R612. Labor Commission, Industrial Accidents.R612-300. Workers' Compensation Rules - Medical Care.
R612-300-1. Purpose, Scope and Definitions.
A. Purpose and scope. Pursuant to authority granted the Utah Labor Commission under Subsection 34A-2-407(9) and Subsection 34A-2-407.5(1) of the Utah Workers' Compensation Act, these rules establish:
1. Reasonable fees for medical care necessary to treat workplace injuries;
2. Standards for disclosure of medical records;
3. Reporting requirements; and
4. Treatment protocols and quality care guidelines.
B. Definitions. The following definitions apply within Rule R612-300:
1. "Health care provider" is defined by Subsection 34A-2-111(1)(a) as "a person who furnishes treatment or care to persons who have suffered bodily injury" and includes hospitals, clinics, emergency care centers, physicians, nurses and nurse practitioners, physician's assistants, paramedics and emergency medical technicians.
2. "Injured worker" is an individual claiming workers' compensation medical benefits for a work-related injury or disease.
3. "Payor" is the entity responsible for payment of an injured worker's medical expenses';
4. "Physician" is defined by Subsection 34A-2-111(1)(b) to include any licensed podiatrist, physical therapist, physician, osteopath, dentist or dental hygienist, physician's assistant, naturopath, acupuncturist, chiropractor, or advance practice registered nurse.
5. "Workplace injury" is an injury or disease compensable under either the Utah Workers' Compensation Act or the Utah Occupational Disease Act.
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.
