Chapter 0052 - 512R - S Ver of HB2221

Be it enacted by the Legislature of the State of Arizona:

Section 1. Section 23-1062.01, Arizona Revised Statutes, is amended to read:

START_STATUTE23-1062.01. Timely payment of medical, surgical and hospital benefit billing; content of bills; contracts between providers and carriers; exceptions; definitions

A. An insurance carrier, self-insured employer or claims processing representative shall make a determination whether to deny or pay a medical bill on an accepted claim, in whole or in part, including the decision as to the amount to pay, within thirty days from the date the claim is accepted, if the billing is received before the date of acceptance, or within thirty days from the date of receipt of the billing if the billing is received after the date of acceptance. All billing denials shall be based on reasonable justification. The insurance carrier, self-insured employer or claims processing representative shall pay the approved portion of the billing within thirty days after the determination for payment is made. If the billing is not paid within the applicable time period, the insurance carrier, self-insured employer or claims processing representative shall pay interest to the health provider on the billing at a rate that is equal to the legal rate. Interest shall be calculated beginning on the date that the payment to the health care provider is due.

B. Any billing by a health care provider shall include all of the following:

1. The correct demographic patient information and claim number, if known.

2. The correct health care provider information, including name, address, telephone number and federal taxpayer identification number.

3. The appropriate medical coding with dollar amounts and units clearly stated with all descriptions.

4. Clearly printed date or dates of service.

5. Legible medical reports required for each date of service if the billing is for direct treatment of the injured worker.

C. An insurance carrier, self-insured employer or claims processing representative is not responsible for payment of any billings for medical, surgical or hospital benefits provided under this chapter unless the billings are received by the insurance carrier, self-insured employer or claims processing representative and any court action for the payment of the billings is commenced within twenty-four months from the date on which the medical service was rendered or from the date on which the health care provider knew or should have known that service was rendered on an industrial claim, whichever occurs later. A subsequent billing or corrective billing does not restart the limitations period.

D. An injured worker is not responsible for payment of any portion of a medical bill for services rendered on an accepted claim and is not responsible for payment of any disputed amount between a health care provider and the insurance carrier, self-insured employer or claims processing representative.

E. An insurance carrier, self-insured employer or claims processing representative that is subject to this chapter may establish an internal system for resolving payment disputes and other contractual grievances with health care providers.

F. This section does not apply to health care providers that enter into an express written contract with the insurance carrier, the self-insured employer or a claims processing representative that specifies the period in which approved bills shall be paid and that includes contractual remedies for untimely bill payment. If the contract does not include remedies for untimely payment, payment must be made according to the provisions of the contract but the interest penalty prescribed by subsection A of this section shall apply to any late payment. The commission does not have jurisdiction over disputes involving timely payment of billings under contracts between the insurance carrier, self‑insured employer or claims processing representative and the health care provider.

G. For the purposes of this section:

1. "Accepted claim" means a claim for benefits under this chapter that has been accepted by a final notice of claim status or final order or award of the commission.

2. "Date of receipt" means the electronic acknowledgement date or, if a bill does not contain an electronic acknowledgment date, the date of receipt is presumed to occur five days after the bill was mailed to the recipient's address. END_STATUTE

Sec. 2. Section 23-1062.02, Arizona Revised Statutes, is amended to read:

START_STATUTE23-1062.02. Off-label and prescription use of controlled substances; prescription of schedule II controlled substances; reports; treatment plans; monitoring program inquiries; preauthorizations; definitions

A. On written request of an interested party as defined in section 23‑901, A physician shall include in the report required under commission rule information pertaining to the following:

1. The off-label use of a narcotic, opium-based controlled substance or schedule II controlled substance by a claimant.

2. The use of a narcotic or opium-based controlled substance or the prescription of a combination of narcotics or opium-based controlled substances at or exceeding a one hundred twenty milligram morphine equivalent dose per day.

3. The prescription of a long-acting or controlled release opioid for acute pain.

B. The information required pursuant to subsection A of this section shall include the justification for use of the controlled substance, and a treatment plan that includes a description of measures that the physician will implement to monitor and prevent the development of abuse, dependence, addiction or diversion by the employee. The interested party may also request that the physician submit and report the results of an inquiry to the Arizona state board of pharmacy requesting prescription information for the employee compiled under the controlled substances prescription monitoring program prescribed in title 36, chapter 28, and that The physician shall include in the treatment plan a medication contract agreement, a plan for subsequent follow‑up visits and random drug testing and documentation that the medication regime is providing relief that is demonstrated by improved clinically meaningful improvement in function. If the drug test of the employee reveals inconsistent results, the physician within five business days shall provide a written report to the carrier, self‑insured employer or commission setting forth a treatment plan to address the inconsistent drug test results.

C. Within two business days of writing or dispensing an initial prescription order for at least a thirty‑day supply of an opioid medication for the employee, a physician shall submit an inquiry to the Arizona state board of pharmacy requesting the employee's prescription information that is compiled under the controlled substances prescription monitoring program prescribed in title 36, chapter 28. The physician shall report the results to the carrier, self‑insured employer or commission as soon as reasonably practicable but no later than thirty days from the date of the inquiry. Thereafter, the carrier, self‑insured employer or commission may request no more than once every two months that the physician perform additional inquiries to the Arizona state board of pharmacy.

D. If the result of an inquiry to the Arizona state board of pharmacy reveals that the employee is receiving opioids from another undisclosed health care provider, the physician shall within five business days report the results to the carrier, self‑insured employer or commission.

C. E. If the physician does not comply with this section:

1. The interested party carrier, self‑insured employer or commission is not responsible for payment for the physician's services until the physician complies with subsection A of this section.

2. Except for a self-insured employer that provides medical care pursuant to section 23-1070, an the employer, carrier or commission may request a change of physician after making a written request to the physician to comply with this section and the request identifies the area of noncompliance. If a change of physician is ordered and the order becomes final, the employee shall select a physician whose practice includes pain management and who agrees to comply with this section. If other medical providers are not available in the employee's area of residence, the employer, carrier or commission shall pay in advance for the employee's reasonable travel expenses, including the cost of transportation, food, lodging and loss of pay, if applicable.

F. If medically necessary, the carrier, self‑insured employer or commission shall provide drug rehabilitation and detoxification treatment for an employee who becomes dependent on or addicted to opioids that are prescribed for a work‑related injury. In the event of a medical conflict regarding the necessity for drug rehabilitation and detoxification, the carrier, self‑insured employer or commission shall continue to provide the opioids until a determination is made after a hearing by an administrative law judge.

G. If the employee resides out of state, the carrier, self‑insured employer or commission may not be responsible for providing medications that are subject to this section if the out-of-state physician fails to comply with this section. If the other state has a controlled substances monitoring program, the physician shall submit an inquiry to the database as prescribed by subsection c of this section.

H. This section does not apply to medications administered to the employee while the employee is receiving inpatient hospital treatment.

D. I. An a carrier, self‑insured employer, a carrier or the commission may request the information required pursuant to subsection A of this section and require physician compliance with this section notwithstanding the existence of a prior award addressing medical maintenance benefits for medications. An employer or a carrier or self‑insured employer is not liable for bad faith or unfair claims processing for any act taken in compliance of and consistent with this section.

E. J. For the purposes of this section: ,

1. "Clinically meaningful improvement in function" means any of the following:

(a) A clinically documented improvement in range of motion.

(b) An increase in the performance of activities of daily living.

2. "Inconsistent results" means:

(a) The employee's reported medications, including the parent drugs or metabolites, are not detected.

(b) Controlled substances are detected that are not reported by the employee.

3. "Off-label use" means use of a prescription medication by a physician to treat a condition other than the use for which the drug was approved by the United States food and drug administration. END_STATUTE