20 Cfr 725.705

Office of Workers’ Compensation Programs, Labor
(c) If adequate treatment cannot be
obtained in the area of the claimant’s
residence, OWCP may authorize the use
of physicians or medical facilities outside such area as well as reimbursement for travel expenses and overnight
accommodations.

rmajette on DSKBCKNHB2PROD with CFR

§ 725.704 How are arrangements for
medical care made?
(a) Operator liability. If an operator
has been determined liable for the payment of benefits to a miner, OWCP will
notify the operator or its insurance
carrier of the names, addresses, and
telephone numbers of the authorized
providers of medical benefits chosen by
an entitled miner, and require the operator or carrier to:
(1) Notify the miner and the providers chosen that the operator or carrier will be responsible for the cost of
medical services provided to the miner
on account of the miner’s total disability due to pneumoconiosis;
(2) Designate a person or persons
with decision-making authority with
whom OWCP, the miner and authorized
providers may communicate on matters involving medical benefits provided under this subpart and notify
OWCP, the miner and providers of this
designation;
(3) Make arrangements for the direct
reimbursement of providers for their
services.
(b) Fund liability. If there is no operator found liable for the payment of
benefits, OWCP will make necessary
arrangements to provide medical care
to the miner, notify the miner and providers selected of the liability of the
fund, designate a person or persons
with whom the miner or provider may
communicate on matters relating to
medical care, and make arrangements
for the direct reimbursement of the
medical provider.
§ 725.705 Is prior authorization for
medical services required?
(a) Except as provided in paragraph
(b) of this section, medical services
from an authorized provider which are
payable under § 725.701 do not require
prior approval of OWCP or the responsible operator.
(b) Except where emergency treatment is required, prior approval of

§ 725.707

OWCP or the responsible operator must
be obtained before any hospitalization
or surgery, or before ordering medical
equipment where the purchase price exceeds $300. A request for approval of
non-emergency hospitalization or surgery must be acted upon expeditiously,
and approval or disapproval will be
given by telephone if a written response cannot be given within 7 days
following the request. No employee of
the Department of Labor, other than a
district director or the Chief, Medical
Audit and Operations Section, DCMWC,
is authorized to approve a request for
hospitalization or surgery by telephone.
§ 725.706 What reports must a medical
provider give to OWCP?
(a) Within 30 days following the first
medical or surgical treatment provided
under § 725.701, the provider must furnish to OWCP and the responsible operator or its insurance carrier, if any, a
report of such treatment.
(b) In order to permit continuing supervision of the medical care provided
to the miner with respect to the necessity, character and sufficiency of any
medical care furnished or to be furnished, the provider, operator or carrier must submit such reports in addition to those required by paragraph (a)
of this section as OWCP may from time
to time require. Within the discretion
of OWCP, payment may be refused to
any medical provider who fails to submit any report required by this section.
§ 725.707 At what rate will fees for
medical services and treatments be
paid?
(a) All fees charged by providers for
any medical service, treatment, drug
or equipment authorized under this
subpart will be paid at no more than
the rate prevailing for the service,
treatment, drug or equipment in the
community in which the provider is located.
(b) When medical benefits are paid by
the fund at OWCP’s direction, either on
an interim basis or because there is no
liable operator, the prevailing community rate for various types of service
will be determined as provided in
§§ 725.708–725.711.

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