Work comp: Medical benefits -- payment of medical expenses

Payer and health care provider payment and billing responsibilities are covered under Minnesota Statutes 176.135, subd. 6 and 7, and Minnesota Rules Part 5221.0600. Excessive charges are under Minnesota Rules Part 5221.0500, while excessive services are under Minnesota Rules Part 5221.0550.

Payer responsibilities

No later than 30 calendar-days after receiving the charge for service and the medical records, the insurer must:

• pay the charge or portion of the charge that is not in dispute;

• request specific additional information to substantiate the nature of the charge and its relationship to the work injury (when the requested information is received, the insurer has 30 days to either pay or deny the charge in question);

• deny all or part of the charge if it is not compensable; or

• deny all or part of the charge if the charge is excessive.

If the charge is denied, the insurer must send the provider a written notification outlining the basis of the denial by the 30-day deadline. A copy of the notification must be sent to the employee.

Health care provider responsibilities

The health care provider is responsible for:

• submitting an itemized statement of charges on the prescribed billing form to the payer within 60 days of the service; and

• submitting copies of medical records or reports that substantiate the nature of the charge and its relationship to the work injury.

A health care provider cannot attempt to collect or initiate any action for collection of the charge from any party until the information required has been furnished.

If the insurer has denied primary liability, the health care provider can bill the employee.

If the employee's health insurance pays the medical expenses, the insurance company has a right to reimbursement if it is later determined the charges are due to a compensable injury.