Atlanta Workers Compensation Law : Atlanta Workers' Compensation Lawyer & Attorney : Seth Bader Law Firm : Construction Accidents, Repetitive Motion Injuries, Disability : Atlanta, Marietta, Roswell, Georgia

(A)  Practice of Law.

(1)  Attorneys Entitled to Practice before the Board: Rule 1-203 of the Rules and Regulations for the Organization and Government of the State Bar of Georgia, as now in effect or as hereinafter amended, is controlling as to the practice of law before the Board and its Administrative Law Judges.

(2)  Any ex parte communication, including electronic mail, with an Administrative Law Judge or the Board in a pending claim is prohibited.

(3)  Attorneys, not licensed in the State of Georgia, shall comply with Uniform Rule of Superior Court 4.4 addressing Admission Pro Hac Vice.

(4)  On all filings with the Board, attorneys shall place their Georgia bar number. In addition, no attorney shall submit any form that has been discontinued or altered.  A violation of this rule may result in the rejection of the filing with the Board, and/or the imposition of a civil penalty under O.C.G.A. § 34-9-18.

(5) Service upon a party or attorney of any form, document, or other correspondence shall be by electronic mail.  Whenever electronic mail is not available, service shall be by U.S. Mail.

(B)  Reporting Requirements:

(1)  The address of record of an employee shall be that address shown on the most recent document filed with the Board.

(2)  A party shall provide notice to the Board of the intent to obtain legal representation and the name of its legal representative, if any, within 21 days from the date of the hearing notice, subject to an assessment of penalties for failure to comply.

(3)  The address of record of an employer shall be the address shown on the Form WC-1, the address on file with a Licensed Rating Organization filed by the insurer on behalf of the employer, or the principal office of the employer within the State of Georgia.

(4)  Any party requesting a hearing shall furnish the correct name and current address of the employee, the employer, and the insurer/self insurer and third party administrator at the time the hearing is requested.

(5)  An attorney who represents a party other than an employee or a claimant in a contested matter must file a notice of representation on a Form WC-102B with the Board, and must serve a copy on all counsel and unrepresented parties.

(6)  An attorney who represents an employee or claimant in a contested matter shall file a fee contract as notice of representation and must serve a copy on all counsel and unrepresented parties.  The contract must be dated, conform to Rule 108, and both the attorney and the client must sign the contract.

(C)  Postponements, Leaves of Absence, and Legal Conflicts:

(1)

(a)  Postponement:  If a hearing is on a calendar for the first time, and if all parties agree to postpone it to be rescheduled, they may obtain the postponement without consulting the Administrative Law Judge before whom it is scheduled, absent prior specific instructions from the judge to the contrary.  This agreement must be communicated to the judge no later than 4:30 p.m. of the business day immediately preceding the hearing by the party who requested the hearing, or by any other party by agreement.  Otherwise and generally, a hearing shall be postponed only upon strict legal grounds, or at the discretion of the Board or an Administrative Law Judge.  For a case that has already been postponed, a second or subsequent request by counsel to postpone the case from a calendar must be made no later than 4:30 p.m. on the business day immediately before the scheduled hearing, and the request must be approved by the Administrative Law Judge.  For a case to be removed from the calendar with no reset, this notification, as with a postponement request, must be made no later than 4:30 p.m. on the business day immediately before the scheduled hearing.  If the judge determines that the case is not ready for trial at this time, the claim may be removed from the calendar, not to be reset until the parties certify that discovery is complete and the case is ready to be tried.

(b)  Whenever the pending hearing issues resolve or a case settles prior to a scheduled hearing date, the parties or attorneys shall immediately notify the Board or assigned Administrative Law Judge:

(1)  first, by telephone call; and

(2)  if so instructed by the Trial Division, by subsequent written or electronic confirmation.

(c)  Any party or attorney who fails to follow the cancellation, postponement, or rescheduling procedures as outlined above in sections (C)(1)(a) & (b), and who is unable to show good cause for such failure, may be subject to civil penalties, assessed attorney's fees, and/or costs, including but not limited to the cost of the court reporter.

(2)  Leave of absence.  In the event that an attorney wishes to obtain a leave of absence from the Board, the request should be submitted on a Form WC-102C and mailed to the Atlanta office of the State Board of Workers' Compensation or filed on-line via ICMS.  The granting of a leave of absence will not apply to cases already calendared on the date the leave is signed, and will apply only to court appearances and mediations.  In the event that leave is requested for a date already calendared, the attorney must request a postponement from the Administrative Law Judge, with permission of opposing counsel or by conference call, prior to the hearing or mediation.

(3)  For the purpose of resolving requests for continuance based upon legal conflict, Rule 17.1(B)(4) of the Uniform Rules of the Superior Courts shall apply.  A conflict letter shall be served upon opposing counsel and unrepresented parties no later than seven days prior to the date of conflict but shall not be filed with the Board unless or until such conflict letter is requested by an Administrative Law Judge or the Board.  The action which was first filed shall take precedence, subject to judicial discretion.

(D)  Motions and Interlocutory Orders Pending a Hearing:

(1) 

(a)   All motions and objections shall be made on Form WC-102D, with the exceptions of motion for reconsideration and request for a change of physician/additional medical treatment under Board Rule 200(b)(1).  Motions and objections, including briefs and exhibits, shall be limited to 50 pages, unless otherwise approved by an Administrative Law Judge or the Board.  When attaching documents as evidence to motions and objections, do not use tabs to separate documents.  Any party or attorney filing a motion or objection shall also serve a copy on all counsel and unrepresented parties, along with supporting documents, including a separate certificate of service identifying the names and addresses served.

(b)  When filing a motion for reconsideration, the parties or attorneys shall:

(1) immediately notify the Board or assigned Administrative Law Judge by telephone call;

(2)  use the ICMS doc-type labeled motion for reconsideration;

(3)  limit their motion to 20 pages, including briefs and exhibits, unless otherwise permitted by the Board or an Administrative Law Judge; and

(4)  serve a copy on all counsel and unrepresented parties, along with supporting documents, including a separate certificate of service identifying the names and addresses served.

(2)  Prior to filing a motion, including requests for documents made pursuant to Rule 102(F)(1), the moving party shall confer with the opposing party, or counsel if the party is represented, in a good-faith effort to resolve the matters involved.

(3)  A party objecting to a motion shall respond on a Form WC-102D, which must be filed with the Board within 15 days of the date of the certificate of service on the request, and shall serve a copy on all counsel and unrepresented parties.

(4)  Whenever the pending issues resolve, in whole or in part, in a motion, the parties or attorneys shall immediately notify the Board or assigned Administrative Law Judge: (1) first, by telephone call; and (2) if so instructed, by subsequent written or electronic confirmation.  Any party or attorney who fails to follow this procedure, and who is unable to show good cause for such failure, may be subject to civil penalties and/or assessed attorney's fees.

(5)  An Administrative Law Judge may issue an interlocutory order suspending or reinstating payment of weekly benefits to an employee pending an evidentiary hearing.

(6)  Where the issue is which of two or more employer/insurers is liable, the Administrative Law Judge or the Board may issue an interlocutory order directing the employer or one of the insurers to pay weekly benefits and medical expenses until the determination of liability of an insurer has been made.  Reimbursement may thereafter be ordered where appropriate.

(E)  Conduct of Hearings:

(1)  No person shall, during the course of a proceeding before an Administrative Law Judge or Director, engage in any discourteous or disruptive conduct.

(2)  Any violation of the Georgia Rules of Professional Conduct of the State Bar of Georgia may subject an attorney to the assessment of a civil penalty pursuant to O.C.G.A. § 34-9-18 and referral to the State Bar of Georgia for disciplinary action.

(3)

(a)  Prior to the commencement of a hearing, the parties shall consolidate any and all records, including but not limited to medical records, and any other documentary evidence to be admitted at a hearing in order to avoid any repetition and duplication.

(b)  All medical evidence regarding the treatment, testing or evaluation of the claimant for the accident which is the subject of the hearing should be exchanged between the parties as soon as practicable, but no later than ten days prior to the hearing, and all depositions should be completed prior to the hearing.  Failure to exchange such evidence within ten days of a hearing may, in the discretion of the Administrative Law Judge or the Board, result in:

(1)  the imposition of civil penalties,

(2)  award of assessed attorney fees,

(3)  a continuance,

(4)  award of costs,

(5)  award of witnesses fees and expenses, and/or

(6)  in limited circumstances, the exclusion of evidence at the hearing.

(c)  If the amount of the average weekly wage is in dispute, counsel shall exchange written contentions with respect to their methods of calculation at least ten days prior to the hearing, and shall present the written contentions to the Administrative Law Judge at the commencement of the hearing.

(d)  If accompanied by an affidavit, a written laboratory test result report is admissible into evidence for purposes of authenticity only. Any other evidentiary objections can be raised by the parties in motions or at evidentiary hearings.

(e)  Any challenge to the testimony of an expert under O.C.G.A. § 24-9-67.1 shall be made not later than 15 days prior to the hearing. Failure to raise a timely challenge shall result in waiver of the challenge unless otherwise agreed to by the attorneys and the Administrative Law Judge.

(4)  Parties may be allowed to make arguments either by the filing of briefs within the time set by the Administrative Law Judge at the hearing, by oral argument at the conclusion of the presentation of evidence at the hearing, or both.  Oral argument shall be limited to five minutes for each party.  Briefs shall be limited to 30 pages, unless otherwise approved by an administrative law judge or the Board.

(5)  It is the policy of the Board to encourage the parties to close the record at the conclusion of the hearing.  The parties are expected to make diligent efforts to present all the evidence at the hearing, without the need for the record to remain open.

(6)  Hearing Transcript: Any Administrative Law Judge is authorized to relieve the court reporter of the duty of transcribing the record of proceedings.  The record shall be transcribed and submitted to the Board or the superior court if there is an application for review of an appeal.  The appellant shall serve a copy of the application for review or appeal on the court reporter at the same time it is served on all other persons.

(7)  Notices of hearing may be sent by electronic mail to the parties and attorneys of record.  Whenever electronic transmission is not available, a notice of hearing will be sent by U.S. Mail.

(F)  Discovery and Submission of Evidence:

(1)  Prior or subsequent to a request for hearing being filed in a claim, the parties shall be entitled to receive from each other without cost the documents specified in Form WC-102.  These documents shall be provided within 30 days of the date of the certificate of service, subject to an assessment of penalties for failure to comply. Neither the request nor response shall be filed with the Board.

(2)  Discovery filed pursuant to the Civil Practice Act shall only be permitted after a hearing has been requested in the claim, or as otherwise specified in these rules.

(3)  Discovery documents, including but not limited to depositions, interrogatories, and notices to produce, shall not be filed with the Board until such time as they are tendered in evidence in a proceeding before the Board.  Correspondence between the parties shall not be filed with the Board.

(4)  All documents, transcripts, exhibits, and other papers filed with the State Board of Workers' Compensation shall be submitted on 8- 1/2 by 11 inch paper only.  Sufficient space shall be left at the top of all documents (at least one and one-half inches) so that all information will remain readable after the documents have been filed.  Copies of items offered in evidence at a hearing must be properly identified and tendered to opposing parties at the hearing.  When submitting any documents as evidence, do not use tabs to separate documents.

(G)  Written Responses: The filing of all written responses will be governed in accordance with O.C.G.A. § 9-11-6(e).

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(a)  A compensation policy must cover all of the operations of an employer, except as hereinafter provided.  An employer has the right to place insurance with more than one insurer; but if this is done with respect to distinct operations, the policies must be concurrent and the written portions must read alike.  If there is any difference in coverage, it can be expressed as applying to a fractional part thereof.  If an employer has more than one place of business, each operation can be covered separately unless the business is interchangeable.  Each insurer on the risk must cover alike all the employees coming under the law.

(b)  Any employer desiring to become a self-insurer shall apply on the form prescribed by the Self-Insurers Guaranty Trust Fund Board of Trustees and approved by the Board.  All inquiries must be answered fully and will be treated as strictly confidential.  The Self-Insurers Board of Trustees, with the approval of the Board, shall set the amount of security in the form of a surety bond or letter of credit to be required, but in no event shall the amount be less than $100,000.00.  It shall be at the discretion of the Self-Insurers Guaranty Trust Fund Board of Trustees if other forms of security are acceptable.  Each case will be considered on its own merits with strict regard to the hazards of the business involved.  So long as an employer shall continue solvent and promptly pay any and all compensation legally due in accordance with the provision of the law there shall be no effort to collect under the securities.

(c) Counties, municipalities, and other political subdivisions must qualify as self-insurers or obtain insurance coverage.  Permission for self-insurance by municipalities and political subdivisions may be granted by application therefor and without deposit of surety bonds security.  Assurance must be given the Board, however, that provision will be made for the payment of all awards.

(d)  When an insurer, self-insurer, or group self-insurance fund obtains the services of a servicing agent or third party administrator for the purpose of administering workers' compensation matters, the insurer, self-insurer, or group self-insurance fund shall give notice to the Board on a Form WC-121 (or annual update) of the name and address of each servicing agent or third party administrator handling Georgia claims, the name, address and telephone number of a contact person with that third party administrator or servicing agent, the effective date of the servicing agent's or third party administrator's commencement of services, and if applicable, the ending date of those services, and shall file Form WC-121 with the Board no later than the agreed commencement date of those services.  The insurer, self-insurer, or group self-insurance fund shall also give notice by regular mail or electronic mail of the servicing agent's or third party administrator's name, address and telephone number to the claimants in all existing claims for which it is commencing administration within 14 days of commencing services.   When the relationship between the insurer, self-insurer or group self-insurance fund and the servicing agent or third party administrator is terminated, the insurer, self-insurer, or group self-insurance fund shall file Form WC-121 with the State Board of Workers' Compensation no later than 30 days prior to the date of cessation of services, and shall give notice, by regular mail or electronic mail to all claimants in existing claims which it has been administering.

(e)  Within 10 days from the date an employer determines its inability to make payment for workers' compensation benefits, the employer shall notify its surety and the Board in writing of its inability to fulfill its obligations under the Act.

Upon receipt of information establishing an employer's inability to meet its obligations under the Act, or upon notice from an employer that it is unable to meet its obligations under the Act, the Board shall make demand of the surety for payment of the bond or other security held.  The Board shall give written notice of the demand for payment to the employer, and all claimants affected by this proceeding.

After the Board receives the proceeds of the bond or other security, then the Board shall determine whether the amount of the security is sufficient to pay all of the employer's obligations arising under this Chapter.  If it is not sufficient, the Board shall apportion the proceeds of the bond, or other security held for distribution.

The Board may enter into an agreement with a servicing agent or the Georgia Self-Insurers Guaranty Trust Fund to administer the settlement of claims pursuant to this section.

(f)  Rules for third party administrators/servicing agents.

(1)  A third party administrator/servicing agent must be licensed by the Office of Commissioner of Insurance pursuant to O.C.G.A. § 33-23-100 and follow the Rules and Regulations of the Insurance Commissioner's Office Chapter 120-2-49 entitled Administrator Regulations.

(2)  The third party administrator/servicing agent must comply with all sections of O.C.G.A. § 34-9 and all rules and regulations of the Board.

(3)  Workers' Compensation claim files of third party administrators/servicing agents are subject to audit by the Board at any time.

(4)  The transfer of files from one third party administrator/servicing agent to another must be handled in a professional and timely manner.

(i)  Open indemnity files must be current as of the date of transfer and the transferring (former) third party administrator/servicing agent must include in the file a complete current Form WC-4 (completed within the last 30 days) reflecting all payments made as of the date of transfer.  The transferring third party administrator/servicing agent must at the date of transfer provide the receiving third party administrator with a payment history on all Medical Only claims with an occurrence date of 90 days or less as of the date of transfer.  Penalties for noncompliance by the transferring third party administrator/servicing agent would be in accordance with O.C.G.A. § 34-9-18(a).

(ii)  The receiving (new) third party administrator/servicing agent must notify all active (open) claimants of the change in administration within 14 days of receiving the files.  Vendors must be notified within 60 days of receipt of medical bills or service invoices.

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(a)  REHABILITATION SERVICES

(1)  Definitions:

(i)  Rehabilitation services by a Board registered rehabilitation supplier are required in claims where the injury is catastrophic and for non-catastrophic claims with dates of injury prior to July 1, 1992.  Services of a Board registered rehabilitation supplier may be utilized in all other non-catastrophic claims only upon written agreement of all parties.  Consistent with O.C.G.A. § 34-9 and Board Rules, a rehabilitation supplier delivers and coordinates services under an individualized Rehabilitation Plan; facilitates coordination of medical care; provides vocational counseling, exploration, and assessment; performs job analysis, job development, modification, and placement, evaluates social, medical, vocational, psychological, and psychiatric information; and may provide additional services upon agreement of the parties or Board order.  The rehabilitation supplier shall comply with the professional standards and code of ethics as set forth by his or her certification or licensure board.  Neither rehabilitation suppliers nor case managers operating under O.C.G.A. § 34-9-208 shall provide services in a workers' compensation claim until and unless registered with, or certified by, the Board.

(ii)  Case managers may be involved in cases where the employer/insurer has contracted with a certified workers' compensation managed care organization (WC-MCO).  These case managers shall operate pursuant to the provisions of O.C.G.A. § 34-9-208 and Board Rule 208.

(iii)  Other than the appointed rehabilitation supplier as defined by O.C.G.A. § 34-9-200.1 and Board Rule 200.1, or a case manager as defined by O.C.G.A. § 34-9-208 and Board Rule 208, only a direct employee of the insurer, third party administrator, or employer may communicate with an injured employee and/or the authorized treating physicians to assess, plan, implement, coordinate, monitor, and evaluate options and services relative to an injured employee's condition and/or vocational needs.  The individual shall identify himself to others as an employee of the insurer, third party administrator, or employer and shall not identify himself as a case manager, rehabilitation supplier, or with any other term suggesting a fiduciary relationship with the injured employee.  Nothing contained in this portion of the Board Rule shall apply to an attorney representing a party.

(2)  Unauthorized Activities:

Rehabilitation suppliers and case managers not registered with the Board or any person performing any of the activities described in subsections (a)(1) of this Board Rule who is not a direct employee of the insurer, third party administrator or employer, shall be subject to civil penalties in accordance with O.C.G.A. § 34-9-18. Complaints pertaining to unregistered or unauthorized rehabilitation suppliers and case managers should be directed in writing to the Director of the Managed Care & Rehabilitation Division of the Board, with copies to all case parties and the rehabilitation supplier.  Upon receipt of a complaint, the Director shall investigate the alleged violation and may refer the issue to the Enforcement Division and/or the Legal Division of the Board for further investigation or for the scheduling of an evidentiary hearing for a determination of whether or not penalties are warranted.

(3)  Appointment of Board Registered Rehabilitation Supplier:

(i)  In all catastrophic injury claims, within forty-eight hours of accepting the injury as compensable, or notification of a final determination of compensability, the employer/insurer shall appoint a Board registered catastrophic rehabilitation supplier.  The employer/insurer shall file a Form WC-R1 with the Board simultaneously with the Employer's First Report of Injury (WC-1), or by filing a WC-R1 within twenty days of notification of an administrative decision that rehabilitation services are required.

(ii)  If the employer/insurer does not timely appoint a registered catastrophic rehabilitation supplier as required pursuant to subsection (a)(3)(i), the employee shall file a WC-R1CATEE to request appointment of a registered catastrophic supplier with service to all parties and the requested supplier.

(iii)  For non-catastrophic claims with date of injury prior to July 1, 1992, unless excused by the Board, any party may file a WC-R1 at any time requesting the appointment of a registered rehabilitation supplier subject to the opposing party's right to file an objection within twenty days.  If the Board deems rehabilitation is appropriate, the Board may appoint a rehabilitation supplier.

(iv)  Absent written objections filed with the Board within fifteen days of the date of the certificate of service on the WC-R1 or WC-R1CATEE, the request for rehabilitation services will be approved if, in the judgment of the Board, the appointment is appropriate.  In the event written objection has been timely filed, the Board shall make a determination regarding appointment of a supplier and notify all parties.

(4)  Rehabilitation Supplier Duties:

(i)  A rehabilitation supplier is not a party to the case.  The registered rehabilitation supplier shall have sole responsibility for the rehabilitation aspects of each individual case.  The registered rehabilitation supplier shall communicate with the injured employee and others to assess, plan, implement and coordinate, monitor and evaluate options and services to meet an injured employee's health care needs through communication and available resources to promote cost effective outcomes with a goal of return to work.

(ii)  The registered rehabilitation supplier shall meet with the injured employee within thirty (30) days of appointment and complete an initial rehabilitation evaluation and an appropriate plan for medical and vocational services.  The initial rehabilitation plan must be filed with the Board on Form WC-R2A within ninety (90) days of the supplier's appointment to the claim, unless excused by the Board.  A current Rehabilitation Plan must be filed with the Board during all phases of service delivery.

(iii)  In the event that a Board approved Rehabilitation Plan proposes that services be provided to the employee that are outside the scope of the qualifications or expertise of the appointed registered supplier, the registered rehabilitation supplier may obtain those specific services from another qualified individual, facility, or agency.

(iv)  For catastrophic claims, the registered catastrophic rehabilitation supplier shall file a WC-R2 and all accompanying rehabilitation reports every ninety days.

(v)  For non-catastrophic claims with dates of injury prior to July 1, 1992, the registered rehabilitation supplier shall file a WC-R2 with all rehabilitation reports and available medical information not previously submitted, every twenty-six weeks.

(vi)  All rehabilitation plans shall be submitted with a current narrative report justifying the proposed action, which may include all pertinent medical documentation, evaluation reports, progress reports made since the last rehabilitation plan, labor market surveys, and other documentation.  If the Board rejects the proposed rehabilitation plan, the registered rehabilitation supplier shall have 30 days to submit a revised plan.  The registered rehabilitation supplier shall develop and submit an amended rehabilitation plan on a WC-R2A at any time that the circumstances change significantly such that the goals, activities, and timeliness of the current approved rehabilitation plan are no longer applicable or realistic.  Amended or extended rehabilitation plans shall be submitted thirty days prior to the expiration of the current approved plan.

(5)  Rehabilitation Plans:

(i)  A Medical Care Coordination Plan assists catastrophically injured employees in attaining maximum medical improvement and independence in activities of daily living.  Each individual medical care coordination plan shall be in place for no longer than one year.

(ii)  An Independent Living Plan encompasses those items and services, including housing and transportation, which are reasonable and necessary for a catastrophically injured employee to return to the least restrictive lifestyle possible.  Each individual independent living plan shall be in place no longer than one year

(iii)  An Extended Evaluation Plan provides evaluation to establish vocational feasibility and appropriate vocational goals.  The extended evaluation plan may include medical care coordination services to meet medical care goals.  The extended evaluation plan shall be in place for no longer than one year.

(iv)  A Return-to-Work Plan assists with job placement in order to return an employee to suitable employment.  Return-to work plans, in order of preference, are:

1) return to same job with the same employer;

2) return to different job with same employer;

3) return to work with new employer;

4) short-term training;

5) long-term training; or

6) self-employment. 

The return-to-work plan shall be in place for no longer than a one-year period.  Following an actual return to work, the plan may be extended for no longer than sixty days for the purpose of monitoring the return to work.

(v)  A Training Plan documents the feasibility and necessity of vocational training.  Each individual training plan shall be in place for no longer than one year.

(vi)  A Self-Employment Plan is considered only when return-to-work plans or training plans are not feasible and when a reasonable probability of success in self-employment can be documented.

(vii)  Any party objecting to a proposed rehabilitation plan shall file a written objection with the Board within fifteen days of the date of the certificate of service.  The Rehabilitation Division may hold a rehabilitation conference and/or issue an administrative decision.

(6)  Communication in Rehabilitation Services:

(i)  A rehabilitation supplier shall recognize the employee's attorney as the employee's representative and shall encourage communication among all parties and their attorneys.

(ii)  A rehabilitation supplier shall simultaneously provide copies of all correspondence to all parties and their attorneys.

(iii)  The rehabilitation supplier shall provide professional identification and shall explain his or her role to any physician at the initial contact with the physician.

(iv)  The employee has the right to a private physical examination and/or consultations with the medical provider.  The rehabilitation supplier shall not attend such examination, except by the revocable written consent of the employee, or his or her attorney, if represented by counsel, after the employee has been advised of the right to a private examination and/or consultation.

(v)  The rehabilitation supplier shall not obtain medical information regarding an injured employee in a private meeting with any treating physician unless the rehabilitation supplier has reserved with the physician sufficient appointment time for the conference and the injured employee and his or her attorney were given ten days advance notice of their option to attend the conference. If the employee is represented by counsel, all efforts shall be made to coordinate the meeting with the employee's attorney.  All legal excuses for the injured employee's attorney's inability to attend the conference will be recognized.  If the injured employee or the physician does not consent to a joint conference, or if, in the physician's opinion, it is medically contraindicated for the injured employee to participate in the conference, the rehabilitation supplier shall note this in his or her report and may in those specific instances communicate directly with the physician.  The rehabilitation supplier shall report to all parties and the employee's attorney the substance of the communication between him or her and the physician.  Exceptions to the above notice requirements may be made in cases of medical necessity or with the consent of the injured employee or his or her attorney.

(vi)  The rehabilitation supplier shall simultaneously provide copies of all written communications and shall report the substance of all oral communications between him or her and the treating physicians to all parties and their attorneys.

(vii)  The rehabilitation supplier may assist the physician in scheduling second opinions and specialized treatment and shall give the injured employee and his or her attorney at least ten days notice of the time and place of any requested examination, unless waived by the Board or by agreement of the parties.

(viii)  The rehabilitation supplier may assist in obtaining a permanent partial disability rating from the authorized treating physician.

(7)  Rehabilitation Closure:

(i)  The registered rehabilitation supplier shall submit a WC-R3, Request for Closure, for all catastrophic and pre-July 1, 1992 claims as follows:

(1)  sixty days after the employee's return to work;

(2)  at any time it is determined that further services are not needed or feasible;

(3)  when a stipulated settlement that does not include rehabilitation services has been approved by the Board; or

(4)  when the Board directs rehabilitation closure.

(ii)  At any time, upon review of the file, the Board may determine that rehabilitation closure is appropriate and may issue an order or an administrative decision to close rehabilitation.

(iii)  A party may request that the Board close rehabilitation services by filing a written request setting forth the specific reasons in support of their request for closure with copies to all parties and the supplier.

(b)  CHANGE IN REGISTERED REHABILITATION SUPPLIER

(1)  A change in registered rehabilitation supplier shall be requested only by parties to the claim and must be approved by the Board.  The WC-R1 requesting a change in supplier shall include the names and addresses of the involved suppliers and the specific reasons the change is requested.  The requesting party shall send copies of the WC-R1 to all parties and their attorneys and to involved rehabilitation suppliers and complete the certificate of service on the WC-R1.

(2)  When a WC-R1 is filed to request a change of registered rehabilitation supplier, the current Board appointed rehabilitation supplier shall maintain responsibility for providing necessary rehabilitation services until all appeals have been exhausted, unless excused by the Board.

(3)  Any party objecting to a change of rehabilitation supplier shall file a written objection with the Board within fifteen days of the date of the certificate of service.  The Rehabilitation Division may hold a rehabilitation conference and/or issue an administrative decision.

(c)  CHALLENGES TO ADMINISTRATIVE DECISIONS

Any party to the claim dissatisfied with an administrative decision must file a WC-14, Request for Hearing, served on all parties and their attorneys and involved rehabilitation supplier within twenty days of the date of the administrative decision.  The Board, in its discretion, may order the parties to participate in a mediation conference before the scheduling of the de novo hearing.  The administrative decision shall be admissible in evidence.

(d)  PEER REVIEW

Peer review shall be the procedure by which disputes concerning the necessity of services and the reasonableness of fees are resolved.

(e)  FAILURE OF A PARTY OR COUNSEL TO COOPERATE

(1)  Benefits may be suspended for failure or refusal to accept or cooperate with authorized rehabilitation services only by order of the Board.

(2)  A party or attorney may be subject to civil penalty or to fee suspension or reduction for failure to cooperate with rehabilitation services.  Failure to cooperate may include, but is not limited to, the following:

(i)  Interference with the services outlined in a Board approved rehabilitation plan;

(ii)  Failure to permit an interview between the employee and supplier within ten days of a request by the supplier or other obstruction of the interview process without reasonable grounds;

(iii)  Interference with any party's or designated rehabilitation supplier's attempts to obtain updated medical information for purposes of rehabilitation planning;

(iv)  Failure to sign and return or object to the proposed rehabilitation plan within twenty days of receipt; or

(v)  Failure to attend a rehabilitation conference without good cause.

(3)  At the request of a party, a rehabilitation supplier, an Administrative Law Judge, or the Board's rehabilitation coordinator, the Board may schedule a mediation or an administrative rehabilitation conference to resolve problems relating to the rehabilitation process.  The parties should make all efforts to resolve the problems before requesting a mediation or conference.  At Board scheduled rehabilitation conferences or mediations, all parties, attorneys of record, and the rehabilitation supplier may be required to attend or to be represented by a person with full authority to resolve the pending disputes.  Only the parties, attorneys of record, and rehabilitation supplier may attend a scheduled mediation or rehabilitation conference.  Exceptions to attendance may be granted if agreed or consented to by the parties and attorneys of record and approved by a mediator, rehabilitation coordinator, or administrative law judge.  Agreements reached at mediations or rehabilitation conferences will be reduced to writing.  Agreements reached at mediation shall be governed by Rule 100.

(i)  Any person notified by the Board who fails to attend a Board scheduled mediation or rehabilitation conference without reasonable grounds may be subject to sanction pursuant to O.C.G.A. § 34-9-18.  Any party requesting cancellation or rescheduling of a rehabilitation conference or mediation shall notify the Board and other parties with adequate notice to all parties.

(ii)  Following the rehabilitation conference, the Board may issue an administrative decision.

(f)  REHABILITATION SUPPLIERS SHALL BE CERTIFIED OR LICENSED AND REGISTERED WITH THE BOARD

(1)  Qualified Certifications or Licenses

Any rehabilitation supplier who wishes to supply services in a Workers' Compensation claim shall hold one of the following certifications or licenses:

(i)  Certified Rehabilitation Counselor (CRC);

(ii)  Certified Disability Management Specialist (CDMS);

(iii)  Certified Rehabilitation Registered Nurse (CRRN);

(iv)  Work Adjustment and Vocational Evaluation Specialist (WAVES);

(v)  Licensed Professional Counselor (LPC);

(vi)  Certified Case Manager (CCM);

(vii)  Certified Occupational Health Nurse (COHN); or

(viii)  Certified Occupational Health Nurse Specialist (COHN-S).

(2)  Registration with the Board

(i)  To register as a rehabilitation supplier or rehabilitation resident, an applicant shall submit a completed, notarized application and a registration fee of one hundred dollars ($100.00).  The registration shall be renewed annually.  Not later than November 30th each year, an applicant shall submit a completed, notarized renewal application, a renewal fee of fifty dollars ($50.00), and documentation of current certification.  Rehabilitation suppliers registered prior to July 1, 1985, who are not certified by CRC, CDMS, WAVES, LPC, CCM, CRRN, COHN, or COHN-S shall continue to renew registration annually.  The renewal application for uncertified rehabilitation suppliers shall be accompanied by proof of completion of at least thirty contact hours of approved continuing education units.  Any person who fails to renew on or before November 30th, shall be penalized an additional twenty-five dollars ($25.00).  Any person who is delinquent on or after January 1st of each year shall be penalized an additional amount up to one hundred dollars ($100.00).  A rehabilitation supplier who has not renewed his or her rehabilitation supplier registration by November 30th of the year following his or her supplier registration expiration date, shall not be eligible for renewal.  If that individual wishes to provide rehabilitation services to injured employees, he or she will be required to submit a new application to become a rehabilitation supplier in accordance with the first paragraph of this section.  In addition, if that supplier was registered as a catastrophic rehabilitation supplier, and wishes to provide catastrophic rehabilitation services, he or she will also be required to re-apply for catastrophic registration pursuant to (4) of this section.

(ii)  Notice of a rehabilitation supplier's registration approval will contain a supplier registration number with the November 30th expiration date, which shall be included on all reports submitted to the Board by the rehabilitation supplier.

(iii)  An appeal of a denial of an application for registration, renewal, or reinstatement may be made within twenty days of notification of the denial by letter to the Board requesting a hearing.  The applicant will be advised by the Board of the date, time, and place of the appeal hearing.

(iv)  The Director of Managed Care and Rehabilitation may require a rehabilitation supplier to submit corrective action plans and/or may recommend the assessment of penalties for the violation of Board Rules, consistent submission of inappropriate rehabilitation or medical care plans, consistent failure to timely revise denied rehabilitation plans, and/or unethical behavior during rehabilitation services.

(v)  Rehabilitation supplier registration may be revoked or suspended for violation of Board Rules.  A complaint against a registered rehabilitation supplier shall be filed in writing, with copies to all case parties and the supplier, with the Director of the Managed Care and Rehabilitation Division of the Board.  Upon receipt of a complaint, or upon the Board's knowledge of a violation, the Director of Managed Care and Rehabilitation shall notify the rehabilitation supplier in writing of the nature of the complaint.  Within fifteen days of the date of the notice, the rehabilitation supplier shall file with the Director of Managed Care and Rehabilitation a written response to the complaint. If the Director of Managed Care and Rehabilitation determines that justification exists for penalties and/or revocation or suspension of the rehabilitation supplier's registration, the issue will be referred to the Enforcement Division and the Legal Division for a hearing to be held before an Administrative Law Judge.  The Administrative Law Judge shall issue an order either dismissing the complaint, assessing penalties and/or revoking or suspending the rehabilitation supplier's registration, or placing the rehabilitation supplier on probation.  The rehabilitation supplier may appeal the order of the Administrative Law Judge in accordance with O.C.G.A. § 34-9-103 and § 34-9-105.

(3)  Rehabilitation Resident

(i)  An individual who meets the academic and experience criteria and who has applied for and been registered to sit for the examination to be certified or licensed as CRC, CDMS, WAVES, CRRN, LPC, CCM, COHN, or COHN-S may register to be a rehabilitation resident.  A resident may provide rehabilitation services under the direct supervision of a registered rehabilitation supplier.  However it is the registered rehabilitation supplier who shall perform the initial evaluation and prepare any rehabilitation plans, job analyses, progress reports, or closure report and who has any personal contact with the injured employee.

(ii)  In the event a rehabilitation resident does not become certified or licensed by the appropriate licensing board within a two-year period from the date of initial application, the rehabilitation resident shall be disqualified from providing services to injured employees.  A rehabilitation resident shall register with the Board on forms supplied by the Board.

(iii)  Nothing contained in this subsection shall be construed to permit a rehabilitation resident to act independently as a registered rehabilitation supplier or to relieve the registered rehabilitation supplier from his or her responsibilities in any claim where a rehabilitation resident is utilized.

(iv)  Any individual participating in a Council on Rehabilitation Education (CORE) approved master's level program of study practicum/internship shall not be required to register with the Board while completing that short term internship.  The registered rehabilitation supplier supervising an educational intern shall be responsible for all activities on the claims.

(4)  Registered Catastrophic Rehabilitation Supplier

In order to provide services to catastrophically injured employees, the rehabilitation supplier must be registered with the Board as a catastrophic supplier.

(i)  A catastrophic applicant shall have been registered as a rehabilitation supplier for a minimum of two years immediately prior to beginning the catastrophic application process.  The applicant for catastrophic supplier registration shall document experience and/or training in at least three of the types of catastrophic injury listed in O.C.G.A. § 34-9-200.1(g) 1 through 5. Other detailed requirements for becoming a catastrophic supplier, including education, experience and renewal are set forth in the current edition of the Board's Procedure Manual.

(ii)  Within thirty days of the date of a denial of an application for registration as a catastrophic supplier, an appeal may be initiated by filing a written request with the Board for a conference with the Catastrophic Certification Committee.  The applicant will be notified in writing of the date, time, and place of the conference within thirty days of the appeal.

(g)  CATASTROPHIC DESIGNATION

(1)  When there is no dispute, the employer/insurer shall file a Form WC-R1 requesting a catastrophic designation and an appointment of a registered catastrophic rehabilitation supplier.  The claim is automatically accepted as a catastrophic claim.

(2)  When a catastrophic designation is disputed, an employee or employee's attorney shall file a WC-R1CATEE, with certificate of service with the Managed Care and Rehabilitation Division to request a catastrophic designation and an appointment of a registered catastrophic rehabilitation supplier. The WC-R1CATEE must be accompanied by documentation as specified in the current edition of the Board's Procedure Manual, or as requested by the Board.

(3)  Any objections must be filed with the Board in writing within twenty days of the certificate of service on the WC-R1CATEE.  In the alternative, either party may file a Form WC-14  requesting an evidentiary hearing within 20 days of the certificate of service on the WC-R1CATEE.  In the event a Form WC-14 is filed, the file shall be transferred to an administrative law judge for an evidentiary hearing without an administrative decision being rendered by the Rehabilitation Coordinator.  The timeliness of the objection or hearing request will be processed in accordance with provisions of O.C.G.A. § 9-11-6(e).

(4)  The Board's Rehabilitation Coordinator will review the file and render an administrative decision, in writing as soon as possible.  Prior to issuing a decision, the Rehabilitation Coordinator may schedule a rehabilitation conference.  The administrative decision will be issued, in writing promptly following the conference.

(5)  Any party to the claim dissatisfied with the administrative decision must, within twenty days of the date of the administrative decision, file a WC-14, Request for Hearing.  The WC-14 must be served on all parties, their attorneys and involved rehabilitation suppliers. The Board, in its discretion, may order the parties to participate in a mediation conference before the scheduling of the de novo hearing.

(6)  When no hearing is requested following an administrative decision by a Board Rehabilitation Coordinator or when an administrative law judge determines that an injury is catastrophic, the employer/insurer have 20 days from the date of such administrative decision or administrative law judge's award to select a Board-registered rehabilitation supplier.  If the employer/insurer fails to select a supplier, or requests a hearing without reasonable grounds following an administrative decision, or files an appeal of the administrative law judge's decision granting catastrophic designation and the catastrophic designation is upheld on appeal, the Board will select the supplier, and may, in the exercise of its discretion, appoint the supplier requested by the employee.

(h)  VOLUNTARY REHABILITATION

Any party may request the appointment of a registered rehabilitation supplier on a voluntary basis upon agreement of the parties.  The registered rehabilitation supplier shall be responsible for obtaining the written agreement from the employee.

If one party does not consent to voluntary rehabilitation services or subsequently withdraws consent for rehabilitation services, the rehabilitation supplier shall have no further contact, written, oral or otherwise, with the employee, the employee's attorney, or the employee's authorized treating physicians.

(i)  PROFESSIONAL RESPONSIBILITIES OF A REHABILITATION SUPPLIER

(1)  A rehabilitation supplier may contract as a consultant with an employer/insurer or attorney, to review files, give recommendations regarding case management, safety and rehabilitation issues, and to perform job analyses of employment positions.  All recommendations and reviews must be submitted directly to the employer/insurer or its agent requesting rehabilitation services.

(2)  The rehabilitation supplier utilized by the parties must hold one of the certifications, or licenses specified in subsection (f) of this Rule and the supplier must be registered with the Board.

(3)  A rehabilitation supplier will inform all parties of the legal limitations of their services or the benefits offered to the injured employee.  The rehabilitation supplier shall function within the limitations of his or her role, training, and technical competency and will accept only those positions for which he or she is professionally qualified.  A rehabilitation supplier will not misrepresent his or her role or competence to an injured employee and will refer the injured employee to a specialist as the needs of the injured employee dictate.

(4)  The rehabilitation supplier shall disclose at the outset of a case to health care providers, the parties, and their attorneys any possible conflicts of interest.  The rehabilitation supplier shall inform any health care providers, the parties, and their attorneys of his or her assignment and proposed role in the case.

(5)  The rehabilitation supplier shall exercise independent professional judgment in making and documenting recommendations for medical and vocational services, including any alternatives for medical treatment and cost-effective return-to-work options including retraining or retirement.  The rehabilitation supplier shall acknowledge that the authorized treating physician directs the medical care of an injured employee.

(6)  Subject to the qualifications of the rehabilitation supplier, he or she may explain medical information to the injured employee, and shall discuss with the injured employee all treatment options appropriate to the injured employee's conditions.

(7)  The rehabilitation supplier shall insure the confidentiality of the injured employee's medical records and shall not disclose the medical records to non-parties without the written consent of the injured employee or unless otherwise legally required to do so.

(8)  As an expert witness or consultant, the rehabilitation supplier shall provide unbiased, objective opinions.  The limits of his or her relationship shall be clearly defined in writing to all parties.

(9)  A rehabilitation supplier shall not conduct or assist any party in claims negotiation, investigative activities, or perform any other non-rehabilitation.

(10)  A rehabilitation supplier shall not advise the injured employee as to any legal matter, including but not limited to claims settlement options or procedures, monetary evaluation of claims, or the applicability of benefits of any kind under the Workers' Compensation Act.  Rehabilitation suppliers shall advise a non-represented injured employee to direct such questions to the State Board of Workers' Compensation and a represented injured employee to direct such questions to his or her counsel.

(11)  A rehabilitation supplier shall not accept any additional compensation or reward from any source as a result of settlement of a case.

(12)  The assigned rehabilitation supplier shall not perform any additional services for either party for compensation not contemplated by the approved plan, unless all parties agree.

(13)  A rehabilitation supplier who possesses information concerning an alleged violation of this rule shall reveal such information to the Managed Care & Rehabilitation Division of the State Board of Workers' Compensation, unless the information is protected by law.

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(a) Application and certification.

(1) All provisions of this Rule constitute the minimum requirements necessary to obtain and maintain certification as a WC/MCO under the Georgia Workers' Compensation Act. To obtain certification of a plan, application shall be submitted on a Form WC-208a accompanied by a non-refundable fee of $1,000.00 and shall include the following information:

(A) An audited financial statement evidencing the ability of the Managed Care Organization to comply with any and all financial requirements to insure the delivery of services the Board may prescribe.

(B) Complete disclosure should be made of the following individuals (an individual may act in more than one capacity):

(1) The names, addresses and resume of all directors and officers of the WC/MCO;

(2) The title, name, address, telephone number and resume of the person to be the day-to-day administrator of the WC/MCO;

(3) The title, name, address, telephone number and resume of the person to be the administrator of the financial affairs of the WC/MCO;

(4) The name, address, medical specialty and resume of the medical director;

(5) The name, address and telephone number of the WC/MCO's communication liaison for the Board, the insurer, the employer, and the employee; and

(6) The name and address or any other information requested by the Board regarding any entity, other than individual health care providers, with whom the WC/MCO has a joint venture or other agreement to perform any of the functions of the managed care plan, and a description of the specific function to be performed by each entity.

(C) The WC/MCO must insure provisions of quality services that meet all uniform treatment standards required by Georgia law and provide appropriate financial incentives to reduce service costs and utilization without sacrificing the quality of service.

(D) The WC/MCO must provide a description of its proposed geographic service area by county and specify the times, places and manner of providing services, including a statement describing how the WC/MCO will insure that an adequate number of each category of health care provider is available to give employees convenient geographic accessibility to all categories of providers and adequate flexibility to choose health care providers from among those who provide services under the plan.

(E) The WC/MCO must include minority providers, and at a minimum, the following types of health care services and providers, unless the WC/MCO provides evidence that a particular service or type of provider is not available in the geographical service area:

(1) Medical doctors, including specialists in at least one of the following fields: family practice, internal medicine, occupational medicine, or emergency medicine;

(2) Orthopedic surgeons, including specialists in hand and upper extremity surgery;

(3) Neurologists and neurosurgeons;

(4) General surgeons;

(5) Chiropractors;

(6) Physical and occupational therapists;

(7) Psychologists or psychiatrists;

(8) Diagnostic pathology and laboratory services;

(9) Radiology services; and

(10) Hospital, outpatient surgery, and emergency care services.

(F) The WC/MCO must submit sample copies of all types of agreements with providers who will deliver services under the WC/MCO and a description of any other relationships with providers who may deliver services to a covered employee.

(G) The WC/MCO must attach to each type of sample agreement a corresponding list of names, clinics, addresses and types of license and specialties for the health care providers with whom they have utilized the agreement.

(H) In all agreements with the WC/MCO and any other provider of services, the agreement shall contain the following provision: "It is the intent of the parties to this agreement to insure quality services that meet all uniform treatment standards required by Georgia law, and any provision herein which may be inconsistent with that intent shall be void."

(I) The WC/MCO must submit a statement certifying that all licensing requirements for the providers and medical case managers are current and in good standing in Georgia or the state in which the provider is practicing.

(J) The WC/MCO must provide a referral for specialty services that are not specified in subparagraph (E) and that may be reasonable and necessary to effect a cure or give relief as required under O.C.G.A. § 34-9-200. The employer or the workers' compensation insurance carrier remains liable for any health service required under the Workers' Compensation Act, provided that the services meet all other requirements of the Workers' Compensation Act.

(K) The WC/MCO must include procedures to insure that employees will receive services in accordance with the following criteria:

(i) The medical case manager shall inform the employee of his right to choose from the providers designated in Rule 208(a)(1)(E), inform the employee that a list of medical providers is available and provide assistance in obtaining the list if necessary. The medical case manager shall assist the employee in choosing a provider appropriate to the injury. The physician so chosen shall be deemed the "authorized treating physician" for all purposes under the Workers' Compensation Act. Employees must be allowed to change authorized treating physicians within the managed care plan at least once without proceeding through the managed care plan's dispute resolution process. In such cases, employees shall give notice to the manage care plan for a change in their authorized treating physician;

(ii) Employees must be able to receive information on a 24-hour basis regarding the availability of necessary medical services available within the managed care plan. The information may be provided through recorded toll-free telephone messages after normal working hours. The message must include information on how the employee can obtain emergency services or other urgently needed care and how the employee can access an evaluation within a reasonable time after request;

(iii) Employees must receive initial evaluation by a participating licensed health care provider within twenty-four hours after the employee's request for treatment, following a work-related injury;

(iv) In cases where the employee has received treatment for the work injury by a health care provider outside the managed care plan, the employee must receive initial evaluation or treatment by a participating health care provider within five (5) working days of the employee's request for a change of doctor or referral to the managed care plan;

(v) Employees must receive any necessary treatment, diagnostic tests or specialty services in a manner that is timely, effective and convenient for the employee, and reasonable under the circumstances;

(vi) Employees must have reasonable access to health care providers. If the employee is medically unable to travel to a participating provider, the managed care plan shall refer the employee to an available or non-participating provider to receive necessary treatment for the injury.

(L) The WC/MCO must designate the procedures for approval of services from a health care provider outside the managed care plan.

(M) The WC/MCO must include a procedure for peer review and utilization, consistent with Rule 208(g).

(N) The WC/MCO must include a procedure for internal dispute resolution, including a method to resolve complaints by injured employees, medical providers, employers and insurers.

(O) The WC/MCO must inform employees of all choices of medical services provided within the plan and how employees can gain access to those providers including but not limited to a wallet-sized card containing this information in a format suitable for carrying on the employee's person. The plan must submit a proposed publication which may be customized according to the needs of the employer, but must include the information required in Rule 201(a)(3) and must also include a complete list of all WC/MCO medical providers in the applicable geographical service area. All employees of covered employers shall be provided with the publication.

(P) The WC/MCO must provide the information required by Rule 208(h) and describe how medical case management will be provided for injured employees, and an effective program for return-to-work and cooperative efforts by the employees, the employer and the managed care plan to promote workplace health and safety and other services.

(Q) The WC/MCO must provide such other information as the Board considers necessary to determine compliance with the Workers' Compensation Act.

(2) Within 60 days of receipt of an application, the Board must notify an applicant for certification of any additional information required or modification that must be made. The Board must notify the applicant in writing of the approval or denial of certification within 60 days of receipt of the additional information or modification. If certification is denied, the applicant must be provided, in writing, with the reason or reasons for the denial.

(3) Any person aggrieved by a denial of certification by the Board may make written request for a hearing within 30 days of the date the denial is served and filed. The Appellate Division shall hold all hearings and issue a final decision.

(b) Coverage responsibility of WC/MCO.

(1) A WC/MCO must contract with the employer or the workers' compensation insurer of an employer. In the event multiple WC/MCO's are contracted to cover the same employer, each employee shall have the initial election of the WC/MCO that will manage the employee's care, and utilization of a WC/MCO will be deemed an election.

(2) An employee who gives notice to an employer of a compensable injury shall receive medical services in the manner prescribed by the terms and conditions of the WC/MCO contract in effect at the time medical services are rendered.

(3) To insure continuity of care, the WC/MCO contract shall specify the manner in which an injured employee will receive medical services when a WC/MCO contract or contract with the health care provider terminates. The employee may continue to treat with the health care provider or the WC/MCO under the terminating contract until such time as the employee elects to utilize the employer's current posted panel of physicians, conformed panel of physicians or WC/MCO, or a change of physician is granted.

(c) Reporting requirements for Board certified WC/MCO's.

(1) A WC/MCO shall provide the Board with a copy of the following contracts:

(A) Contracts between the WC/MCO and any employer or workers' compensation insurer, prior to utilization of the contract. If the Board does not issue a written approval or denial within 90 days, then the contract shall be approved. Any contract rejected by the Board shall be deemed void for purposes of this Rule. Standard contracts may be submitted instead of individual contracts if no modifications are made. Standard contracts must include a list of signatories and a listing of all employers covered by each contract, including the employers' name, business address and estimated number of employees governed by the WC/MCO. Amendments and addendums to the contracts must be submitted to the Board within 30 days of execution. Contract provisions must be consistent with O.C.G.A. § 34-9-208 and this Rule. The contract must specify the billing and payment procedures and how the medical case management and return-to-work functions will be coordinated.

(B) New types of agreements between participating health care providers and the WC/MCO that are not identical to the agreements previously submitted to the Board shall not be effective until approved by the Board. Any contract which is neither approved nor rejected by the Board within 90 days from submission shall be deemed approved.

(C) Contracts between the WC/MCO and any entity, other than individual participating providers that performs some of the functions of the WC/MCO.

(D) Any changes in the individuals or information required by Board Rule 208(a)(1)(B)(1)-(5).

(2) In order to maintain certification, each WC/MCO shall provide on the first working day following each anniversary of certification the following information in the form of a certified annual report:

(A) A current listing of all individuals identified in Board Rule 208(a)(1)(B)(1)-(5) and all participating health care providers, including provider names, types of license, specialty, business address, telephone number and a statement that all licenses are current and in good standing;

(B) A summary of any sanctions or punitive actions taken by the WC/MCO against any participating providers;

(C) A report that summarizes peer review, utilization review, supplier profiles, reported complaints and dispute resolution proceedings showing cases reviewed, issues involved, and any action taken; and

(D) An audited financial statement for the most recent fiscal year, upon request of the Board.

(E) The annual report must be accompanied by a non-refundable fee of $500.00.

(3) Any proposed changes to the Board certified WC/MCO falling within the categories enumerated below, other than changes to the health care provider list, may not be implemented under the plan until approved by the Board:

(A) Amendments to any contract with participating health care providers;

(B) Amendments to contracts between the WC/MCO and another entity performing functions of the managed care plan; and

(C) Any other amendments to the WC/MCO as certified.

(4) The WC/MCO must report to the employer or insurer any data regarding medical services and suppliers related to the workers' compensation claim required by the self-insured employer or insurer to determine compensability under the Workers' Compensation Act, and any other data required by the Board. The Board may require additional information from the managed care organization if the information is relevant to the Workers' Compensation Act.

(d) Commencement and termination of contract between the WC/MCO and participating providers.

(1) Prospective new participating health care providers under a WC/MCO shall submit an application to the WC/MCO. A director, executive director or administrator may approve the application under the requirements of the WC/MCO. The managed care plan shall verify that each new participating health care provider meets all licensing, registration and certification requirements necessary to practice in Georgia or other applicable state of practice.

(2) A participating provider may elect to terminate participation in the WC/MCO or to be subject to cancellation by the managed care plan under the requirements of the managed care plan. Upon termination of a provider contract, the managed care plan shall make alternate arrangements to provide continuing medical services for an affected injured employee under the plan in compliance with Board Rule 208(b)(3).

(e) A health care provider who is not a participating health care provider may provide medical services to an employee covered by a WC/MCO in any other circumstances provided below:

(1) Emergency treatment;

(2) When the employee is referred to the provider by the managed care organization;

(3) By order of the Board, or by consent of the parties.

(f) Disputes which arise on an issue related to managed care shall first be processed without charge through the dispute resolution process of the WC/MCO. The WC/MCO dispute resolution process must be completed within 30 days of a written notice. If the dispute cannot be resolved, the WC/MCO must immediately notify the employer or insurer. If the dispute involves treatment/test prescribed by the authorized treating physician, the employer or insurer must follow the procedure outlined in Rule 205.

(g) Utilization review and peer review.

(1) The WC/MCO must implement a system for peer review to improve patient care and cost effectiveness of treatment. Peer review must include a majority of health care providers of the same discipline being reviewed. The peer review must be designed to evaluate the quality of care given by a health care provider to a patient or patients. The plan must describe in its application for certification how the providers will be selected for review, the nature of the review and how the results will be used.

(2) The WC/MCO must implement a plan for utilization review. The program must profile each medical supplier and include the collection, review, analysis of group data (utilizing CPT-4 codes) to improve overall quality of care, efficient use of resources and duration of disability. In its application for certification, the WC/MCO must specify the data that will be collected, how the data will be analyzed and how the results will be applied to improve patient care and increase cost effectiveness of treatment.

(h) Medical case management.

(1) The medical case manager must monitor, evaluate and coordinate the delivery of quality, cost effective medical treatment and other health services needed by an injured employee, and must promote an appropriate, prompt return to work. Medical case managers must facilitate communication between the employee, employee's representative, employer, employer's representative, insurer, health care provider, WC/MCO and, when authorized, any qualified rehabilitation consultant to achieve these goals. The WC/MCO must describe in its application for certification how injured employees will be subject to case management, the services to be provided, and who will provide services.

(2) Case management for an employee covered by a WC/MCO must be provided by a licensed registered health care professional holding one of the following certifications: Certified Rehabilitation Registered Nurse (CRRN), Certified Case Manager (CCM), Certified Occupational Health Nurse (COHN), Certified Occupation Health Nurse Specialist (COHN-S), Certified Disability Management Specialist (CDMS), Certified Rehabilitation Counselor (CRC), Work Adjustment/Vocational Evaluation Specialist (WAVES), or Licensed Professional Counselor (LPC). Case managers must have at least one year experience in workers' compensation. In catastrophic cases, case management must include assignment to a Board-registered rehabilitation supplier, who has been designated by the board as qualified to manage catastrophic cases (Rule 200.1(f)(4)). If qualified, the case manager may register with the Board to serve as the catastrophic rehabilitation supplier.

(3) The parties to the claim and their representatives shall cooperate with medical case management services when such services are being provided by a WC/MCO which has been certified pursuant to O.C.G.A. § 34-9-208 and Board Rule 208 and which has posted a WC-P3 panel. The unreasonable refusal to cooperate with or the unreasonable interference with medical case management services by any party or its representative may subject that party or its representative to civil penalties pursuant to O.C.G.A. § 34-9-18. The employer/insurer may suspend weekly benefits for the failure of the employee to cooperate with medical case management only by order of the Board.

(i) Monitoring records.

(1) The Board shall monitor and may conduct audits and special examinations of the WC/MCO as necessary to insure compliance with the WC/MCO certification and performance requirements.

(2) All records of the WC/MCO and its participating health care providers relevant to determining compliance with the Workers' Compensation Act shall be disclosed in a reasonable time after request by the Board. Records must be legible and cannot be kept in a coded or semi-coded manner unless a ledger is provided for codes.

(3) The release of records filed with the Board must clearly identify the portions of the application or records which are believed to be non-public trade secret data or otherwise confidential.

(j) Suspension; revocation.

(1) The WC/MCO shall work with all parties and their representatives in a reasonable manner consistent with the purposes of this Act. Complaints pertaining to violations by the WC/MCO shall be directed in writing to the Board. Upon receipt of a written complaint or after monitoring the managed care plan operation, the Board shall investigate the alleged violation. The investigation may include, but shall not be limited to, requests for and review of pertinent managed care records. If the investigation reveals reasonable cause to believe that there has been a violation warranting suspension or revocation of certification, the Board shall schedule a hearing.

(2) The certification of any WC/MCO issued by the Board may be suspended or revoked, in the discretion of the Board, if the WC/MCO fails to meet any of the requirements of O.C.G.A. § 34-9-208 or Board Rule 208.

(3) For purposes of this Rule, "suspension" and its variations means the cessation of the WC/MCO's authority to enter into new contracts with employers or insurers for a specified period of time up to a maximum of one (1) year. Upon suspension, the WC/MCO may continue to provide services in accordance with the contracts in effect at the time of the suspension. A suspension may be set aside prior to the end of the designated suspension period if it is shown to the satisfaction of the Board that the WC/MCO is in compliance. Furthermore, if it is shown that the WC/MCO is not in compliance immediately prior to the end of the designated suspension period, the suspension may be extended without further hearing, or revocation proceedings may be initiated.

(4) For purposes of this Rule, "revocation" and its variations means a revocation of a WC/MCO's certification to provide services under these Rules. If the WC/MCO certification is revoked, no employee is covered by the contract between the WC/MCO and the employer or workers' compensation carrier. However, upon revocation of certification, the WC/MCO may continue to provide services under contracts in effect to the extent the Board determines that it is necessary for injured employees to continue to receive medical services in that manner.

(5) Suspension or revocation under this Rule will not be made until the WC/MCO has been given notice and the opportunity to be heard through a show-cause hearing before the Board. The Board shall provide the WC/MCO written notice of an intent to suspend or revoke the WC/MCO's certification and the grounds for such action. The notice shall also advise the WC/MCO of the right to participate in the show-cause hearing and specify the date, time and place of the hearing. The notice shall be issued from the Board at least twenty-one (21) days prior to the scheduled date of the hearing. After the show-cause hearing, the Board may issue a final order suspending or revoking the WC/MCO's certification.

(6) Upon revocation of a WC/MCO's certification, the employer or the workers' compensation insurer of an employer with whom the revoked WC/MCO had been contracted to provide managed care shall make alternate arrangements to provide continuing medical services for injured employees who had been receiving medical care through the revoked WC/MCO. Any injured employee receiving medical services through a WC/MCO prior to revocation of the WC/MCO's certification may continue to treat with one of the individual health care providers with whom the employee had received medical services prior to revocation until such time as the employee elects to utilize the employer's replacement posted panel of physicians, conformed panel of physicians or WC/MCO, or a change of physician is ordered.

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Any party or attorney filing a form with the Board shall use the most current version of the form. In addition, no party or attorney shall submit any form that has been discontinued or altered. A violation of this rule may result in the rejection of the filing with the Board, and/or the imposition of a civil penalty under O.C.G.A. § 34-9-18.

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