2020 Colorado Revised Statutes
Title 8 - Labor And Industry
Article 42. Benefits
Section 8-42-101. Employer must furnish medical aid - approval of plan - fee schedule contracting for treatment - no recovery from employee - medical treatment guidelines accreditation of physicians and other medical providers - rules - repeal.
(1) (a) Every employer, regardless of said employer's method of insurance, shall furnish such medical, surgical, dental, nursing, and hospital treatment, medical, hospital, and surgical supplies, crutches, and apparatus as may reasonably be needed at the time of the injury or occupational disease and thereafter during the disability to cure and relieve the employee from the effects of the injury.
In all cases where the injury results in the loss of a member or part of the employee'sbody, loss of teeth, loss of vision or hearing, or damage to an existing prosthetic device, the employer shall furnish within the limits of the medical benefits provided in paragraph (a) of this subsection (1) artificial members, glasses, hearing aids, braces, and other external prosthetic devices, including dentures, which are reasonably required to replace or improve the function of each member or part of the body or prosthetic device so affected or to improve the employee's vision or hearing. The employee may petition the division for a replacement of any artificial member, glasses, hearing aid, brace, or other external prosthetic device, including dentures, upon grounds that the employee has undergone an anatomical change since the previous device was furnished or for other good cause shown, that the anatomical change or good cause is directly related to and caused by the injury, and that the replacement is necessary to improve the function of each member or part of the body so affected or to relieve pain and discomfort. Implants or devices necessary to regulate the operation of, or to replace, with implantable devices, internal organs or structures of the body may be replaced when the authorized treating physician deems it necessary. Every employer subject to the terms and provisions of articles 40 to 47 of this title must insure against liability for the medical, surgical, and hospital expenses provided for in this article, unless permission is given by the director to such employer to operate under a medical plan, as set forth in subsection (2) of this section.
In any case in which a firefighter, emergency medical services provider, or peaceofficer, as described in section 16-2.5-101, C.R.S., is exposed during the course and within the scope of employment to a known or possible source of hepatitis C, the employer, or if insured, the insurer, shall, at their expense, provide for baseline testing within the period of time specified in section 8-41-208 (1)(a) to determine whether the employee was free of hepatitis C at the time of the on-the-job exposure. The employer, or if insured, the insurer, shall pay for all reasonable and necessary medical procedures and treatment for exposure to hepatitis C during the period of time set forth in section 8-41-208 (1)(d).
Every such plan, which is agreed to between the employer and employee, for thefurnishing of medical, surgical, and hospital treatment, whether or not the employee is to pay any part of the expense of such treatment, before being put into effect, shall receive the approval of the director. The director has full power to formulate the terms and conditions under which any such plan may operate and the essentials thereof, and at any time the director may order modifications or changes in any such plan or withdraw prior approval thereof. No plan shall be approved by the director which relieves the employer from the burden of assuming and paying for any part of the medical, surgical, and hospital services and supplies required.
(a) (I) The director shall establish a schedule fixing the fees for which all surgical, hospital, dental, nursing, vocational rehabilitation, and medical services, whether related to treatment or not, pertaining to injured employees under this section shall be compensated. It is unlawful, void, and unenforceable as a debt for any physician, chiropractor, hospital, person, expert witness, reviewer, evaluator, or institution to contract with, bill, or charge any party for services, rendered in connection with injuries coming within the purview of this article or an applicable fee schedule, which are or may be in excess of said fee schedule unless such charges are approved by the director. Fee schedules shall be reviewed on or before July 1 of each year by the director, and appropriate health care practitioners shall be given a reasonable opportunity to be heard as required pursuant to section 24-4-103, C.R.S., prior to fixing the fees, impairment rating guidelines, which shall be based on the revised third edition of the "American Medical Association Guides to the Evaluation of Permanent Impairment", in effect as of July 1, 1991, and medical treatment guidelines and utilization standards. Fee schedules established pursuant to this subparagraph (I) shall take effect on January 1. The director shall promulgate rules concerning reporting requirements, penalties for failure to report correctly or in a timely manner, utilization control requirements for services provided under this section, and the accreditation process in subsection (3.6) of this section. The fee schedule shall apply to all surgical, hospital, dental, nursing, vocational rehabilitation, and medical services and to expert witness, expert reviewer, or expert evaluator services, whether related to treatment or not, provided after any final order, final admission, or full or partial settlement of the claim.
Notwithstanding the provisions of subparagraph (I) of this paragraph (a) the fees setforth in the schedule established pursuant to subparagraph (I) of this paragraph (a) shall be those fees in effect immediately prior to July 1, 1991, and such fees shall remain in effect until July 1, 1995.
Notwithstanding the provisions of subparagraph (I) of this paragraph (a), until theimpairment rating guidelines and medical treatment guidelines and utilization standards required by subparagraph (I) of this paragraph (a) and subsection (3.5) of this section are adopted and level I accreditation is received, compensation for fees for chiropractic treatments shall not be made more than ninety days after the first of such treatments nor after the twelfth such treatment, whichever first occurs, unless the chiropractor has received level I accreditation.
(b) Medical treatment guidelines and utilization standards, developed by the director, shall be used by health care practitioners for compliance with this section.
(3.5) (a) (I) (A) "Physician" means, for the purposes of the level I and level II accreditation programs, a physician licensed under the "Colorado Medical Practice Act". For the purposes of level I accreditation only and not level II accreditation, "physician" means a dentist licensed under the "Dental Practice Act", article 220 of title 12; a podiatrist licensed under article 290 of title 12; and a chiropractor licensed under article 215 of title 12.
A physician assistant licensed under the "Colorado Medical Practice Act", article240 of title 12, may receive level I accreditation. In order for a level I accredited physician assistant to perform medical services requiring level I accreditation, a level I accredited physician must delegate the performance of those medical services to the level I accredited physician assistant.
A physician shall not be deemed accredited under either level I or level II solely byreason of being licensed.
An advanced practice nurse with prescriptive authority pursuant to section 12-255112 may receive level I accreditation for purposes of receiving one hundred percent reimbursement under the medical fee schedule created in accordance with subsection (3) of this section.
Nothing in this subsection (3.5)(a) grants any person other than a physician licensedunder the "Colorado Medical Practice Act" the authority to determine that no permanent medical impairment has resulted from the injury pursuant to subsection (3.6)(b) of this section or that a claimant has attained maximum medical improvement pursuant to section 8-42-107 (8)(b)(I).
(II) The director shall promulgate rules establishing a system for the determination of medical treatment guidelines and utilization standards and medical impairment rating guidelines for impairment ratings as a percent of the whole person or affected body part based on the revised third edition of the "American Medical Association Guides to the Evaluation of Permanent Impairment", in effect as of July 1, 1991.
A medical impairment rating system shall be maintained by the director.
(I) This subsection (3.5) is repealed, effective September 1, 2025.
(II) Prior to such repeal the accreditation process created by this subsection (3.5) and subsection (3.6) of this section shall be reviewed as provided for in section 24-34-104, C.R.S.
(3.6) The two-tier accreditation system shall comprise the following programs:
(a) (I) A program establishing the accreditation requirements for physicians providing primary care to patients who have, as a result of their injury, been unable to return to work for more than three working days, referred to in this section as "time-loss injuries", which program shall be voluntary except in the case of chiropractors, for whom it shall be mandatory, and which shall be known as level I accreditation; and
(II) A program establishing the accreditation requirements for physicians providing impairment evaluation of injured workers, which program shall be known as level II accreditation.
A physician who provides impairment evaluation of injured workers shall completeand must have received accreditation under the level II accreditation program. However, the authorized treating physician providing primary care need not be level II accredited to determine that no permanent medical impairment has resulted from the injury. Specialists who do not render primary care to injured workers and who do not perform impairment evaluations do not require accreditation. The facility where a physician provides such services cannot be accredited.
Both the level I and level II accreditation programs shall be implemented and available to physicians. All physicians who are required to be accredited shall complete the level II accreditation program or programs.
The level I and level II accreditation programs shall operate in such a manner that thecosts of the program are fully met by registration fees paid by the physicians. The registration fee for each program must cover the cost of all accreditation course work and materials.
The accreditation system shall be established so as to provide physicians with anunderstanding of the administrative, legal, and medical roles and in such a manner that accreditation is accessible to every licensed physician, with consideration of specialty and geographic diversity.
Initial accreditation shall be for a three-year period and may be renewed for successive three-year periods. The director by regulation may determine any additional training program required prior to accreditation renewal.
The director shall, upon good cause shown, revoke the accreditation of any physicianwho violates the provisions of this subsection (3.6) or any rule promulgated by the director pursuant to this subsection (3.6), following a hearing on the merits before an administrative law judge, subject to review by the industrial claim appeals office and the court of appeals, in accordance with all applicable provisions of article 43 of this title.
If a physician whose accreditation has been revoked submits a claim for payment forservices rendered subsequent to such revocation, the physician shall be considered in violation of section 10-1-128, C.R.S., and neither an insurance carrier nor a self-insured employer shall be under any obligation to pay such claim.
A physician who provides treatment for nontime loss injuries need not be accreditedto be reimbursed for the costs of such treatment pursuant to the provisions of the "Workers' Compensation Act of Colorado".
(Deleted by amendment, L. 96, p. 151, § 2, effective July 1, 1996.)
The division shall make available to insurers, claimants, and employers a list of allaccredited physicians and a list of all physicians whose accreditation has been revoked. Such lists shall be updated on a monthly basis.
The registration fees collected pursuant to paragraph (d) of this subsection (3.6) shallbe transmitted to the state treasurer, who shall credit the same to the physicians accreditation program cash fund, which is hereby created in the state treasury. Moneys in the physicians accreditation program cash fund are hereby continuously appropriated for the payment of the direct costs of providing the level I and level II accreditation courses and materials.
All administrative costs associated with the level I and level II accreditation programs shall be paid out of the workers' compensation cash fund in accordance with appropriations made pursuant to section 8-44-112 (7).
The director shall contract with the medical school of the university of Colorado forthe services of a medical director to advise the director on issues of accreditation, impairment rating guidelines, medical treatment guidelines and utilization standards, and case management and to consult with the director on peer review activities as specified in this subsection (3.6) and section 8-43-501. The medical director shall be a medical doctor licensed to practice in this state with experience in occupational medicine. The director may contract with an appropriate private organization that meets the definition of a quality improvement organization as set forth in 42 U.S.C. sec. 1320c-1 to conduct peer review activities under this subsection (3.6) and section 843-501 and to recommend whether or not adverse action is warranted.
Except as provided in this subsection (3.6), neither an insurance carrier nor a selfinsured employer or injured worker shall be liable for costs incurred for an impairment evaluation rendered by a physician where there is a determination of permanent medical impairment if such physician is not level II accredited pursuant to the provisions of this subsection (3.6).
(I) For purposes of this paragraph (p):
"Case management" means a system developed by the insurance carrier in which thecarrier shall assign a person knowledgeable in workers' compensation health care to communicate with the employer, employee, and treating physician to assure that appropriate and timely medical care is being provided.
"Managed care" means the provision of medical services through a recognized organization authorized under the provisions of parts 1, 3, and 4 of article 16 of title 10, C.R.S., or a network of medical providers accredited to practice workers' compensation under this subsection (3.6).
(II) Every employer or its insurance carrier shall offer at least managed care or medical case management in the counties of Denver, Adams, Jefferson, Arapahoe, Douglas, Boulder, Larimer, Weld, El Paso, Pueblo, and Mesa and shall offer medical case management in all other counties of the state.
The division is authorized to accept moneys from any governmental unit as well asgrants, gifts, and donations from individuals, private organizations, and foundations; except that no grant, gift, or donation may be accepted by the division if it is subject to conditions which are inconsistent with this article or any other laws of this state or which require expenditures from the workers' compensation cash fund which have not been approved by the general assembly. All moneys accepted by the division shall be transmitted to the state treasurer for credit to the workers' compensation cash fund.
(I) This subsection (3.6) is repealed, effective September 1, 2025.
(II) Prior to such repeal the accreditation process created by subsection (3.5) of this section and this subsection (3.6) shall be reviewed as provided for in section 24-34-104, C.R.S.
(3.7) On and after July 1, 1991, all physical impairment ratings used under articles 40 to
47 of this title shall be based on the revised third edition of the "American Medical Association Guides to the Evaluation of Permanent Impairment", in effect as of July 1, 1991. For purposes of determining levels of medical impairment pursuant to articles 40 to 47 of this title a physician shall not render a medical impairment rating based on chronic pain without anatomic or physiologic correlation. Anatomic correlation must be based on objective findings.
Once there has been an admission of liability or the entry of a final order finding thatan employer or insurance carrier is liable for the payment of an employee's medical costs or fees, a medical provider shall under no circumstances seek to recover such costs or fees from the employee.
If any party files an application for hearing on whether the claimant is entitled tomedical maintenance benefits recommended by an authorized treating physician that are unpaid and contested, and any requested medical maintenance benefit is admitted fewer than twenty days before the hearing or ordered after application for hearing is filed, the court shall award the claimant all reasonable costs incurred in pursuing the medical benefit. Such costs do not include attorney fees.
(a) If an employer receives notice of injury and the employer or, if insured, the employer's insurance carrier, after notice of the injury, fails to furnish reasonable and necessary medical treatment to the injured worker for a claim that is admitted or found to be compensable, the employer or carrier shall reimburse the claimant, or any insurer or governmental program that pays for related medical treatment, for the costs of reasonable and necessary treatment that was provided. An employer, insurer, carrier, or provider may not recover the cost of care from a claimant where the employer or carrier has furnished medical treatment except in the case of fraud.
(b) If a claimant has paid for medical treatment that is admitted or found to be compensable and that costs more than the amount specified in the workers' compensation fee schedule, the employer or, if insured, the employer's insurance carrier, shall reimburse the claimant for the full amount paid. The employer or carrier is entitled to reimbursement from the medical providers for the amount in excess of the amount specified in the worker's compensation fee schedule.
Source: L. 90: Entire article R&RE, p. 485, § 1, effective July 1. L. 91: (3)(b) repealed, p. 694, § 4, effective April 20; (1)(b) and (3) amended and (3.5), (3.6), and (3.7) added, p. 1296, § 10, effective July 1. L. 92: (3.5)(a)(II) amended, p. 2165, § 1, effective June 2; (3.6)(p)(I)(B) amended, p. 1723, § 2, effective July 1. L. 94: (1)(b) amended, p. 311, § 1, effective March 22; (3.5)(k) and (3.6)(r) amended, p. 1457, § 7, effective May 25; (3)(a)(II) amended, p. 2001, § 2, effective July 1. L. 95: (3.6)(g) amended, p. 234, § 1, effective April 17. L. 96: (3.6)(b) and (3.6)(o) amended, p. 268, § 1, effective April 8; (3)(a)(I), (3)(b), (3.5), and (3.6) amended, p. 151, § 2, effective July 1. L. 2002: (1)(c) added, p. 441, § 2, effective May 16. L. 2003: (3.5)(c)(I) and (3.6)(r)(I) amended, p. 918, § 2, effective July 1; IP(3.6) and (3.6)(h) amended, p. 614, § 4, effective July 1; (1)(c) amended, p. 1613, § 4, effective August 6. L. 2004: (3)(a)(I) amended, p. 396, § 4, effective August 4. L. 2007: (3)(a)(I) and (3.6)(k) amended, p. 1471, § 1, effective May 30. L. 2008: (1)(b) and (3)(a)(I) amended, p. 1675, § 1, effective July 1. L. 2009: (3)(a)(I) amended, (SB 09-243), ch. 269, p. 1222, § 2, effective July 1. L. 2010: (5) added, (SB 10-187), ch. 310, p. 1456, § 2, effective July 1. L. 2013: (6) added, (SB 13-285), ch. 301, p. 1593, § 1, effective July 1. L. 2014: (3.5)(a)(I) amended, (HB 14-1227), ch. 363, p. 1735, § 36, effective July 1; (3.5)(c)(I), (3.6)(d), and (3.6)(r)(I) amended, (HB 14-1278), ch. 293, pp. 1197, 1198, §§ 1, 3, effective July 1. L. 2015: (2)(b) added, (SB 15-264), ch. 259, p. 942, § 8, effective
August 5. L. 2016: (3.5)(a)(I) amended, (SB 16-158), ch. 204, p. 720, § 3, effective August 10.
L. 2019: (3.5)(a)(I)(D) and (3.5)(a)(I)(E) added, (HB 19-1105), ch. 77, p. 281, § 1, effective August 2; (3.6)(n) amended, (SB 19-241), ch. 390, p. 3463, § 3, effective August 2; (3.5)(a)(I)(A) and (3.5)(a)(I)(B) amended, (HB 19-1172), ch. 136, p. 1647, § 22, effective October 1.
Editor's note: (1) This section is similar to former § 8-49-101 as it existed prior to 1990.
Although subsection (3)(b) was repealed by House Bill 91-1100, the repeal was harmonized with the amendments to the entire subsection (3) by Senate Bill 91-218.
Amendments to subsection (3.6) by House Bill 96-1040 and House Bill 96-1126 were harmonized.
Cross references: (1) For the "Colorado Medical Practice Act", see article 240 of title 12; for the "Dental Practice Law of Colorado", see article 220 of title 12.
(2) For the legislative declaration in SB 16-158, see section 1 of chapter 204, Session Laws of Colorado 2016.
