HAR §12-15-80. Reports of providers of service

(a) Any provider of service required by chapter 386, HRS, this chapter, or any related rules to 33 3 6 1 9 .,, make and submit reports of an injury and treatment shall: (1) Submit those reports to the director and the self- insured employer, or the insurer of the employer when the employer is not self-insured, whichever is applicable; and (2) Itemize its statement of services rendered in a manner showing the date of injury, diagnosis, date of each visit or service, the appropriate code number used as the basis for the charge, and the fee not to exceed the maximum allowed under the medical fee schedule. No service charge for preparing and submitting reports required by section 386-96, HRS, and any related rules shall be allowed. (3) Interim WC-2 reports shall be submitted monthly with the corresponding billing invoice, if applicable, to the employer and shall include the following: (A) Current diagnosis and prognosis; (B) Complete information as to the nature of the examination(s) and treatments performed, dates of those treatments, and the results obtained within the current reporting period; (C) A complete listing of all tests performed within the current reporting period and the results of the tests; (D) A statement of whether the injured employee is improving, worsening, or if "medical stabilization" has been reached; and (E) Dates of disability, work restrictions, if any, return to work date (4) When an injured employee is returned to full-time, regular, light, part-time, or restricted work, the attending physician shall submit a report to the employer within seven calendar days indicating the date of release to work or medical stabilization. (b) Interim WC-2 reports and all medical documentation shall be submitted by the employer to the di rector upon submission of a "Request For Hearing" or within ten calendar days of a request by 34 the director. Any party who fails to furnish medical reports within ten calendar days after being requested by the director may be subject to penalties pursuant to section 386-97.5, HRS. (c) The repeated failure of a physician, surgeon, hospital, or provider of service to comply with chapter 386, HRS, and any related rules shall be a reasonable basis for an employer to refuse to pay or withhold payment for services rendered. [Eff 1/1/96; am 11/22/97; am 12/17/01; am 12/13/04; comp DEC 2 7 2025] (Auth: HRS §§386-26, 386-27, 386-72) (Imp: HRS §§386-21, 386-26, 386-27, 386-96) §§12-15-81 to 12-15-84 (Reserved) §12-15-85 Rules for allowable fees for medical, surgical, and hospital services and supplies. (a) Under no circumstances shall a provider of service directly charge the injured employee for treatments relating to the industrial injury. (b) When all the required care for a case reasonably falls within the range of qualifications of one physician, no other physician may claim a fee, except for consultation service or for ~urgical assistance. For groups of physicians or hospitals with satellite clinics, when service is rendered by a group member of the same specialty, the group shall submit bills as though one physician had cared for the patient. ( c) Medical, surgical, or hospital care of an unusual type or unlisted fee may occur which represents a type of service over and beyond listed procedures. Appropriate fees may be allowed, subject to the employer's approval prior to the service being provided and after submission of a report to the employer containing at least the following information: (1) Diagnosis (post-operative); (2) Size, location, and number of lesions or procedures where appropriate; (3) Major surgical procedure and supplementary procedures; 35 3 6 l 9 --- (4) Estimated follow-up period. (d) Medical conditions which are pre- existing or not resulting from the injury or occupational disease shall not be compensable. Palliative temporary treatment of unrelated conditions shall be allowed, provided these conditions directly retard, prevent, or endanger the surgical care or recovery from the compensable injury or illness. This treatment will cease as soon as it no longer exerts influence on the compensable condition. This shall be adequately explained in the physician's regular report. (e) Certain of the listed procedures are commonly carried out as an integral part of a total service and, as such, do not warrant a separate charge. When such a procedure is carried out as a separate procedure, not immediately related to other services, the indicated fee is applicable. (f) Minimal dressings, counseling incidental to treatment, etc., are covered by the office visit fee. Necessary drugs, supplies, and materials provided by the provider of service may be charged separately in accordance with section 12-15-55 . (g) Fees, including office visits and rating examinations, shall not be paid for more than one visit per day by the same provider of service regardless of the number of industrial injuries or conditions treated. (h) Each provider of service shall certify on the bill or charges that such charges are in accordance with chapter 386, HRS, and any related rules. (i) Repeated failure to comply with chapter 386, HRS, and any related rules shall be a reasonable basis for an employer to refuse to pay o r withhold payment for services rendered. The employer shall make payment within sixty calendar days of compliance with Chapter 386, HRS, and related rules. [Eff 1/1/96; comp ni:c ?. 7 ?O?fi (Auth: HRS §§386-21, 386-72) (Imp: H1ts 3386"-:21) §§12-15-86 to 12-15-89 (Reserved) 36 3 6 1 9 §12-15-90 Workers' compensation medical fee schedule. (a) Charges for medical services shall not exceed one hundred ten per cent of participating fees prescribed in the Medicare Resource Based Relative Value Scale System fee schedule (Medicare Fee Schedule) applicable to HawaiiL or listed in Exhibit A, located at the end of this chapterL and made a part of this chapter, entitled "Workers' Compensation Supplemental Medical Fee Schedule", dated January 1, 2026. The Medicare Fee Schedule in effect on January 1, 1995 shall be applicable through June 30, 1996. Beginning July 1, 1996 and each calendar year thereafter, the Medicare Fee Schedule in effect as of January 1 of that year shall be the effective fee schedule for that calendar year. (b) If maximum allowable fees for medical services are listed in both the Medicare Fee Schedule and the Workers' Compensation Supplemental Medical Fee Schedule, dated January 1, 2026, located at the end of this chapter as Exhibit A, charges shall not exceed the maximum allowable fees allowed under the Workers' Compensation Supplemental Medical Fee Schedule, dated January 1, 2026, located at the end of this chapter as Exhibit A. (c) If the charges are not listed in the Medicare Fee Schedule or in the Workers' Compensation Supplemental Medical Fee Schedule, dated January 1, 2026, located at the end of this chapter as Exhibit A, the provider of service shall charge a fee not to exceed the lowest fee received by the provider of service for the same service rendered to private patients. Upon request by the director or the employer, a provider of service shall submit a statement to the requesting party, itemizing the lowest fee received for the same health care, services, and supplies furnished to any private patient during the one-year period preceding the date of a particular charge. Requests shall be submitted in writing within twenty calendar days of receipt of a questionable charge. The provider of service shall reply in writing within thirty-one calendar days of receipt of the request. Failure to comply with the request of the employer or the director shall be reason for the employer or the director to deny payment. (d) Fees listed in the Medicare Fee Schedule shall be subject to the current Medicare Fee Schedule bundling and global rules if not specifically addressed in these 37 rules. The Health Care Financing Administration Common Procedure Coding System (HCPCS) alphabet codes adopted by Medicare will not be allowed, except for injections and durable medical equipment, unless specifically adopted by the director. The director may defer to a fee listed in the Medicare HCPCS Fee Schedule when a fee is not listed in the Workers' Compensation Supplemental Medical Fee Schedule, Exhibit A. (e) Providers of service will be allowed to add the applicable Hawaii general excise tax to their billing. [Eff 1/1/96; am 1/1/97; am 11/22/97; am 12/17/01; am 12/13/04; am 11/6/06; am 12/14/07; am 2/28/11; am 12/30/13; am 12/28/17; am and comp DEC 27 2025 ] (Auth: HRS §§386-21, 386-26, 386-72) (Imp: HRS §§386-21, 386-26) §12-15-91 (Reserved)