Utah Admin. Code R612-300-2 - Obtaining Medical Care for Injured Workers
A. Right of payor to designate initial health
care provider.
1. A Payor may adopt managed
health care programs. Such programs may designate specific health care
providers as "preferred providers" for providing initial medical care for
injured workers.
2. A preferred
provider program must allow an injured worker to select from two or more health
care providers to obtain necessary medical care. At the time a preferred
provider program is established, the payor must notify employees of the
requirements of the program.
3. If
the requirement of subsection A.2. are met, an injured worker subject to a
preferred provider program must seek initial medical care from a preferred
provider unless:
a. No preferred provider is
available;
b. The injured worker
believes in good faith that his or her medical condition is not a workplace
injury; or
c. Travel to a preferred
provider is unduly burdensome.
4. If an injured worker who is subject to a
preferred provider program fails to obtain initial medical care from a
preferred provider, the payor's liability for the cost of such initial medical
care is limited to the amount the payor would have paid a preferred provider.
The injured worker may be held personally liable for the remaining
balance.
B. Liability
for medical expense incurred at payor's direction. If a payor directs an
injured worker to obtain an initial medical assessment of a possible work
injury, the payor is liable for the cost of such assessment.
1. A medical provider performing an initial
assessment must obtain the payor's preauthorization for any diagnostic studies
beyond plain x-rays.
C.
Injured worker's right to select provider after initial medical care. After an
injured worker has received initial care from a preferred provider, the injured
worker may obtain subsequent medical care from a qualified provider of his or
her choice. The payor is liable for the expense of such medical care.
1. An injured worker's right to select
medical providers is subject to subsection D. of this rule, "Limitations to
Injured Worker's Right to Change Physicians."
D. Limitations on injured worker's right to
change physicians.
1. An injured worker may
change health care providers one time without obtaining permission from the
payor. The following circumstances DO NOT constitute a change of health care
provider:
a. A treating physician's referral
of the injured worker to another health care provider for treatment or
consultation;
b. Transfer of
treatment from an emergency room to a private physician, unless the emergency
room was designated as the payor's preferred provider;
c. Medically necessary emergency
treatment;
d. A change of physician
necessitated by the treating physician's failure or refusal to rate a permanent
partial impairment.
2.
The injured worker shall promptly report any change of provider to the
payor.
3. After an injured worker
has exercised his or her one-time right to change health care providers, the
worker must request payor approval of any subsequent change of provider. If the
payor denies or fails to respond to the request, the injured worker may request
approval from the Director of the Division of Industrial Accidents. The
Director will authorize a change of provider if necessary for the adequate
medical treatment of the injured worker or for other reasonable
cause.
4. An injured worker who
changes health care providers without payor or Division approval may be held
personally liable for the non-approved provider's fees.
E. Hospital or surgery pre-authorization.
Except when immediate surgery or hospitalization is medically necessary on an
emergency basis, surgery or hospitalization must be pre-authorized by the
payor.
1. Within two working days of receipt
of a request for authorization, the payor shall notify the physician and
injured worker that the request is either approved or denied, or is undergoing
medical review.
2. Any medical
review of a pending request for authorization must be conducted
promptly.
F.
Notification required from injured workers leaving Utah. Section
34A-2-604
of the Workers' Compensation Act requires injured workers receiving medical
care for a workplace injury to notify the Industrial Accidents Division before
leaving the state or locality. Division forms 043 and Form 044 are to be used
to provide such notice.
G. Injured
worker's right to privacy. No agent of the payor may be present during an
injured worker's medical care without the consent of the injured worker.
However, if the payor's agent is excluded from a medical visit, the physician
and the injured worker shall meet with the agent at the conclusion of the visit
or at some other reasonable time so as to communicate regarding medical care
and return-to-work issues.
H.
Payor's right of medical examination. The payor may arrange for the medical
examination of an injured worker at any reasonable time and place. A copy of
the medical examination report shall be made available to the Commission upon
request.
Notes
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