Title of Regulation: 16VAC30-110. Medical Fee Schedule Regulations (adding 16VAC30-110-10 through 16VAC30-110-40).

Statutory Authority: § 65.2-605 of the Code of Virginia.

Effective Date: January 24, 2018.

Agency Contact: James J. Szablewicz, Chief Deputy Commissioner, Virginia Workers' Compensation Commission, 333 East Franklin Street, Richmond, VA 23219, telephone (804) 205-3097, FAX (804) 823-6936, or email james.szablewicz@workcomp.virginia.gov.

Summary:

The regulatory action establishes and implements the medical fee schedules required by § 65.2-605 of the Code of Virginia for all medical services rendered to injured workers under the Virginia Workers' Compensation Act on or after January 1, 2018, regardless of the date of injury. The schedules establish the maximum amount payable for fee schedule medical services, which include services provided by physicians, surgeons, hospitals, ambulatory surgery centers, and other health care service providers and suppliers.

CHAPTER 110
MEDICAL FEE SCHEDULES REGULATIONS

16VAC30-110-10. Definitions.

The following words and terms when used in this chapter shall have the following meanings unless the context clearly indicates otherwise:

"Commission" means the Virginia Workers' Compensation Commission.

"Community" means one of the six medical communities as defined in § 65.2-605 A of the Code of Virginia.

"Ground rules" means the Medical Fee Schedule Ground Rules adopted by the Commission on June 13, 2017, and revised on November 14, 2017, incorporated by reference and available on the commission's website at http://www.workcomp.virginia.gov/content/virginia-medical-fee-schedules-ground-rules.

"Medical services" means any medical, surgical, or hospital service required to be provided to an injured person pursuant to Title 65.2 of the Code of Virginia, exclusive of a medical service provided in the treatment of a traumatic injury or serious burn as those terms are defined in § 65.2-605 A of the Code of Virginia.

"Virginia fee schedules" means the fee schedules adopted by the commission on June 13, 2017, and revised on November 14, 2017, incorporated by reference and available on the commission's website at http://www.workcomp.virginia.gov/content/virginia-medical-fee-schedules.

16VAC30-110-20. Applicability of fee schedules and ground rules; determination of communities.

A. The Virginia fee schedules and ground rules shall apply to all medical services rendered on or after January 1, 2018, regardless of the date of injury.

B. The applicable community for providers of medical services rendered in the Commonwealth shall be determined by the zip code of the location where the services were rendered.

C. The applicable community for providers of medical services rendered outside of the Commonwealth shall be determined by the zip code of the principal place of business of the employer if located in the Commonwealth or, if no such location exists, then the zip code of the location where the commission hearing regarding a dispute concerning the services would be conducted.

16VAC30-110-30. Disputes.

A. Administrative review process. Any dispute concerning the application of the Virginia fee schedules and ground rules to a particular medical service shall be submitted to the commission for an administrative review and determination according to such procedures as the commission may adopt from time to time.

B. Judicial review. If a request for hearing is made to the commission within 30 days after issuance of an administrative decision pursuant to subsection A of this section, the dispute shall be referred to the appropriate hearing docket and adjudicated in the same manner as change-in-condition claims, with the same rights of review and appeal as set forth in §§ 65.2-705 and 65.2-706 of the Code of Virginia and subject to the applicable Rules of the Commission.

C. Finality. An administrative decision of the commission issued pursuant to subsection A of this section shall be final and binding 30 days after its issuance unless a request for hearing is made pursuant to subsection B of this section.

16VAC30-110-40. Periodic review of fee schedules.

The commission shall review the Virginia fee schedules and ground rules biannually and shall make necessary adjustments as directed by § 65.2-605 D of the Code of Virginia.

DOCUMENTS INCORPORATED BY REFERENCE (16VAC30-110)

Virginia Workers' Compensation Medical Fee Schedules Ground Rules, adopted June 13, 2017, revised November 14, 2017, Virginia Workers' Compensation Commission

Virginia Workers' Compensation Medical Fee Schedules, adopted June 13, 2017, revised November 14, 2017, Virginia Workers' Compensation Commission, http://www.workcomp.virginia.gov/content/virginia-medical-fee-schedules.