2025 Code of Georgia
Title 34 - Labor and Industrial Relations (Chs. 1 — 15)
Appendix A - Rules and Regulations of the State Board of Workers’ Compensation
Rule 203 - Payment of Medical Expenses; Procedure When Amount of Expenses Are Disputed
(a) Medical expenses shall be limited to the usual, customary and reasonable charges as found by the Board pursuant to O. C. G. A. § 34-9-205. Employer/insurers may automatically conform charges according to the fee schedule adopted by the Board and the charges listed in the fee schedule shall be presumed usual, customary, and reasonable and shall be paid within 30 days from the date of receipt of charges. Requests for reimbursement of mileage expenses incurred by the employee shall be paid within 15 days after receipt of an itemized written request. Employer/insurers shall not unilaterally change any CPT-4 or CDT code of the provider. All automatically conformed charges according to the fee schedule adopted by the Board shall be for the CPT-4 or CDT code listed by the provider. In situations where charges have been reduced or payment of a bill denied, the carrier, self-insured employer, or third-party administrator shall provide an Explanation of Benefits with payment information explaining why the charge has been reduced or disallowed, along with a narrative explanation of each Explanation of Benefits code used. In all claims, any health service provider whose fee is reduced to conform to the fee schedule and who disputes that fee, or employer/insurers who dispute the CPT-4 or CDT code used by the provider for services rendered shall, in the first instance, request peer review of the charges, and may thereafter request a mediation conference or an evidentiary hearing by filing Form WC-14 with the Board. For disputed charges or payments, the aggrieved party shall follow the procedures provided in subsections (b) and (c).
(b)
(1) A medical provider or an employee who has incurred expenses for healthcare goods and services or other medical expenses shall submit the charges to the employer or its workers’ compensation carrier for payment within one year of the date of service. In the event that the claim or the expense is controverted, the medical expenses or request for reimbursement must be submitted for payment within one year of the date of service or within one year of the date that the claim is accepted or established as compensable, whichever is later. Failure by the medical provider or employee to submit expenses within the time prescribed shall result in waiver of such expenses.
(2) Any challenge by a medical provider to the amount of payment for goods, services, or expenses shall be submitted to the payer within 120 days of payment. Failure by a medical provider to challenge the amount of payment of such goods, services, or expenses within 120 days shall result in the waiver of additional payment. If the challenge is not resolved, the medical provider may request peer review as provided in subsection (c).
(c) Disputes
(1) An employer or insurer shall pay when due all charges deemed reasonable, and follow the procedures set forth in subsection (2) for review of only those specified charges which are disputed.
(2) For charges not contained in the fee schedule, or allegedly not paid pursuant to the fee schedule, and/or which are otherwise disputed as not being the usual, customary and reasonable charges prevailing in the State of Georgia, the employer, insurer, or physician shall file a request for peer review with a peer review organization authorized by the Board within 180 days of the payment, reduction denial, or decision of an appeal of charges by the employer/insurer, and shall serve a copy of the request and supporting documentation upon all parties and counsel, and shall follow the rules of the peer review organization with respect to any required additional copies.
The peer review organizations approved by the Board are listed on the Board’s website at www. sbwc. georgia.(3) Unless peer review is requested as set forth in Rule 203 (c)(2), all reasonable charges for medical, surgical, hospital and pharmacy goods and services shall be payable by the employer or its worker’s compensation insurer within 30 days from the date that the employer or the insurer receives the charges and the medical reports required by the Board or within 15 days after receipt of an itemized written request for mileage incurred by the employee. Failure of the health care provider to include with submission of charges the reports or other documents required by the Board, constitutes a defense for the employer or insurer’s failure to pay the submitted charges within 30 days of receipt, or within 15 days of receipt of an itemized written request for mileage incurred by the employee; however, the employer or insurer must submit to the health care provider or employee written notice indicating the need for further documentation within 30 days of receipt of the charges or within 15 days of an itemized written request for mileage incurred by the employee and failure to do so will be deemed a waiver of the right to defend a claim for failure to pay such charges in a timely fashion on the ground that the charges were not properly accompanied by required documentation. Such waiver shall not extend to any other defense the employer and insurer may have with respect to a claim of untimely payment.
If any charges for health care goods or services are not paid when due, or any reimbursement for health care goods or services paid by the employee or any charges for mileage incurred by the employee are not paid when due, penalties shall be added to such charges and paid at the same time as, and in addition to, the charges claimed for the health care goods and services. For any payment of charges made more than 30 days after their due date, but paid within 60 days of such date, there shall be added to such charges an amount equal to 10 percent of the amount due. For any payment of charges made more than 60 days after the due date, but paid within 90 days of such date, there shall be added to such charges an amount equal to 20 percent of the amount due. For any charges not paid within 90 days of the due date, in addition to the 20 percent add-on penalty, the employer or insurer shall pay interest on the combined total in an amount equal to 12 percent per annum from the 91st day after the date the charges were due until full payment is made. All such penalties and interest shall be paid to the provider of the health care goods or services.(4) No penalties or interest shall be due on disputed charges submitted to peer review until the peer review organization makes a decision regarding the disputed charges.
(5) The employer, insurer, or physician requesting review must comply with the requirements of the statute, Board Rules, and rules of the appropriate peer review organization before the Board will rule on any disputed charges.
(6) If there is no appropriate peer review organization, the party requesting review may request a mediation conference by filing Form WC-14 with the Board. The charges submitted which conform to the list as published by the Board shall be prima facie proof of the usual, customary, and reasonable charges for the medical services provided.
(7) The employer/insurer shall, within 30 days from the date that a decision regarding the peer review of charges or treatment is issued by a peer review organization, make payment of disputed charges based upon the recommendations, or request a mediation conference or an evidentiary hearing. The peer review organization shall serve a copy of its decision upon the employee if unrepresented, or the employee’s attorney. A physician whose fee has been reduced by the peer review organization shall have 30 days from the date that the recommendation is mailed to request a mediation or hearing. In the event of a hearing or mediation conference, the recommendations of the peer review organization shall be evidence of the usual, customary, and reasonable charges.
(8) The penalties and interest for late payment detailed in Paragraph (c)(3) above shall not be applicable until after a decision by a peer review organization or a final decision of the Board after a hearing, whichever is later.
(9) In the event the decision of the peer review organization is that the fee be reduced, the employer/insurer shall pay the physician the fee amount recommended by the peer review organization less the fee for peer review initially paid by the employer/insurer. In the event the decision of the peer review organization is that the entire fee be disallowed, the employer/insurer may automatically deduct the fee for the peer review from future allowable expenses submitted by the physician for treatment or services rendered to the employee arising out of the same injury.
In the event the decision of the peer review organization is that an additional fee is due the medical provider, the employer/insurer shall pay the medical provider the additional fee plus the fee for peer review initially paid by the medical provider.(10) Peer review shall not apply to charges not yet incurred for prospective medical treatment, services, or equipment.
(11) Peer review shall not apply or be utilized to determine the issue of necessity of treatment or services.
(d) Medical expenses shall include the reasonable cost of attendant care that is directed by the treating physician, during travel or convalescence.
(e) Medical expenses shall include but are not limited to the reasonable cost of travel between the employee's home and the place of examination or treatment or physical therapy, or the pharmacy. When travel is by private vehicle the rate of mileage shall be 45 cents per mile. This rate is subject to change based upon changes in fuel costs. Reimbursement for any charges for mileage incurred by the employee shall be paid within 15 days from the date that the employer or the insurer receives the itemized written request required by the Board. Travel expenses beyond the employee's home city shall include the actual cost of meals and lodging. Travel expenses shall include the actual cost of meals when total elapsed time of the trip to obtain outpatient treatment exceeds four hours. Where overnight travel is reasonably necessary, travel expenses shall include the actual reasonable cost of meals and lodging. Cost of meals shall not exceed $45 per day.
Annotations
Notes
Note as to revisions.The revision effective July 1, 1996, rewrote subsections (a) and (b).
The revision effective July 1, 1997, made minor stylistic changes.
The revision effective July 1, 1998, in subsection (a), added the third, fourth and fifth sentences, and in the sixth sentence substituted “In all claims,” for “In any claim which has been accepted as compensable,”, and inserted “or employer/insurers who dispute the CPT-4 code used by the provider for services rendered”; and in the undesignated paragraph following paragraph (2) of subsection (b), substituted “Medical Peer Review” for “MedQual” and made a minor punctuation change.
The revision effective July 1, 1999, in the undesignated paragraph under paragraph (b)(2), deleted the word “and” following “Georgia Psychological Association;”; at the end of paragraph (b)(4), substituted “on” for “in” preceding “any disputed charges”; and made minor stylistic changes.
The revision effective July 1, 2000, in subsection (a), substituted “30 days” for “60 days” in the first and last sentence, and added “or an evidentiary hearing” following “request a mediation conference”; in subsection (b), substituted “30 days” for “60 days” in paragraph (2) and (3); added “or an evidentiary hearing” following “payment of mediation conference” at the end of the first sentence, added “mediation or” following “mailed to request a” near the end of the third sentence, and added “hearing or” preceding “mediation conference,” in the last sentence of paragraph (6); in subsection (c), substituted “that” for “which” near the middle; and, in subsection (d), substituted “28 cents” for “25 cents” in the second sentence.
The revision effective July 1, 2001, rewrote paragraph (b)(3).
The revision effective July 1, 2003, added subsection (b) and redesignated former subsections (b) through (d) as subsections (c) through (e), respectively.
The revision effective July 1, 2004, substituted “Medical Directors Solutions, LLC” for “Disability Solutions Plus, Inc.” in the undesignated paragraph of (c)(2).
The revision effective July 1, 2005, substituted “(c)(2)” for “(b)(2)” in the first sentence in paragraph (c)(3).
The revision effective July 1, 2006, in subsection (e), substituted “40 cents” for “28 cents” in the second sentence, and added the third sentence.
The revision effective July 1, 2007, designated the existing provisions of subsection (b) as paragraph (b)(1), and added the last sentence, and added paragraph (b)(2).
The revision effective July 1, 2010, deleted the former last sentence of the second paragraph of paragraph (c)(2), which read: “A request for peer review of any other treatment or charges shall attach to the application two copies of the charges and all of the reports dealing with the treatment of the injured employee.”
The revision effective July 1, 2011, deleted “Medical Directors Solutions, LLC;” preceding “Georgia Psychological Association” in the concluding paragraph of paragraph (c)(2).
The revision effective July 1, 2013, added the third sentence in subsection (a); inserted “or employee” in the last sentence of paragraph (b)(1); substituted “payer” for “payor” in the first sentence of paragraph (a)(2); in paragraph (c)(3), inserted “or within 15 days of an itemized written request for mileage incurred by the employee” three times, and deleted “its” preceding “submission” in the second sentence; in the ending paragraph of subsection (c), inserted “or any reimbursement for health care goods or services paid by the employee or any charges for mileage incurred by the employee are not paid when due” in the first sentence, and substituted “percent” for “%” in the second, third, and fourth sentences; and added the fourth sentence in subsection (e).
The revision effective July 1, 2014, substituted the present provisions of the undesignated paragraph of paragraph (c)(2) for the former provisions, which read: “The peer review committees approved by the Board are as follows: Georgia Psychological Association; Georgia Chiropractic Association, Inc.; Appropriate Utilization Group, LLC; and such other committees as the Board has posted as so designated at its Atlanta office.”
The revision effective July 1, 2015, substituted “peer review organization” for “peer review committee” throughout; in paragraph (c)(2), deleted “; Exam Works” following “Dane Street”, in paragraph (c)(7), substituted “fee for per review” for “filing costs”, substituted “organization” for “committee” and substituted “fee” for “filing costs”.
The revision effective July 1, 2017, inserted “or CDT” in three places in subsection (a) and deleted “Dane Street” before “and such other organizations” near the end of the undesignated paragraph following paragraph (c)(2).
The revision effective July 16, 2018, inserted “Medical Consultants Network (MCN);” in the undesignated paragraph following paragraph (c)(2).
The revision effective September 1, 2019, in the undesignated language following paragraph (c)(2), inserted “(psychologists)”, “(chiropractors)”, and “(physical therapists)”, and deleted “Medical Consultants Network (MCN)” preceding “and such other organizations.”
The revision effective July 1, 2022, made some changes to the process and procedures for filing for peer review.
The revision effective July 1, 2023, modified paragraph (c)(9) and subsection (e).
The revision effective July 1, 2024, in subsection (e), deleted “further” following “shall” in the sixth sentence, added the seventh sentence, and substituted “$45 per day” for “$30 per day” in the last sentence; and made editorial changes.
