Proposed Rule 409--5/21/98 DRAFT
OBTAINING INFORMATION FROM MEDICAL CARE PROVIDERS
1. Party representatives.
(a) When used herein, the term "employer" includes the employer, its carrier or third-party administrator, its attorney or their agents.
(b) When used herein, the term "employee" shall also include and apply to his or her attorney if the employee is represented. Whenever the employee is represented by an attorney, any notices or copies required to be provided herein shall be provided to the employee’s attorney in lieu of the employee.
2. Medical record requests. Upon written notice to the employee or his or her attorney, the employer may obtain directly from the medical care providers medical records of evaluation or treatment of a current injury or current condition for which an employee is receiving or claiming compensation under the Act.
3. Oral and written communication between employers and medical care providers.
(a) An employer paying compensation for an admitted claim or paying without prejudice pursuant to G.S. §97-18(d) may communicate with the employee’s medical care providers as follows:
(1) In writing, limited to the use of specific questions or guidelines promulgated by the North Carolina Industrial Commission, to determine, among other information, the diagnosis for the employee’s condition, the reasonable and necessary treatment, the anticipated time that the employee will be out of work, the relationship, if any, of the employee’s condition to the employment, the restrictions from the condition, the kind of work for which the employee may be eligible, the anticipated time that the employee will be restricted, and the permanent impairment, if any, as a result of the condition. When these questions or guidelines are used, a copy of the written communication shall be provided to the employee at the same time and by the same means as the communication is provided to the provider. If further information or clarification is needed, the inquiry must be in writing, by letter prepared by the employer, and a copy of the written communication shall be provided to the employee at the same time and by the same means as the communication is provided to the provider.
(2) In writing, if further supporting information is provided, by letter prepared by the employer. If the letter is accompanied by any supporting information, the information provided shall be balanced and objective. When a letter with supporting information is used, the letter and any accompanying information shall be received by the employee at least five business days prior to the date it is transmitted to the medical care provider.
(3) Orally, provided the employee or his or her attorney, if any, shall be given prior reasonable notice and opportunity to participate. However, if the employer, after reasonable efforts is unable to contact the employee or his or her attorney or if the employee is unable to participate, the employer shall thereafter submit in writing the substance of any oral communication that takes place to the employee or his or her attorney. If the employer is requesting the medical care provider to review any supporting information in preparation for an oral conference, the supporting information shall be provided to the employee at the same time as the notice of the conference, or at least five business days prior to being supplied to the provider. Provided, however, in a time-sensitive job availability situation, by consent of the parties, or in emergency or exigent circumstances, this process may be expedited. Any communications pursuant to this paragraph shall be balanced and objective, and shall have been provided to the employee or to his or her attorney as early as practical.
(b) Except as provided in G.S. §97-18(d), an employer, prior to admitting or denying the claim, may proceed under sub-section (a) of this rule while investigating a claim for a period not to exceed 45 days. After expiration of this 45 day period without admitting the claim or without paying without prejudice, the employer must use formal discovery procedures under section 5 of the rule. When necessary for the administration of a claim, the employer may request, orally or in writing, that medical provider office personnel read to the employer any information contained in the medical records concerning evaluation or treatment of a current injury or current condition for which an employee is receiving or claiming compensation under the Act. This sub-section is intended for discovery purposes only and is not intended in any way to change the effects of G.S. §97-18(c).
4. Employee consent and Commission order. Other forms of communication with medical care providers may be authorized by a valid authorization signed by the employee, by agreement of the parties, or by order of the Commission issued upon a showing that the information sought is not reasonably obtainable through discovery or upon a showing of other good cause.
5. Formal discovery required. Except as provided in Paragraphs 2 and 4, and Industrial Commission Rule 607, the employer may obtain medical facts and opinions related to disputed matters only pursuant to the Commission’s formal discovery procedures:
(a) When the employer has denied the employee’s workers’ compensation claim; or
(b) When an I. C. Form 24 or 33, motion or other disputed matter is pending before the Commission or the courts.
(c) When no admission or denial of liability has occurred within 45 days and when the employer is not paying according to G.S.§97-18(d).
Whenever the employee is represented by an attorney, any notices or copies required to be provided herein shall be provided to the employee’s attorney in lieu of the employee.
6. Emergency communications regarding treatment. In a medical emergency, arrangements for immediate care may be made by any expedient means, including telephone. The employer shall promptly notify the employee or his or her attorney, if any, in writing of the substance of any such communications.
7. Billing and scheduling. An employer may orally communicate with persons in a medical provider’s office who are responsible for billing and scheduling when those communications are limited to those matters.
8. Communications necessary for pre-authorization. An employer requiring pre-authorization pursuant to G.S. §97-25.3 may have such communications with a medical care provider requesting pre-authorization as is reasonably necessary to comply with G.S. §97-25(a)(2), limited to the information required for review of the request for pre-authorization.
9. Rehabilitation professionals. Rehabilitation professionals, as defined in the North Carolina Industrial Commission Rules for Utilization of Rehabilitation Professionals in Workers’ Compensation Claims (Rehabilitation Rules), may communicate with medical care providers as provided in this Rule or in the rehabilitation rules.
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