Claims Kit

Physician Selection  R612-300-2

An injured worker has initial medical control but only if there is no managed care program in place. 

Self-insured employers and insurance carriers may adopt a managed health care program. If a preferred provider program (PPP) is developed, employees are required to initially utilize preferred provider physicians and medical care facilities. Failure of an industrial claimant to utilize a PPP facility or failure to initially receive treatment from a preferred physician may, if the claimant has been notified of the program, result in the claimant being obligated for any charges in excess of the preferred provider allowances.

A preferred provider program must, however, allow an injured worker to select from 2 or more health care providers from whom they may receive their related necessary medical care. A worker will be able to treat elsewhere if no preferred provider is available, the worker believes--in good faith--that their medical condition is not work-related, or travel to a preferred provider is unduly burdensome to the worker. 

The worker must utilize the preferred provider program (if in place, as above) for their initial care. They may elect a provider of their own choosing thereafter. The employer or insurer remains liable for payment of reasonable, related, and necessary medical care.

An injured worker may subsequently change health care providers a single time without needing to first obtain approval, authorization, or permission from the employer or insurer. The worker must provide prompt notice of any such change to the employer or insurer. The following circumstances do not constitute a change of physician or health care provider:

• A treating physician's referral of the injured worker to another health care provider for treatment or consultation;

• Transfer of treatment from an emergency room to a private physician, unless the emergency room was designated as the employer or insurer's preferred provider;

• Medically necessary emergency treatment; and

• A change of physician necessitated by the treating physician's failure or refusal to rate a permanent partial impairment.

After an injured worker has exercised their one-time right to change health care providers they must request approval of any subsequent change of provider. If the employer denies or fails to respond to the request, the injured worker may request approval from the Director of the Division on Industrial Accidents. The Director will authorize a change of provider if necessary for the adequate medical treatment of the injured worker or for other reasonable cause.

An injured worker who changes health care providers without employer or Division approval may be held personally liable for the non-approved provider's fees.

Application to Change Doctors (Form 102)

Reporting of Claim by Employer  34A-2-407  R612-200-1

Employers are not required to report first-aid only claims. All other claims must be reported within 7 days of receipt of initial notice of the injury. 

An employer will be considered to have notice of an injury upon the earliest of the following:

• Observation of the injury;
• Verbal or written notice of the injury--from any source; or
• Receipt of any other information sufficient to warrant further inqury.

The employer should report the injury and claim to their insurer within the above prescribed 7 day window. A self-insured employer or insurance carrier thereafter must proceed with reporting the claim to the Industrial Accidents Division via Electronic Data Interchange (EDI).

Penalties for Late Reporting  34A-2-407

An employer or insurance carrier who refuses or neglects to make or file a required report related to injury may be subject to a civil assessment imposed by the Division. This may not exceed $500.

An employer or carrier is not subject to the civil assessment if the they submitted the report later than required and the Division finds that the employer or carrier has shown good cause for the delay. 

Posting Requirements 34A-2-204

Employers are required to post in conspicuous places typewritten or printed notices stating that they have complied with all the rules and regulations securing compensation to employees and their dependents. The notices should state the name of the insurance carrier, the phone number, and steps to report an industrial claim.

Poster - English

Poster - Spanish