managed care plan may refer the claimant to a provider outside of the stated mileage restrictions.

(3) The MCO must file with the department a map, of a scale not smaller than that used by the official Montana highway map, showing circles of a 30 mile radius and a 100 mile radius from each town where the primary medical services are offered by the managed care plan.

(2) An applicant must provide the following information:

(a) the complete name of the MCO;

(b) all fictitious business names which the MCO will use;

(c) the type of organizational entity (e.g. corporation, partnership, joint venture, limited liability company) used by the MCO, supported by documentation from the Montana secretary of state showing that the entity is qualified to do business in Montana and is in good standing;

(d) the street and mailing address of the principal Montana office of the MCO;

(e) an organization chart that depicts the primary departments or functions of the MCO;

(f) the names and occupations of all directors and officers, by whatever title, of the MCO; and

(g) a signed statement from the day-to-day administrator of the MCO certifying that the MCO is not formed, owned or operated by a workers' compensation insurer or self-insured employer, other than a health care provider.

(3) An applicant must disclose the existence of any of the following relationships and provide such information concerning the relationship(s) as the department may reasonably request:

(a) common ownership by or with any other business entity;

(b) common management with any other business entity;

(c) management or ownership by any person or entity that was or currently is associated with a MCO or MCO applicant; or

(d) the name of any entity, other than individual health care providers, with whom the MCO has a joint venture or other agreement to perform any of the functions of the plan, and a description of the specific functions to be performed by each entity.

(1) A description of the number and specialties of persons who are eligible to be treating physicians. The following list is a minimum of the number and specialties which must be part of the plan:

(a) a minimum of five medical doctors or osteopaths, providing at least three of the following areas of practice:

(i) orthopedic;

(ii) surgery;

(iii) neurology or neurosurgery;

(iv) osteopathic treatment of musculoskeletal injury;

(v) family practice or internal medicine; and

(vi) occupational medicine or physical medicine;

(b) one chiropractor; and

(c) one dentist.

(2) A description of how the MCO will provide physical therapy services. As provided by 39-71-1105 , MCA, each MCO is encouraged to utilize the services of independent physical therapists.

(3) A description of the number and specialties of other health care providers (including, but not limited to podiatrists, physician assistants, nurse practitioners, occupational therapists, and optometrists) who will be furnishing services to injured workers.

(4) A description of how and where the following services are to be provided:

(a) in-patient surgery;

(b) out-patient surgery;

(c) radiology services, including magnetic resonance (MR) and computerized tomography (CT) imaging;

(d) psychological or psychiatric counseling;

(e) diagnostic pathology and laboratory services;

(f) hospital; and

(g) urgent care.

(5) A description of how the MCO will designate the treating physician. The description must include an explanation of how the MCO will decide which physician will be designated as the treating physician, and how the injured worker's preference of treating physician will be taken into account.

(6) A description of under what circumstances injured workers will be referred to physicians or other providers that are not members of the MCO.

(7) A description of what secondary medical services, if any, will be available.

(8) An explanation of how injured workers, once referred to MCO, will be advised of the availability of services provided by the MCO. The injured worker must be able to receive information on a 24 hour basis regarding the availability of necessary medical services provided within the MCO and information on how an injured worker can obtain emergency services or other urgently needed care. The information may be provided through recorded telephone messages after normal working hours.

(9) An explanation of how services will be provided in a timely manner.

(10) A description of how the MCO will monitor, evaluate, and coordinate the delivery by its members of quality, cost-effective medical treatment and other health services needed in the care of injured workers. The plan must adhere to any treatment standards developed by the medical advisory committees and adopted by rule by the department.

(11) A description of the program that will be used to promote an early return to work for the injured worker. The program must provide for a cooperative effort between the worker, employer, rehabilitation provider(s) , and the MCO.

(12) A description of how continuity of care will be ensured.

(13) A description of the MCO's program of peer review for services provided by its members. The peer review program must include a review of medical necessity and appropriateness of services being rendered by the health care provider in order to improve the quality of patient care and the cost-effectiveness of treatment.

(14) A description of the MCO's program for utilization review for services provided by its members. The program must include the collection, review, and analysis of group data to improve overall quality of care and efficient use of resources. The plan must adhere to any utilization standards developed by the medical advisory committees and adopted by rule by the department.

(15) A description of the financial incentives that will be implemented to reduce service costs and utilization without sacrificing the quality of services.

(16) A description of the quality assurance program to be implemented by the MCO. Such a program must include information which will allow the MCO to determine injured worker satisfaction with the level of service and care provided by the MCO. The department may forward complaints received directly from injured workers to the MCO and require the MCO to respond to the department in writing regarding issues raised in the complaints.

(17) A description of the procedure for resolving disputes, including a process to resolve disputes raised by injured workers, members, and insurers. At a minimum, the dispute resolution process must:

(a) be fair and unbiased;

(b) provide injured workers with a reasonably convenient method of presenting disputes to the MCO; and

(c) provide a written response from the MCO addressing the dispute within 15 working days of when the dispute became known.

(18) Provision for a person or persons who will act as communication liaison with the department and insurers with which the MCO contracts. The responsibilities of the liaison shall include, but are not limited to:

(a) coordinating correspondence and compliance with reporting requirements with the department;

(b) unless otherwise provided by a contract with an insurer, coordinating and channeling medical bills to insurers;

(c) unless otherwise provided by a contract with an insurer, providing centralized receipt and distribution of all reimbursements from insurers back to the MCO members; and

(d) serving as a member of the quality assurance committee.

(2) The department will approve preliminary applications which meet the criteria established by these rules and relevant statutes. Once all preliminary application certification requirements have been met, within 60 days of receipt of all required information from the MCO, the department will notify the applicant of the approval or denial of their preliminary application. An applicant that is aggrieved by a decision of the department may request administrative review of the decision or request a contested case hearing.

(3) If the department approves the preliminary application, the applicant may then prepare and submit a final application.

(2) A final application consists of the following elements:

(a) the approved preliminary application on file with the department;

(b) the name, title, address and telephone number of a contact person who will act as liaison between the department and the MCO;

(c) the name, title, address, and duties of the person who will be the day-to-day administrator of the MCO;

(d) the name, address, medical specialty, and duties, of the medical director, if any, of the MCO;

(e) a list of the name of each individual required by 24.29.2331(1) , (2) , and (3) , who will provide services under the plan;

(f) the name and professional address of each individual who is eligible to be designated as a treating physician;

(g) the name, of each individual, if any, who will coordinate medical services; and

(h) a signed statement from the medical director or dayto-day administrator of the MCO certifying that all persons who are required to hold a current professional license or certification to render services under the plan are properly licensed or certified by the state of Montana.

(3) Any portion of the final application (other than portions previously identified in the preliminary application) that the applicant believes in good faith to be a trade secret, protected by the Uniform Trade Secrets Act (Title 30, chapter 14, part 4, MCA) , must be clearly identified as such by the applicant. Any portion of the final application which is not specifically identified as a trade secret is subject to public inspection and disclosure. In the event that a person seeks disclosure of information that is identified as a trade secret, the department will determine whether the individual right to privacy is outweighed by the public right to know, and whether an appropriate protective order can be fashioned to permit disclosure in a way that does not injure the property rights of the applicant.

(2) Within 30 days of receipt of a complete final application which contains all required information from the MCO, the department will approve final applications which meet the criteria established by these rules and relevant statutes. An applicant that is aggrieved by a decision of the department may request administrative review of the decision or request a contested case hearing.

(3) Upon approval of a final application for certification, the department will certify the applicant as a MCO. The original certification will be effective for a specified period of not less than one year or more than two years from the date the certification is issued, unless suspended or revoked by the department. The exact period of certification will be determined by the department on a case-by-case basis, in order to stagger the renewal dates of MCO certifications. The certification will specify when annual reports (see 24.29.2351) must be filed with the department.

(2) A MCO must provide to the department an executed copy of the following contracts within 10 days of signing:

(a) service contracts; and

(b) modifications to service contracts.

(3) A MCO must provide to the department an executed copy of contracts between the MCO and any entity, other than individual members of the plan and personal doctors, to perform some of the functions of the plan within 30 days of signing.

(4) A MCO must report to the department any changes in the following information within 30 days of the change:

(a) the addition or termination of members of the MCO;

(b) any change in the licensure of members or staff of the MCO;

(c) changes in the administrative staff of the MCO including, but not limited to, the liaison with the department and the day-to-day administrator of the MCO;

(d) changes in service locations; and

(e) the expiration, termination or cancellation of any service contract.

(5) The MCO must annually report to the department the following:

(a) a summary of the results of the programs implemented to promote early return to work, including the numbers of employers and injured workers involved in the cooperative effort;

(b) a summary of peer review activities describing the number of cases reviewed and the number of cases where alternative treatment strategies were recommended;

(c) a summary of utilization review activities describing the number of cases reviewed and the number of cases where different utilization strategies were recommended; and

(d) a summary of disputes which were processed through the dispute resolution procedures established by the plan. The summary must generally identify:

(i) how many disputes were raised;

(ii) the issues involved;

(iii) the relative numbers of injured workers, members, insurers or others that were involved in the disputes; and

(iv) how many of the disputes were resolved within the procedure established by the plan.

(6) The MCO must report to insurers any data regarding medical services related to workers' compensation claims which are required by the insurer to determine compensability in accordance with the Montana Workers' Compensation and occupational Disease Acts, or to comply with reporting requirements of the department.

(7) The department may require additional information from the MCO to determine if the MCO is complying with the provisions of the plan.

(2) The department may monitor and conduct periodic audits and special examinations of the MCO as necessary to ensure compliance with the plan certification and performance requirements.

(3) All records of the MCO relevant to determining compliance with the plan shall be disclosed within a reasonable time, not to exceed 10 days, after request by the department. Records must be legible and cannot be kept in a coded or semicoded manner unless a legend is provided for the codes.

(2) In order to be eligible to renew its certification, the MCO must be current with all reports and information required to be filed with the department.

(3) Each approved MCO, in order to renew certification, must submit an application for renewal containing the following information:

(a) a signed statement from the day-to-day administrator of the MCO certifying that the MCO is not formed, owned or operated by a workers' compensation insurer or self-insured employer, other than a health care provider;

(b) the name, title, address and telephone number of the person who will act as the liaison between the department and the MCO;

(c) the name, title, address and telephone number of the person who is the day-to-day administrator of the MCO;

(d) the name, address and medical specialty, of the medical director, if any, of the MCO;

(e) a list of the current members, including names, specialty, addresses, and telephone numbers, together with a signed statement from the medical director or day-to-day administrator of the MCO certifying that each individual on the list is properly licensed to perform those services;

(f) a list of the insurers with which the MCO has contracts and the expiration dates of the contracts; and

(g) a summary of any sanctions or punitive actions taken by the MCO against members.

(2) Within 60 days of receipt of a complete renewal application, the department will approve renewal applications which meet the criteria established by these rules and relevant statutes. The failure to have timely filed all required reports and information is grounds for the department denying a renewal application. A MCO that is aggrieved by a decision of the department may request administrative review of the decision or request a contested case hearing.

(3) Upon approval of a renewal application, the department will certify the MCO for an additional two years. The certification is subject to being suspended or revoked by the department for cause. The renewal certification will specify when annual reporting (see 24.29.2351) must be filed with the department.

(4) The department may briefly extend a MCO's certification while the renewal process is pending.