N.D. Admin Code 92-01-02-31 - Who may be reimbursed

1. Only treatment that falls within the scope and field of the treating allied health care professional's license to practice is reimbursable.

2. Paraprofessionals who are not independently licensed must practice under the direct supervision of a licensed allied health care professional whose scope of practice and specialty training includes the service provided by the paraprofessional, in order to be reimbursed.

3. Medical service providers may be refused reimbursement to treat cases under the jurisdiction of the organization.

4. Any entity operating under the authority of the federal government and granted authority to receive direct reimbursement for payments made for medical treatment determined to be related to the workers' compensation injury.

5. Reasons for holding a medical service provider ineligible for reimbursement include one or more of the following:

a. Failure, neglect, or refusal to submit complete, adequate, and detailed reports.

b. Failure, neglect, or refusal to respond to requests by the organization for additional reports.

c. Failure, neglect, or refusal to respond to requests by the organization for drug testing.

d. Failure, neglect, or refusal to observe and comply with the organization's orders and medical service rules, including cooperation with the organization's managed care vendors.

e. Failure to notify the organization immediately and prior to burial in any death if the cause of death is not definitely known or if there is question of whether death resulted from a compensable injury.

f. Failure to recognize emotional and social factors impeding recovery of claimants.

g. Unreasonable refusal to comply with the recommendations of board-certified or qualified specialists who have examined the claimant.

h. Submission of false or misleading reports to the organization.

i. Collusion with other persons in submission of false or misleading information to the organization.

j. Pattern of submission of inaccurate or misleading bills.

k. Pattern of submission of false or erroneous diagnosis.

l. Billing the difference between the maximum allowable fee set forth in the organization's fee schedule and usual and customary charges, or billing the claimant any other fee in addition to the fee paid, or to be paid, by the organization for individual treatments, equipment, and products.

m. Failure to include physical conditioning in the treatment plan. The medical service provider should determine the claimant's activity level, ascertain barriers specific to the claimant, and provide information on the role of physical activity in injury management.

n. Failure to include the injured worker's functional abilities in addressing return-to-work options during the recovery phase.

o. Treatment that is controversial, experimental, or investigative; which is contraindicated or hazardous; which is unreasonable or inappropriate for the work injury; or which yields unsatisfactory results.

p. Certifying disability in excess of the actual medical limitations of the claimant.

q. Conviction in any court of any offense involving moral turpitude, in which case the record of the conviction is conclusive evidence.

r. The excessive use, or excessive or inappropriate prescription for use, of narcotic, addictive, habituating, or dependency inducing drugs.

s. Declaration of mental incompetence by a court of competent jurisdiction.

t. Disciplinary action by a licensing board.

Notes

N.D. Admin Code 92-01-02-31

Effective January 1,1994; amended effective October 1, 1998; January 1, 2000; July 1, 2010. Amended by Administrative Rules Supplement 2017-365, July 2017, effective 7/1/2017. Amended by Administrative Rules Supplement 367, January 2018, effective 1/1/2018. Amended by Administrative Rules Supplement 376, April 2020, effective 4/1/2020.

General Authority: NDCC 65-02-08, 65-02-20, 65-05-07

Law Implemented: NDCC 65-02-20, 65-05-07