Colorado Division of Workers' Compensation Rules of Procedure

(A) “Act” means articles 40 through 47 of title 8 of the Colorado Revised Statutes.

(B) “Claimant” means an employee or dependent(s) of a deceased employee claiming entitlement to benefits under the Act. For the purpose of notification and pleadings, the term claimant shall include the claimant’s legal representative.

(D) “Division” means the Division of Workers’ Compensation in the Department of Labor and Employment.

(E) “Electronically recorded” means a recording made using tape recording, digital recording, or some other generally accepted medium.

(F) “Employee” means an individual who meets the definition of “employee” in the Act.

(G) “Employer” means anyone who meets the definition of “employer” in the Act.

(H) "Insurer” means every mutual company or association, every captive insurance company, and every other insurance carrier, including Pinnacol Assurance, providing workers’ compensation insurance in Colorado and every employer authorized by the Executive Director of the Department of Labor and Employment to act as its own insurance carrier as well as any workers’ compensation self-insurance pool authorized pursuant to statute.

Unless a specific rule or statute states to the contrary, the date a document or pleading is filed is the date it is mailed or hand delivered to the Division of Workers’ Compensation or the Office of Administrative Courts. Computation of days is consistent with Rule 6 of the Colorado Rules of Civil Procedure.

The claimant’s signature must be notarized on all releases filed with the Division of Workers’ Compensation pursuant to §8-47-203(1)(e), C.R.S.

(A) Whenever a document is filed with the Division, a copy of the document shall be mailed to each party to the claim and attorney(s) of record, if any.

(B) Any document that is certified as mailed, including admissions, must be placed in the U.S. mail or delivered on the date of certification.

(C) Vocational reports for claims based upon an injury on or after July 2, 1987 at 4:16 p.m. shall not be filed with the Division except when requested by the Director, when attached to a final admission. If the claimant participates in a vocational evaluation, or if the insurer offers vocational services and the claimant accepts, written reports must be produced and should be produced within 30 days and a copy of every vocational report not filed with the Division shall be exchanged with all parties within 15 working days of receipt.

(A) Requests made to the Division of Workers’ Compensation pursuant to §8-47-203(2), C.R.S., for copies or inspection of orders entered by the Director or an administrative law judge shall:

(2) state the name of the requester and include the requester’s mailing address and phone number; and,

(3) specifically identify the criteria for orders being requested. For example, all orders on the merits from a specific time period or all orders involving specified issues or injuries, etc.; and

(B) The requester shall provide any additional information required by the Division. After receiving such a request the Division will provide a cost estimate for processing the request. The requester may agree to pay the costs involved or decline further processing of the request. At the discretion of the Division payment may be required prior to the work being performed.

(1) requests shall not be accepted for orders based on claimant or employer names, or other uniquely identifying claimant or employer information; and,

(2) requests shall not be accepted for any criteria resulting in the inclusion of fewer than three claimants or employers in the group of orders inspected, unless approved by the Director or the Director’s designee.

Parties to a dispute may consent to submit any dispute to mediation pursuant to the provisions of §8-43-205, C.R.S. Requests for mediation should be filed with the Division of Workers’ Compensation.

Whenever any rule in the Workers’ Compensation Rules of Procedure has been violated, the Director may impose penalties authorized by the Act.

(A) An employer who wishes to pay salary or wages in lieu of temporary disability benefits may apply to the Director for authorization to proceed pursuant to §8-42-124(2), C.R.S.

(1) a reference to the contract, agreement, policy, rule or other plan under which the employer wishes to pay salary or wages in excess of the temporary disability benefits required by the act, and

(2) a description of the employees covered by the application and a statement that these employees will not be charged with earned vacation leave, sick leave, or other similar benefits during the period the employer is seeking a credit or reimbursement.

(C) An employer who has received approval from the Director to proceed under §8-42-124(2), C.R.S., shall indicate on the employer’s first report of injury form whether the claim is subject to §8-42-124, C.R.S.

Every insurance carrier shall semi-annually file a surcharge return with the Division within the time period specified in section 2-4 of this rule. The return shall be verified by affidavits of its president and secretary or other chief officers or agents, and shall state the amount of premiums written, including any policy expense constants, membership fees, finance and service, or other administrative fees charged to the policyholder in connection with the issuance or renewal of a policy, as reported to the Division of Insurance in accordance with §10-3-208, C.R.S., and regulations promulgated thereunder, during the period covered by such return. With this filing the insurance carrier shall pay the surcharges required by statute. Forms for such returns shall be provided by the Division.

Every self-insured employer shall semi-annually file a surcharge return with the Division, within the time period specified in section 2-4 of this rule. The return shall be verified by affidavits of its president and secretary or other chief officers or agents, and shall state the total amount of its payroll for the period covered by such return. With this filing the employer shall pay the surcharges required by statute. Forms for such return shall be provided by the Division.

(A) Surcharges paid by self-insured employers shall be based upon the manual premium, adjusted by Pinnacol Assurance discounts applicable for the surcharge period covered and modified by the experience rating factor as calculated by the National Council on Compensation Insurance (NCCI). No other rating factor shall be allowable. The self-insured employer may elect not to provide such a rating factor; however, failure to submit the required rating factor will result in the premium surcharge being computed on the basis of manual premium only.

(B) If the self-insured employer is unable to develop the experience rating factor due to the unavailability of reliable and adequate data, the employer may apply to the Director for approval to use a 1.0 experience rating factor for the following two semiannual surcharge periods. If at the conclusion of the two semiannual surcharge periods that the 1.0 factor is used, the NCCI has been unable to develop an experience modification, the Director may permit an extension of time for the 1.0 factor to be used.

(C) In order that consideration be given to the experience modification, a completed NCCI form setting forth all of the information and methodology used in the calculation of the experience modification shall accompany each corresponding payroll report.

(A) The premium and payroll surcharges for the semiannual period beginning July 1, shall be based upon premiums written, including any policy expense constants, membership fees, finance and service, or other administrative fees charged to the policyholder in connection with the issuance or renewal of a policy, as reported to the Division of Insurance in accordance with §10-3-208, C.R.S., and regulations promulgated thereunder, for Colorado workers' compensation insurance or the self-insured employer's total payroll during the previous six months, and shall be paid to the Division on or before July 31 of that year, with a return form provided by the Division.

(B) The premium and payroll surcharges for the semiannual period beginning January 1 shall be based upon premiums written, including any policy expense constants, membership fees, finance and service, or other administrative fees charged to the policyholder in connection with the issuance or renewal of a policy, as reported to the Division of Insurance in accordance with §10-3-208, C.R.S., and regulations promulgated thereunder, for Colorado workers' compensation insurance or the self-insured employer's total payroll during the previous six months, and shall be paid to the Division on or before January 31 of that year, with a return form provided by the Division.

(C) An insurance carrier is entitled to a credit for canceled or returned premiums, including any policy expense constants, membership fees, finance and service, or other administrative fees charged to the policyholder in connection with the issuance or renewal of a policy, as reported to the Division of Insurance in accordance with §10-3-208, C.R.S., and regulations promulgated thereunder, actually refunded. The credit must be taken as an offset against surcharges due within one year of the date the premium amount was refunded.

(D) An insurance carrier or employer is not entitled to offset a credit of one subsidiary against the surcharge owed by another subsidiary.

(A) For the annual period beginning July 1, 2009 and continuing indefinitely with annual review by the Director, the workers' compensation cash fund premium surcharge rate authorized under §8-44-112(1)(a), C.R.S., shall be 1.5 percent of the amount of all premiums written, including any policy expense constants, membership fees, finance and service, or other administrative fees charged to the policyholder in connection with the issuance or renewal of a policy, as reported to the Division of Insurance in accordance with §10-3- 208, C.R.S., and regulations promulgated thereunder, or the premium equivalent amount established in section 2-3 of this rule, for Colorado workers' compensation insurance during the period of January 1, 2009 continuing indefinitely.

(B) For the purpose of funding the direct and indirect costs of the Premium Cost Containment program of the Division as authorized under §8-44-112(1)(b)(I), C.R.S., there is added to the surcharge imposed pursuant to Section 2-5 of this rule, an additional increment for the annual period beginning July 1, 2009 and continuing indefinitely with annual review by the Director, against workers' compensation insurance premiums written, including any policy expense constants, membership fees, finance and service, or other administrative fees charged to the policyholder in connection with the issuance or renewal of a policy, as reported to the Division of Insurance in accordance with §10-3-208, C.R.S., and regulations promulgated thereunder, during the period of January 1, 2009, continuing indefinitely. The amount of this assessment shall be 0.03 percent. No assessment shall be imposed upon self-insured employers under this subsection.

(C) For the purposes of funding the financial liabilities of the Subsequent Injury Fund as authorized under §8-46-102(2)(A)(I), C.R.S. And the Major Medical Fund under §8-46-202, C.R.S., for the period beginning July 1, 2009, and continuing indefinitely with annual review by the Director, the tax shall be assessed at 2.088 percent of the amount of Workers' Compensation premiums written, including any policy expense constants, membership fees, finance and service, or other administrative fees charged to the policyholder in connection with the issuance or renewal of a policy, as reported to the Division of Insurance in accordance with §10-3-208, C.R.S., and regulations promulgated thereunder, or the premium equivalent amount established in Section 2-3 of this rule, for Colorado Workers' Compensation insurance during the period of January 1, 2009, continuing indefinitely.

(A) The Division designates the National Council on Compensation Insurance, Inc. (NCCI) as its agent to receive, process, and make available to the Division, all the required notices. Insurance carriers shall transmit this data and all other data elements in the electronic format as directed by the Division through NCCI.

(B) Every insurance carrier shall advise the Division, by filing with NCCI, notice of the issuance or renewal of insurance coverage within thirty (30) calendar days of the effective date of coverage.

(C) Every insurance carrier shall advise the Division, by filing with NCCI, final notice of the cancellation of insurance coverage no later than thirty (30) calendar days after coverage is actually canceled. This subsection does not pertain to the preliminary notice of cancellation referenced in §8-44-110, C.R.S.

(D) Every employer shall provide on request to its insurance carrier all federal employer identification number(s) (“FEINS”) or other taxpayer identification number(s) for all the employer’s business operations, client companies, and/or any other similar employing entities, in Colorado to which the insurance applies. All changes in FEIN or other taxpayer I.D. numbers shall be reported immediately to the insurance carrier. The insurance carrier shall report all changes in FEINS and taxpayer I.D. numbers to NCCI within thirty (30) calendar days of receipt.

(E) For purposes of the performance of the Director’s responsibilities under §8-43-409, the prehearing conference and any hearing that the Director may determine necessary as referenced in §8-43-409(1), may be conducted, as determined by the Director, by any competent person appointed by the Director under § 8-43-208 or § 8-47-101 or by such other person as the Director may designate.

Every insurance carrier shall notify the Division’s designated agent of the name, address and telephone number of its representative responsible for reporting coverage information. This information shall be provided within thirty (30) days upon request of either the Division or its agent, or within thirty (30) days of a change in the information.

(A) Any pool authorized to self-insure shall advise the Division in writing of the effective date of self-insurance, the name and address of the pool administrator and the federal employer identification number of each covered member. This information shall be provided within thirty (30) days upon request of either the Division or its agent, or within thirty (30) days of a change in the information.

(B) All individual self-insurance permit holders shall advise the Division in writing of the federal employer identification number of the permit holder as well as of all covered subsidiaries. This information shall be provided within thirty (30) days upon request of either the Division or its agent, or within thirty (30) days of a change in the information.

(A) An officer of a corporation or a member of a Limited Liability Company who elects to reject the provisions of the Act under §8-41-202, C.R.S., shall complete the Division prescribed form and send it or a substantial equivalent, to the insurance carrier for the corporation’s or company’s other employees, if any, by certified mail. An agricultural corporation electing to reject coverage for its corporate officers pursuant to §8-40-302(6), C.R.S., shall notify the insurance carrier in writing. If there is no insurance carrier, such documents shall be provided, by certified mail, to the Division.

(B) The Notice of Election to Reject Coverage shall become effective the next business day following receipt of the notice by the insurance carrier or, if none, by the Division.

(A) Every employer shall continuously post a notice to employees in one or more conspicuous places on the employer’s work site advising employees that the employer is insured for workers’ compensation as required by law, identifying the name of the employer’s insurance carrier or stating that the employer is self-insured, and containing information about the Colorado workers’ compensation system on a form prescribed or approved by the Division and furnished by the carrier or self-insured.

(B) Every employer also shall continuously post a notice to employees in one or more conspicuous places on the employer’s work site advising employees that written notice must be given to an employer within 4 working days after an injury as set forth in §8-43-102(1) or (1.5), C.R.S.

3-6 FINES FOR DEFAULTING EMPLOYER

(A) Following the Director’s determination that an employer has failed to obtain the required insurance or has failed to keep such insurance in force or has allowed the insurance to lapse or has failed to renew such insurance, the Director will impose fines on the defaulting employer and/or will compel the employer to cease and desist its business operations.

(B) For the Director’s initial finding that an employer is or was in default of its insurance obligations, daily fines up to $250/day for each day of default will be assessed in accordance with the following schedule of fines until the employer complies with the requirements of the Workers’ Compensation Act regarding insurance or until further order of the Director:

(C) Where the Director determines that an employer was required to but did not have a policy of workers’ compensation insurance in place during any period between July 1, 2005 and the date the employer is sent a Notice to Show Compliance and where such employer has not previously been sent a Notice to Show Compliance, the Director may regard such violation as a Class I violation under Rule 3-6 (B) and impose the fine therein provided for each day of the employer’s default during such period.

(D) For the Director’s finding of an employer’s second and all subsequent defaults in its insurance obligations, daily fines from $250/day up to $500/day for each day of default will be assessed in accordance with the following schedule of fines until the employer complies with the requirements of the Workers’ Compensation Act regarding insurance or until further order of the Director:

(A) Every insurer shall submit to compliance audits of its claims by the Division of Workers’ Compensation. The purpose of compliance audits is to examine whether claims are adjusted in accordance with the Workers’ Compensation Act and the Workers’ Compensation Rules of Procedure. Compliance audits are a method for the Division to regulate and oversee the Workers’ Compensation System. A compliance audit conducted pursuant to this Rule 4 is intended to be an autonomous process.

(1) Identifying and underlying claim information examined as part of a compliance audit is accessible only to the insurer under review and shall not otherwise be open to any person except upon order of the Director. If the Director issues an order in a specific claim the order will be sent to all parties.

(2) Division personnel shall give advance written notice of the compliance audit to the insurer and provide an initial list of claims to be audited. If additional information is requested for the compliance audit, it must be provided. Unless the Division determines that circumstances warrant otherwise, the insurer will be given at least 15 calendar days notice.

(3) The insurer shall make the claims selected for the compliance audit and any requested information, including training and procedure manuals, available to the auditor at the time and place designated by the auditor. If the audit requires out-of-state travel by the auditor, the insurer may be required to pay travel costs.

(4) Failure to make claims and/or information requested by the auditor available to the auditor for audit shall be considered willful refusal to comply with Division efforts.

(5) The insurer shall indicate the dates of its receipt on all documents it files with the Division as well as on all medical bills and reports. For those documents required to be exchanged, the insurer shall indicate on the face of the documents or by some other verifiable method, the date the documents were mailed or delivered and to whom they were mailed or delivered.

(B) A compliance level will be determined for each category examined during the audit. A compliance level is the ratio of deficiencies found within a category in relation to the total number of applicable audit inquiries reviewed in that category. A deficiency is a failure to comply with statute or rule. The categories to be examined during the compliance audit may include but are not limited to the following:

(C) For the categories listed in subparagraphs 1 through 7 in paragraph (B) of this Rule 4-1, fines will be imposed for the repeated failure to demonstrate satisfactory compliance. A compliance level of 90% or higher is considered satisfactory compliance. No fine will be imposed for deficiencies in any category in which satisfactory compliance is determined in the compliance audit. For the categories listed in subparagraphs 8 through 10 in paragraph (B) of this Rule 4-1, the auditor will comment upon the insurer’s adjusting practices but fines will not be imposed for deficiencies found on compliance audits in those categories.

(D) After reviewing the insurer’s procedures and examining the claims selected for audit and other information requested, the auditor will provide the insurer with preliminary audit findings, including compliance levels. Thereafter:

(1) The insurer will have thirty (30) calendar days within which to agree in writing with the preliminary audit findings. If the insurer does not agree with the preliminary audit findings it shall, within the same 30 calendar days, state with particularity and in writing to the auditor its reasons for all disagreements and provide therewith in writing all relevant legal authority, and/or other relevant proof upon which it relies in support of its position(s) concerning its disagreements with the preliminary findings.

An extension of time not to exceed 30 additional days may be granted to the insurer to submit its written reasons for disagreement and to provide the authority and/or proof upon which it relies as is required by this rule by filing a written request for such extension of time with the auditor prior to the expiration of the 30 calendar days afforded to the insurer to agree with the preliminary findings. Any disagreement not so submitted to the auditor within the 30 day period or within such additional time as was granted in response to the insurer’s written request for an extension of time is waived.

(2) The auditor, the auditor’s manager and the insurer shall have twenty (20) calendar days after submission of the written disagreement with the preliminary audit findings within which to resolve those disagreements and to agree to the preliminary audit findings.

(3) If the auditor, the auditor’s manager, and the insurer are unable to agree on the preliminary findings within the 20 day period afforded in paragraph (D)(2) of this Rule 4-1, the preliminary audit findings along with the insurer’s written disagreements will be referred to the Director for the Director’s determination regarding the audit findings. The final determination of the relevance and/or weight given to any authority or proof submitted in connection with the insurer’s disagreements regarding audit findings is reserved to the Director.

(4) When a determination regarding audit findings has been made by the Director, the Director will thereafter cause the Final Audit Report to be prepared and/or order such other action as the Director may determine warranted.

(5) When the insurer has agreed to the preliminary audit findings without disagreement, or when the insurer fails to disagree therewith in the manner provided in this Rule 4-1(D) or, when the insurer agrees to the preliminary findings before the time for referral to the Director under Rule 4-1(D)(4) has occurred, or when the Director has made a determination regarding audit findings as provided in paragraph (D) of this Rule 4-1, the Final Audit Report will issue. The Final Audit Report will contain a summary of the final audit findings, comments on the insurer’s adjusting practices, and a determination of the insurer’s compliance levels. Fines will be ordered as determined by the Director in accordance with Rule 4-2.

(6) Insurers may be required to correct deficiencies in all claims covered by the audit period if the compliance level for any identified category is below 90%. Insurers may also be required to undergo training if indicated by audit results or for such other reasons as may be determined by the Director.

(A) An insurer’s first audit conducted after January 1, 2006 measures and establishes the insurer’s levels of compliance with applicable statutes and rules in identified categories. A compliance level below 90% in any compliance category is considered unsatisfactory. A compliance level below 90% in a compliance category listed in subparagraphs 1 through 7 in paragraph (B) of Rule 4-1, on consecutive compliance audits is considered repeated non-compliance. Repeated non-compliance in any category set out in Rule 4-1(B)(1) through (7) shall result in the insurer being ordered to pay a fine.

(B) In order for an insurer’s unsatisfactory performance to result in fines for failure to meet the 90% compliance standard in any category set out in Rule 4-1(B)(1) through (7), its compliance level in that category must be below 90% on at least two consecutive audits.

(C) Each category for which a fine may be imposed has a fine schedule. The amount of any fine will be determined in accordance with the findings in the Final Audit Report and in accordance with this Rule 4-2. Fines for repeated violations in any category set out in Rule 4-1(B)(1) through (7) are based on the compliance level for that category and as set out in this Rule 4-2.

(D) The dollar amount of a fine is arrived at by first locating the insurer’s compliance level on the appropriate schedule found in paragraph (E) of this Rule 4-2. The number of identified deficiencies in the relevant category is multiplied by the “per deficiency” dollar amount for the appropriately numbered finable occurrence indicated in the schedule to arrive at a fine amount for that category.

(A) Information required on Division forms shall be typed or legibly written in black or blue ink, completed in full and in accordance with Division requirements as to form and content. Forms that do not comply with this rule may not be accepted for filing. Position statements relative to liability which do not meet Division requirements will be returned to the insurer.

(B) Insurers may transmit data in an electronic format as directed by the Division.

(C) Effective July 1, 2006, all first reports of injury and notices of contest that are required to be filed with the Division shall be transmitted electronically. Transmitted electronically includes either electronic data interchange (EDI), or via the Division’s internet filing process. First Reports of Injury and Notices of Contest cannot be submitted via electronic mail.

(D) The Director may grant an exemption to an insurer from filing electronically because of a small number of filings or financial hardship. Any insurer requesting an exemption from electronic filing may do so in letter form addressed to the Director. The request should provide specific justification(s) for the requested exemption. The letter should address whether an exemption is sought for only EDI or also for internet filing.

(A) Within ten days of notice or knowledge an employer shall report any work-related injury, illness or exposure to an injurious substance as described in subsection (F), to the employer’s insurer. An employer who does not provide the required notice may be subject to penalties or other sanctions.

(B) A First Report of Injury shall be filed with the Division in a timely manner whenever any of the following apply. The insurer or third-party administrator may file the First Report of Injury on behalf of the employer.

(1) In the event of an injury that results in a fatality, or an accident in which three or more employees are injured, the Division shall be notified immediately.

(2) Within ten days after notice or knowledge by an employer that an employee has contracted an occupational disease listed below, or the occurrence of a permanently physically impairing injury, or that an injury or occupational disease has resulted in lost time from work for the injured employee in excess of three shifts or calendar days. An occupational disease that falls into any of the following categories requires the filing of a First Report of Injury:

        (a) Chronic respiratory disease;
        (b) Cancer;
        (c) Pneumoconiosis, including but not limited to Coal worker’s lung, Asbestosis, Silicosis, and Berylliosis;
        (d) Nervous system diseases;
        (e) Blood borne infectious, contagious diseases.

(3) Within ten days after notice or knowledge of a claim for benefits, including medical benefits only, that is denied for any reason.

(C) The insurer shall state whether liability is admitted or contested within 20 days after the date the employer’s First Report of Injury is filed with the Division. If an Employer’s First Report of Injury should have been filed with the Division, but wasn’t, the insurer’s statement concerning liability is considered to be due within 20 days from the date the Employer’s First Report of Injury should have been filed. The date a First Report of Injury should have been filed with the Division is the last day it could have been timely filed in compliance with paragraph (B) above.

(D) The insurer shall state whether liability is admitted or contested within 20 days after the date the Division mails to the insurer a Worker’s Claim for Compensation or Dependent’s Notice and Claim for Compensation.

(E) No statement regarding liability is required unless a Workers’ Compensation claim number is assigned or a First Report of Injury should have been filed pursuant to paragraph (B) of this rule. The Division cannot accept a statement regarding liability without a First Report of Injury, Worker’s Claim for Compensation, or Dependents Notice and claim having been successfully filed and assigned a claim number.

(F) In the format required by the Director, each insurer shall submit a monthly summary report to the Division containing the following:

(1) Injuries to employees that result in no more than three days’ or three shifts’ loss of time from work, no permanent physical impairment, no fatality, or contraction of an occupational disease not listed in subsection (B) of the rule; and

(2) Exposures by employees to injurious substances, energy levels, or atmospheric conditions when the employer requires the use of methods or equipment designed to prevent such exposures and where such methods or equipment failed, was not properly used, or was not used at all.

At the time an insurer notifies the Division of its position on a claim, the insurer shall notify the claimant in writing of the insurer’s claim number, the name and address of the individual assigned to the adjustment of the claim, and the toll-free telephone number of the adjuster.

(A) Medical reports on claims that have been reported to the Division shall be filed with the Division under the following circumstances:

(1) When attached to an admission of liability form, or a petition to suspend benefits, or

(2) In connection with a request to the Division to determine the claimant’s eligibility for vocational rehabilitation benefits or to review a vocational rehabilitation plan, or to review requests regarding the provision of vocational rehabilitation services, or

(5) A copy of every medical report not filed with the Division shall be exchanged with all parties within fifteen (15) working days of receipt.

(B) For claims which are not required to be reported to the Division, the parties shall exchange medical information immediately upon request for such information by any interested party. Five (5) working days is considered to be a reasonable time within which to exchange information.

(C) A party shall have 15 days from the date of mailing to complete, sign, and return a release of medical and/or other relevant information. If a written request for names and addresses of health care providers accompanies the medical release(s), a claimant shall also provide a list of names and addresses of health care providers reasonably necessary to evaluate/adjust the claim along with the completed and signed release(s). Medical information from health care providers who have treated the part(s) of the body or conditions(s) alleged by the claimant to be related to the claim, during the period five years before the date of injury and thereafter through the date of the request, will generally be considered reasonable. If a party disputes that such request is reasonable or that information sought is reasonably necessary, that party may file a motion with the Office of Administrative Courts or schedule a prehearing conference. The request for and release of medical information as well as informal disclosures necessary to evaluate/adjust the claim are not considered discovery.

(D) A party shall have 15 days from the date of mailing to respond to a reasonable request for information regarding wages paid at the time of injury and for a reasonable time prior to the date of injury, and other relevant information necessary to determine the average weekly wage. Any dispute regarding such a request may be resolved by the Director or an Administrative Law Judge. The
request for and exchange of information under this Rule 5-4(D) is not considered discovery.

(A) When the final admission is predicated upon medical reports, such reports shall accompany the admission along with the worksheets or other evaluation information associated with an impairment rating. The admission shall specify and describe the insurer’s position on the provision of medical benefits after MMI, as may be reasonable and necessary within the meaning of the Act. The admission shall make specific reference to the medical report by listing the physician's name and the date of the report.

(1) The objection form prescribed by the Division as part of the final admission form shall precede any attachment.

(B) An admission filed for medical benefits only, shall include remarks outlining the basis for denial of temporary and permanent disability benefits.

(C) Admissions shall be filed with supporting attachments immediately upon termination or reduction in the amount of compensation benefits. An admission shall be filed within 30 days of resumption or increase of benefits.

(D) For all injuries required to be filed with the Division with dates of injury on or after July 1, 1991:

(a) When an authorized treating physician providing primary care is not Level II accredited and has determined the claimant has reached MMI and has sustained any permanent impairment, such physician shall, within 20 days after the determination of MMI, refer the claimant to a Level II accredited physician for a medical impairment rating. If the referral is not timely made, the insurer shall refer the claimant to a Level II accredited physician for a medical impairment rating within 40 days after the determination of MMI.

(b) If the authorized treating physician determining MMI is Level II accredited, within 20 days after the determination of MMI, such physician shall determine the claimant’s permanent impairment, if any.

(a) When an authorized treating physician providing primary care is not Level II accredited and has determined the claimant has reached MMI and has sustained any permanent impairment, within 20 days after the determination of MMI, such physician shall conduct tests to evaluate impairment and shall transmit to the insurer all test results and relevant medical information. Within 20 days of receipt of the medical information, the insurer shall appoint a Level II accredited physician to determine the claimant’s medical impairment rating from the information that was transmitted.

(b) When the claimant chooses not to have the treating physician providing primary care conduct tests to evaluate impairment, or if the information is not transmitted in a timely manner, the insurer shall arrange and pay for the claimant to return to Colorado for examination, testing, and rating, at the expense of the insurer. The insurer shall provide to the claimant at least 20 days advance written notice of the date and time of the impairment rating examination, and a warning that refusal to return for examination may result in the loss of benefits. Such notification shall also include information identifying travel and accommodation arrangements.

(E) For those injuries required to be filed with the Division with dates of injury on or after July 1, 1991, and subject to §8-42-107(8), C.R.S., medical impairment:

Within 30 days after the date of mailing or delivery of a determination of medical impairment by an authorized Level II accredited physician, or within 30 days after the date of mailing or delivery of a determination by the authorized treating physician providing primary care that there is no impairment, the insurer shall either:

(1) File an admission of liability consistent with the physician’s opinion, or

(2) Request a Division Independent Medical Examination (IME) on the issue of medical impairment in accordance with Rule 11-3.

(F) Within 30 days after the date of mailing of the IME’s report determining medical impairment the insurer shall either admit liability consistent with such report or file an application for hearing. This section does not pertain to IMEs rendered under §8-43-502, C.R.S.

(G) The insurer may modify an existing admission regarding medical impairment, whenever the medical impairment rating is changed pursuant to a binding IME, an IME selected in accordance with RULE 5-5(E); or an order. Any such modifications shall not affect an earlier award or admission as to monies previously paid.

(H) For those injuries required to be filed with the Division with dates of injury on or after July 1, 1991, and subject to §8-42-107(2), C.R.S. scheduled injuries:

(2) Within 30 days after a determination of permanent impairment from an authorized Level II accredited physician is mailed or delivered, or a determination by the authorized treating physician providing primary care that there is no impairment is mailed or delivered, the insurer shall either:

(a) File an admission of liability consistent with the physician’s opinion, or

(I) When an insurer files an admission admitting for a medical impairment, the insurer shall admit for the impairment rating in a whole number. If the impairment rating is reported with a decimal percentage, the insurer shall round up to the nearest whole number.

(J) This section (J) applies to claims with a date of injury on or after July 1, 2008. A carrier may not reduce a claimant’s temporary total disability, temporary partial disability or medical benefits because of a prior injury, whether work-related or non work-related.

(A) Benefits awarded by order are due on the date of the order. After all appeals have been exhausted or in cases where there have been no appeals, insurers shall pay benefits within thirty days of when the benefits are due. Any ongoing benefits shall be paid consistent with statute and rule.

(B) Temporary disability benefits awarded by admission are due on the date of the admission and the initial payment shall be paid so that the claimant receives the benefits not later than 5 calendar days after the date of the admission. Temporary total disability benefits are payable at least once every two weeks thereafter. In some instances an Employer’s First Report of Injury and admission can be timely filed, but the first installment of compensation benefits will be paid more than 20 days after the insurer has notice or knowledge of the injury. So long as the filings are timely and benefits timely paid and for the entire period owed as of the date of the admission, the insurer will be considered in compliance.

(C) Permanent disability benefits awarded by admission are retroactive to the date of maximum medical improvement and shall be paid so that the claimant receives the benefits not later than 5 calendar days after the date of the admission. Subsequent permanent disability benefits shall be paid at least once every two weeks.

(D) An insurer shall receive credit against permanent disability benefits for any temporary disability benefits paid beyond the date of maximum medical improvement.

(A) Permanent partial disability benefits paid as compensation for a non-scheduled injury or illness which occurred on or after July 1, 1991, shall be paid at the temporary total disability rate, but not less than one hundred fifty dollars per week and not more than fifty percent of the state average weekly wage at the time of the injury.

(B) Scheduled impairment benefits shall be paid at the calculated rate pursuant to §8-42-107 (6) C.R.S.

(C) Where scheduled and non-scheduled injuries occurred resulting in impairment, the impairment benefits and the scheduled impairment benefit shall be paid concurrently.

(A) An insurer shall file an admission of liability for permanent total disability benefits on a final admission of liability form prescribed by the Division.

(B) An insurer may terminate permanent total disability benefits without a hearing by filing an admission of liability form with all of the following attachments:

(2) A receipt or other proof substantiating payment of compensation to the claimant through the date of death; and

(b) If there are dependents, the unpaid portion of permanent total disability benefits the claimant would have received had s/he lived until receiving compensation at the regular rate for a period of six years.

(A) Within the time limits for objecting to the final admission of liability pursuant to §8-43-203, C.R.S., the Director may allow an insurer to amend the admission for permanency, by notifying the parties that an error exists due to a miscalculation, omission, OR clerical error.

(B) The period for objecting to a final admission begins on the mailing date of the last final admission.

(C) This subsection applies to claimants with an open claim with dates of injury on or after July 1, 1991 and before August 5, 1998 with the most recent and valid Final Admission of Liability filed before September 1, 1999 to which a timely objection was filed by the claimant but no Division independent medical examination was held before September 1, 1999. The carrier, self-insured employer, or non-insured employer may file an amended Final Admission of Liability providing notice to the claimant of the requirement to mail a notice and proposal to select an independent medical examiner per §8-42-107.2 C.R.S. Failure to provide such notice by amended Final Admission of Liability as indicated in this subsection shall preclude the carrier, self-insured employer or non-insured employer from asserting that the claimant failed to timely file a notice and proposal to select an independent medical examiner per §8-42-107.2 C.R.S. If the notice is provided by amended Final Admission of Liability the carrier, self-insured employer or non-insured employer is not precluded from subsequently raising any relevant equitable argument, such as waiver, laches or estoppel, regarding whether the notice and proposal was timely filed.

(A) When the permanent partial disability award is for whole person or scheduled impairment and the injury or illness occurred on or after July 1, 1991, the following applies per § C.R.S. 8-42-107 (8):

(1) Where the injury or illness occurred on or after July 1, 1991, but prior to April 29, 1992, a lump sum payment of $10,000.00 or the remainder, if less, may be paid on the claimant’s written request to the insurer. The insurer shall respond within ten (10) business days from the date of the mailing of the request as to whether it will grant the lump sum. If a lump sum is granted, the insurer shall calculate the sum certain and issue payment taking applicable offsets (i.e., disability benefits, incarceration, garnishments) within ten (10) business days from the date of mailing of the request by the claimant.

(2) Where the injury or illness occurred on or after April 29, 1992, a lump sum of $10,000.00 or the remainder, if less shall automatically be paid, less discount, on the claimant’s written request to the insurer. The insurer shall calculate the sum certain and issue payment taking applicable offsets (i.e., disability benefits, incarceration, garnishments) within ten (10) business days from the date of mailing of the request by the claimant.

(1) If the claimant is represented by counsel, a request for a lump sum payment of a portion or remaining permanent partial, permanent total, or dependents’ benefits shall be made by submitting a Request for Lump Sum Payment form to the insurer and the Division, if the claimant has indicated that the admission will be accepted as filed, relative to permanency and maximum medical improvement. The requirement to accept the admission relative to permanency and maximum medical improvement does not apply to paragraph A (2) above. Within ten (10) business days of the date the Request for Lump Sum Payment form was mailed, the insurer shall issue the payment and file the required benefit payment information with the Division, the claimant and the claimant’s attorney.

(2) The insurer shall have ten (10) business days from the claimant’s request to object to the payment of the lump sum. Prior to payment and within the same ten (10) day time period, the insurer shall submit the lump sum calculations to claimant, claimant’s attorney and the Division providing the reason for the objection. Upon receipt of the form the Director shall make a determination on the lump sum request.

(3) The claimant shall have ten (10) business days from the date the payment or payment information was mailed to object to the accuracy of the payment by stating the basis for the objection, in writing, to the Division and insurer. Following receipt of the objection, the Director shall make a determination on the lump sum payment.

(1) If the claimant is not represented by counsel, a request for a lump sum payment of a portion or remaining permanent partial, permanent total, or dependents’ benefits shall be made by submitting a Request for Lump Sum Payment to the insurer and the Division if the clamant has indicated that the admission will be accepted as filed, relative to permanency and maximum medical improvement. Within ten (10) business days of the date the Request for Lump Sum Payment form was mailed, the insurer shall file the required lump sum calculation information with the Division and the claimant.

(2) The claimant shall have ten (10) business days from the date of mailing of the benefit payment information provided by the insurer to object to the accuracy of this information. In the absence of an objection, a lump sum order issued by the Director will be based upon the information submitted.

(D) The insurer shall issue payment within ten (10) business days of the date of mailing of the order by the Director.

(A) The workers’ compensation benefit amount is based upon a seven day calendar week.

(B) An insurer shall file a final payment notice in every compensable claim that was filed with the Division in which benefits were paid. The final payment notice shall reflect cumulative totals for all benefits paid and be submitted in the format required by the Division. A final payment notice shall be filed after all compensation issues have been resolved by final admission, final order or stipulation. The final payment notice shall be filed within 60 days after the claim is closed. For permanent total claims, a final payment notice shall be filed within 60 days after benefits have terminated. If a claim is reopened a final payment notice shall be filed within 60 days after the reopened claim closes.

Upon demand of the Director, an insurer shall produce to the Division a receipt, canceled check, or other proof substantiating payment of compensation to the claimant or medical reimbursement to a provider or claimant.

Every insurer, or its designated claims adjusting administrator; shall provide the following information on claims adjusting practices to the Division:

(A) The name, address and telephone number of the administrator(s) responsible for its claims adjusting. This information shall be provided upon request or within 30 days of any change in the administrator(s) or the geographical location of the administrator(s). Notice of such change shall be provided in writing to both the claimant and the Division. Notice shall include the name, address, and toll-free telephone number of the claims administrator(s).

(B) A list of all claims established with the Division that are affected by the change described in the preceding paragraph. The list shall include claimant name, social security number, date of injury, insurer’s claim number, and worker’s compensation claim number, if available.

(C) Upon request of the Director, any or all records, including any insurer administrative policies or procedures, pertaining to the adjusting of Colorado Workers' Compensation claims. This authority shall not extend to personnel records of claims personnel. All documents shall remain confidential.

(A) In all claims based upon an injury or disease occurring on or after July 1, 1991, an insurer may terminate temporary disability benefits without a hearing by filing an admission of liability form with:

(1) a medical report from an authorized treating physician stating the claimant has reached maximum medical improvement; provided such admission of liability states a position on permanent disability benefits. This paragraph shall not apply in cases where vocational rehabilitation has been offered and accepted, or

(2) a medical report from the authorized treating physician who has provided the primary care, stating the claimant is able to return to regular employment, or

(3) a written report from an employer or the claimant stating the claimant has returned to work and setting forth the wages paid for the work to which the claimant has returned provided such admission of liability admits for temporary partial disability benefits, if any, or

(4) a letter to the claimant or copy of a written offer delivered to the claimant with a signed certificate indicating service, containing both an offer of modified employment, setting forth duties, wages and hours and a statement from an authorized treating physician that the employment offered is within the claimant’s physical restrictions. A copy of the written inquiry to the treating physician shall be provided to the claimant by the insurer or the insured at the time the authorized treating physician is asked to provide a statement on the claimant’s capacity to perform the offered modified duty. The claimant is allowed a period of 3 business days to return to work in response to an offer of modified duty. The 3 business days runs from the date of receipt of the job offer. Such admission of liability shall admit for temporary partial disability benefits, if any, or

(5) a copy of a certified letter to the claimant or a copy of a written notice delivered to the claimant with a signed certificate of service, advising that temporary disability benefits will be suspended for failure to appear at a rescheduled medical appointment with an authorized treating physician, and a statement from the authorized treating physician documenting the claimant’s failure to appear, OR

(6) a letter or death certificate advising of the death of the claimant with a statement by the insurer as to its liability for death benefits.

(A) In all claims based upon an injury or disease which occurred after July 2, 1987, at 4:16 p.m., an insurer may terminate disability benefits without a hearing by filing an admission of liability form with:

(1) a medical report from the authorized treating physician who has provided the primary care stating the claimant has reached maximum medical improvement; provided such admission of liability states a position on permanent disability benefits. This paragraph shall not apply in cases where vocational rehabilitation has been offered and accepted, or

(2) a medical report from the authorized treating physician who has provided the primary care stating the claimant is able to return to regular employment provided such admission of liability states a position on permanent partial disability benefits, or

(3) a written report from the employer or the claimant stating the claimant has returned to work and setting forth the wages paid for the work to which the claimant has returned; provided such admission of liability admits for temporary partial disability benefits, if any, or

(4) a letter or death certificate advising of the death of the claimant with a statement by the insurer as to its liability for death benefits.

(A) In all claims based upon an injury or disease which occurred prior to July 2, 1987, at 4:16 p.m., an insurer may terminate temporary disability benefits without a hearing by filing an admission of liability form with:

(1) a report from the authorized treating physician who has provided the primary care stating the claimant has reached maximum medical improvement and is released to return to an occupation which the claimant regularly performed at the time of the injury, or

(2) a report from the authorized treating physician who has provided the primary care stating the claimant has reached maximum medical improvement and a Director’s determination that the claimant is not eligible for vocational rehabilitation services, or

(3) a written report from the employer or the claimant stating the claimant has returned to work and setting forth the wages paid for the work to which the claimant has returned; provided such admission admits for temporary partial disability benefits, if any, or

(4) a letter or death certificate advising of the death of the claimant with a statement by the insurer as to its liability for death benefits, OR

(5) a report from the authorized treating physician who has provided the primary care stating the claimant has reached maximum medical improvement and documentation the claimant has completed an approved vocational rehabilitation plan.

(A) When an insurer seeks to suspend, modify or terminate temporary disability benefits pursuant to a provision of the Act, and Rules 6-1, 6-2, 6-3, 6-5, 6-6, 6-7 or 6-9 are not applicable, the insurer may file a petition to suspend, modify or terminate temporary disability benefits on a form prescribed by the Division. All documentation upon which the petition is based shall be attached to the petition. The petition shall indicate the type, amount and time period of compensation for which the petition has been filed and shall set forth the facts and law upon which the petitioner relies.

(B) A copy of a response form prescribed by the Division shall be mailed with a copy of the petition to the claimant and claimant’s attorney and the Division. Certification of this mailing shall be filed with the petition.

(C) If the claimant does not file a written objection with the Division within twenty (20) days of the date of mailing of the petition and response form, the Director may grant the insurer’s request to suspend, modify or terminate disability benefits as of the date of the petition.

(D) When a claimant files a timely objection to a petition, the insurer shall continue temporary disability benefits at the previously admitted rate until an application for hearing is filed with the Office of Administrative Courts, and the matter is resolved by order. The Director finds that good cause exists to expedite a hearing to be held within forty (40) days from the date of the setting, because overpayment of benefits may result if the suspension, modification or termination is granted.

(E) When a hearing is continued at the request of the claimant, the administrative law judge shall temporarily grant the relief requested in the petition, pending the continued hearing, if the reports and evidence attached to the petition and objection indicate a reasonable probability of success by the insurer. The continued hearing shall be held no later than 30 days from the date of the request for continuance.

(F) When a hearing is continued at the request of the insurer, temporary disability benefits shall continue until the matter is resolved by order after the hearing.

An insurer may modify temporary disability benefits to offset social security, disability pension or similar benefits pursuant to statute by filing an admission of liability form with the Division, with documentation which substantiates the offset and figures showing how the amount of the offset was calculated pursuant to statute.

An insurer may terminate or modify temporary disability benefits pursuant to statute, by filing an admission of liability form with the Division with a certified copy of a mittimus, or other document issued by a court of criminal jurisdiction, which establishes that the claimant is confined in a jail, prison, or any department of corrections facility as a result of a criminal conviction.

An insurer may terminate temporary disability benefits pursuant to statute, by filing an admission of liability form with the Division with a copy of a document substantiating the claimant received money damages from a third-party claim arising from the worker’s compensation injury and the amount of the award that may be offset pursuant to §8-41-203, C.R.S. and case law.

(A) Temporary disability benefits may not be suspended, modified or terminated except pursuant to the provisions of this rule or pursuant to an order from the Director under 6-4(C), or an order of the Office of Administrative Courts following a hearing.

(B) If the Director concludes the insurer has not met the applicable requirements of this rule, the Director may order the insurer to continue payment of temporary disability benefits, pursuant to §§8-42-105(3) and 8-42-106(2), C.R.S., until the requirements of this rule are followed or until a hearing is held and further order entered.

(A) An insurer may terminate temporary disability benefits by filing an admission of liability with:

(1) a copy of the initial written offer of modified employment provided to the claimant, which clearly states that future offers of employment need not be in writing, a description of the policy of the temporary help contracting firm regarding how and when employees are expected to learn of such future offers, and a statement that benefits shall be terminated if an employee fails to timely respond to an offer of modified employment;

(2) a written statement from the employer representative giving the date, time, and method of notification which forms the basis for the termination of temporary disability benefits; and

(3) a statement from the attending physician that the employment offered is within the claimant’s restrictions.

(B) The claimant is allowed a period of at least twenty-four hours, not including any part of a Saturday, Sunday, or legal holiday within which to respond to any such offer.

Rule 7 Closure of Claims, Approval of Settlement Agreements and Petitions to Reopen

(A) A claim may be closed by order, final admission, or pursuant to paragraph (C) of this section.

(B) A Final Admission of Liability may be filed based on abandonment of the claim if the claimant:

(2) has not attended two or more consecutive scheduled medical appointments; and

(3) has failed to respond within 30 days to a letter from the insurer or the insured asking if the claimant requires additional medical treatment or is claiming permanent impairment. The letter shall be sent to the claimant and the claimant’s attorney if the claimant is represented. The letter must also advise the claimant in bold type and capital letters that failure to respond to the letter within 30 days will result in a final admission being filed. If the claimant timely responds to the letter the insurer may not file a Final Admission of Liability pursuant to this rule.

A. If a claim is abandoned and a Final Admission of Liability is filed pursuant to this rule, an MMI date should not be included.

B. A copy of the letter sent to the claimant must be attached to the final admission of liability.

C. If the claimant timely objects to a final admission of liability filed pursuant to this rule the insurer must withdraw the final admission and provide an opportunity for the claimant to attend a medical appointment(s).

(C) When no activity in furtherance of prosecution has occurred in a claim for a period of at least 6 months, a party may request the claim be closed.

(1) The request to close the claim shall include a separate, properly captioned proposed order to show cause and prepared certificate of mailing, along with addressed, stamped envelopes for the claimant, insurer and each attorney of record who has entered an appearance in the case.

(2) Following receipt of a request to close a claim, the Director may issue the order to show cause why the claim should not be closed. If no response is mailed or delivered within 30 days of the date the order was mailed, the claim shall be closed automatically, subject to the reopening provisions of §8-43-303, C.R.S. If a response is timely received, the Director will determine whether the claim should remain open.

(D) An application for hearing or for a Division Independent Medical Examination without further action does not automatically constitute prosecution.

(A) When the parties enter into a full and final settlement of a claim, they shall use the appropriate form settlement agreement prescribed by the Division of Workers’ Compensation. The parties shall not alter the prescribed form, except as set out in subparagraphs (1) and (2) below. Parties who are settling a claim for a fatality are not required to use the Division’s prescribed form settlement agreement.

(1) When the claimant is represented by counsel the parties shall use the “Workers’ Compensation Claim(s) Settlement Agreement: Represented Claimant.” The parties may include terms in Paragraph 9(A) that are both specific to that agreement and involve an issue or matter that falls within the Workers’ Compensation Act. The parties may attach other written agreements to the prescribed form and may refer to these agreements in Paragraph 9(B) of the settlement agreement. These other written agreements may include a Workers’ Compensation Medicare Set-Aside Arrangement (WCMSA), an agreement involving employment, or a waiver of bad faith. These other written agreements attached to a settlement agreement shall not be reviewed and approval of the settlement agreement does not constitute approval of any written agreement attached to the settlement agreement. If a represented claimant does not wish to waive the right to an appearance before the Director to review the terms of the agreement, a settlement proceeding shall be scheduled with the Division’s Pre-Hearing Unit.

(2) When the claimant is unrepresented the parties shall use the “Pro Se (Unrepresented) Workers’ Compensation Claim(s) Settlement Agreement.” The parties may include terms in Paragraph 9(A) that are both specific to that agreement and involve an issue or matter that falls within the Workers’ Compensation Act. The parties may attach a Workers’ Compensation Medicare Set-Aside Arrangement (WCMSA) to the prescribed form and may refer to the WCMSA in Paragraph 9(B) of the settlement agreement. The parties shall not attach any other written agreement to the settlement agreement. A settlement proceeding shall be scheduled with the Division’s Pre-Hearing Unit to consider approval of this agreement.

(B) The parties shall file the original, with all original signatures, plus two copies of a settlement agreement and a completed settlement routing sheet. The settlement agreement must be signed by all parties with the claimant’s signature verified by a Notary Public consistent with the Notaries Public Act. A proposed order in the form prescribed by the Division must also be provided.

(C) Parties requesting approval of a stipulation resolving one or more issues in dispute shall submit a motion for approval of joint stipulation to the Director or an ALJ and should not use the Division’s prescribed form settlement agreement.

(A) A claimant or insurer may request to reopen a claim, pursuant to §8-43-303, C.R.S. by submitting a request to reopen on the Division prescribed form. The request must be provided to the other party and all attorneys of record. The request shall state the basis for reopening, and supporting documentation must accompany the request.

(1) If the other party agrees to reopen the claim the Division must be notified by the insurer in writing or by admission.

(2) Upon request to reopen the requesting party may file an Application for Hearing with the Office of Administrative Courts.

(B) For those injuries arising after July 2, 1987 at 4:16 p.m. and prior to July 1, 1991, a Petition to Reopen shall be filed when a claimant is requesting a redetermination of the original permanent partial disability award pursuant to Section §8-42-110(3), C.R.S., (repealed 7/1/91). The petition shall be filed with a statement outlining the circumstances of termination from employment.

(A) Employers who meet the criteria in §8-43-404(5)(a)(I)(B) or (II)(A), are exempt from the requirement to provide a list of at least two physicians or two corporate medical providers, or at least one physician and one corporate medical provider, when notified of an on the job injury. This Rule 8 does not apply to those exempt employers, except for the provisions of 8-2(B) and (C). If emergency care is provided an exempt employer may designate an authorized treating physician as allowed by statute when emergency care is no longer required. If an exempt employer refers an injured worker to a physician who can attend the injured worker when the injury occurred while the worker was away from the worker’s usual place of employment, such employer may designate an authorized treating physician as allowed by statute within seven (7) business days following the date the employer has notice of the injury. If an exempt employer does not properly designate an authorized treating physician as allowed by statute the injured worker may select a provider of the worker’s choosing.

(A) When an employer has notice of an on the job injury, the employer or insurer shall provide the injured worker with a written list in compliance with §8-43-404(5)(a)(I)(A), that for purposes of this rule 8 will be referred to as the designated provider list, from which the injured worker may select a physician or corporate medical provider.

1) The designated provider list can initially be provided to the injured worker verbally or through an effective pre-injury designation. If provided verbally or through a pre-injury designation, a written designated provider list shall be mailed, hand-delivered or furnished in some other verifiable manner to the injured worker within seven (7) business days following the date the employer has notice of the injury.

2) The designated provider list shall state the insurer responsible for the claim, or that the employer is self-insured. In addition, the designated provider list shall include the name and contact information of the person, or a maximum of two people, that the employer and/or insurer designate as their representative(s). For purposes of this Rule 8, the person or people so designated shall be referred to as the respondents’ representative(s).

(B) In an emergency situation the injured worker shall be taken to any physician or medical facility that is able to provide the necessary care. When emergency care is no longer required the provisions of paragraph (A) of this rule apply.

(C) If the injured worker is away from the worker’s usual place of employment at the time of the injury, the injured worker may be referred to a physician in the vicinity where the injury occurred who can attend to the injury. Within seven (7) business days following the date the employer has notice of the injury the employer shall comply with the provisions of paragraph (A) of this rule.

(D) If the employer fails to comply with this Rule 8-2, the injured worker may select an authorized treating physician of the worker’s choosing.

(A) An interested party to a particular claim, as referenced in §8-43-404(5)(a)(I)(A) and for purposes of this Rule 8-3, includes the injured worker, the attorneys of record, the employer, the insurer, and any third party administrator authorized to handle the specific claim.

(B) In order to provide information to assist in choosing a physician or deciding to change physicians, an interested party is entitled to receive a list of ownership interests and employment relationships involving the provision of medical care, if any, by making a written request for such information from a designated provider. A copy of the written request must be provided by the interested party to the respondents’ representative(s). A physician who provides medical services on behalf of a corporate medical provider, but does not act as a primary care physician, is not subject to this provision. A designated provider shall utilize a form established by the Division to provide this information.

1) The designated provider’s list of ownership interests and employment relationships shall be current to within thirty (30) days of the date of the request.

2) If the form was not previously provided and an interested party requests such information from a designated provider, the form shall be provided within five (5) business days of the request.

3) If the information referenced in this paragraph (B) is provided, no follow-up questions or request for additional information shall be permitted, except for information allowed pursuant to a hearing or discovery process.

(C) If the list of ownership interests and employment relationships was not previously provided, and an interested party requests the information in compliance with the provisions of Rule 8-3(B) and the information is not provided in a timely manner, the interested party may notify the respondents’ representative(s) in writing. To be effective, such notification must be made within seven (7) business days following the date the information should have been provided.

1) Within seven (7) business days following timely notification pursuant to this paragraph (C), the injured worker shall be provided with a substitute authorized treating physician. If a substitute authorized treating physician is not timely furnished the injured worker may select an authorized treating physician of the worker’s choosing.

(A) If an employer has a qualified on-site health care facility, the employer may designate that facility as the authorized treating physician.

(B) To be a qualified on-site health care facility under this Rule 8-4, the on-site facility must be under the supervision and control of a physician, and a physician must be on the premises or reasonably available.

(C) If the employer designates an on-site health care facility, the employer must, within seven (7) business days following notice of an on the job injury, provide the injured worker with a designated provider list consistent with the provisions of Rule 8-2(A)(2). While the on-site health care facility shall be the initial authorized treating physician, the injured worker may thereafter change to a physician or corporate medical provider on the designated provider list if the injured worker complies with all statutory and rule requirements for the one time change of physicians.

(A) Within ninety (90) days following the date of injury, but before reaching maximum medical improvement, an injured worker may request a one-time change of authorized treating physician. The new physician must be a physician on the designated provider list or provide medical services for a designated corporate medical provider on the list. The medical provider(s) to whom the injured worker may change is determined by the designated provider list given to the injured worker pursuant to Rule 8-2 or 8-4(C).

(B) To make a change pursuant to this Rule 8-5 the injured worker must complete and sign the form established by the division for this purpose. The injured worker shall submit the form to the employer by mailing or hand-delivering the completed form to the person(s) designated by the employer to receive the form. The person(s) so designated is listed on the designated provider list given to the injured worker pursuant to Rule 8-2 or 8-4(C) as the respondents’ representative(s). The injured worker may, but is not required to, provide the form to the impacted physicians. In any event, the respondents’ representative(s) shall notify the impacted physicians and the individual adjusting the claim of the change, unless an objection is submitted pursuant to paragraph (C) of this Rule 8-5.

(C) An injured worker may obtain a one time change of physician by providing notice that meets the requirements set out in statute. If the insurer or employer believes the notice does not meet statutory requirements and does not want to recognize the change of physicians, it must provide written objection to the injured worker within seven (7) business days following receipt of the form referenced in paragraph (B). The written objection shall set out the reason(s) for the belief that the notice does not meet statutory requirements.

1) If the employer or insurer does not provide timely objection as set out in this paragraph (C), the injured worker’s request to change physicians must be processed and the new physician considered an authorized treating physician as of the time of the injured worker’s initial visit with the new physician.

2) If written objection is provided and the dispute continues, any party may file a motion or, if there is a factual dispute requiring a hearing, any party may request that the hearing be set on an expedited basis.

(A) When there is a change of authorized treating physicians, the physician who had been the authorized treating physician remains authorized and is expected to provide necessary care until the injured worker’s initial visit with the new authorized physician.

(B) The insurer or employer may facilitate the transfer of medical records to the new authorized physician. Otherwise, the new authorized physician should request medical records from the previous physician as soon as practicable. Upon receipt of a request for medical records, the physician receiving the request shall provide the medical records to the new physician within seven (7) calendar days following the physician’s receipt of the request. If any copying is necessary the insurer shall pay for the copies consistent with the medical fee schedule.

(C) The insurer, employer or injured worker may schedule an appointment for the injured worker with the new authorized physician. If the new authorized physician is unwilling or unable to schedule an appointment to treat the injured worker, the injured worker shall notify the respondents’ representative(s) in writing. Upon receiving such a notification, the respondents’ representative(s) shall attempt to facilitate the scheduling of an appointment, which shall be scheduled to take place within thirty (30) days following the date of receipt of the notification. If a timely appointment cannot be scheduled and the injured worker does not agree to a later appointment, the injured worker shall be provided with a substitute authorized treating physician. If, within seven (7) business days following the date the respondents’ representative(s) received written notice that the appointment could not be scheduled, an appointment is not scheduled or a substitute physician provided, the injured worker may select an authorized treating physician of the worker’s choosing.

One of the goals of the workers’ compensation system is to minimize litigation, but disputes do arise and a system for resolution is necessary. One of the underlying premises of an administrative adjudication system is that parties should be able to resolve disputes in, as much as possible, a quick, inexpensive and simple manner. Therefore, when discovery is authorized and appropriate, the following apply:

(1) One set of written interrogatories and requests for production of documents may be served upon each adverse party. The number of interrogatories, including the requests for production of documents, to any one party shall not exceed 20, each of which shall consist of a single question or request.

(2) The responses to the interrogatories and production of documents shall be provided to all opposing parties within 20 days of mailing of the interrogatories and requests.

(3) The interrogatories and the requests for production of documents may not be submitted later than 40 days prior to hearing, except for expedited hearings.

(1) Depositions of a party may be taken upon written motion and order. Permission to take a deposition of a party will be granted only when there is a specific showing:

(a) That a party who has been served with written interrogatories has failed to respond to the interrogatories; or

(b) That the responses to the written set of interrogatories are insufficient; or

(2) Depositions of other witnesses may be taken upon written motion, order, and written notice to all parties.

(C) Each party is under a continuing duty to timely supplement or amend responses to discovery up to the date of the hearing.

(D) Discovery, other than evidentiary depositions, shall be completed no later than 20 days prior to the hearing date, except for expedited hearings.

(E) If any party fails to comply with the provisions of this rule and any action governed by it, an administrative law judge may impose sanctions upon such party pursuant to statute and rule. However, attorney fees may be imposed only for violation of a discovery order.

(F) All asserted privileges shall be accompanied by a privilege log with sufficient description to allow the other parties to assess the applicability of the privilege claims.

(G) Once an order to compel has been issued and properly served upon the parties, failure to comply with the order to compel shall be presumed willful.

(H) Upon agreement of the parties or for good cause shown, an administrative law judge may allow additional discovery, may limit discovery or may modify the time limits set forth in this rule. Setting of a formal hearing on an expedited schedule shall constitute good cause. Good cause shall include but not be limited to an agreement of the parties.

(A) Mediation. Parties to a dispute may consent to submit any dispute to mediation. A request for mediation may be presented to either the Division of Workers’ Compensation or the Office of Administrative Courts. If all parties agree a conference will be scheduled.

(B) Settlement Conferences. Parties to a dispute may request a settlement conference subject to the limitations set forth in §8-43-206, C.R.S.

(C) Prehearing Conferences. The Director, administrative law judges in the Office of Administrative Courts, or any party to a claim may request a prehearing conference before a prehearing administrative law judge. Prehearing administrative law judges may order any party to a claim to participate in a prehearing conference.

(1) The issues raised for consideration may be raised by motion, either written or oral. At least five days prior to the prehearing conference, the parties shall notify each other of the issues they intend to present to the prehearing administrative law judge. Additional time to respond to an issue raised at the prehearing conference may be requested by any party. It shall be within the discretion of the prehearing administrative law judge to determine if such additional time is necessary to protect the rights of the parties.

(2) Once a prehearing conference has been requested by a party to a claim, it shall be set. If any party objects to the prehearing conference as set, the following procedures shall apply:

(a) A party objecting to the setting of a prehearing conference or refusing to participate in the conference shall fax or hand-deliver any objections to the prehearing unit within 2 days after the date the prehearing conference is set. If the prehearing administrative law judge orders that the prehearing conference proceed as set, the requesting party shall send written notice of the time and place of the prehearing conference to all other parties.

(3) At the time of the prehearing conference, each party may submit a prehearing statement setting forth a brief summary of the issues in dispute, the names of all witnesses each party intends to call, the estimated time each party will require to present testimony and evidence, and the status of settlement discussions. Each party may also submit any discovery or pre-trial motion.

(4) Any party to a claim may request, either in advance or on the date of the prehearing conference, that the prehearing conference be recorded electronically or by court reporter. If a request for electronic recording is made, a party shall have until the date of the merit hearing, if such hearing date is pending at the time of the prehearing conference, or 100 days following the prehearing conference, whichever is shorter, within which to request that the prehearing conference unit prepare a transcript. The cost of preparing such transcripts shall be paid by the requesting party directly to the vendor providing the service.

(5) The prehearing administrative law judge may require a party to provide available vocational, medical, hospital and employment records, or reports to the other parties.

(D) Arbitration. Parties to a dispute may consent to submit any dispute to binding arbitration by written agreement. Binding arbitration shall be conducted by an administrative law judge of the parties' mutual choice from the Office of Administrative Courts, or pursuant to arbitration procedures as provided by the Colorado Rules of Civil Procedure. Unless otherwise provided by the administrative law judge or upon mutual consent of the parties and/or upon the order of the arbitrator(s), proceedings in any such arbitration shall be conducted in a manner consistent with the Colorado Rules of Civil Procedure.

(A) All matters for the Director’s determination shall be filed with the Division of Workers' Compensation, Customer Service Unit. Matters for the Director’s determination include:

(3) Matters regarding claims handling or administration, for example, benefit distribution, petitions to modify, terminate or suspend temporary benefits, lump sum requests;

(4) Requests for payment of costs of a transcript due to indigence pursuant to §8-43-213 (3), C.R.S.;

(9) Settlement documents in which all parties are represented by counsel, unless settlement was finalized before an administrative law judge, in which case an administrative law judge may approve the settlement documents.

(b) To avoid duplication, and unnecessary expense to all parties and the Division of Workers’ Compensation and the Office of Administrative Courts, copies of matters for the determination of the Director shall not be filed with the Office of Administrative Courts. However, copies of these documents may be filed if required as attachments, evidence submissions, and other instances to complete the record at the Office of Administrative Courts.

(C) All other motions and responses shall be filed, unless otherwise specifically ordered, with the Office of Administrative Courts office closest to the claimant’s residence.

(d) To avoid duplication, and unnecessary expense to all parties and the Division of Workers’ Compensation and the Office of Administrative Courts, copies of these motions and responses shall not be filed with the Division of Workers’ Compensation. However, copies of these documents may be filed if required as attachments, evidence submissions, and other instances to complete the record for determination of a matter before the Director.

The file at the Division of Workers’ Compensation will be retained at the Division and is not subject to subpoena for administrative hearings. Certified copies of any documents in the Division file can be tendered by a party to the Office of Administrative Courts and should be considered self-authenticating. Parties may obtain certified copies of documents in the Division file by contacting the Division of Workers’ Compensation, Customer Service Section. Absent extraordinary circumstances, no employee of the Division of Workers’ Compensation should be expected or required to testify at a hearing.

(A) The Subsequent Injury Fund Unit of the Division of Workers’ Compensation is designated as trustee for purposes of §8-43-408(2). C.R.S. When the provisions of §8-43-408, C.R.S. apply, an administrative law judge or the Director shall compute, using the best information available, the present value of the total indemnity and medical benefits estimated to be due on the claim. The employer shall provide the funds so ordered by check within ten days of the order. The trustee shall pay an amount to bring the claim current, and continue to pay the claimant benefits on a regular basis in an interval and amount ordered by an administrative law judge or the Director. The trustee shall also make payments for medical services consistent with the order of an administrative law judge or the Director. Any interest earned shall accrue to the benefit of the trust. The amount ordered to be placed in trust can be amended from time to time, and any excess amount shall be returned to the employer. The trustee shall make such disbursements as appropriate so long as funds are available, and shall not be subject to penalties or any other actions based on administration of the trust.

(b) In the alternative to the establishment of a trust, the employer shall provide a bond as set forth in §8-43-408(2), C.R.S. In the event that the employer fails to bring the claimant current with medical and indemnity benefits owed, or fails to continue to pay the claimant such benefits on a regular basis in an interval and amount ordered by an administrative law judge or the director, the surety will be obliged to do so. The surety’s liability to fulfill such obligation shall extend to the amount fixed, which can be amended by order, and exist in the form prescribed by the Director.

(C) Any disputes about the proper disbursement of funds in the trust shall be made to the Director or an administrative law judge for determination.

Two or more claims or applications may be consolidated for hearing or other purposes upon the order of a judge or the Director for good cause shown.

A party requesting that the Director assess penalties shall file a motion with the Division of Workers’ Compensation directed to the attention of the Director. If no response to the motion is filed the Director will issue an order to show cause. If necessary the Director may hold a hearing or may refer the matter for a hearing.

(A) To represent a party in a claim at the Division of Workers’ Compensation, an attorney shall file an entry of appearance with the Division. Any application for hearing, response, or other pleading filed at the Office of Administrative Courts by an attorney on behalf of a party shall be considered to be an entry of appearance at the Office of Administrative Courts.

(B) When a claim has closed, an attorney may withdraw by filing a substitution of counsel signed by both attorneys and sent to all parties, or by filing a notice of withdrawal sent to the client and all parties.

(C) When a claim is not closed, an attorney may withdraw by filing a substitution of counsel signed by both attorneys and sent to all parties. Otherwise, an attorney must request an order allowing withdrawal from the claim by filing a motion with the Office of Administrative Courts and including the required notice. The motion must be sent to the client and all parties. The notice must contain all the following:

(2) A statement that the client is responsible for keeping the Division of Workers’ Compensation and the other parties informed of the client’s current address and telephone number;

(4) The date scheduled for any future hearings, the dates by which any pleadings or briefs are to be filed; and notice that these dates will not be affected by the withdrawal of counsel;

(5) A statement that the client may object to the withdrawal by filing a written objection within 10 days of the date on the certificate of mailing of the notice, and mailing a copy of the objection to the attorney.

(A) A party shall request a utilization review by filing the Request for Utilization Form (request form) with the Division Utilization Review Coordinator. The request form must be the one prescribed by the Division, but a duplicated or reproduced request form may be used as long as it is an exact version of the original in both appearance and content.

(B) The provider under review shall remain as an authorized provider for the associated claimant during the medical utilization review process. The provider shall continue to submit bills for services rendered to the associated claimant during the review period and the insurance carrier shall continue to pay the provider’s bills as provided in these rules of procedure.

(C) As provided in section 10-2, below, an information package and medical records package shall be filed with the request form.

(A) One copy of an information package shall be filed and shall contain the following items:

(3) a list containing the full names and medical degrees of all providers, including the provider under review, other treating providers, and individuals who are considered as referrals or who performed consultations, independent medical examinations and/or second opinions, and

(B) In addition, seven (7) copies of a medical records package shall be filed in accordance with the instructions on the prescribed request form, Each copy shall be two-hole punched at the top center of each page and securely fastened. (Notebooks and plastic type covers and binders shall not be used). A blank sheet of paper shall be placed and bound to the front and back of each copy of the submitted material and if tabs are used to divide sections, they shall be positioned to the right side of the document and each copy shall contain the following items:

(2) A case report, which shall be prepared, signed and dated by a licensed medical professional. This report shall be dated within thirty (30) days prior to the date of filing with the Division pursuant to §8-43-501(2)(b). The case report shall be limited to the following:

(b) claimant’s standard demographic information (age, sex, marital status, etc.),

(d) Date of initial treatment, a brief chronological history of treatment to the present date, and any significant contributing factors which may have had a direct effect on the length of treatment; (e.g., diabetes).

(e) A brief statement from the medical professional after review of the medical records in support of utilization review.

Section 1 – a copy of the Employer’s First Report of Injury and/or the Worker’s Claim for Compensation form.

Section 2 – all reports, notes, etc., from the provider under review as submitted to the requesting party.

Section 3 – all reports, notes, etc., of the other treating providers as submitted to the requesting party.

Section 4 – all reports resulting from referrals, consultations, independent medical examinations and second opinions as submitted to the requesting party.

Section 6 – all medical management reports as submitted to the requesting party.

Section 7 – all hospital/clinic records related to the injury as submitted to the requesting party.

(C) The medical records package shall not contain billing statements, adjustor notes, vocational rehabilitation records, surveillance tapes or reports, admissions, denials or comments directed to the utilization review committee.

(D) All material contained in the medical records package shall be presented in identified sections, each section’s contents presented in chronological order.

(E) A minimum filing fee of $1,250.00 shall be paid at the time of filing by the requesting party. The Division will notify the requesting party of additional costs incurred which require a supplemental fee. Payment of any such supplemental fee will be required for completion of the utilization review and prior to the issuance of the Director’s order.

(A) The Division will notify in writing the provider under review of the review request, and provide a copy of the written notification to each party to the case.

(B) Along with the written notification, the provider under review, as well as each party to the case, will receive one copy of the medical records package as filed by the requesting party.

(C) Within seven (7) days of receiving the written notification, the provider under review may submit a concise written statement no longer than two (2) pages in length, limited to whether the treatment provided was reasonably necessary or reasonably appropriate. The provider shall send a copy of the written statement to all parties. A timely and properly submitted written response will be added to the review packets.

(D) Any motions or requests regarding the utilization review must be submitted, in writing, to the Medical Utilization Review Coordinator. Until such time as the Director issues a final order, the medical utilization review is an internal process at the Division, under the jurisdiction of the Director.

(A) The Division will not accept additional medical records filed by any individual who has not been identified as a party to the case.

(B) The Division will incorporate all properly and timely filed additional medical records into the review file. Additional medical records that are not filed timely and properly will not be included in the review file.

(C) Parties filing additional medical records should not duplicate records already submitted for review. Seven copies of any additional medical records must be provided.

(D) The provider under review and each party to the case shall have one opportunity to submit additional medical records. Medical records must be received or postmarked within thirty (30) days from the mailing of the review notification. This thirty (30) day period can be extended upon a written request which sets forth good cause.

(1) The first item in each copy shall be a dated and signed transmittal letter which contains the following information:

(2) The presentation of any additional medical records shall be in an identical manner to those as provided in section 10-2(B), above.

(F) The Division will send the provider under review and each party to the case a copy of all properly filed additional medical records.

(A) The Director, with input from the Medical Director, shall appoint appropriate peer professionals to serve on the utilization review committees for three years.

(B) A committee member may be suspended from participation if the member has been the subject of a utilization review which resulted in an order for change of provider, retroactive denial of payment of medical bills and/or revocation of accreditation.

(C) Committee members shall be paid a fee of $225 per hour for their time incurred in preparing and completing their reports and recommendations to the director. Services rendered by the committee members on behalf of the Division shall be concluded upon acceptance by the Division of their final reports and recommendations. Any party to a claim for benefits or any party to a utilization review proceeding who requests the presence as a witness of one or more committee members at a proceeding for any purpose, by subpoena or otherwise, shall be responsible for payment to said committee member(s) pursuant to the fee schedule set forth in these rules of procedure.

(D) A provider may not serve on a UR Committee unless his or her professional license or certification, if applicable, is current, active and unrestricted.

(E) After the members of the utilization review committee have been established, the provider and each party to the case will receive written notice of the names of the committee members. Within ten (10) days of receiving the written notification, any allegation that a committee member has a conflict and should be removed from the committee must be submitted in writing to the medical utilization review coordinator, setting forth the basis for the alleged conflict. Any such allegations that are not raised in a timely manner are deemed to have been waived and will not be considered at any subsequent stage of the utilization review proceedings. A conflict will be presumed to exist when the provider under review and a member of the review committee have a relationship which involves a direct or substantial financial interest. The following guidelines apply to any allegations of conflict under this Rule:

(1) Direct or substantial financial interest is a substantial interest which is a business ownership interest, a creditor interest in an insolvent business, employment or prospective employment for which negotiations have begun, ownership interest in real or personal property, debtor interest or being an officer or director in a business.

(2) The relationship will be reviewed as of the time the utilization review is being conducted. Relationships in existence before or after the review in and of themselves will have no bearing, unless a direct or substantial financial interest is raised at the time of the utilization review.

(3) Being members of the same professional association or medical group, sharing office space or having practiced together in the past are not the types of relationships which will be considered a conflict, absent a direct or substantial financial interest.

(4) Any provider who has provided services to the claimant in the case for which the utilization review has been requested, or who has any type of personal or professional relationship with the claimant, will not be allowed to serve on the utilization review committee.

(5) This rule is not intended as an opportunity to conduct discovery. Depositions, interrogatories or any other type of discovery will not be permitted in order to make determinations as to whether a conflict exists.

(F) Members of UR Committees shall not review any material other than what is provided by the Division, and shall not engage in communication regarding the Utilization Review with any person other than Division staff, except under the following circumstances: by approval of the Director; by written agreement of the parties to the case, including the provider under review; the provider under review and the parties to the case are strictly prohibited from having any communication with the members of the UR committee while the review is pending.

(A) The Division will strive to compose utilization committees that reflect a balance of interests. Membership of the committees may include the following:

(1) Joints/Musculoskeletal Committee – Two practitioners licensed in the same discipline of care as the provider under review and one occupational medicine practitioner (M.D. or D.O.) with a minimum of 2 years experience in occupational medicine where 30% of practice time is in occupational medicine cases or a minimum of 5 years of experience with a minimum of 15% of practice time in occupational medicine cases;

(3) Psychiatry Committee – One occupational medicine practitioner (M.D. or D.O.) and two psychiatrists; and,

(4) Other – Committee shall be determined by the Director to meet the specific circumstances of the utilization review case.

(A) Each committee member shall perform the review based on the materials provided, and work independently while performing his/her review. The review shall be a paper review only unless a specialist opinion is requested by a majority of the committee members. The specialist’s opinion may require a physical examination of the claimant.

(B) When performing a utilization review, the members of the medical utilization review committee shall consider all applicable medical treatment guidelines under these rules of procedure. The Division shall provide copies of the appropriate guidelines to the committee upon request.

(C) The report of each member of the utilization review committee should be limited to answers to the specific questions submitted by the Division, along with a written narrative supporting or explaining the answers for each of the questions.

(A) If the Director orders that a change of provider be made, the claimant and insurer or self-insured employer shall follow the procedures set forth in §8-43-501(4) in order to obtain a new provider. The parties shall notify the Division, on the prescribed form, as to whether the parties have agreed upon a new provider or whether the Director shall select the new provider as provided in §8-43-501(4).

(B) If the claimant chooses to remain under the care of the provider under review during the period of appeal resolution, the payor shall be responsible for payment of medical bills to the provider until an order on appeal is issued. If the insurance carrier, employer or self-insured employer prevails on appeal, the claimant may be held liable by the prevailing party for such medical costs paid during the appeal period.

(C) A provider who wishes to become a new treating provider candidate shall not be eligible unless his or her professional license or certification, if applicable, is current, active and unrestricted.

(A) The appealing party shall complete the appeal form prescribed by the Division. The form shall be filed with the Medical Utilization Review coordinator within the timeframes set forth in the appeal procedures.

(B) Should the Director order both retroactive denial of fees and change of provider, upon appeal the issues shall be separated and transferred to the Office of Administrative Courts for a de novo hearing on retroactive denial or a record review for change of provider.

(C) Should the appealing party be entitled to a de novo hearing, the hearing shall be scheduled according to the instructions on the appeal form. The appealing party must file an application for hearing with the Office of Administrative Courts and a copy must be provided to the Medical Utilization Review Coordinator.

These rules apply to parties and physicians participating in the workers’ compensation IME program pursuant to the authority of the Workers’ Compensation Act.

A physician who seeks appointment to the Division’s medical review panel for the purpose of performing IME’s under the authority of the Workers’ Compensation Act, Title 8, Articles 40 through 47 of the Colorado Revised Statutes, shall make application and meet the following qualifications:

(A) Be licensed by the Board of Dental Examiners, the Board of Chiropractic Examiners, the Colorado Podiatry Board, the Board of Medical Examiners and board certified (or board eligible) by the American Board of Medical Specialties or the American Osteopathic Association or another organization acceptable to the Division;

(B) For determination of maximum medical improvement (MMI), have attained at least Level I accreditation and have 384 hours per year of direct patient care (excluding medical/legal evaluation); and

(C) For purposes of determining permanent impairment have attained Level II accreditation and either have 384 hours per year of direct patient care (excluding medical/legal evaluation) or demonstrated additional competency in the field of disability evaluation through certification by the American Board of Independent Medical Examiners or the American Academy of Disability Evaluation Physicians.

(E) A physician who has agreed to perform an IME as a result of negotiation and agreement by the parties, and who has not applied for appointment to the Division’s IME panel, is not required to complete the application for appointment to the IME panel as set forth in section 11-2. However, such physician shall comply with all other qualifications and procedures governing the conduct of IME proceedings as established by this rule.

The physician shall complete the Division application form, certify to and, upon approval of the application, comply with the following:

(A) Unless otherwise approved by both parties, or the Division, the physician shall conduct an IME no earlier than 35 calendar days, nor later than 50 calendar days from the telephone call requesting an appointment;

(B) Within 20 calendar days of the examination submit the original report with all attachments to the Division and a copy to all parties;

(E) Conduct an IME pursuant to this section in an objective and impartial manner;

(F) Not refer any IME claimant to another physician for treatment or testing unless an essential test is required pursuant to section 11-4(A) of this rule;

(G) Not become the treating physician for the IME claimant, unless approved by the Director, ordered by an administrative law judge, or by both parties by written agreement;

(H) Not evaluate an IME claimant if the appearance of or an actual conflict of interest exists; a conflict of interest includes, but is not limited to, instances where the physician or someone in the physician’s office has treated the claimant. Further, a conflict may be presumed to exist when the IME physician and a physician that previously treated the claimant has a relationship which involves a direct or substantial financial interest. The following guidelines are to assist in determination of conflict or the appearance of a conflict:

(1) direct or substantial financial interest is a substantial interest which is a business ownership interest, a creditor interest in an insolvent business, employment or prospective employment for which negotiations have begun, ownership interest in real or personal property, debtor interest or being an officer or director in a business.

(2) The relationship should be determined at the time the IME is being requested. Relationships in existence before or after the review will have no bearing, unless a direct and substantial interest is present at the time of the IME.

(3) Being members of the same professional association, society or medical group, sharing office space or having practiced together in the past are not the types of relationships that will be considered a conflict or the appearance of a conflict, absent the present existence of a direct or substantial financial interest.

(I) Not employ invasive diagnostic procedures unless approved as provided in 11-4 (A), below;

(J) Not substitute any other physician as the designated IME physician without written permission of the director;

(K) In order to assure fair and unbiased IME’s, not engage in communication regarding the IME with any person other than Division staff, except under the following circumstances: the claimant during the IME examination, the requesting party when setting the appointment, by approval of the Director, both party written agreement, an order by an administrative law judge, by deposition or subpoena as approved by an administrative law judge;

(L) No later than 30 calendar days after the cancellation of an examination, refund to the paying party part or all of the fee paid by that party as may be required by these rules or by the Director.

(M) For each IME case assigned, address the following issues and make findings if relevant: maximum medical improvement, permanent impairment, and apportionment of impairment. Also consider any issues presented on the “Application for IME” or as directed by an administrative law judge. If the IME is requested pursuant to §8-42-107(8)(b)(ii)(a-d), C.R.S., the requesting party shall clearly note such on the IME application form.

(1) Either party that disputes the determination of MMI or impairment made by an authorized treating physician in a workers’ compensation case may apply for an IME.

(2) Requirement to Negotiate: Prior to Division intervention, the parties must attempt to negotiate the selection of a physician to conduct the IME. Parties that have agreed upon a physician to conduct the IME shall schedule the appointment pursuant to section 11-2(A) of this rule and shall notify the Division on the IME application form. If despite the good faith efforts of the parties, an agreement that was reached fails, either party may apply to the Division for the selection of an IME physician, using the form required under 11-3(B), below, within 30 days of such failure.

(3) The requesting party shall submit an application for an IME according to 11-3(B), below. If the parties did not agree on the physician, the insurer shall notify the Division and the other party on a prescribed form regarding the failed negotiation within 30 calendar days of their failure to agree. The party disputing the determinations of the authorized treating physician, and seeking review of those determinations (“requesting party”) shall file an application for IME within 30 days of the date of the failure to agree upon an IME physician.

(4) Insurers are not designated the requesting party simply due to their obligation to submit the documents referenced above. The requesting party is the party disputing the determinations of the authorized treating physician and seeking review of those determinations. The requesting party must complete the application for IME.

(5) The parties may agree to limit the issues addressed in an IME exam. Such agreement shall be in writing, signed by both parties, and provided to the IME unit no later than five (5) days prior to the IME appointment date. An opinion from an IME examiner concerning MMI, impairment or apportionment in a case in which the parties agreed to limit such issue, is not entitled to any weight before an administrative law judge.

(B) Form Required: The prescribed form, "Application for a Division Independent Medical Examination" shall be used in all cases to request an IME. The Division requires that the party requesting the IME designate:

(2) The body part(s) or medical conditions to be evaluated, including whether mental impairment shall be evaluated;

(3) Other physicians that have previously evaluated, treated, or are currently treating the claimant.

The requesting party shall certify that all parties and the Division have been sent the application form at the same time by the same means. Only the Division application form or a materially substantial equivalent duplication approved by the Division is acceptable.

(C) IME Physician Selection: If the parties are unable to agree upon a physician to conduct the IME, the Division will select via a revolving selection process a panel of three qualified physicians from its list of qualified physicians, from which one physician shall be designated to perform the IME. To obtain a pool of qualified physicians from which the Division shall make the selection of the three physician panel, the Division shall consider to the extent possible the criteria identified in the application for IME as set forth in section 11-3(B) of this rule. The Division will correlate the body parts or medical conditions on the IME application with the appropriate medical treatment guideline on the table designated in section 11-12. The three-physician panel will be comprised of physicians based on their accreditation to perform impairment ratings on the body part(s) and/or medical conditions designated by the requesting party on the IME application. At the time a physician applies to join the IME panel of physicians, he/she shall designate the body parts or medical conditions that he/she is willing and able to evaluate. Physicians electing not to perform impairment ratings on certain body parts or conditions shall not be included in any three-doctor panel where those body parts or conditions are listed on the IME application pursuant to section 11-3(B)(2).

(D) The Division will apply the same selection process for designation of the three-physician panel for injuries or conditions for which no Division medical treatment guideline exists.

(E) All potential candidate names will be kept confidential until the selection of the three physician panel is made. The Division will notify the parties in writing by mail or fax of the names and the medical specialties of the three physician panel within ten calendar days after receipt of the application. The physician names and related information will be listed on a form generated and provided by the Division.

(F) Within seven (7) business days of issuance of the three-physician list by the Division, the requesting party shall strike one name and inform the other party and the Division. Within five (5) business days of receiving that information from the requesting party, the other party shall strike one of the two remaining physicians and inform the Division’s IME Unit, with confirmation to the requesting party, of the name of the remaining physician. That information shall be provided to the Division via fax or telephone. The parties may exchange information under this rule via fax, e-mail or telephone.

If the Division is not notified of the selected physician within fifteen (15) business days of the date the Division issued the three-physician panel, the Division shall randomly select one name from the three-physician list. If one party fails to timely strike a physician from the list, the other party shall notify the Division and at the same time provide to the Division the name of the physician that party wishes to strike. In that situation the Division will randomly select one name from the remaining two physicians. The Division shall confirm to the parties by telephone and/or in writing the name of the selected physician.

If the selected physician declines or is unable to perform the IME, the Division shall provide one replacement name to the original list of three physicians, and present that revised list to the parties where each shall strike one name according to the procedures set forth in this section. Additionally, if a physician is removed from the three-physician panel for any reason other than having been struck by one of the parties, the Division will issue one replacement name using the same criteria and process set forth in section 11-3(C), above.

(G) When a physician is selected from the three-physician panel to perform the IME, the Division will remove his/her name from the revolving list of physicians for a period of time so that he/she is not available for assignment to another three-physician panel. This period of time may be adjusted by the Division as necessary to balance the mandate to reduce over utilization of individual physicians, yet ensure that an adequate pool of physicians is available in each geographic area. This procedure shall not preclude the parties from agreeing-upon such physicians to perform division IMEs.

(H) Appointment Date: The date of the examination shall be set in accordance with section 11-2(A). The requesting party shall call the IME physician within five business days after providing and/or receiving notice of the final IME physician selection to schedule the examination, and shall immediately notify the Division and the opposing party by telephone, and confirm in writing, the date and time of the examination. Absent good cause as determined by the Director or an administrative law judge, failure to make the appointment and advise all parties within five business days permits the opposing party, after notifying the Division of such failure, to either schedule the IME appointment or to request cancellation of the IME.

(I) Submission of Medical Records: The insurer shall concurrently provide to the IME physician and all other parties, a complete copy of all medical records in their possession pertaining to the subject injury, postmarked or hand-delivered no fewer than 14 calendar days prior to the IME examination. If the insurer or its representative fails to timely submit medical records to the designated IME physician, the claimant may request the Division cancel the IME; or the claimant may submit all medical records he/she has available no later than 10 calendar days prior to the IME examination; or as otherwise arranged by the Division with the IME physician. This rule does not prohibit the rescheduling of the IME. The defaulting party may supplement the records pursuant to section 11-3(K).

(J) Form/Content of Medical Records Package: Pertinent medical records shall include all medical reports and medical records reflecting the diagnosis and treatment of the claimant’s work-related injury, and shall include available medical records regarding relevant pre-existing condition(s) or work-related injury(ies). The medical file shall be two-hole punched at the top center of each page and clipped at the top with paper fasteners. A dated cover sheet shall be included listing the claimant’s name, IME physician’s name, date and time of the appointment, and the workers’ compensation number. The medical file shall be in chronological order and tabbed by year. It shall include a written summary of medical providers with the range of dates of treatment. Medical records not meeting these requirements shall be resubmitted to the IME physician and all other parties in the correct format within three business days of notification by the Division. Failure to timely and properly resubmit such records may result in cancellation of the IME by the Director, at the cost of the submitting party. Penalties otherwise available under these rules and the Act may be determined by the Director.

Medical bills, adjustor notes, surveillance tapes, admissions, denials, vocational rehabilitation reports, non-treating case manager records or commentaries to the IME physician shall not be submitted without written agreement of all parties, order of an administrative law judge, or prior permission of the Division.

(K) Submission of Supplemental Medical Records: Supplemental medical records shall be prepared according to section 11-3(J), above, and may be mailed or hand-delivered by any party concurrently to the IME physician and all other parties no later than seven calendar days prior to the IME examination.

(L) Depositions: Medical depositions may be submitted as part of the medical records package only by written agreement of all parties or pursuant to an order issued by the director or an administrative law judge. The IME physician shall be reimbursed for time spent reviewing medical depositions at the rate set forth in Rule 18, Testimony Fees. The party submitting the medical deposition shall be responsible for payment of the additional fees.

(M) Interpreter: The claimant shall be responsible for notifying the insurer of the necessity for a language interpreter, a minimum of 14 calendar days before the examination. The paying party shall be responsible for arranging for the services of and paying for such language interpreter. The language interpreter shall be impartial and independent, and have no professional or personal affiliation with any party to the claim or the IME physician.

(N) IME Proceedings Held in Abeyance: If a party files a motion involving a pending IME proceeding, the moving party shall provide a copy of the motion directly to the Division’s IME section. The IME proceeding shall be held in abeyance until the Division IME section is notified of the disposition as provided in this rule. When the motion is disposed of by written order or other means, the moving party shall provide a copy of the order or other dispositive document to the Division’s IME section.

11-4 Payments/Fees: Unless the party requesting the IME is determined indigent pursuant to SECTION 11-11 of this rule, the following shall apply to payments and fees:

(A) The physician performing the IME shall receive from the requesting party a fee of $675 at least 10 calendar days prior to the scheduled examination. If the fee is not timely received the fee for the IME shall be $775. If the record review is unusually extensive or complex or involves multiple body parts and requires longer than an hour for review, the physician shall contact the Division and request additional payment. This request should be made no later than three calendar days prior to the IME examination. The Division will transmit the request to the requesting party. If the requesting party declines to pay, the IME physician shall complete the IME process to the best of his/her ability without expending the additional time on record review. If additional file review charges are approved, the physician shall bill at the rate set forth in Rule 18-6(G)(3). The same process described in this paragraph shall apply with regard to any clinical or diagnostic testing requested by physicians performing IMEs.

It is expected that a test essential under the AMA Guides, 3rd Edition (revised) or the Level II accreditation curriculum for an impairment rating to be rendered will have been performed prior to the IME. Routine tests necessary for a complete IME should be performed as part of the IME with no additional cost. If an essential test is non-routine or requires special facilities or equipment, and such test was not previously performed, or was previously performed but the findings are not usable at the time of the IME, the physician performing the IME shall notify the Division, who will notify the parties. Unless extraordinary circumstances exist that result in an ALJ issuing a ruling to the contrary, the physician performing the IME will either perform the essential test or refer out the essential test for completion, and the insurer shall be responsible for paying for the essential test.

(B) An IME examination may be canceled only by the requesting party, or the Division, no later than three (3) business days prior to the examination. The non-canceling party may contact the Division to determine whether the IME may be rescheduled. If the IME is not timely canceled or the claimant fails to keep the IME appointment, or the medical records are not submitted in a timely manner, the IME physician shall be entitled to retain $250.00 from the total fee when the IME was requested by the defaulting party. If the fee has not yet been paid, or the party responsible for untimely cancellation is not the requesting party, the physician shall be entitled to collect from the defaulting party a $250.00 cancellation/penalty fee. The insurer may be entitled to offset the cancellation fee against any future permanent or temporary benefits if the claimant fails to appear for the IME examination without good cause as determined by the Director or an administrative law judge.

(C) Services rendered by an IME physician shall conclude upon acceptance by the Division of the final IME report. An IME report is final for the purpose of this section 11-4(C) of this rule, when it includes the requested determination regarding MMI and/or final impairment rating worksheets. A party who seeks the presence of an IME physician as a witness at a proceeding for any purpose, by subpoena or otherwise, shall be responsible for payment to the IME physician pursuant to Rule 18, Testimony Fees.

Only one IME impairment rating per case shall be administered by the Division’s IME Section, pursuant to §8-42-107 (8), C.R.S., unless otherwise directed by written agreement of the parties, by order of an administrative law judge or the Director, or by request of the originally designated impairment rating IME physician.

(A) During the IME process, there shall be no communication allowed between the parties and the IME physician unless approved by the Director, or an administrative law judge. Any violation may result in cancellation of the IME.

(B) After acceptance by the Division of the final report, no communication with the IME physician shall be allowed by any party or their representative except under the following circumstances: approval by the Director, both party written agreement, an order by an administrative law judge, by deposition or subpoena as approved by an administrative law judge. The parties shall provide the Division IME section with copies of any correspondence permitted under this section with the IME physician. See section 11-4(D) for fee information.

Sections of this Rule 11 apply to follow-up procedures, as appropriate. If a Level II IME physician determines a claimant has not reached MMI and recommends further treatment a follow-up IME examination shall to the extent possible be scheduled with the original IME physician. The party requesting the follow-up appointment shall provide written notification on a Division prescribed form or a substantially similar form of such request to the Division’s IME section, with a copy to the other party.

A return visit for range of motion validation shall be considered a part of the initial IME. Absent agreement by both parties or an order from an administrative law judge, any additional fees required for repeat range of motion shall be paid by the party that requested the IME.

A new IME physician may be selected only if agreed upon by both parties. The parties shall have reached prior agreement on who shall pay the $675.00 to the new IME physician prior to the patient visit. Payment shall be made in accordance with the procedures set forth in section 11-4. Upon good cause shown, an administrative law judge may also order a new physician and designate which party shall pay the examination fee.

Absent both party agreement or an order from an administrative law judge, the party requesting the follow-up shall pay any additional examination expense according to the Relative Value for Physicians Fee Schedule, incorporated by reference in Rule 18, set forth in the RVP’s Evaluation & Management Section.

99243 Follow-up for evaluation on cases that are older than six months and less than one year from the original evaluation.

Follow-up for evaluation on cases older than one year from the original evaluation. These follow-ups may be charged at the full fee of $675.00. Charges described above are allowed due to the need for additional history-taking. Any additional pertinent medical records may be submitted prior to the follow-up appointment in accordance with sections 11-3(I) and (J).

Complaints regarding an IME physician may be submitted to the Director or to the Medical Director. Upon request of the IME physician, or whenever the Director determines it is appropriate, a physician may be made temporarily inactive and not included in the revolving selection process. The Director, in consultation with the Medical Director, may permanently remove a physician from the medical review panel on the following grounds:

(2) Refusal and/or substantial failure to comply or two or more incidents of failure to comply with the provisions of these Workers’ Compensation Rules of Procedure and any statutes relevant to physicians;

(4) Any other reason for good cause as determined by the Director. After six months from the date of removal, a physician may apply to the director for reinstatement on the panel. The decision to return the physician to the panel is in the sole discretion of the Director.

Members of the medical review panel and any person acting as a consultant, witness, or complainant shall be immune from liability in any civil action brought against said person for acts occurring while the person was acting as a panel member, consultant, witness, or complainant, respectively, if such person was acting in good faith within the scope of the respective capacity, made a reasonable effort to obtain the facts of the matter as to which action was taken, and acted in the reasonable belief that the action taken by such person was warranted by the facts. Such grant of immunity from liability is necessary to ensure that the purposes of the IME provisions are met and participating physicians can exercise their professional knowledge, skills and judgment.

Disputes concerning the division IME process that arise in individual cases that cannot be resolved by agreement of the parties, may be taken to an administrative law judge for resolution.

(A) When a claimant applying for an IME pursuant to section 11-3(A) of this Rule asserts indigence, this process shall be followed:

(1) At the same time the “Notice and Proposal to Select an Independent Medical Examiner” form is submitted, the claimant may also indicate on the form whether indigence is asserted.

(2) Within twenty (20) days following submission of the Notice and Proposal to Select an Independent Medical Examiner and statement asserting indigence, the claimant wishing to assert indigent status shall file an “Application for Indigent Determination (IME)” form at the Office of Administrative Courts, and provide a copy to the other parties. A blank Application for Indigent Determination (IME) form may be obtained at the Division of Workers’ Compensation Customer Service Unit, at the IME unit, on the Division’s website, or at the Office of Administrative Courts.

(3) The IME process will not be held in abeyance during the pendency of indigent application except that an IME physician will not be selected by the Division until a determination is made as to whether the claimant is indigent.

(4) Within eight (8) days after the date of mailing of the Application for Indigent Determination (IME) form, any other party to the claim may file a response at the Office of Administrative Courts. Any such response shall state with specificity the grounds for objection.

(5) Within twenty (20) days after the Application for Indigent Determination (IME) is filed, an administrative law judge shall issue an order based on the written submissions determining whether or not the claimant is indigent for purposes of paying for the IME. A hearing will be held only if the administrative law judge determines that one is necessary because a timely submitted response raises genuine issues of disputed material fact that must be resolved. In the event no response is filed but an administrative law judge determines there is a lack of sufficient information in the Application for Indigent Determination (IME), the administrative law judge may hold a hearing to obtain additional information. Any such hearing shall be held as expeditiously as possible, and if a hearing is held a determination must be issued within thirty (30) days of the date of filing of the Application for Indigent Determination (IME).

(6) The determination regarding indigence shall be based on the claimant’s financial status as of the date the Application for Indigent Determination (IME) is filed. In making the determination on the Application for Indigent Determination (IME), the ALJ shall apply the following standard. A person shall be found to be indigent only if income is at or below the eligibility guidelines with liquid assets of $1,500 or less; or, income is up to 25% above the eligibility guidelines, liquid assets equal $1,500 or less, and the claimant’s monthly expenses equal or exceed monthly income; or, if “extraordinary circumstances” exist which merit a determination of indigence. The following definitions shall apply in making the determination:

*For family units with more than eight members, add $354 per month for “monthly income” or $4,250 per year for "yearly income" for each additional family member.

(a) Income is gross income from all members of the household who contribute monetarily to the common support of the household.

(b) Liquid assets include cash on hand or in accounts, stocks, bonds, certificates of deposit, equity and personal property or investments which could readily be converted into cash without jeopardizing the applicant’s ability to maintain home and employment. “Liquid assets” exclude any equity in any vehicle which the injured worker or his/her family must use for essential transportation unless the ALJ makes an affirmative finding of fact that the worker is credit worthy, can borrow against the equity in this vehicle, and can afford to pay back a loan without compromising his/her needs for food, clothing, shelter, and transportation.

(c) Expenses for nonessential items such as cable television, club memberships, entertainment, dining out, alcohol, cigarettes, etc. shall not be included.

(d) “Extraordinary circumstances” are deemed to be those which cause extraordinary financial hardship by depriving the claimant of the ability to provide for basic necessities that cannot be deferred, such as food, shelter, clothing, utilities, and medical costs not covered by insurance.

(7) The administrative law judge shall provide the determination regarding indigence in writing to all the parties. The determination shall include discussion sufficient to explain the basis of determination.

(1) If an Administrative Law Judge determines that the claimant is not indigent, the claimant shall be responsible for payment of the IME. The process for selection of the physician and completion of the IME shall be as set forth in this rule.

(2) If an Administrative Law Judge determines that the claimant is indigent, the insurer shall advance payment for the cost of the IME. Such a payment must be made to the doctor no later than ten (10) days prior to the date of the scheduled IME appointment. The insurer shall also pay for any additional costs as identified in sections 11-4(B), 11-4(C), and 11-7 of this Rule.

(3) The IME will proceed as set forth in section 11-3 of this Rule. The claimant shall be considered the requesting party.

(4) After a final order is issued, a final admission of liability is uncontested, or the parties have settled the case on a full and final basis, claimant shall reimburse the cost of the IME to the insurer or employer who paid initially. The obligation to reimburse the cost does not arise until a final order or order approving the settlement is issued. Any reimbursement shall be taken as an offset against permanent indemnity benefits.

11–12 TABLE OF DIAGNOSES OR MEDICAL CONDITIONS – INDEPENDENT MEDICAL EXAMINATIONS PROGRAM

Guideline	Conditions	Body Part or System	Accreditation Units	Specialty
Lower Extremity	Ankle Sprain/Fracture	Ankle	Lower Extremity	Fully Accredited Specialists (Level II) Limited-Accredited Specialists: Orthopedics Neurology/Neurosurgery Plastic Surgery Rheumatology
	Talar fracture
	Calcaneal fractures
	Midfoot (Lisfranc's) Fracture Dislocation
	Metatarsal-Phalangeal, Tarsal-Metatarsal, and Interphalangeal Joint Arthropathy
	Pilon Fracture
	Puncture wounds of the foot
	Achilles Tendon Injury/Rupture
	Ankle Osteoarthropathy
	Ankle or Subtalar Joint Dislocation
	Heel Spur Syndrome/Plantar Fasciitis	Foot
	Tarsal Tunnel Syndrome
	Neuroma
	Knee – Chondral Defects	Knee
	Aggravated Osteoarthritis
	Anterior Cruciate Ligament Injury
	Posterior Cruciate Injuries
	Meniscus Injury
	Patellar Subluxation
	Retropatellar Pain Syndrome
	Tendonitis/Tenosynovitis
	Bursitis of the Lower Extremity
	Hip fracture	Hip
	Acetabulum Fracture
	Hamstring Tendon Rupture
	Hip Dislocation
	Trochanteric Fracture	Hip, leg, pelvis
	Femur Fracture	Leg Pelvis
	Tibia Fracture	Leg Pelvis
	Pelvic Fracture	Leg Pelvis	Spine Lower Extremity	Fully Accredited Specialists (Level II) Limited-Accredited Specialists: Orthopedics Neurology/Neurosurgery Plastic Surgery Rheumatology
Cervical Spine Injury	Incomplete Spinal Cord Injury Syndrome: Anterior Cord Syndrome Brown-Sequard Syndrome Central Cord Syndrome Posterior Cord Syndrome	Cervical Spine	Neuro/Spine	Fully Accredited Specialists (Level II) Limited-Accredited Specialists: Orthopedics Neurology/Neurosurgery Plastic Surgery Rheumatology
	Soft Tissue Injury, Quebec Classification, Grades I-IV
	Disc Herniation
Low Back Pain	No diagnoses other than Low Back Pain given.	Lumbar Spine	Spine	Fully Accredited Specialists (Level II) Limited-Accredited Specialists: Orthopedics Neurology/Neurosurgery Plastic Surgery Rheumatology
Traumatic Brain Injury	Mild TBI (MTBI)	Head Skull Brain	Neuro	Fully Accredited Specialists (Level II) Limited-Accredited Specialists: Neurology/Neurosurgery Psychiatry
Traumatic Brain Injury	Moderate-Severe TBI	Head Skull Brain	Neuro
Cumulative Trauma Disorder	DeQuervain’s Tenosynovitis	Arm	Upper Extremity	Fully Accredited Specialists (Level II) Limited-Accredited Specialists: Neurology/Neurosurgery Orthopedics Hand Surgery Plastic Surgery Rheumatology
	Extensor Tendinous Disorders
	Flexor Tendinous Disorders
	Lateral Epicondylitis
	Medial Epicondylitis
	Cubital tunnel syndrome
	Hand-Arm Vibration Syndrome
	Guyon Canal (Tunnel) Syndrome
	Pronator Syndrome
	Radial Tunnel Syndrome
	Elbow Musculoskeletal Disorders (Epicondylitis)	Elbow
	Wrist Tendonitis, including DeQuervain's Tenosynovitis	Wrist
	Trigger Finger	Hand, finger
	Upper Extremity Tendonitis or bursitis	Elbow, shoulder
Chronic Pain Disorder	Chronic Pain	N/A	Not rated separately – refer to initial injury
Reflex Sympathetic Dystrophy/Complex Regional Pain Syndrome	CRPS-I (RSD), Stages 1-3 CRPS-II (Causalgia)	Neurologic system; also match specialty to body part, e.g., upper/lower extremity	Neuro; also check to see if the initial injury requires rating	All except: Pulmonology Otolaryngology (ENT) Ophthalmology Cardiology
Occupational Carpal Tunnel Syndrome	Carpal Tunnel Syndrome	Hand Wrist	Upper Extremity	Fully Accredited Specialists (Level II) Limited-Accredited Specialists: Neurology/Neurosurgery Orthopedics Hand Surgery Plastic Surgery Rheumatology
Thoracic Outlet Syndrome	Definite Thoracic Outlet Syndrome Probable Thoracic Outlet Syndrome Possible Thoracic Outlet Syndrome	Thoracic spine Thoracic nerves	Neuro	Fully Accredited Specialists (Level II) Limited-Accredited Specialists: Neurology/Neurosurgery Cardiothoracic Surgery Orthopedics
Shoulder	Acromioclavicular Joint Sprains/Dislocations Adhesive Capsulation/Frozen Shoulder Disorders Bicipital Tendon Disorders Brachioplexus Injuries Bursitis of the Shoulder Impingement Syndrome Rotator Cuff Tear Rotator Cuff Tendinitis Shoulder Fractures Shoulder Instability	Shoulder	Upper Extremity (Spine if cervical spine involvement)	Fully Accredited Specialists (Level II) Limited-Accredited Specialists: Neurology/Neurosurgery Orthopedics Plastic Surgery Rheumatology

Other Conditions
Condition	Specialty	Body Part or System
Dermatological	Fully Accredited Specialists (Level II); Limited-Accredited Specialist: Dermatology	Skin
Ophthalmic	Fully Accredited Specialists (Level II); Limited-Accredited Specialist: Ophthalmology	Eye, visual system
Ear, Nose & Throat deformities	Fully Accredited Specialists (Level II) Limited-Accredited Specialists: Allergist, Otolaryngology, Plastic surgery	Ear, nose & throat; deformities
Hearing or vestibular problems	Fully Accredited Specialists (Level II) Limited-Accredited Specialist: Otolaryngology	Ear, middle ear
Cardiac	Fully Accredited Specialists (Level II) Limited-Accredited Specialist: Cardiac Surgery	Heart, cardiopulmonary system
Allergies (not isolated to skin or lungs)	Fully Accredited Specialists (Level II) Limited-Accredited Specialists: Allergist, Otolaryngology	Sinus
Pulmonary	Fully Accredited Specialists (Level II) Limited-Accredited Specialists: Allergist, Pulmonology	Lungs, cardiopulmonary system
Hernia	Fully Accredited Specialists (Level II)	Gastrointestinal
Surgery	Go to specific condition and choose surgical specialty accordingly	N/A
Mental/ Psychological Disorders	Fully Accredited Specialists (Level II) Limited-Accredited Specialists: Psychiatry, Neurology/Neurosurgery	Mental/Behavioral

Pursuant to §8-42-101(3.5)(a)(II), C.R.S., all permanent impairment ratings shall be based upon the American Medical Association Guides to the Evaluation of Permanent Impairment, Third Edition (Revised), in effect as of July 1, 1991, (AMA Guides). This rule implements the Division's permanent impairment rating guidelines on how to appropriately utilize and report permanent impairment ratings.

(A) Where the authorized treating physician has determined that the injured worker is at maximum medical improvement (MMI) and has not returned to his/her pre-injury state, physically and/or mentally, the treating physician shall determine or cause to be determined a permanent medical impairment rating in accordance with this Rule 12.

(B) Any Level II accredited physician determining permanent impairment shall rate in accordance with their administrative, legal and medical roles as established by Level II accreditation.

(A) For claims with a date of injury prior to July 1, 2008, a Level II accredited physician (“the Physician”) shall apportion any preexisting medical impairment, whether work-related or non work-related, from a work-related injury or occupational disease using the AMA Guides, 3^rd Edition, Revised, where medical records or other objective evidence substantiate a preexisting impairment to the same body part. Any such apportionment shall be made by subtracting from the injured worker’s impairment the preexisting impairment as it existed at the time of the subsequent injury or occupational disease. The physician shall explain in their written report the basis of any apportionment. If there is insufficient information to measure the change accurately, the physician shall not apportion.

(B) For claims with a date of injury on or after July 1, 2008, the Physician may provide an opinion on apportionment for any preexisting work related or non work- related permanent impairment to the same body part using the AMA Guides, 3^rd Edition, Revised, where medical records or other objective evidence substantiate a preexisting impairment. Any such apportionment shall be made by subtracting from the injured worker’s impairment the preexisting impairment as it existed at the time of the subsequent injury or occupational disease. The Physician shall explain in their written report the basis of any apportionment. If there is insufficient information to measure the change accurately, the Physician shall not apportion. If the Physician apportions based on a prior non work-related impairment, the Physician must provide an opinion as to whether the previous medical impairment was identified, treated and independently disabling at the time of the work-related injury that is being rated. Identified and treated in this context requires facts reflecting that a medical provider previously noted and provided some level of treatment for the non work-related impairment.

(1) The effect of the Physician’s apportionment determination is limited to the provisions in section 8-42-104. When filing an admission an insurer shall provide documentation reflecting compliance with section 8-42-104.

(A) Limit such rating to physical impairments not likely to remit despite medical treatment; and

(D) Report final whole person and/or scheduled impairment rating percentages in whole numbers.

(A) Any physician determining permanent mental or behavioral disorder impairment shall:

(1) Limit such rating to mental or behavioral disorder impairments not likely to remit despite medical treatment; and

(2) Use the instructions contained in the AMA Guides giving specific attention to:

(3) Complete a full psychiatric assessment following the principles of the AMA Guides, including:

(a) A nationally accepted and validated psychiatric diagnosis made according to established standards of the American Psychiatric Association as contemplated by the AMA Guides; and

(b) Complete history of impairment, associated stressors, treatment, attempts at rehabilitation and premorbid history so that a discussion of causality and apportionment can occur.

(B) If the permanent impairment is due to organic deficits of the brain and results in disturbances of complex integrated cerebral function, emotional disturbance or consciousness disturbance, then Chapter 4, "Nervous System," shall be consulted and, may be used, when appropriate, with Chapter 14, "Mental and Behavioral Disorders." The same permanent impairment shall not be rated in both sections. The purpose is to rate the overall functioning, not each specific diagnosis. Determination of the appropriate chapter(s) is left to the professional judgment of the physician.

(C) The permanent impairment report shall include a written summary of the mental evaluation and the work sheet incorporated herein as part of this rule (Division form WC-M3-PSYCH). The impairment rating shall be established using the “category definition guidelines” set forth in this rule, and which shall supplement the related instructions in the AMA guides. When appropriate, the physician shall address apportionment.

(D) Where other work-related permanent impairment exists, a combined whole-body permanent impairment rating may be determined by the authorized treating physician providing primary care if Level II accredited. Where the authorized treating physician providing primary care is not determining permanent impairment, it shall be determined by the Level II accredited rating physician designated by the authorized treating physician providing primary care.

(A) The AMA Guides do not provide for permanent impairment ratings specifically for the partial loss of use of the following:

(B) When an injury causes the partial loss of use of any member specified in the scheduled injuries, as set forth in §8-42-107(2), C.R.S., the physician shall use the most distal body part. The most distal body part is the body part farthest away from the central body.

(C) In calculating partial loss-of-use benefits, the most distal permanent impairment rating provided by the physician shall be multiplied by the number of weeks corresponding to the scheduled injury for the appropriate entire finger, whole hand, or whole upper extremity, or the appropriate entire toe, whole foot, or whole lower extremity, then multiplied by the amount pursuant to §8-42-107(6),C.R.S.

(A) The Cumulative Trauma Disorder (CTD) rating system is designed for disorders that primarily involve muscular, tendinous, ligamentous and bony structures. It follows the same general principles set forth in section 3.1j of the AMA Guides and has similar relative values for traumatic soft tissue conditions. Disorders that have vascular or neurologic involvement are rated by other sections of the AMA Guides.

(B) Impairments secondary to Cumulative Trauma Disorders may be accompanied by impairments that are ratable using existing portions of the AMA Guides. The Level II accredited physician shall first calculate any applicable impairment from range of motion, neurologic and/or vascular findings, or other disorders (section 3.1j) excluding grip strength. If no impairment exists under these sections of the AMA Guides and the physician has determined that the claimant has an impairment of daily living activities with anatomic and physiologic correlation, the physician shall proceed to rate the impairment as follows:

(1) Multiple joint and upper extremity sites can be involved in CTD. Limit the impairment determination to areas of primary pathology, with anatomic or physiologic correlation based on objective findings. Do not rate areas of reactive muscular spasm and radiating or referred pain.

(2) Determine the stage of cumulative trauma for each joint involved, Stage 1 is 0-10%, Stage 2 is 11-20%, Stage 3 is 21-30%, and Stage 4 is 31-40%. Refer to Rule 17, Exhibit 2.

(3) Identify the appropriate joint impairment found on Table 17 of Chapter 3 of the AMA Guides.

(4) Multiply the joint impairment from Table 17 by the CTD stage impairment from step B to yield an upper extremity impairment.

(5) If there is anatomic and physiologic basis to rate other joints in the same extremity, complete the rating in the manner described and combine the extremity ratings distal to proximal.

(6) If extremity impairment is bilateral, convert each upper extremity impairment to whole person rating and then combine whole person ratings for both right and left upper extremities as referenced in the AMA Guides. Complete the upper extremity worksheets, Figure 1 of Chapter 3 of the AMA Guides, for each extremity separately.

(C) The CTD rating system is preferred to impairment determined by decrease in grip strength. If grip strength is used, the CTD rating system shall not be used as it would be duplicative. Similarly, care must be taken to avoid duplicative ratings with other associated disorders where there is significant neurovascular involvement or where there is limitation in ranges of motion. For further reference to these cautions, refer to the AMA Guides, section 3.1j.

	Fines per Audit Deficiency per Compliance Category
Compliance Level	1^st Finable Occurrence	2^nd Finable Occurrence	3rdand Later Finable Occurrence
80-89%	$30	$60	$90
70-79%	60	90	120
60-69%	90	120	150
<60%	120	150	180

Family size	Monthly income guidelines*	Monthly income guideline plus 25%	Yearly income guideline*	Yearly income guideline plus 25%
1	$1,021	$1,276	$12,250	$15,313
2	$1,375	$1,719	$16,500	$20,625
3	$1,729	$2,161	$20,750	$25,938
4	$2,083	$2,604	$25,000	$31,250
5	$2,438	$3,047	$29,250	$36,563
6	$2,792	$3,490	$33,500	$41,875
7	$3,146	$3,932	$37,750	$47,188
8	$3,500	$4,375	$42,000	$52,500

3-6 FINES FOR DEFAULTING EMPLOYER

Family size

11–12 TABLE OF DIAGNOSES OR MEDICAL CONDITIONS – INDEPENDENT MEDICAL EXAMINATIONS PROGRAM

Guideline

Conditions

Body Part or System

Accreditation Units

Specialty

Other Conditions

Condition

Specialty

Body Part or System

COLORADO DEPARTMENT OF LABOR AND EMPLOYMENT

REPORT WORK SHEET