FAQs

What is the procedure for disputing a denied claim?

If the insurance company denies your claim, you can file a Complaint with the Industrial Commission (IC 72-706). The Complaint initiates the formal legal process to bring the issue to the Commission for a hearing and decision. The Industrial Commission also offers a voluntary mediation program to help resolve the dispute. Contact the Industrial Commission for information regarding filing of a complaint, the judicial process or to request a mediation.

Does an injured worker have to be represented by an attorney to file a Complaint?

No. Legal representation is not required to file a Complaint with the Industrial Commission. However, due to the complexity of the judicial process, you may wish to consider legal counsel.

Can the Industrial Commission recommend a workers’ compensation attorney?

It is not appropriate for the Commission to recommend counsel. However, you can call the Idaho State Bar Lawyer Referral Service at (208) 334-4500 or look in the Yellow Pages in the Attorneys – Workers’ Compensation section.

My employer hasn’t or won’t fill out a work injury report. What can I do?

Contact the Industrial Commission immediately to report this activity and to request a First Report of Injury form. Completely filling out and filing the First Report of Injury with the Commission will register your claim. See also, Rehabilitation Services for Injured Workers

How do I find out if my employer has workers’ compensation insurance?

Contact the Industrial Commission Compliance Department at (208)334-6000 or toll free at (800) 950-2110. Or, you can use our Employers’ Workers’ Compensation Insurance Coverage Verification system online.

I have an employee who will be working out of the state for a while.  Will he still be covered under our Idaho workers’ compensation insurance?

If the employee is hired in Idaho to work in Idaho and is on a temporary work assignment in another state, the employee’s coverage would be through the employer’s Idaho Workers’ Compensation insurance. Regarding longer term out of state assignments, if the employer has current coverage in Idaho and their employee(s) will be working in OR, WA, MT, WY, UT, NV and ND, we can process an extraterritorial certificate for them. Otherwise the employer will have to purchase workers’ compensation insurance in the state their employee(s) will be working.

What is the income benefit allowance for the medically authorized time I have missed from work?

Computing the income benefit allowance is a complex process. The basic benefit is sixty-seven percent (67%) of your average weekly wage, subject to the minimums and maximum of 90% of the average state wage provided in Idaho Code (I.C.) 72-408 and 72-409. After 52 weeks, the basic benefit is 67% of the average state wage subject to maximums and minimums in I.C. 72-409. Contact your work comp insurance company or the Industrial Commission for more information. A table of typical benefits levels has been created by the Industrial Commission.

When will I get paid for the time I have missed from work?

You may generally expect to receive your first check within twenty-eight days of the injury, unless you have been notified that the claim was denied or is being investigated. Contact the insurance company to determine exactly when benefits checks are issued.

Will I receive benefits for every day I am injured?

You do not receive income benefits for the first 5 days you are off work due to an injury, unless the injury requires overnight hospitalization or the time loss exceeds 14 days. There is no waiting period for eligibility for medical benefits.

How are impairment ratings paid?

If a physician has given you an impairment rating, it usually is paid monthly until paid in full, although in some cases it can be paid in a lump sum. The insurance company is required to notify you of the benefit amount, which is based on 55% of the average state weekly wage (ASW) for the year the injury occurred, and is expressed in the number of weeks of benefits. For example, a 5% impairment would qualify for 25 weeks worth of payments, each equal to 55% of the ASW. The weekly payments are converted to monthly amounts and paid monthly.

Are retraining benefits available?

Retraining benefits are available only when required to restore lost earning capacity. They must be ordered by the Industrial Commission or agreed to by the insurance company. Additional vocational guidance and assistance are available through the Commission’s Rehabilitation Division at 208-334-6040.

Is an incarcerated claimant entitled to workers’ compensation benefits?

Assuming this question refers to a person who is eligible for workers’ compensation benefits and becomes incarcerated, the Claimant would continue to receive workers’ compensation benefits after incarceration. If released from medical restrictions by a doctor to return to work, but Claimant is unable to report due to being incarcerated, income benefits would stop.

Am I required to pay any balances on medical bills?

No, you are not responsible for the cost of medical treatment covered by workers’ compensation on an accepted claim. Bills for approved medical treatments are sent by the medical care provider to the insurance carrier, or the employer if self-insured.

When an insurance company schedules me for a medical appointment, do they have to provide transportation?

The insurance company must pay for transportation. In some case you may be reimbursed for other travel related expenses. I.C. 72-432 (12). See I.C. 72-433 for rates of reimbursement.

What is the allowable reimbursement for trips to a doctor or therapist for mileage, meals & housing?

If you use a private vehicle, reimbursement is computed at the prevailing state employee rate. An employee shall not be reimbursed for the first fifteen (15) miles of any round trip or any trip totaling fifteen (15) miles or less. Meals will be reimbursed at the current state-employee reimbursement rate and housing will be reimbursed at “reasonable” rates (IC 72-433).

Are companions given an allowance for mileage, meals & housing?

Yes, if your injury-related medical condition requires that a companion accompany you.

Can an employer designate a doctor?

Yes, but if the employer requires injured workers to be seen first by a designated doctor, the employer must make that requirement known to the employees before they report to a physician in regard to a work-related injury.

Can I choose my own doctor?

Yes, if the employer has not designated a treating physician. Under emergency conditions you may seek the most available medical treatment, even when another physician has been designated.

What if the insurance company’s designated doctor or Independent Medical Examiner disagrees with my physician?

The insurance company can accept the opinion of any physician as long as it is reasonable. If you feel the insurance company is unreasonable, you can file a formal complaint (IC 72-706) with the Industrial Commission. The Complaint initiates the formal legal process to bring the issue to the Commission for a hearing and decision.

Can an insurance company require me to see a doctor other than my treating physician?

The insurance company may require attendance at an Independent Medical Examination and then choose the medical opinion rendered in that report. The insurance company may also refuse to pay for future visits to your treating physician in certain circumstances.

At what time is the treating physician’s opinion no longer considered?

The treating physician’s opinion may be considered as evidence to support your contention, but an insurance company may base its decisions on the opinion of a physician other than the treating physician.

Can I change treating physicians?

Yes, you may ask the current treating physician for a referral to a new treating physician. If the physician declines to do so, then that request may be made of the insurance company. If the insurance company declines to do so, you may file a Petition for Change of Physician (IC 72-432 (4)). Without pre-authorization from the insurance company or a successful Petition for Change of Physician, you may be liable for the fees charged by a physician of your choice.

My injury was rated on a specific body part and on the whole person. Which rating is used to determine benefits?

The rating should be based on the body part closest to the injury and converted to the whole person in the exact percentage (IDAPA 17.01.01.402.01). The AMA Guidelines do not necessarily convert ratings in the exact percentage.

Two or more physicians have given an impairment rating on my injury. Which rating will be used?

They are typically averaged (IDAPA 17.01.01.402.02) unless the matter goes to hearing, in which case the Industrial Commission will determine the impairment rating.

Do I have to accept light duty work when the work is not my regular job or if the pay is less?

In most cases, yes, if the work can be done within the restrictions imposed by a doctor. Upon release to light duty work, you should contact your employer to express your availability for such work.

Can an employer terminate me while I am receiving workers’ compensation benefits?

Generally, yes. There is no workers’ compensation law that prevents this. However, if you believe you have been wrongfully terminated, you may wish to seek legal counsel. Your workers’ compensation benefits may or may not continue after termination, depending on the circumstances.

Can I draw workers’ compensation benefits and unemployment benefits at the same time?

There is no workers’ compensation statute or rule prohibiting receiving both benefits. You should contact the Department of Commerce & Labor without delay to determine your eligibility for unemployment benefits.

Is there a statute of limitation on medical benefits?

If you have met the filing and notice requirements, there is no statue of limitations on medical benefits, unless the claim has been closed with a lump sum settlement (IC 72-706 (5)).

Is there a statute of limitation on income benefits?

You must first meet the filing and notice requirements. For more information on filing and notice, call the Idaho Industrial Commission at (208) 334-6000. If you have met these requirements, income benefits may still be subject to a statute of limitations.

According to IC 72-706(3), if income benefits have been paid and discontinued more than four (4) years from the date of the accident causing the injury or the date of first manifestation of an occupational disease, you shall have one (1) year from the date of the last payment of income benefits within which to make and file with the commission an application requesting a hearing for additional income benefits.”

Also, if no benefits are paid during the first year after the injury, then income benefits may not be due thereafter. Contact your work comp insurance company or the Idaho Industrial Commission (208) 334-6000 for more information.

In some cases, you may elect coverage for exempt employment. Contact your insurance agent or representative for more information on electing coverage for exempt employment.

No. In fact, waivers are specifically prohibited under the Workers’ Compensation Law.

Idaho uses the right to control test to determine if a worker is an employee or independent contractor.  A copy of the right to control guidelines is available online to view or print.

You can check to see if an employer has a workers’ compensation insurance policy by going to the coverage verification link on the Commission’s website. Coverage Verification will provide the name of the insurance company that wrote a workers compensation policy for a specific employer on a specific date.

Workers’ compensation insurance premiums are based on payroll and vary according to the type of business or work performed by the employees. The employer is required by law to pay the entire cost of workers’ compensation insurance coverage. Deducting any portion of the cost of these premiums from employee wages is specifically prohibited. Your insurance agent or representative can assist you with determining your individual workers’ compensation insurance cost.

Yes. Idaho law mandates that all injuries must be reported to the Industrial Commission through the filling of a First Report of Injury form.

If one of your employees is injured and you do not have workers’ compensation insurance in effect at the time of the injury, you can be personally liable for all benefits, including medical and wage loss, provided under the Workers’ Compensation Law. An uninsured employer may also be liable for a penalty of 10% of the amount of medical and wage loss benefits as well as attorney fees if an attorney represents the injured worker.

In addition, employers who operate without workers’ compensation insurance can be liable for a penalty of $2.00 per day per employee or $25.00 per day, whichever amount is greater. The Workers’ Compensation Law authorizes the Industrial Commission to file a lawsuit in district court to obtain an injunction prohibiting the employer from operating the business while in violation of the Workers’ Compensation Law.

Operating a business without workers’ compensation insurance is a misdemeanor under Idaho law and the employer may be subject to criminal penalties.

• Household domestic service.
• Employment of family members living in the employer’s household (applies only to sole proprietorships).
• The owner of a sole proprietorship; working members of a partnership or limited liability company; individuals who are corporate officers and who own at least 10% of the stock and who are directors, if the corporation has directors.
• Employment covered under Federal Workers’ Compensation Laws.
• Pilots of agricultural spraying or dusting planes (under certain conditions).
• Associate real estate brokers and real estate salespersons when paid solely by commission.
• Volunteer ski patrollers.
• Officials of athletic contests in secondary schools only (grades 7-12 inclusive or any combination thereof).
• Casual employment or work which occurs occasionally or at irregular times and which is not related to the type of business conducted by the employer.
• Employment as an outworker. (Defined as a person to whom materials are furnished to be treated in any way at a location not under the control of the employer. An example would be a worker who receives mass mailing materials from the employer and assembles them at home.)
• Certain family member employees of a sole proprietor employer who do not reside in the same household as the employer may file an election for exemption with the Industrial Commission. See chart for relationships eligible to file an election for exemption.  We have posted a copy of the form for your convenience.

To determine if you quality for an exemption, contact one of the Industrial Commission offices.

If you have contract workers, whether the contract is verbal or written, the workers may be considered employees under the Workers’ Compensation Law. To ensure you are in compliance with the law, contact an Industrial Commission Employer Compliance representative to discuss your situation. Your requirement for coverage is considered on a case-by-case basis.

Employers can obtain workers’ compensation insurance through one of four options:

• Private Insurance. There are over 300 insurance companies authorized to issue workers’ compensation insurance in Idaho. For information, contact an insurance agent or company representative.
• State Insurance Fund. The State Insurance Fund is a quasi-governmental entity, NOT a state agency, headquartered in Boise, with field offices located throughout Idaho. Contact any of their offices or your insurance agent for more information.
• Assigned Risk Pool. Employers unable to obtain coverage from private insurance companies or the State Insurance Fund can apply for coverage through the assigned risk pool. The National Council on Compensation Insurance (NCCI) administers the pool. Contact your insurance agent or NCCI at (800) 622-4123 for more information.
• Self-Insurance. This option is available to Idaho employers with large payrolls and who are able to meet specific requirements. The Idaho Industrial Commission must grant approval for self-insurance.

Employers with one or more full-time, part-time, seasonal, or occasional employees are required to maintain a workers’ compensation policy unless specifically exempt from the law. Workers’ Compensation is required to be in place before the first employee is hired.

Benefits of Rehabilitation

The Industrial Commission offers “no cost” rehabilitation services to Idaho employers and injured workers who have sustained a workplace injury. Rehabilitation professionals can mutually benefit employers and injured workers by keeping claim costs low and facilitating an early return to work or compatible employment opportunities.

Our rehabilitation consultants act as a neutral party to coordinate return-to-work efforts with the injured worker, employer, insurance company, physician, attorney, and other individuals involved in the industrial claim. The function of the rehabilitation consultant is to assist these parties with the vocational aspects related to the industrial claim and its resolution.

The goal of the rehabilitation consultant is to return the injured worker back to the labor market as close as possible to his or her pre-injury status and wage. Due to this, employers may experience a reduction in time loss expenditures and the injured worker may experience an easy and timely return to the labor market.

The rehabilitation consultant can be a valuable resource to both you and your employees in answering and resolving workplace injury issues.

How we can help

• Analyze and discuss the injured worker’s job duties with treating medical providers.
• Share medical condition, diagnosis, and treatment information as it relates to employability and return-to-work timeframes.
• Identify and address concerns associated with the industrial accident.
• Contact your insurance carrier to coordinate medical recovery and keep you apprised of vocational status.
• Work with you and the employee to make job accommodations enabling a return to work.
• Help the injured worker develop a new employment goal if a job change is required.
• Contact other employers if job development or placement is needed.
• Maintain frequent contact with the injured worker to support motivation and return-to-work efforts.
• Provide assistance in job placement if return to the time-of-injury employer is not possible.

The rehabilitation consultant will work with you to document your injured employee’s job duties and will converse with the attending medical providers to obtain timely, accurate information. The physician’s recommendations will be shared with you so that informed business decisions can be made. The result may be reducing costs and insurance expenditures by increasing productivity and facilitating an early return to employment.

The notice of injury form can be found on the Industrial Commission website under the section for employers and the link for reporting injuries. This form can be printed and sent to the Idaho Industrial Commission Boise office or completed and e-mailed to froi@iic.idaho.gov

You may either call to request assistance from a local office or you may visit the website, print a referral for services, and mail or fax it to the nearest field office.

The rehabilitation services of the Industrial Commission are provided as a no-charge service. We do not charge the employer, injured worker, or the insurer for assistance with their industrial claims. Rehabilitation services are funded by a tax collected from workers’ compensation premiums.

Any dispute concerning your workers’ compensation benefits should be referred to the Idaho Industrial Commission. If you believe a person other than your employer is responsible — in whole or in part — for your injury, you may be able to seek compensation from that party in a civil court.

If a worker dies of a job-related injury or disease, their surviving spouse usually receives benefits for 500 weeks. (Benefits will change if their spouse remarries). Their children ordinarily receive benefits until they are 18 years of age. The amount of these benefits depends on the average weekly state wage.

If the death occurred within four (4) years of the job-related injury or disease, the law provides some compensation for funeral expenses.

To discuss the specific details regarding the benefits for which you may be entitled, contact an Industrial Commission Program Analyst by calling 1-208-334-6000 or toll free 1-800-950-2110.

For more information visit Survivor Death Benefit.

• Report your job-related injury or disease immediately!
• To qualify for workers’ compensation benefits, you must report your job-related injury or disease to your employer IMMEDIATELY. You could lose all benefits if you wait longer than 60 days to report your injury.
• Tell your employer about your injury or disease.
• You should tell your employer when, where, and how the injury happened. If possible, help your employer fill out your First Report of Injury or Illness form. The employer should file this notice with the Industrial Commission. If your employer declines to do so, file the form yourself.
• If your employer does not have the “First Report of Injury or Illness” form, call the Industrial Commission at one of the phone numbers listed and request that a form be sent to you.
• Report ALL injuries, even minor injuries.
• To protect your right to receive workers’ compensation benefits, you must report any job-related injury or disease to your employer.

To begin the formal hearing process, you must file a Complaint Form with the Industrial Commission. You may obtain a copy of the Complaint Form from the Industrial Commission or your attorney.

To obtain a date for your hearing, you or your attorney must file a Request for Calendaring with the Idaho Industrial Commission.

Your employer’s workers’ compensation insurance company pays for “reasonable and necessary” medical care to treat your job-related injury or disease.

Such care usually includes, but is not limited to, payment for emergency medical care, doctor bills, x-rays, medications, hospitalization, crutches, and some travel expenses required for medical care.

You are not responsible for the cost of medical treatment covered by workers’ compensation. Bills for medical treatment are to be sent by the medical care provider directly to the insurance carrier, or to the employer if self-insured.

If it is determined that the result of your job-related injury or disease is permanent, but that you will be able to return to the same or some other type of work, you will receive benefits for your permanent partial impairment and/or disability.

The benefits you receive and how long you receive them depends on the extent of your permanent impairment or disability.

If it is determined that you are totally and permanently disabled as a result of a job-related injury or disease, you may receive income benefits for an extended period of time. If such a total and permanent disability was partly caused by a previous injury or condition, the Industrial Special Indemnity Fund may pay some of your benefits.

If you have suffered a job-related injury or disease, the Industrial Commission Rehabilitation Division provides rehabilitation services and consultants to assist you in returning to employment in a position as close as possible to your pre-injury status and wage. The consultants do not work for employers, insurance companies, attorneys or anyone else involved in the workers’ compensation process. Instead, they are employees of the Industrial Commission and serve as professionals who are neutral and objective in their efforts to assist you in your recovery.

For more information about the service provided by the Industrial Commission Rehabilitation Division, refer to the section entitled What If I Need Help Returning to Work?

If your physician confirms that you cannot work because of your job-related injury or disease, you may be eligible for temporary total disability benefits until you are released to return to work or your condition has reached a point of maximum improvement. You normally qualify for time-loss benefits (compensation for lost wages) if your injury or disease causes you to miss more than five days of work, or you are hospitalized as an in-patient.

If you are able to return to part-time or modified work while you are still recovering from your injury or disease, and you are receiving less than your usual earnings, you may be entitled to temporary partial disability benefits.

• The State Insurance Fund. The State Insurance Fund is an insurance company and issues workers’ compensation insurance policies.
• The Industrial Special Indemnity Fund. The Industrial Special Indemnity Fund provides special disability benefits for workers who are totally and permanently disabled due to job-related injuries and diseases.
• The Department of Insurance. The Department of Insurance administers Idaho insurance laws and regulations, to protect the interest of the public in all insurance transactions, and to provide safety and stability of insurance institutions through regulations.

If you suffer a job-related injury or disease, you may be entitled to receive compensation for medical care, lost wages, or other related benefits and/or services, depending upon your individual situation. Note: Your employer’s insurance carrier or your employer, if self-insured, is responsible for payment of your workers’ compensation benefits if the injury or disease is found to be compensable.

If you have a job-related injury or disease and you believe your employer may not have but should have workers’ compensation insurance, you should:

• Call the Idaho Industrial Commission at 208-334-6000, toll free 1-800-950-2110, and request the name of your employer’s insurance company. The Industrial Commission can confirm whether or not your employer has coverage.
• Ask your employer or the Idaho Industrial Commission for a First Report of Injury or Illness form. Fill out the form to the best of your ability.
• Return your completed form to the Idaho Industrial Commission’s main office in Boise.

The Idaho Industrial Commission will notify your employer of your claim. In addition, your employer will be advised of its responsibility to pay your workers’ compensation benefits. The Industrial Commission’s Employer Compliance department will also take the appropriate action to make sure that your employer obtains the required insurance.

Legal Help

The information contained in this web page is general in nature and is not intended as a substitute for legal advice. Changes in the law or the specific facts of your case may result in legal interpretations, which are different than presented here.

The Idaho State Bar can provide you names of lawyers in your area who are familiar with workers’ compensation issues. The Idaho State Bar is located in Boise, Idaho and can be reached by calling 1-208-334-4500.

No Job Guarantee

Idaho’s Workers’ Compensation Law does not require your employer to hold your job or rehire you after you recover from your job-related injury or disease. However, Rehabilitation Consultants with the Idaho Industrial Commission can provide return-to-work assistance. You can contact the Idaho Industrial Commission Rehabilitation Division at 1-800-950-2110 V/TDD, or at one of the local offices.

Taxable Benefits

Questions often arise regarding whether or not workers’ compensation, disability and/or Social Security benefits are taxable. Since each person’s tax situation is different and related tax laws are complex, contact your accountant or an Internal Revenue Service representative to address your specific concerns.

Anti-Discrimination Law

The Idaho Human Rights Act and the federal Americans with Disabilities Act (ADA) prohibit employment discrimination based on disability. It is illegal to discriminate against a worker or job candidate because that person has a physical or mental disability. An employer has an obligation to attempt reasonable accommodation to meet the special needs of persons with disabilities. For more information about your rights within these laws, contact your employer, attorney, or the Idaho Human Rights Commission by calling 1-208- 334-2873, TDD 1-208- 334-4921. All calls are confidential.

If you believe you are entitled to receive certain workers’ compensation benefits and are not receiving them, you should:

• Talk directly with your employer and your employer’s insurance company about your concerns.
• If your employer or your employer’s insurance company cannot help you with your questions or concerns, contact an Idaho Industrial Commission Program Analyst, by calling 1-208-334-6000, toll free 1-800-950-2110 V/TDD.
• While discussing your case with your Program Analyst, ask about Mediation, a voluntary, informal dispute resolution process.

You may also choose to resolve your differences, regarding your claim for benefits, through the formal hearing process. Hearings are formal litigation proceedings where disputed workers’ compensation claims are presented before representatives of the Idaho Industrial Commission, either judicial referees (attorneys working for the Commission) or the Commissioners. After the hearing, you will receive a written order resolving the dispute.

If you choose to formally contest the decision of your employer or the employer’s insurance company, you may want to consult an attorney.

Rehabilitation Consultants at the Idaho Industrial Commission will assist you with returning to work within the physical limits set by your treating medical provider. Rehabilitation Consultants may:

• Help you set return-to-work goals.
• Conduct a job-site evaluation to help your doctor understand what is required of you at work.
• Work with your employer to make job modifications or to identify other job possibilities.
• Help you develop a new employment goal if a job change is required due to your job-related injury or disease.
• Help you find a job with a new employer that is as close to your pre-injury status and wage as possible.
• Help you develop a plan for on-the-job or formal training when such training is required to restore your pre-injury wage.

If you would like more information about the Rehabilitation Division and the services it offers, call toll free 1-800-950-2110 V/TDD, or contact one of our offices.

Mediation is a voluntary, informal meeting between the people involved in a disputed workers’ compensation claim. The goal of the meeting is for all sides to reach agreement on a fair solution to the dispute.

A neutral Industrial Commission mediator who has experience in resolving disputes assists in mediation. The mediator conducts the meeting but does not give advice to the participants. Mediation is often requested because it:

• Makes Everybody a Winner. All participants must agree to mediate a dispute or mediation will not take place.  The participants control the outcome. Everybody must be in agreement for a settlement to be reached.
• Saves Time. Mediation frequently results in an immediate solution. The formal hearing process is often very time-consuming.
• Has a High Success Rate. Over 90% of mediated disputes are successfully resolved.
• Involves No Risk. Cases unsuccessfully mediated may pursue a formal hearing or work toward settlement outside the mediation process.

Contact the Idaho Industrial Commission at 1-208-334-6000; toll free 1-800-950-2110 V/TDD, for more information about the mediation process, or request a mediation.

The Idaho Industrial Commission is the state agency, which administers the Idaho Workers’ Compensation Law.

When formal hearings are held on disputed workers’ compensation claims, the Industrial Commission makes findings of fact and reaches legal conclusions, then issues a decision containing its findings of fact and conclusions of law.

Industrial Commission employees can assist you with many of your questions or concerns about workers’ compensation. However, they cannot provide you with legal advice. If you believe that you need legal advice, you should consult an attorney.

Workers’ compensation insurance is a no-fault insurance policy, which provides wage loss and medical benefits to workers with a job-related injury or disease. Nearly every working Idahoan is protected by workers’ compensation insurance, as state law requires most employers to have workers’ compensation insurance.

If you are not sure whether your employer has workers’ compensation insurance, ask your supervisor or visit our Employers’ Workers’ Compensation Insurance Coverage Verification service online.

If your employer is required to carry workers’ compensation insurance, you are covered from your first day of work and normally every minute you are on the job.

The workers’ compensation law lists the few types of employers not required to have workers’ compensation insurance. If your employer does not have workers’ compensation insurance and you believe that you should receive workers’ compensation benefits, you may contact an Idaho Industrial Commission Compensation Consultant by calling toll free 1-800-950-2110 V/TDD; or consult with an attorney.

If you believe you have suffered a job-related injury or disease, you should:

• Tell your employer immediately.
• Seek first aid and medical care.
• Tell the medical care provider that your injury or disease is job-related.
• Your employer may have a designated physician for treating all work-related diseases or injuries except for emergency care. Ask your employer before seeking medical treatment. If your employer has designated a physician, you must have your employer’s approval or petition for approval from the Industrial Commission before visiting another physician.
• Help your employer fill out your First Report of Injury or Illness form.
• Call your employer or your employer’s insurance company if you have questions about your workers’ compensation benefits.

Call the Idaho Industrial Commission at 1-208-334-6000, toll free 1-800-950-2110, if you have problems or if your employer or your employer’s insurance company cannot help you with your questions or concerns. The Idaho Industrial Commission has people trained to assist you.

To schedule a mediation session, complete a Mediation Request Form. The session can be scheduled on the first mutually available date. Mediation sessions are held throughout the state, usually at the nearest Industrial Commission field office.

The Industrial Commission does not charge participants for a mediation session. The mediator’s expenses, such as salary and transportation costs, are paid for by the Commission.

During the meeting, participants discuss suggested settlements to the workers’ compensation claim dispute. The mediator will provide information to all participants but will not give advice. The offers of settlement may be accepted or rejected by the other party, or a counter-offer may be made. If an agreement is reached, it will be put into writing and signed by the parties. If no agreement is reached, either party may pursue other methods for resolving the claim.

The mediation process frequently results in an immediate solution. However, if the participants are unable to reach agreement through mediation, they may pursue other means to resolve the claim.

Mediation is a voluntary, informal meeting between all sides to reach agreement on a fair settlement to the dispute. The Idaho Industrial Commission offers a mediation process for people involved in a workers’ compensation claim dispute.

A mediation session can occur anytime after the workers’ compensation Notice of Injury and Claim for Benefits Form (IC Form 1) is filed with the Industrial Commission. A mediation session can occur only when ALL parties agree to mediate the dispute.

The participants of a mediation session typically include representatives for the employee and insurer. You are not required to be represented by an attorney to participate in mediation.

Each mediation is conducted by a neutral Industrial Commission mediator who has experience in resolving disputes. The mediator oversees the meeting but does not give advice to the participants.

The following questions pertain to the rules and regulations governing charges for medical services provided under the Idaho Workers’ Compensation Law IDAPA 17.01.01.404.

The Idaho Industrial Commission adopts the Resource-Based Relative Value Scale (RBRVS), published by the Centers for Medicare & Medicaid Services of the US Department of Health & Human Services, as the standard to be used for determining the acceptable charge for medical services provided by physicians.

Effective January 1, 2012, the Commission adopts the Medicare Severity – Diagnosis Related Group (MS-DRG) reimbursement method for inpatient services provided by hospitals other than critical access hospitals (CAH) or rehabilitation hospitals. The Ambulatory Payment Classification (APC) reimbursement method is adopted as the standard for hospital outpatient departments (HOPD) and Ambulatory Surgery Centers (ASC).

The standard reimbursement for medical services provided by Providers other than physicians, hospitals, or ASCs is the reasonable charge not to exceed the Provider’s “usual” charge and not to exceed the “customary” charge.

Are CPT codes required for billing physician services? Are modifiers required?

A provider’s bill shall, whenever possible, describe the medical service provided using the American Medical Association’s appropriate Current Procedural Terminology (“CPT”) coding, including any applicable modifiers, for the year in which the service was performed, and using current International Classification of Diseases (“ICD”) diagnostic coding, as well. IDAPA 17.01.01.404.01 & 17.01.01.803.06(b)(i).

What are medical reports as referenced in the IDAPA rule?

Medical reports are records that have been generated because a patient has been treated. Medical Report “Means and includes without limitation, all bills, chart notes, surgical records, testing results, treatment records, hospital records, prescriptions, and medication records.” IDAPA 17.01.01.010.31.

Does the medical report have to be sent at the same time as the bill for services? What happens if the report does not accompany the bill? Can payers demand to see an invoice before issuing payment?

If requested by the payer, the provider’s bill must be accompanied by the corresponding medical report. Where the bill is not accompanied by the requested report, the timelines requiring prompt payment and the issuance of Preliminary Objections/Requests for Clarification by the payer do not commence until the report and bill have both been received by the payer. IDAPA 17.01.01.803.06.b.iii.

A payer can request invoices for implantable hardware or durable medical equipment. However, apart from when the invoice is required to calculate the acceptable charge, the invoice is not considered a required medical report and generally a bill should not be denied on the basis that an invoice was not provided to support it. Nevertheless, providing the invoice to the payer may assist the provider in rebutting the payer’s argument that the charge is unreasonable. For implantable hardware items the invoice must be provided to payer, as it is necessary to calculate the acceptable charge under IDAPA 17.01.01.803.03.d.

What is an acceptable charge?

An acceptable charge is the lower of the following: 1) the charge for medical services calculated in accordance with the fee schedule under IDAPA 17.01.01.803; 2) the charge billed by the provider; or, 3) the charge agreed to pursuant to a written contract. IDAPA 17.01.01.07.a.

For calculation of the acceptable charge for medical services provided by physicians, the conversion factors are to be multiplied by the facility or non‑facility total relative value unit (“RVU”) as determined by place of service found in the latest RBRVS, as amended, in effect on the first day of January of the current calendar year. IDAPA 17.01.01.803.02.

For calculation of the acceptable charge for inpatient hospital services, the base rate for hospital inpatient services is to be multiplied by the current MS-DRG weight for that service. Surgically implanted hardware may be allowed at the rate of actual cost plus fifty‑percent (50%), if the implant threshold criteria is met. IDAPA 17.01.01.803.03.b.

For calculation of the acceptable charge for outpatient hospital and ambulatory surgery center services, the applicable base rate is to be multiplied by the APC weight in effect on the first day of January of the current calendar year. IDAPA 17.01.01.803.03.c.

For critical access hospitals, the acceptable charge is 90% of the reasonable charge. IDAPA 17.01.01.803.03.a.

For non-critical access hospitals and ASCs, there are other payments that might be allowed in certain circumstances in addition to the amount allocated within the MS-DRG or APC payment. IDAPA 17.01.01.803.03.d.

For medicine provided by pharmacies, the acceptable charge is the average wholesale price (“AWP”) plus a dispensing fee for prescription medication, or the reasonable charge plus a dispensing fee for over-the-counter medication. IDAPA 17.01.01.803.04.

For historical medical fee schedules, click here.

What is a reasonable charge?

A reasonable charge does not exceed the provider’s usual charge and does not exceed the customary charge. IDAPA 17.01.01.010.07.c. Therefore, a reasonable charge is one that is both usual and customary.

What is a provider’s usual charge?

A usual charge is the most frequent charge made by an individual provider for a given medical service to non‑industrially injured patients. IDAPA 17.01.01.010.07.d.

NOTE: When Industrial Commission staff reviews a provider’s motion* to determine whether a provider’s charge is usual, the staff looks for evidence that the disputed charge did not exceed that charged by the provider to non-industrial patients for the same service. A non-industrial patient is one who is not claiming a work-related injury or illness.

*The filing of motions is discussed below.

What types of evidence should be sent to establish that the charge is “usual?”

Examples of evidence include copies of billing statements, explanations of benefits, fee schedules and/or affidavits from which the Commission can conclude that the charges are the same regardless of whether the injury or illness arose out of and in the course of the patient’s employment.

What is a customary charge?

A customary charge shall have an upper limit no higher than the 90th percentile, as determined by the Commission, of usual charges made by Idaho providers for a given medical service. IDAPA 17.01.01.010.07.b.

Is it necessary to submit evidence that the charge is “customary?”

Whenever possible, it is helpful to submit evidence that the charge falls within the 90th percentile of what Idaho providers bill for the same services. If such evidence is not available, the Commission may determine whether the disputed charge is customary based on a survey of Idaho provider charges or any other provider charge data available to the Commission.

What forms are required when filing a motion for Approval of Disputed charges? To whom should the motion be sent?

A provider’s motion must be filed on the forms provided in the Commission’s Judicial Rules. These forms include the Motion, Certificate of Mailing, and Appendix A. JRP 19(E)(1)(a)(i).

“Motions or responses by any party may be submitted in writing by hand delivery to the Boise Office at the Chinden Campus 11321 W. Chinden Blvd. (Bldg. #2), Boise, Idaho 83714, faxed to 208-334-2321, mailed via USPS to P.O. Box 83720, Boise, Idaho 83720-0041, or emailed to medicalfees@iic.idaho.gov. Email requests will be considered as an original document. Additional original documents are not required.

Required documents shall be served on parties by mail, fax, or personal delivery.” JRP 19(C).

See Tips for Success With a Motion for Approval of Disputed Charge.

If the dispute concerns a payer’s failure to comply with timelines, what types of documentation should be submitted with the motion?

The provider should submit evidence demonstrating that it complied with all applicable timelines and that the payer did not.

Additionally, it would also be a best practice for a provider’s motion to document how its charge comports with the applicable fee schedule rule. For example, if a usual and customary analysis applies to the charge (such as would be the case with durable medical equipment) the provider should, whenever possible, also document that their charge is both usual and customary. This is the best practice even if the only issue appears to be based on timeliness as the payer may raise the issue in its response and the Commission will look to any information relevant to or bearing upon the calculation of the acceptable charge under the rules, regardless of whether the issue was raised by a party.

What types of documentation must be submitted when the medical service in dispute is not CPT-coded, or is unusual/exceptional?

As with any other motion, the provider should submit evidence that the disputed charge is its usual charge for that service, or a similar service.

When a service is not CPT-coded, or is unusual/exceptional, reasonableness is determined based on all relevant evidence available. The provider should submit documentation relating to and/or supporting the reasonableness of its charge for the service, as well as an explanation as to why the service provided is unusual/exceptional.

Motions in medical fee disputes:

• Motion for Approval of Disputed Charge
• Response to Motion for Approval of Disputed Charge
• Motion to Present Additional Evidence
• Motion for Reconsideration

Tips for Success in Medical Fee Disputes:

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 or a response to a motion. The Commission has also created a separate page to answer frequently asked questions.

Disclaimer: Please keep in mind these are best practices to facilitate a favorable outcome for you on your motion if you are the provider, or in defense of your handling of the bill or calculation of the acceptable charge if you are the payer. You need not be dissuaded from filing a motion or a response if you suspect that you missed a deadline or feel that you cannot provide adequate documentation. Document what you can and make your best argument.

1. DO document in your motion or response:
   • The date you sent or received the bill;
   • The date you sent or received the Preliminary Objection or Request for Clarification;
   • The date you sent or received the written Reply;
   • The date you sent or received the Final Objection;
   • The date and amount of any payments sent or received;
   • Any other relevant actions taken in response to the above;
   • A brief explanation of how you have satisfied each step of the required Procedures Preliminary to Dispute Resolution under IDAPA 17.01.01.803.06. The IDAPA rules can be downloaded from our Laws, Rules, Legislation and Policy Memos page here; and,
   • If relevant, how you have calculated the acceptable charge and/ or what AMA or CMS coding guidelines you are relying on.

2. DO file your motion or response timely.
   • See Judicial Rule of Practice and Procedure (“JRP”) 19(E) for timelines regarding when the filing of a motion and/or response is timely. The JRP can be downloaded from our Laws, Rules, Legislation and Policy Memos page here.

3. DO use the standard forms.
   • The forms can be downloaded from our FAQ page here.

4. DO include:
   • Copies of all bills actually sent (indicating which portion of the bill is in dispute);
   • The Preliminary Objection or Request for Clarification sent or received;
   • The written Reply sent or received;
   • The Final Objection sent or received; and,
   • Any other relevant communications and/or correspondence between the parties.

5. DO include a brief narrative description of the issues, actions taken, communications that occurred, or other relevant information that might bear on the calculation of the acceptable charge or support your position on the issue.
6. DO understand that Commission staff are legal, not medical or coding, professionals, and that the dispute process is a legal, not medical, forum.
7. DO include a Certificate of Service documenting that you sent a copy of your motion or response and all supporting documents to the other party, as required by JRP 19(C).
   • If you complete service via facsimile, you must include the fax number on the Certificate of Service in addition to the name of the party served to adequately document proof of service. Although not required, it can also be helpful to include the facsimile transmission confirmation page that reflects a successful facsimile transmission.
   • Remember, you can file your motion or response via email by sending it to medicalfees@iic.idaho.gov, but you must still serve the motion or response on the other party via facsimile, mail or personal delivery.

8. DO NOT send in multiple copies of the same document. Ex.: If you are responding to a motion as a payer, it is generally not necessary to also send us a copy of the original motion and supporting documents that you received from the provider.
9. DO NOT send irrelevant medical records or bills and expect the Commission staff to sort them out.
   • Be specific and reference in your narrative explanation how or why each document is relevant and/or supports your position.
   • If you cite to specific authorities, please include adequate details for Commission staff to be able to reference the source material (if you reference online materials, please include a link to the source page).

DO NOT hesitate to call Commission staff before you send in a motion or response to a motion if you have any questions. Please bear in mind that Commission staff will only be able to assist you with procedural matters. We cannot assist you in how to make your case.

A Settlement Agreement is a legal and binding agreement. It is recommended that you consult an attorney to either assist with developing the settlement or to review a settlement that has previously been developed.

Money paid for your permanent impairment rating is not a final settlement. The money for your impairment rating is yours, whether you agree to a settlement or not. In most situations, once the impairment is paid in full the claim is placed in an inactive or closed status. The claim can be reopened if additional treatment is related to the original injury. No time limitation applies to medical benefits, but income benefits are limited to five years from the date of injury unless a complaint is filed with the Commission.

• Your medical benefits will remain available.
• Your income benefits may be resumed if you are disabled again by your work injury within applicable limitations. The surety may choose to make a lesser offer should you later decide to settle.

If the Commission declines to approve a Settlement Agreement under its discretion, it must issue a written decision, including factual findings, conclusions of law, and an order declining to approve the agreement.

A Settlement Agreement is a final settlement between the injured worker and the surety/employer, which allows benefits to be paid all at once instead of over time. Most settlements close all benefits forever. However, it is possible to finalize some types of benefits and leave other benefits (usually medical) open. Once a Settlement Agreement is agreed to by all parties, the claim finalized by the settlement cannot be reopened for future workers’ compensation benefits.

Subrogation is the right of one party to be reimbursed for something that was the responsibility of another party. If there is third-party liability, the workers’ compensation surety has a legal right to reimbursement for all or a portion of the benefits paid. The surety may waive all or part of its rights to recover the money as part of the settlement.  Other health care payers who paid for care denied by the workers’ compensation surety may also have a legal right to reimbursement if the Settlement Agreement includes consideration for the disputed treatment.

Effective July 1, 2022, most Settlement Agreements no longer require approval by the Industrial Commission.  All Settlement Agreements must be filed with the Commission before they are considered effective.  The Commission is required to conduct a review of all Settlement Agreements entered into by non-represented persons (pro se), minor children, or legally incompetent persons.  Either party may also request the Commission’s review.  The Commission shall approve the agreement if it determines that the approval is in the best interests of the parties.

If a third party is found to be responsible for the accident, a separate claim may be made and legal action may be taken. (Your employer cannot be a third party.) However, if recovery is made against a third party, it is subject to subrogation.

Since a settlement agreement will forever close the claim, injured workers may consider any future costs they believe will arise. Most common are:

• Medically verified future medical costs
• Unpaid impairment balance
• Money for disability related to decreased wage-earning capacity OR retraining costs (Time Loss, books, tuition)

I received something in the mail called a “Notice of Filing of Appeal.”  Do I have to do anything?

• No.  The “Notice of Filing of Appeal” simply informs all of the interested parties in your case that an appeal has been filed with the Commission.

I have some additional documents, witness statements, or other information I did not submit to the Appeals Examiner.  Can I submit them to the Commission?

• Yes.  You may submit to the Commission anything you believe is relevant to your case.  You must submit it within seven (7) days from the date stamp found on the certificate of service accompanying the compact disc of the Appeals Examiner’s hearing.  The additional evidence you submit will not automatically be included in the record.  The Commission will review the additional evidence and determine whether it should be included in the evidentiary record created during the Appeal Examiner’s hearing.

I want another chance to tell my story.  Can I ask for a hearing with the Commission?  

• Yes, you can ask for a new hearing before the Commission.  However, the Commission only grants those requests when there are extraordinary circumstances.  If you wish to request a new hearing, you must send the request in writing, within seven (7) days from the date stamp found on the certificate of service accompanying the compact disc of the Appeals Examiner’s hearing.  You must explain why you feel a new hearing is necessary.  The other information you should include in a request for a new hearing is more fully explained in the Rules of Appellate Practice and Procedure Under the Idaho Employment Security Law.

My spouse/son/daughter/friend filed an appeal with the Commission and asked me to find out what’s going on with the case.  How can I get that information?  

• You can’t.  The information in unemployment insurance appeals is confidential.  Therefore, the staff at the Commission can only talk to and provide information about a particular case to the named parties in that case and their representatives.  Representatives are only entitled to information under a power of attorney or similar instrument that has been filed in the case with the Commission.

I filed my appeal weeks ago.  What’s taking so long?

• The Commission reviews unemployment insurance cases in the order in which they are filed.  A referee designated by the Commission will review all of the documents in the file and listen to the audio recording of the hearing and will prepare a decision for the Commissioners to review.  Once the Commissioners have reviewed and signed that Decision and Order, you will receive a copy by mail.  To ensure that the parties in the case received due process and the decision is consistent with the law, the process takes time.

How can I get more information about my case?

• Call the Commission and ask to speak to someone in unemployment insurance appeals.  If you have to leave a message, make sure to include your name, telephone number where you can be reached, and if you have it handy, your case number.  The Commission staff makes every effort to return calls the same day in which they are received.

Can I get information by email?

• No.  The Commission staff can only disclose case information to interested parties.  Because we have no way to verify that an emailed request is from an interested party, Commission staff WILL NOT respond to specific inquiries regarding unemployment insurance appeals cases received through email.  If you send a request for information through email, you will receive a response explaining that the Commission does not respond to email inquiries and directing you to call the Commission with your question or request for information.  The best way to get information about your case is by phone.

Do I need an attorney?  

• That depends on who you are.  Claimants do not need attorneys to file appeals with the Industrial Commission.  Employers that are business entities, such as corporations, partnerships, Limited Liability Corporations (LLC) or Professional Corporations (PC) must be represented by counsel for any reason other than filing the initial appeal.  For example, the human resources manager files the appeal and then discovers some additional documentation that the Commission should consider.  In order to properly put that additional documentation before the Commission, the employer will need to ask the Commission for a new hearing to take additional evidence.  That request must come through an attorney.  Idaho law does not permit business entities to represent themselves when they seek new hearings before the Commission or an opportunity to argue their cases in legal briefs.

I was represented by an attorney at the Appeals Examiner’s hearing and I want my attorney to represent me at the Commission.  Does my attorney have to do anything?

• YES, your attorney must file a Notice of Appearance with the Commission.  Because the Idaho Industrial Commission is an agency separate from the Idaho Department of Labor and because Unemployment Insurance information is governed by strict confidentiality rules, the Commission cannot release any information to a non-interested party.  Until your attorney files a notice of appearance with the Commission, he or she is a non-interested party and therefore will not be allowed to participate in your case.

Who pays my attorney?

• You do.  There is no provision in the Idaho Employment Security Law allowing for the recovery of attorney fees from either the unemployment insurance fund or an opposing party.

What else should my attorney know?

• The only rules of procedure that apply to unemployment insurance appeals before the Commission are the Rules of Appellate Practice and Procedure Under the Idaho Employment Security Law.  Neither the Idaho Rules of Civil Procedure nor the Federal Rules of Civil Procedure apply to unemployment insurance appeals.

I use an unemployment claim management firm (i.e. Talx UC Express) and they represented me at the Appeals Examiner’s hearing.  Can they represent me at the Commission?  

• No.  Only interested parties can file and participate in unemployment insurance appeals before the Commission. Professional employer representative firms are not interested parties and therefore cannot file appeals on behalf of their clients with the Commission as they can with the Idaho Department of Labor.

PROTECT YOUR RIGHTS – FILE YOUR APPEAL ON TIME AND IN THE RIGHT PLACE!!!!!
Who can file an appeal with the Commission?  

• Any interested party.  Interested parties usually include the claimant, the employer, and the Idaho Department of Labor.  If the employer files the appeal, the appeal must be prepared and signed by an individual usually authorized to deal with unemployment insurance matters, such as the human resources manager, or an officer of the firm.

How can I file an appeal with the Commission?

• There are three ways you can file an appeal with the Idaho Industrial Commission:

1. You can deliver it in person to our office at 700 S. Clearwater Lane, Boise, Idaho, 83712; mail it to us at: Industrial Commission, P.O. Box 83720, Boise, Idaho, 83720-0041, or fax it to us 208-332-7558.  If personally delivered, the appeal must be received no later than 5:00 p.m. on the last day to appeal.
2. You can mail your appeal.  The appeal shall be deemed to be filed on the date of mailing as determined by the postmark applied by the U.S. Postal Service on the envelope containing the appeal.  Private Postage Meter stamps will not substitute for a postmark.  If you use a postage meter to apply postage, protect yourself and make sure the post office cancels it. If there is no postmark applied by the U.S. Postal Service, the date the Commission receives the envelope will become the date of filing.
3. You can fax your appeal.  IF YOU FAX YOUR APPEAL, PLEASE NOTE:  Appeals transmitted by facsimile to the Commission and received by 5:00 p.m. on a business day shall be deemed filed on that day.  An appeal transmitted by facsimile and received by the Commission on a weekend, holiday, or after 5:00 p.m. on a business day shall be deemed filed on the next business day.  The Industrial Commission is located in Boise, Mountain Time, and the time the Commission receives your appeal over our fax machine will establish the filing time, not the time your fax machine says it transmitted the fax.

Is there a special form I need to use to file my appeal with the Industrial Commission?

• No, any piece of paper will do so long as it indicates that it is an appeal of an unemployment insurance decision issued by an Appeals Examiner and is signed by the party filing the appeal.  Please include your name, current mailing address, and the docket number of the Decision you are appealing along with a statement indicating that you are appealing or protesting the Decision the Appeals Examiner issued in your case.

Can I file my appeal with the Department of Labor like I filed my other appeal?  

• NO!!  The only place you can file your appeal is with the Industrial Commission’s main office in Boise.  The Commission WILL NOT accept appeals filed through the Idaho Department of Labor.  This is explained in the Appeals Examiner’s Decision under “APPEAL  RIGHTS.”

There was a telephone hearing in my case with an Appeals Examiner, but I missed the hearing.  What should I do?

• Wait until you receive the Appeals Examiner’s Decision.  It should arrive in your mail about 10 days after the hearing.  When you receive that Decision, you have 10 days from the date the Appeals Examiner mailed it to ask that the hearing be reopened.  You must file your request in writing with the APPEALS BUREAU, not the Industrial Commission.  This information is explained in the document entitled “IMPORTANT INFORMATION ABOUT YOUR HEARING” you received with your hearing information.  Once you file your request to reopen, the Appeals Examiner will issue an Order.  If the Appeals Examiner denies your request, then you can appeal your case to the Industrial Commission.

I filed a request with the Appeals Examiner to reopen my hearing, but I’m afraid he or she won’t rule on it before the time runs out to appeal the Decision of Appeals Examiner about the unemployment benefits.  What should I do?

• Wait for the Appeals Examiner to issue an Order on your request to reopen the hearing.  If the Appeals Examiner grants you a new hearing, the Appeals Bureau will schedule that new hearing as soon as possible and your case will continue with the Appeals Examiner.  If the Appeals Examiner denies your request, that order starts the clock over on your appeal rights of the Decision regarding the unemployment benefits.  You will have fourteen (14) days from the date the Appeals Examiner issues the Order denying your request for a new hearing to appeal to the Commission.  You can appeal that Order denying your request to reopen the hearing AND the Decision you wanted to reopen.