N.D. Admin Code 92-01-02-30 - Medical services
1. Medical
services.
a. Medical services that are not
medically necessary are not reimbursable.
b. Frequency and extent of treatment may not
be more than the nature of the injury or process of recovery requires, and must
be provided in accordance with utilization and treatment standards as
prescribed by the organization or the managed care vendor. The organization may
require evidence of the efficacy of treatment.
2. Medical services may be reimbursed only
when provided according to a written treatment plan. A copy of the treatment
plan, signed by the allied health care professional, must be provided to the
organization within fourteen days of beginning the treatment or within fourteen
days of learning that the treatment is claimed to be work-related, whichever
occurs later. However, a treatment plan is not required for a short course of
treatment consisting of one or two visits.
3. For purposes of this section, a treatment
plan must include:
a. Objectives, including
the degree of restoration anticipated.
b. Measurable goals.
c. Modalities and specific therapies to be
used.
d. Frequency and duration of
treatments to be provided.
e.
Condition of the claimant which may require periodic modification of the plan
of care based on:
(1) Improvements in the
claimant's status.
(2) Failure of
the claimant to improve as expected.
(3) Intervention of care rendered, including
education of the claimant, when appropriate.
(4) Specific operative reports, test results,
and consultation reports.
4. The cost of preparing a written treatment
plan and supplying progress notes under this section is included in the fee for
the medical service.
5. The
treatment plan requirements of this section may be modified or waived by the
organization.
6. X-ray images must
be of diagnostic quality. Billings for x-rays are not reimbursable without a
report of the findings. Upon request of either the organization or the managed
care vendor, original x-ray images must be forwarded to the organization or the
managed care vendor. A reasonable charge may be made for the costs of delivery
of images.
7. A generic brand of
therapeutic equivalence must be dispensed, provided the generic medication
costs less. If the injured employee does not accept the generic equivalent at a
lower price, the injured employee is responsible for the cost difference
between the generic and brand name prescription medication. A branded
equivalent of a generically available medication requires prior approval by the
organization and will be covered only when objective medical evidence exists
that the injured employee developed an adverse response to the generic
medication.
Notes
General Authority: NDCC 65-02-08, 65-02-20, 65-05-07
Law Implemented: NDCC 65-02-20, 65-05-07
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