DWD 80.72(8)(a)(a) To obtain certification from the department, an applicant shall submit a complete description of the items covered in sub. (7) to the department. The department may require the submission of other information which it deems relevant.

DWD 80.72(8)(b)(b) The applicant shall clearly identify any trade secrets under s. 19.36 (5), Stats. The department shall treat any information marked as trade secrets as confidential and shall use it solely for the purpose of certification and shall take appropriate steps to prevent its release.

DWD 80.72(8)(c)(c) Notwithstanding par. (b), the department may create a technical advisory group consisting of individuals with special expertise from both the public and private sectors to assist the department in reviewing and evaluating an application.

DWD 80.72(8)(d)(d) The department shall certify a data base for one year at a time. The department may extend the one-year certification period while an application for renewal is under review by the department.

DWD 80.72(8)(e)(e) If the department determines that an applicant has misrepresented a material fact in its application or that it no longer meets the requirements in sub. (7), the department may decertify a data base after providing the applicant with notice of the basis for decertification and an opportunity to respond.

DWD 80.72(9)(9) Applicability. This section first applies to health service procedures provided on July 1, 1992 and shall take effect on July 1, 1992.

DWD 80.72 HistoryHistory: Cr. Register, June, 1992, No. 438, eff. 7-1-92; CR 03-125: am. (3) (a) (intro.) Register June 2004 No. 582, eff. 7-1-04; CR 07-019: am. (2) (i) and (L), Register October 2007 No. 622, eff. 11-1-07.

DWD 80.73(1)(1) Purpose. The purpose of this section is to establish the procedures and requirements for resolving a dispute under s. 102.16 (2m), Stats., between a health service provider and an insurer or self-insurer over the necessity of treatment rendered by a provider to an injured worker.

DWD 80.73(2)(a)(a) “Dispute” means a disagreement between a provider and an insurer or self-insurer over the necessity of treatment rendered to an injured worker where the insurer or self-insurer refuses to pay part or all of the provider’s bill.

DWD 80.73(2)(b)(b) “Expert” means a person licensed to practice in the same health care profession as the individual health service provider whose treatment is under review, and who provides an opinion on the necessity of treatment rendered to an injured worker for an impartial health care services review organization or as a member of an independent panel established by the department.

DWD 80.73(2)(c)(c) “Licensed to practice in the same health care profession” means licensed to practice as a physician, psychologist, chiropractor, podiatrist or dentist.

DWD 80.73(2)(d)(d) “Provider” includes a hospital, physician, psychologist, chiropractor, podiatrist, physician’s assistant, advanced practice nurse prescriber, or dentist, or another licensed medical practitioner who provides treatment ordered by a physician, psychologist, chiropractor, podiatrist, physician’s assistant, advanced practice nurse prescriber, or dentist whose order of treatment is subject to review.

DWD 80.73(2)(e)(e) “Review organization” or “impartial health care services review organization” means a public or private entity not owned or operated by, or regularly doing medical reviews for, any insurer, self-insurer, or provider, and which, for a fee, can provide expert opinions regarding the necessity of treatment provided to an injured worker.

DWD 80.73(2)(f)(f) “Self-insurer” means an employer who has been granted an exemption from the duty to insure under s. 102.28 (2), Stats.

DWD 80.73(2)(g)(g) “Treatment” means any procedure intended to cure and relieve an injured worker from the effects of an injury under s. 102.42, Stats.

DWD 80.73(3)(a)(a) In a case where liability or the extent of liability is in dispute, an insurer or self-insured employer shall provide written notice of the dispute to the health care provider within 60 days after receiving a bill that documents the treatment provided to the worker, unless there is good cause for delay in providing notice. An insurer or self-insurer which refuses to pay for treatment rendered to an injured worker because it disputes that the treatment is necessary shall, in a case where liability or the extent of liability is not an issue, give the provider written notice within 60 days of receiving a bill which documents the treatment provided to the worker. The notice shall specify all of the following:

DWD 80.73(3)(a)5.5. The reason that the insurer or self-insurer believes the treatment was unnecessary, including the organization and credentials of any person who provides supporting medical documentation and a copy of the supporting medical documentation from that person.

DWD 80.73(3)(a)6.6. The provider’s right to initiate an independent review by the department within 9 months under sub. (6), including a description of how costs will be assessed under sub. (8).

DWD 80.73(3)(a)8.8. That pursuant to s. 102.16 (2m) (b), Stats., once the notice required by this subsection is received by a provider, the provider may not collect a fee for the disputed treatment from, or bring an action for collection of the fee for that disputed treatment against, the employee who received the treatment.

DWD 80.73(3)(b)(b) At the request of an insurer or self-insurer, the department may extend the 60-day period in par. (a) where the insurer or self-insurer is unable to obtain the supporting medical documentation within the 60-day period, or where the department determines other extraordinary circumstances justify an extension.