Below are Idaho's workers' compensation rules on billing denials and dispute resolution.
Preliminary Objections & Requests for Clarification
Preliminary Objections & Requests for Clarification
IDAPA § 17.01.01.06 - Billing And Payment Requirements For Medical Services And Procedures Preliminary To Dispute Resolution.
e. Preliminary Objections and Requests for Clarification.
i. Whenever a Payor objects to all or any part of a Provider's bill on the ground that such bill contains a charge or charges that do not comport with the applicable administrative rule, the Payor shall send a written Preliminary Objection to the Provider within thirty (30) calendar days of the Payor’s receipt of the bill explaining the basis for each of the Payor's objections.
ii. Where the Payor requires additional information, the Payor shall send a written Request for Clarification to the Provider within thirty (30) calendar days of the Payor’s receipt of the bill, and shall specifically describe the information sought.
iii. Each Preliminary Objection and Request for Clarification shall contain the name, address, and phone number of the individual located within the state of Idaho that the Provider may contact regarding the Preliminary Objection or Request for Clarification.
iv. Where a Payor does not send a Preliminary Objection to a charge set forth in a bill or a Request for Clarification within thirty (30) calendar days of receipt of the bill, or provide an in-state contact in accord with Subparagraph 06.e.iii., it shall be precluded from objecting to such charge as failing to comport with the applicable administrative rule.
f. Provider Reply to Preliminary Objection or Request for Clarification.
i. Where a Payor has timely sent a Preliminary Objection, Request for Clarification, or both, the Provider shall send to the Payor a written Reply, if any it has, within thirty (30) calendar days of the Provider's receipt of each Preliminary Objection or Request for Clarification.
ii. If a Provider fails to timely reply to a Preliminary Objection, the Provider shall be deemed to have acquiesced in the Payor's objection.
iii. If a Provider fails to timely reply to a Request for Clarification, the period in which the Payor shall pay or issue a Final Objection shall not begin to run until such clarification is received.
g. Payor Shall Pay or Issue Final Objection.
The Payor shall pay the Provider's bill in whole or in part or shall send to the Provider a written Final Objection, if any it has, to all or part of the bill within thirty (30) calendar days of the Payor's receipt of the Reply.
h. Failure of Payor to Finally Object.
Where the Payor does not timely send a Final Objection to any charge or portion thereof to which it continues to have an objection, it shall be precluded from further objecting to such charge as unacceptable.
i. Dispute Resolution Process.
If, after completing the applicable steps set forth above, a Payor and Provider are unable to agree on the appropriate charge for any Medical Service, a Provider which has complied with the applicable requirements of this rule may move the Commission to resolve the dispute as provided in the Re: Disputes Between Providers and Payors, as referenced in Paragraph 803.01.c. of this rule.
If Provider's motion disputing CPT or MS-DRG coded items prevails, Payor shall pay the amount found by the Commission to be owed, plus an additional thirty percent (30%) of that amount to compensate Provider for costs and expenses associated with using the dispute resolution process.
For motions filed by a Provider disputing items without CPT or MS-DRG codes, the additional thirty percent (30%) shall be due only if the Payor does not pay the amount found due within thirty (30) days of the administrative order.
Dispute Resolution Process
Judicial Rules of Practice and Procedure (JRP) - Rule 19 - Disputes between Providers and Payors
E. Dispute Resolution Process
1. Pleadings.
a. Provider - If a provider has received from a payor a final objection to all or part of a provider's bill, or if 45 days have passed from the date provider sent the bill without response from payor, the provider may file with the Commission and serve on the payor a request for approval of the disputed charge.
If a payor has finally objected to more than one charge in a single billing, the provider may seek approval of all such charges in a single motion.
(i) Form. The provider shall file such request on the form provided in Appendix 6A and attach thereto affidavits or other documents evidencing facts sufficient to show that the charge in dispute is acceptable pursuant to the applicable regulation.
If the dispute is over a charge that does not have a CPT code or a conversion factor, the Provider will provide evidence of the provider's usual charge for that medical service to nonindustrially injured patients.
(ii) Timing. Such request must be filed with the Commission and served on the payor within 30 calendar days of the date the provider receives the payor's final objection, or within 90 days from the date provider sent the bill to payor if payor has not responded. A provider's failure to timely file a request for the disputed charge shall forever bar the provider from seeking the Commission's approval of any charge as to which a final objection has been made.
b. Payor - A payor served with a request for the disputed charge shall file a response with the Commission, together with affidavits and/or other documents evidencing facts sufficient to show that the charge in dispute is not acceptable pursuant to the applicable regulation. The response and accompanying documents shall be served on the provider within 21 calendar days of the date it receives the provider's motion.
If no response is filed and served within the time provided herein, the Commission shall enter a default in favor of the provider and the charges will be deemed acceptable.
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