Physicians in workers' compensation cases are defined in Idaho Code as "medical physicians and surgeons, ophthalmologists, otorhinolaryngologists, dentists, osteopaths, osteopathic physicians and surgeons, optometrists, podiatrists, chiropractic physicians, and members of any other healing profession licensed or authorized by the statutes of this state to practice such profession within the scope of their practice as defined by the statutes of this state and as authorized by their licenses."
This page is designed to provide basic information regarding billing and treatment in workers' compensation cases. It is by no means exhaustive. Contact the Idaho Industrial Commission for additional information.
The Industrial Commission has issued a policy statement regarding HIPAA's application to workers' compensation and the Idaho Industrial Commission.
Change of Physician (top)
Under the Idaho workers' compensation system, the employer/surety may assign a medical provider to treat the injured worker. However, the worker may appeal that assignment to the Idaho Industrial Commission.
- Rules for Change of Physician appeals
- Change of Physician, Claimant Request Form
- Change of Physician, Employer/Insurer Response Form
Medical Billing (top)
ICD-9 To ICD-10 Migration Advisory
In accordance with IDAPA 17.02.09.035.03(a), the Commission adopts the diagnostic and procedure coding set required by Centers for Medicare & Medicaid Services (CMS). Idaho providers will therefore be required to bill for workers' compensation medical services using the ICD-10 diagnostic and procedure coding sets concurrent with the implementation of ICD-10 by CMS on October 1, 2014.
Proposed Rule for 2014 Legislative Session
17-0209-1301 Medical Fees
Anyone may submit written comments regarding this proposed rulemaking. All written comments must be directed to the undersigned and must be delivered on or before October 23, 2013.
Mindy Montgomery, Director
700 S. Clearwater Lane
PO Box 83720
Boise, Idaho 83720-0041
IDAPA 17.02.09 governs payments for medical services under the Idaho Workers' Compensation Law. The FY 2014 annual adjustment to the medical fee schedule has been made in accordance with Section 72-803, Idaho Code, and is effective July 1, 2013.
Pharmaceuticals dispensed by a pharmacy on or after July 1, 2013 are now reimbursed according to a standard of the Average Wholesale Price (AWP) plus a dispensing fee of $5 for brand name and $8 for generic.
Pharmaceuticals dispensed by physicians on or after July 1, 2013 are now reimbursed according to a standard of the Average Wholesale Price (AWP) without a dispensing fee.
Repackaged drugs will be reimbursed according to the Average Wholesale Price for the medicine prior to repackaging.
A Temporary Rule was adopted by the Commission to include adjustments to the pharmaceutical dispensing fees as detailed above.
The Temporary Rule also corrects an error involving a range of CPT codes in the conversion factor table that is corrected as follows:
Surgery Group 2: 64550-64999
Surgery Group 3: 64000-64549
For questions regarding this Temporary Rule, please contact Patti Vaughn, 208-334-6084.
2014 National Physician Fee Schedule Relative Value File (RVU14A)
- Medical services provided between 07/01/12 through 06/30/13
- Medical services provided between 04/07/11 through 06/30/12
- Facility services provided between 04/07/11 through 12/31/11
- Medical services provided between 03/29/10 through 04/06/11
- Medical services provided between 05/08/09 through 03/28/10
- Medical services provided between 07/01/08 through 05/07/09
- Medical services provided between 04/02/08 through 06/30/08
- Medical services provided between 03/15/07 through 04/01/08
- Medical services provided between 04/01/06* through 03/14/07
*All medical services preceding 4-01-06 are subject to usual and customary charges.
Questions regarding the medical fee schedule may be directed to Patti Vaughn, Medical Fee Schedule Analyst.
Idaho is a zero-deductible state for workers' compensation medical charges. No portion of the unpaid medical bill is to be paid by the injured worker on claims accepted by the surety.
As noted in IDAPA 17.02.04.322.02, Providers shall submit written medical reports for each medical visit to the Payor. Payers and Providers may contract with one another to identify specific records that will be provided in support of billings. The Provider shall also submit the same written medical reports to the Claimant upon request. These reports shall be submitted within fourteen (14) days following each evaluation, examination and/or treatment. The first copy of any such reports shall be provided to the Payor and the Claimant or Claimant's Counsel at no charge. If duplicate copies of reports already provided are requested by either the Payor or the Claimant, the Provider may charge the requesting party a reasonable charge to provide the additional reports.
The first copy of any such reports shall be provided to the Payor and the Claimant at no charge. If duplicate copies of reports already provided are requested by either the Payor or the Claimant, the Provider may charge the requesting party a reasonable charge to provide the additional reports.
This means the medical provider must give one free copy to one of each of the following:
- Employer or insurance company
- Claimant (patient) or claimant’s attorney
- The Idaho Industrial Commission
Consultant Reports (top)
A medical fee schedule consultant from Ingenix presented highlights of their findings on physician charges in a public hearing held in Boise on October 15, 2007.
Informational sessions regarding facility reimbursement were held in May 2008. The sessions were presented by the medical fee consultant from Ingenix.
Dispute Resolution (top)
The Commission has prepared some items to help navigate the medical fee dispute process. Below are tips for filing a motion for approval of a disputed charge. The Commission has also created a separate page to answer frequently asked questions.
- DO list in the motion:
- The date the bill was sent/received.
- The date the Preliminary Objection was sent/received.
- The date the Response was sent/received.
- The date the Final Objection was sent/received.
- DO check the deadlines before you send the motion.
- DO use the standard forms.
- DO itemize billings by CPT code.
- DO provide copies of the
- Bills (but indicate which part of the bill is in dispute)
- Preliminary Objection
- Final Objection
- DO understand that Commission staff are legal, not medical, professionals, and that the dispute process is a legal, not medical, forum.
- DO send copies to the other parties.
- DO indicate the dates of the documents.
- DON’T send in multiple copies of the same item.
- DON’T send a bunch of medical records or billing items and expect the Commission staff to sort them out.
- DON’T forget to fully complete a certificate of service/mailing.
- DON’T hesitate to call Commission staff before you send in the motion if you have any questions.