Health Care Payment System
Rules & Regulations for the Certification of Health Care Providers
In accordance with the provisions of 19 Del.C. §2322(D), certification is required for a health care provider to provide treatment to an employee, pursuant to Delaware's Workers' Compensation Statute, without the requirement that the health care provider first pre-authorize each health care procedure, office visit or health care service to be provided to the employee with the employer if self-insured, or the employer's insurance carrier. Pursuant to 19 Del.C. §2322B and F, for purposes of the Certification requirements of §2322D, "health care provider in an inpatient hospital setting" specifically includes physicians, chiropractors and physical therapists providing treatment to an injured worker during his/her period of inpatient hospitalization; all other personnel employed by a hospital providing treatment to an injured worker during his/her period of inpatient or outpatient hospitalization are excluded from the Certification requirements of this Subsection. With regard to any hospital facility providing inpatient and/or outpatient services, to be Certified in accordance with the provisions of §2322D so that pre-authorization from the employer or insurance carrier for the employer is not required for each health care procedure, office visit or health care service provided to an injured employee, the person completing and signing the Health Care Provider Application for Certification on behalf of the hospital shall have the authority to do so and must attest to and be responsible for the completion of all of the requirements set forth on such Application. Services provided by an emergency department of a hospital pursuant to §2322B(h)(3) shall not be subject to the requirement of Certification. The provisions of §2322(D) shall apply to all treatments to employees provided after the effective date of the rule/regulation provided by this subsection and regardless of the date of injury. A health care provider shall be certified only upon meeting the following minimum certification requirements:
- Have a current license to practice, as applicable;
- Meet other general certification requirements for the specific provider type;
- Possess a current and valid Drug Enforcement Agency ("DEA") registration, unless not required by the provider's discipline and scope of practice;
- Have no previous involuntary termination from participation in Medicare, Medicaid or the Delaware workers' compensation system. Any such involuntary termination shall be considered to be inconsistent with certification;
- Have no felony convictions in any jurisdiction, under a federal-controlled substance act or for an act involving dishonesty, fraud or misrepresentation. A felony conviction in any jurisdiction under a federal-controlled substance act or for an act involving dishonesty, fraud or misrepresentation shall be considered to be inconsistent with certification;
- Provide proof of adequate, current professional malpractice and liability insurance.
In addition to the above, the health care provider to be certified must agree to the terms and conditions set forth on the Health Care Provider Application for Certification, as follows:
- Comply with Delaware workers' compensation laws and rules;
- Maintain acceptable malpractice coverage;
- Complete state-approved continuing education courses in workers' compensation every two (2) years from the last date the health care provider renewed his or her Delaware professional license. Out of state health care providers, who are not licensed in Delaware, must complete State-approved continuing education courses in workers' compensation every two (2) years from the date of the out of state provider's initial certification. A listing of continuing education courses in workers' compensation care approved by the State of Delaware, Department of Labor, Office of Workers' Compensation, will be posted on the Office of Workers' Compensation website. To maintain certification, the health care provider must provide written notification to the Office of Workers' Compensation of compliance with the continuing education course requirement noted above, setting forth the name of the course(s) completed and the date of completion;
- Practice in a best-practices environment, complying with practice guidelines and Utilization Review Accreditation Council ("URAC") utilization review determinations;
- Agree to bill only for services and items performed or provided, and medically necessary, cost-effective and related to the claim or allowed condition;
- Agree to inform an employee of his or her liability for payment of non-covered services prior to delivery;
- Accept reimbursement for and not unbundle charges into separate procedure codes when a single procedure code is more appropriate;
- Agree not to balance bill any employee or employer. Employees shall not be required to contribute a co-payment or meet any deductibles;
- Agree to have knowledge of all statements authorized under the certified health care provider's signature and to be responsible for the content of all bills submitted pursuant to the provisions of 19 Del.C. §2322B, C, E, F;
- Agree to provide written notification to the Department of Labor, Office of Workers' Compensation, State of Delaware, of any relevant changes to the requirements set forth in the Certification Form within thirty (30) days of the health care provider's knowledge or receipt of notice of any and all such change(s).
Notwithstanding the provisions of §2322(D), any health care provider may provide services during one office visit, or other single instance of treatment, without first having obtained prior authorization from the employer if self-insured, or the employer's insurance carrier, and receive reimbursement for reasonable and necessary services directly related to the employee's injury or condition at the health care provider's usual and customary fee, or the maximum allowable fee pursuant to the workers' compensation health care payment system adopted pursuant to 19 Del.C. §2322(B), whichever is less. The provisions of this subsection, §2322(D), are limited to the occasion of the employee's first contact with any health care provider for treatment of the injury, and further limited to instances when the -2- health care provider believes in good faith, after inquiry, that the injury or occupational disease was suffered in the course of the employee's employment. The provisions of this subsection, §2322(D), shall apply to all treatments to injured employees provided after the effective date of this subsection, and regardless of the date of injury.
The health care provider's completed Certification Form is to be mailed to:
Ms. Donna Forrest
State of Delaware
Department of Labor
Office of Workers' Compensation
4425 N. Market St.
Wilmington, DE 19802
Instructions and provisions for completing the Certification Form online will be published on the Office of Workers' Compensation website when available.
Workers' Compensation Certified Health Care Providers
The Health Care Advisory Panel in accordance with 19 Del. C. §2322D, established a certification process for health care providers who treat Delaware's injured workers. This link provides a list of those health care providers who are certified to date. Each day the Office of Workers' Compensation receives additional applications and updated information; consequently, the list cannot be all inclusive and will regularly change to reflect newly certified providers. If you do not see a particular health care provider on this list and you need to know if that provider is certified to treat workers' compensation patients, we recommend you check directly with the provider.
Continuing Education Course Requirement
Health care providers certified under the Delaware Workers Health Care Payment System (HCPS) agree to complete state-approved continuing education courses in workers' compensation every two (2) years from the date of the health care provider's initial certification.