DAR File No. 27893

Labor Commission, Industrial Accidents

R612-2-18

Dental Injuries

NOTICE OF PROPOSED RULE

DAR File No.: 27893
Filed: 05/13/2005, 11:52
Received by: NL

RULE ANALYSIS

Purpose of the rule or reason for the change:

This amendment sets fees for treatment of work-related dental injuries. It also establishes procedures by which insurance carriers can manage expenses of dental treatment.

Summary of the rule or change:

This amendment completely removes this section of the Commission's rule. The amendment establishes a benchmark for determining the "usual and customary rate" for dental services. The amendment authorizes workers to make their own initial selection of dentist for emergency dental care. Thereafter, the employer is authorized to negotiate for additional dental care. The amendment also establishes procedures and time limits for this process.

State statutory or constitutional authorization for this rule:

Sections 34A-2-101 et seq., 34A-3-101 et seq., and 34A-1-104

Anticipated cost or savings to:

the state budget:

The Commission does not anticipate any appreciable cost or savings to the state in administering this rule. Because the amendment increases employers/insurance carriers' ability to limit the cost of work-related dental treatment, the state may experience some small reduction in its workers' compensation expenses.

local governments:

This rule only affects local government in their capacity as employers. Because the amendment increases employers/insurance carriers' ability to limit the cost of work-related dental treatment, local governments may experience some small reduction in their workers' compensation expenses.

other persons:

Workers' compensation insurance companies should realize some small savings from their increased ability under the amendment to limit the cost of work-related dental treatment. This reduction in dental expenses will, over time, be factored into workers' compensation premiums, to the benefit of employers.

Compliance costs for affected persons:

Affected persons (primarily workers' compensation insurance carriers, self-insured employers and dental care providers) already have management systems that can be adapted to the requirements of this rule. The Commission anticipates no significant costs to such person as a result of adoption of this rule.

Comments by the department head on the fiscal impact the rule may have on businesses:

This proposal allows workers' compensation insurance carriers and self-insured employers to more closely manage the cost of dental treatment for injured workers. Insurance carriers and self-insured employers already have case management capabilities, so the addition of dental management responsibilities should not result in any additional costs. The result of this increased control over dental care will, over time, tend to reduce workers' compensation costs by a relatively small amount. R. Lee Ellertson, Commissioner

The full text of this rule may be inspected, during regular business hours, at the Division of Administrative Rules, or at:

Direct questions regarding this rule to:

Joyce Sewell at the above address, by phone at 801-530-6988, by FAX at 801-530-6804, or by Internet E-mail at jsewell@utah.gov

Interested persons may present their views on this rule by submitting written comments to the address above no later than 5:00 p.m. on:

07/01/2005

This rule may become effective on:

07/02/2005

Authorized by:

R Lee Ellertson, Commissioner

RULE TEXT

R612. Labor Commission, Industrial Accidents.

R612-2. Workers' Compensation Rules-Health Care Providers.

R612-2-18. Dental Injuries.

[Where a worker sustains an accident in the course of his employment resulting in the loss of or injury to teeth, making dental work necessary, the injured worker shall consult a dental surgeon and receive such first aid as may be necessary to preserve, if possible, the normal function of the injured teeth. The dental surgeon shall then file with the insurance carrier a report setting forth the nature of the injury together with an estimate of the cost of restoration. The dental surgeon shall not proceed with the restoration until authority has been granted by the insurance carrier, provided, however, that if an employer maintains a medical staff or designates a company doctor, the employee shall first report to that medical staff or medical officer and be guided by directions then given. If the carrier refuses payment at the level estimated by the dental surgeon, the employee may choose to pay the difference and seek adjudication by Application for Hearing. A dental surgeon may choose to settle for the payment allowed, or the carrier shall direct the employee to a dental surgeon who will provide his services at the payment level specified by the carrier.]A. This rule establishes procedures to obtain dental care for work-related dental injuries and sets fees for such dental care.

B. Initial Treatment.

1. If an employer maintains a medical staff or designates a company doctor, an injured worker seeking dental treatment for work-related injuries shall report to such medical staff or doctor and follow their instructions.

2. If an employer does not maintain a medical staff or designate a company doctor, or if such staff or doctor are not available, an injured worker may consult a dentist to obtain immediate care dental for injuries caused by a work-related accident. The insurer shall pay the dentist providing this initial treatment at 70% of UCR for the services rendered.

C. Subsequent care by initial treatment provider.

1. If additional treatment is necessary, the dentist who provided initial treatment may submit to the insurer a request for authorization to continue treatment. The transmission date of the request must be verifiable. The request itself must include a description of the injury, the additional treatment required, and the cost of the additional treatment. If the dentist proceeds with treatment without authorization, the dentist must accept 70% of UCR as payment in full and may not charge any additional sum to the injured worker.

2. The insurer shall respond to the request for authorization within 10 working days of the request's transmission. This 10-day period can be extended only with written approval of the Industrial Accidents Division. If the insurer does not respond to the dentist's request for authorization within 10 working days, the insurer shall pay the cost of treatment as contained in the request for authorization.

3. If the insurer approves the proposed treatment, the insurer shall send written authorization to the dentist and injured worker. This authorization shall include the anticipated payment amount.

4. On receipt of the insurer's written authorization, and if the dentist accepts the payment provisions therein, the dentist may proceed to provide the approved services. The dentist must accept the amount to be paid by the insurer as full payment for those services and may not bill the injured worker for any additional amount.

D. Subsequent care by other providers.

1. If the dentist who provided initial treatment does not agree to the payment offered by the insurer, the insurer shall within 20 calendar days direct the injured worker to a dentist located within a reasonable travel distance who will accept the insurer's payment offer.

2. If the insurer cannot locate another dentist to provide the necessary services, the insurer shall attempt to negotiate a satisfactory reimbursement with the dentist who provided initial treatment. The negotiated reimbursement may not include any balance billing to the claimant.

3. If the insurer is successful in arranging treatment with another dentist, the insurer shall notify the injured worker.

4. If, after having received notice that the insurer has arranged the services of another dentist, the injured worker chooses to obtain treatment from a different dentist, the insurer shall only be responsible for payment at 70% of UCR. Under the circumstances of this subsection (4), the treating dentist may bill the injured worker for the difference between the dentist's charges and the amount paid by the insurer.

E. Payment or treatment disputes that cannot be resolved by the parties may be submitted to the Labor Commission's Adjudication Division for decision, pursuant to the Adjudication Division's established forms and procedures.

KEY: workers' compensation, fees, medical practitioner

[July 2, 2003]2005

Notice of Continuation May 28, 2003

34A-2-101 et seq.

34A-3-101 et seq.

34A-1-104

ADDITIONAL INFORMATION

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For questions regarding the content or application of this rule, please contact Joyce Sewell at the above address, by phone at 801-530-6988, by FAX at 801-530-6804, or by Internet E-mail at jsewell@utah.gov

For questions about the rulemaking process, please contact the Division of Administrative Rules (801-538-3764). Please Note: The Division of Administrative Rules is NOT able to answer questions about the content or application of these administrative rules.