R 418.10101 Scope.

Rule 101. (1) These rules do all of the following: (a) Establish procedures by which the employer shall furnish, or cause to be furnished, to an employee who receives a personal injury arising out of and in the course of employment, reasonable medical, surgical, and hospital services and medicines, or other attendance or treatment recognized by the laws of the state as legal, when needed. The employer shall also supply to the injured employee dental services, crutches, artificial limbs, eyes, teeth, eyeglasses, hearing apparatus, and other appliances necessary to cure, so far as reasonably possible, and relieve from the effects of the injury. (b) Establish schedules of maximum fees by a health facility or health care provider for such treatment or attendance, service, device, apparatus, or medicine. (c) Establish procedures by which a health care provider shall be paid. (d) Provide for the identification of utilization of health care and health services above the usual range of utilization for such services, based on medically accepted standards, and provide for acquiring by a carrier and by the agency the necessary records, medical bills, and other information concerning any health care or health service under review. (e) Establish a system for the evaluation by a carrier of the appropriateness in terms of both the level of and the quality of health care and health services provided to injured employees, based upon medically accepted standards. (f) Authorize carriers to withhold or recover payment from health facilities or health care providers, that have made excessive charges or that have required unjustified treatment, hospitalization, or visits. (g) Provide for the review by the agency of the records and medical bills of any health facility or health care provider that have been determined by a carrier not to comply with the schedule of charges established by these rules or to require unjustified treatment, hospitalization, or office visits. (h) Provide for the certification by the agency of the carrier's professional health care review program. (i) Establish that when a health care facility or health care provider provides health care or health care service that is not usually associated with, is longer in duration than, is more frequent than, or extends over a greater number of days than that health care or service usually does with the diagnosis or condition for which the patient is being treated, the health facility or health care provider may be required by the carrier to explain the necessity in writing. (j) Provide for the interaction of the agency and the department for the utilization of departmental procedures for the resolution of workers' compensation disputes. (k) Are intended for the implementation and enforcement of section 315(2) to (9) of the act, MCL 418.315, and provide for the implementation of the agency's review and decision responsibility vested in it by those statutory provisions. The rules and definitions are not intended to supersede or modify the workers’ disability compensation act, the administrative rules of practice of the agency, or court decisions interpreting the act or the agency's administrative rules. (2) An independent medical examination is exempt from these rules and may be requested by a carrier or an employee. An independent medical examination, (IME), shall be conducted by a practitioner other than the treating practitioner. Reimbursement for the independent medical evaluation shall be based on a contractual agreement between the provider of the independent medical evaluation and the party requesting the examination. (3) These rules and the fee schedule do not pertain to health care services that are rendered by an employer to its employee in an employer-owned and employer-operated clinic. (4) Payments made pursuant to a redemption order or a voluntary payment agreement signed by a magistrate, director, or director’s representative are subject to these rules and fee schedule. (5) If a carrier and a provider have a contractual agreement designed to reduce the cost of workers' compensation health care services below what would be the aggregate amount if the fee schedule were applicable, the contractual agreement shall be exempt from the fee schedule. The carrier shall do both of the following: (a) Perform technical and professional review procedures. (b) Provide the annual medical payment report to the agency’s health care services division.