NAC616C.129. Rules for treatment of injured employees by members of panel of physicians and chiropractors.

The members of the panel of physicians and chiropractors, approved for treatment of employees protected by workers’ compensation, shall adhere to the following rules:

     1. There may be only one treating physician or chiropractor in any one case at any one time, unless prior authorization is obtained from the insurer. Physicians and chiropractors associated with the treating physician or chiropractor may treat the injured employee during the temporary absence of the treating physician or chiropractor. In all cases, the treating physician or chiropractor is directly responsible for the management of the health care of the injured employee. Physicians in emergency rooms are not considered treating physicians within the meaning of NAC 616C.126 to 616C.141, inclusive.

     2. The insurer shall give written notice to all interested persons of the transfer of an injured employee to a new physician or chiropractor.

     3. Except as otherwise provided in this subsection, an injured employee or an insurer is not financially liable for the payment of the fees of a provider of health care who renders treatment to an injured employee for an industrial accident or occupational disease, knowing that the injured employee is already under the care of another provider of health care. The insurer may be liable for the payment of the fees pursuant to this subsection if the insurer gives prior written approval for the treatment or good cause is shown for the treatment provided.

     4. Any prescription or service ordered by a physician or chiropractor other than:

     (a) The treating physician or chiropractor; or

     (b) A physician or chiropractor associated with the treating physician or chiropractor who is treating the injured employee during the temporary absence of the treating physician or chiropractor,

Ê is not a financial liability of the insurer unless good cause is shown for the prescription or service.

     5. The treating physician or chiropractor must request written authorization from the insurer before ordering or performing any one of the following services with an estimated billed amount of $200 or more:

     (a) Consultation;

     (b) Diagnostic testing;

     (c) Elective hospitalization;

     (d) Any surgery which is to be performed under circumstances other than an emergency; or

     (e) Any elective procedure.

     6. Any request for prior authorization to order or perform any of the services set forth in subsection 5 must contain an explanation of the need for each service to be ordered or performed. If any of the services are performed without the insurer’s written authorization, the insurer is not liable for the fee for the service, unless good cause is shown for providing the services without prior authorization.

     7. A treatment program that consists of more than six visits, not including the initial evaluation, and is billed under codes 97010 to 97799, inclusive, or 98925 to 98943, inclusive, whether the visits are billed separately or included under different codes, must be authorized in advance by the insurer to verify the medical necessity for continued treatment. The first six visits do not require the prior authorization of the insurer. The number of requests for additional visits and any written authorization granted therefor are not restricted, and are subject only to the treatment prescribed by the treating physician or chiropractor and the determination of the insurer. A report of the status of an injured employee may be requested by an insurer at any time during the course of treatment. The initial evaluation shall be deemed to be separate from the initial six treatments. An initial evaluation may be performed on the same day as the initial treatment.

     [Industrial Comm’n, No. 14.031, eff. 6-30-82]—(NAC A by Div. of Industrial Insurance Regulation, 10-26-83; 2-22-88; A by Div. of Industrial Relations, 10-11-93; 3-5-96; R121-97, 12-10-97, eff. 1-1-98; R090-99, 10-28-99; R118-02, 9-7-2005)