24.29.2614    REIMBURSEMENT PROCESS

(1) The department shall determine the right of an insurer to SIF reimbursement of medical and indemnity payments to an SIF-certified individual in accordance with the criteria outlined by this rule.

(2) An insurer shall send the following to the department to document 104 weeks of payments for medical and indemnity after SIF has been notified of the insurer's intent to seek reimbursement:

(a) for medical benefit reimbursements:

(i) a cover letter;

(ii) medical notes from first and last visit from the treating physician; and

(iii) a spreadsheet documenting all medical benefits, including prescriptions, paid by the insurer for the first 104 weeks.

(b) for indemnity benefit reimbursements:

(i) a cover letter; and

(ii) a spreadsheet documenting all indemnity benefits paid.

(3) After an insurer's right to SIF reimbursement has been established, the department recommends the insurer request SIF reimbursement in writing at six-month intervals.

(a) The department shall not reimburse the insurer for medical benefits paid to or on behalf of an SIF-certified individual during the first 104 weeks following the date of injury.

(b) The department shall not reimburse an insurer for indemnity benefits until after the insurer has paid a total of 104 weeks of indemnity benefits to the SIF-certified individual.

(4) Each reimbursement request must state the amount of reimbursement claimed for medical and indemnity payments and include the following documentation for the six-month reimbursement period:

(a) computer printout or comparable listing that identifies the type of indemnity payment to the SIF-certified individual (temporary partial disability, temporary total disability, permanent partial disability, or permanent total disability) and includes:

(i) dates checks were issued;

(ii) dates of indemnity;

(iii) total weeks of indemnity; and

(iv) the total amount paid.

(b) computer printout or comparable listing of all medical bills paid, including:

(i) dates checks were issued;

(ii) provider names;

(iii) dates of service;

(iv) billed amount;

(v) paid amount;

(vi) NDC# or drug type and dosage;

(vii) date of fill; and

(viii) amount paid; and

(c) copies of all medical bills with the corresponding explanations of benefits and directly related medical records.

(5) The insurer shall notify the SIF representative and the department at the outset of settlement negotiations involving an injured individual who is SIF-certified. The insurer shall waive the right to SIF contribution by failing to notify the department at the outset of settlement negotiations.

(6) The insurer shall submit any negotiated settlement agreement to the SIF representative and the department for approval prior to final settlement.

(a) Attorney fees must be itemized separately from medical and/or indemnity benefits.

(7) Disputes arising over payment or reimbursement between the department and the insurer may be resolved by the contested case hearing process, pursuant to ARM 24.29.207, at the written request of the either party.

 

History: 39-71-203, 39-71-904, MCA; IMP, 39-71-907, 39-71-908, 39-71-909, 39-71-912, 39-71-920, MCA; NEW, 2010 MAR p. 2967, Eff. 12/24/10; AMD, 2018 MAR p. 2527, Eff. 1/1/19.