Report | Due/Needed by Insurer | What Information Should Be Included In the Report? | Special Notes |
Report of Industrial Injury or Occupational Disease (form) | Immediately - Within five days of first visit. | See form | Only MD, DO, DC, ND, DPM, DDS, ARNP, PA, and OD may sign and be paid for completion of this form. |
Self-Insurance: Provider's Initial Report (form) | | If additional space is needed, please attach the information to the application. The claim number should be at the top of the page. | |
Sixty Day (narrative) | Every sixty days when only conservative (nonsurgical) care has been provided. | (1) The conditions diagnosed, including the current federally adopted ICD-CM codes and the subjective complaints and objective findings. | Providers may submit legible comprehensive chart notes in lieu of sixty day reports provided the chart notes include all the information required as noted in the "What Information Should Be Included?" column. |
Purpose: Support and document the need for continued care when conservative (nonsurgical) treatment is to continue beyond sixty days |
| | (2) The relationship of diagnoses, if any, to the industrial injury or exposure. | However, office notes are not acceptable in lieu of requested narrative reports and providers may not bill for the report if chart notes are submitted in place of the report. |
| | (3) Outline of proposed treatment program, its length, components and expected prognosis including an estimate of when treatment should be concluded and condition(s) stable. An estimated return to work date and the probability, if any, of permanent partial disability resulting from the industrial condition. | |
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| | (4) Current medications, including dosage and amount prescribed. With repeated prescriptions, include the plan and need for continuing medication. | Providers must include their name, address and date on all chart notes submitted. |
| | (5) If the worker has not returned to work, indicate whether a vocational assessment will be necessary to evaluate the worker's ability to return to work and why. | |
| | (6) If the worker has not returned to work, a doctor's estimate of physical capacities should be included. | |
| | (7) Response to any specific questions asked by the insurer or vocational counselor. | |
Opioid Authorization Requirement | Opioids in subacute phase - Six weeks from the date of injury or surgery. | | |
| Opioids in chronic phase - Twelve weeks from the date of injury or surgery. | | |
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| Opioids for ongoing chronic therapy - Every ninety days. | | |
Special Reports/Follow-up Reports (narrative) | As soon as possible following request by the department/insurer. | Response to any specific questions asked by the insurer or vocational counselor. | "Special reports" are payable only when requested by the insurer. |
Consultation Examination Reports (narrative) | At one hundred twenty days if only conservative (nonsurgical) care has been provided. | (1) Detailed history. | If the injured/ill worker had been seen by the consulting doctor within the past three years for the same condition, the consultation will be considered a follow-up office visit, not consultation. |
Purpose: Obtain an objective evaluation of the need for ongoing conservative medical management of the worker. | | (2) Comparative history between the history provided by the attending or treating provider and injured worker. | |
| | (3) Detailed physical examination. | |
The attending or treating provider may choose the consultant. | | (4) Condition(s) diagnosed including the current federally adopted ICD-CM codes, subjective complaints and objective findings. | A copy of the consultation report must be submitted to both the attending or treating provider and the department/insurer. |
| | (5) Outline of proposed treatment program: Its length, components, expected prognosis including when treatment should be concluded and condition(s) stable. | |
| | (6) Expected degree of recovery from the industrial condition. | |
| | (7) Probability of returning to regular work or modified work and an estimated return to work date. | |
| | (8) Probability, if any, of permanent partial disability resulting from the industrial condition. | |
| | (9) A doctor's estimate of physical capacities should be included if the worker has not returned to work. | |
| | (10) Reports of necessary, reasonable X-ray and laboratory studies to establish or confirm diagnosis when indicated. | |
Attending Provider Review of IME Report (form) | As soon as possible following request by the department/insurer. | Agreement or disagreement with IME findings. If you disagree, provide objective/subjective findings to support your opinion. | Payable only to the attending provider upon request of the department/insurer. PAs can concur with treatment recommendations but not PPD ratings. |
Purpose: Obtain the attending provider's opinion about the accuracy of the diagnoses and information provided based on the IME. |
Loss of Earning Power (form) | As soon as possible after receipt of the form. | See form | Payable only to the attending or treating provider. |
Purpose: Certify the loss of earning power is due to the industrial injury/occupational disease. | | | |
Application to Reopen Claim Due to Worsening of Condition (form) | Immediately following identification of worsening after a claim has been closed for sixty days. | See form | Only MD, DO, DC, ND, DPM, DDS, ARNP, PA, and OD may sign and be paid for completion of this form. |
Purpose: Document worsening of the accepted condition and need to reopen claim for additional treatment. | Crime Victims: Following identification of worsening after a claim has been closed for ninety days. | | |
