Licensing fee schedules is based on the number of users in your organization.
A User is an individual who uses information from the ground rules and/or rate tables to make decisions about, to charge or to pay for services related to claims for injured workers.
Examples:
- A physician practice using the fee schedule to bill for services provided to a patient who was injured at work
- Anyone adjudicating a bill whereby the fee schedule is used to price services
- A business analyst interpreting rules and regulations for automation into a software program for bill adjudication or other processing needs
- A claims processor at an insurer/TPA/bill review agency who is reviewing a workers’ compensation bill to evaluate appropriate review or payment for medical services
- Reviewing a bill for the purposes of adjusting or completing a potential re-evaluation due to errors, a state or hearing directive or a provider dispute
- Reviewing the fee schedule information for purposes of preparing litigation, attending a hearing or arbitration
The following are examples of individuals who would NOT be considered Users of the fee schedule:
- IT staff who load the fee schedule to a company’s computer system or software program for use by claims processors or bill reviewers, running reports or other IT functions
- Quality assurance staff who review rates to ensure they are properly reflected in an organization’s internal systems
- A physician’s billing manager, who bills for workers’ compensation claims on behalf of the physician/practice
- Customer service representatives or other individuals who access information from an Explanation of Review or other secondary documentation as a result of application of the fee schedule
