6-2(N) Standard Terminology for Rules 16, 17, and 18
The Colorado Division of Workers’ Compensation (DOWC) defines “non-physician providers” as individuals who are registered, certified, or licensed by the Colorado Department of Regulatory Agencies (DORA), the Colorado Secretary of State, or a national entity recognized by the State of Colorado as follows:
Excerpt from list:
(i) Advanced Practice Nurse (APN) — licensed by the Colorado Board of Nursing; Advanced Practice Nurse Registry;
(ii) Nurse Practitioner (NP) — licensed as an APN and authorized by the Colorado Board of Nursing;
(iii) Physician Assistant (PA) — licensed by the Colorado Medical Board;
16-3(D) Referrals
(1) All providers must have a referral from a physician provider managing the claim (or NP/PA working under that physician provider). A physician making the referral to another provider shall, upon request of any party, answer any questions and clarify the scope of the referral, prescription, or the reasonableness or necessity of the care.
(2) A payer or employer shall not redirect or alter the scope of a referral to another provider for treatment or evaluation of a compensable injury. Any party who has concerns regarding a referral or its scope shall advise the other parties and providers involved.
16-3(E) Use of PAs and NPs in Colorado Workers’ Compensation Claims:
(1) All Colorado workers’ compensation claims (medical only or lost time claims) shall have a physician responsible for all services rendered to an injured worker by any PA or NP.
(2) The physician must evaluate the injured worker at least once within the first three visits tot he designated provider’s office.
(3) For services performed by an NP or a PA, the physician must counter sign patient records related to the injured worker’s inability to work resulting from the claimed work injury or disease, and the injured worker’s ability to return to regular or modified employment, as required by §§ 8-42-105(2)(b) and (3)(c-d). The physician must counter-sign Form WC 164certifying that all requirements of this rule have been met.
16-8(A) The Medical Fee Schedule, Rule 18, applies to authorized services provided for workers’ compensation claims.
Rule 18-4(A)(2)(b-c) Professional Fees and Services - Maximum Allowable
The maximum fee schedule value for professional services performed by Physician Assistants (PAs) and Nurse Practitioners (NPs) shall be 85% of the Medical Fee Schedule.
However, PAs and NPs are allowed 100% of the Medical Fee Schedule value if the requirements of Rule 16 have been met and one of the following conditions applies:
(1) The service is provided in a rural area. Rural area means:
(a) a county outside a Metropolitan Statistical Area (MSA) or
(b) a Health Professional Shortage Area, either located outside of an MSA or in a rural census tract, as determined by the Office of Rural Health Policy, Health Resources and Services Administration, United States Department of Health and Human Services.
(2) The PA or NP is Level I Accredited.
The payer may negotiate reimbursement of travel expenses not addressed in the fee schedule(including transit time) with providers traveling to a rural area to service an injured worker. This reimbursement shall be in addition to the maximum allowance for services addressed in the fee schedule.
Reference Colorado Division of Workers’ Compensation Rules
https://cdle.colorado.gov/workers-compensation-rules-of-procedure
Questions? Please contact us at provider_management@pinnacol.com or 303.361.4945.