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Medical records review guidelines: IMEs and special reports

Pinnacol has established guidelines for special reports not otherwise addressed in the Colorado
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Pinnacol has established guidelines for special reports not otherwise addressed in the Colorado Division of Workers’ Compensation (DOWC) Rule 16, Utilization Standards, Rule 17, Medical Treatment Guidelines, and Rule 18, including any form, questionnaire or letter with variable content.

These guidelines apply to independent medical evaluations (IMEs) and reviews when the physician is asked to review records associated with an injured worker’s (IW) medical claim to provide an opinion for Pinnacol Assurance which is performed outside of the DOWC IME process.

According to Rule 18, the reimbursement for the preparation of special reports or records requires prior agreement with Pinnacol (see below guidelines). The provider is entitled to a two hour advance deposit for a scheduled IME. The IME issues letter will reflect the number of inches of medical records for review.

Pinnacol Assurance is implementing these guidelines to meet DOWC requirements and avoid delays in treatment for the injured worker or payment disputes after the review has been performed or the report written.

The following guidelines apply for IMEs and special reports:

  • Pre-payment will be per the DOWC IME fee schedule.
  • The itemized bill will include, but is not limited to:

— The IW’s name, claim number, and dates of service

— Coded billing components with descriptions for each:

— The medical records review

— Conferences with Pinnacol claims representatives and medical case managers,

treating providers or attorneys: Paid in 15-minute increments per DOWC fee schedule

— Evidence based research

— The review of surveillance

— The IW exam or interview

— The written IME report

  • Additional diagnostics or services shall be itemized by CPT code and paid per the DOWC fee schedule.

Separate and additional documentation will be required for record reviews that exceed these guidelines. Pinnacol conducts pre- and post-payment documentation reviews. If your documentation does not support the services being billed, your request for payment could be denied or you could receive a letter requesting a refund based on an overpayment.

References

Colorado Division of Workers’ Compensation, Rule 18

SelectNet Provider Manual — Participation standards

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