Utilization Standards/Medical Billing Disputes
What are Utilization Standards?
Section 8-42-101(3) of the Colorado Revised Statues requires the Director of the Division of Workers' Compensation to develop utilization standards, which are promulgated in Rule 16. This Rule includes terminology, administrative procedures and dispute resolution procedures required to implement the Division's Medical Fee Schedule and Medical Treatment Guidelines.
When parties have followed the contesting payment process as outlined in Rule 16-11(A)-(D) and a payment dispute still exists, or a party is unable to contest a payment because the other party has not satisfied the 30-day notice requirements, the parties should follow dispute resolution. Either party may initiate a dispute by completing and submitting a Medical Billing Dispute Resolution Intake Form to the Division's Medical Policy Unit (MPU).
The Intake Form provides guidance on the information the MPU will require in order to properly review your request. We ask that all applicable information be provided at the time of submission, including all relevant supporting documentation as outlined at the bottom of the form.
The Intake Form and all supporting documentation can be submitted to the MPU by fax at 303-318-8758, encrypted email to the Medical Policy Unit, or mail to:
Division of Workers' Compensation
Medical Policy Unit
633 17th Street, Suite 400
Denver, CO 80202-3626
Once a completed request has been received, you will receive a Confirmation of Receipt and your case will be assigned to an MPU staff member. The dispute will be reviewed to determine compliance with Rules 16 and 18. Communication between parties will ensue as needed until a determination is reached. Disputes resulting from violation of Rules 16 and/or 18 may result in a Director's Order that cites the specific violation and failure to respond or cure said violations may result in penalties. Resolution of disputes not pertaining to Rule violations will be facilitated by the MPU to the extent possible. Typical review time is within 30 days and parties will be notified in writing once the case is closed.