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Workers' Compensation

Big Doings in Delaware--Lower Extremity Added to Practice Guidelines and Procedural Changes to UR (and a whole lot of other cool stuff)

Well, time for a tickertape parade if you ask me.  The long-awaited Practice Guidelines for the lower extremity (including the knee) are now available.  And the Utilization Review process has been reportedly streamlined.  Will this make it more user friendly?  Will the lawyers now step out of the submission process?  Will carriers fare any better under the new system?

I am re-printing the email below sent out today by the DOL with the permission of John Kirk.  Thanks to Donna Forrest, the Medical Component Manager for the OWC, for a concise and easy read below.  Admittedly I have not yet read this in its entirety, including the links, or committed it to memory.  And for those of you who didn't realize that Delaware comp practice is a veritable hotbed of excitement, read it and weep.

Effective June 13, 2011 - Changes to DE Workers' Compensation Health Care Payment System

If you have any additional questions, feel free to call (302-761-8200) or e-mail (, the Delaware Office of Workers' Compensation, Medical Component.

Effective June 13, 2011, the Department of Labor (DOL) will make the following changes to 19 De Admin Code 1341 (the "regulations") the Delaware Workers' Compensation Health Care Payment System (HCPS):

The DOL added a 7th health care practice guideline to the regulations - Lower Extremities (19 DE Admin Code 1342, Part G).  The current list of health care practice guidelines - carpal tunnel, chronic pain, cumulative trauma disorder, low back, shoulder (all effective 5/23/08), as well as cervical (effective 6/1/09), and lower extremities (effective 6/13/11) - is available on the DOL web page at the following link:

The DOL revised sections of the Workers' Compensation Regulations (19 De Admin Code 1341).  The revised regulations are available in their entirety on the DOL web page at the following link:

The regulatory revisions required changes to the following "forms," which also go into effect on June 13, 2011:

   Health Care Provider Application for Certification

   Request for Utilization Review

   Physician's Report of Workers' Compensation Injury

   Employer's Modified Duty Availability Report

The following list itemizes and summarizes the regulatory changes to 19 De Admin Code 1341.

3.0   Health Care Provider Certification7
3.1.4   Added "in an inpatient hospital setting" to line 6 and deleted "or outpatient" to line 9.
3.2   Changed who received the completed certification application - from "Mr. John F. Kirk, III" to "Ms. Donna Forrest."

4.2   HCPCS (Healthcare Common Procedure Coding System) (Level II)
Changed the wording in line 3 and 4 to include Current Dental Terminology (CDT) codes for dental offices.

4.7   Dental Services
The itemized fee schedule pricing does not include any dental items, so this update removes references (4.7.1) to the methodology (i.e. 90% of the 75th percentile) used to determine the itemized fee schedule and only mentions 85POC.  The section numbering changes, as well.  Payment for dental services will not change.  This just removes unnecessary language.

5.0   Utilization Review
5.1   Added to last sentence, "Without the employer or its insurance carrier obtaining legal representation, or incurring the costs associated with legal involvement in the utilization review process." 
5.4.3 - 5.4.4   Added language that requires an answer (approve or deny, send to UR) for surgery preauthorization requests.  If a certified health care provider performs surgery without ever requesting preauthorization, this added preauthorization language does not take away that certified provider's right to prompt payment (or a payers right to challenge the surgery through the UR process), pursuant to
19 Del.C. §2322F(d).
5.4.5   Changed the language to clarify the clock starts ticking on the turnaround time for the UR when the company performing the review receives the information.
APPENDIX A.   Revised UR request form.   The UR Request form no longer includes attorney information; adds room for a second health care provider under review; and streamlines the medical documentation requirements.

6.0   Forms
   Physician's Form. Added language to the first paragraph of the form instructions/definitions that allows paperless physicians' offices to electronically generate the information.
6.3   Employer's Form. Added language in the instructions that does not require employers to fill out the form when the physician's report releases the employee to full duty. Slightly changed the form to eliminate some redundancies.

Again, please feel free to e-mail ( or call (302-761-8200) the Office of Workers' Compensation, Medical Component, if you have any additional questions.

Again, my sincere thanks to the Department of Labor.  I admittedly have been a little silent on the blog as we have made our way through Sweet Caroline's graduation and are getting ready to attend Camp War Eagle.  Look for many new posts in the coming weeks.  The decisions on Legal Hearings alone could fill a book.

Irreverently yours,
Cassandra Roberts

Delaware Detour & Frolic   Visit Delaware Detour & Frolic, a law blog by Cassandra Roberts

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