Chapter 15, Title 12 Medical Fee Schedule Rules (1/1/2026)

HAWAII ADMINISTRATIVE RULES
TITLE 12
DEPARTMENT OF LABOR AND INDUSTRIAL RELATIONS
CHAPTER 15
WORKERS' 	COMPENSATION MEDICAL FEE SCHEDULE
Subchapter 	1 	General 	Provisions
§12-15-1 	Definitions
§§12-15-2 	to 	12-15-11 	(Reserved)
Subchapter 	2 	Health 	Care 	Providers
§12-15-12
§12-15-13
§12-15-14
§12-15-15
§12-15-16
§12-15-17
§12-15-18
§12-15-19
§12-15-20
§12-15-21
§12-15-22
§12-15-23
§§12-15-24 	to
Qualification of health care providers
Health care provider standards
Sanctions and fines
Filing complaints
Withdrawal of complaint
Decision and order
(Reserved)
Reinstatement
Advisory panel of health care providers
Advisory panel function
Advisory panel fees
Selection of new health care
provider upon 	suspension or
revocation of qualification
12-15-29 	(Reserved)
Subchapter 	3 	Treatment
§12-15-30
§12-15-31
§12-15-32
§12-15-33
§12-15-34
Provider of service responsibilities
Who may provide services
Physicians
(Reserved)
Providers of service other than
physicians
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§12-15-35
§12-15-36
§12-15-37
§12-15-38
(Reserved)
Assistants to providers of service
(Reserved)
Change of physician, 	surgeon, 	hospital,
or 	rehabilitation 	facility
(Reserved)
Concurrent medical treatment
(Reserved)
Consultations
to 	12-15-49 	(Reserved)
§12-15-39
§12-15-40
§12-15-41
§12-15-42
§§12-15-43
§12-15-50
§12-15-51
§12-15-52
§12-15-53
§12-15-54
§12-15-55
§§12-15-56 	to
Emergency treatment
Surgery
Anesthesia services
Hospital services
Radiology services
Drugs, 	supplies, 	and materials
12-15-79 	(Reserved)
Subchapter 	4 	Administration
§12-15-80 	Reports of providers of service
§§12-15-81 	to 	12-15-84 	(Reserved)
§12-15-85 	Rules for allowable fees for medical,
§§12-15-86
§12-15-90
§12-15-91
§12-15-92
§12-15-93
§12-15-94
surgical, 	and hospital 	services and supplies
to 	12-15-89 	(Reserved)
Workers' 	compensation medical fee schedule
(Reserved)
Controverted case payments
(Reserved)
Payment by employer
Historical 	note: 	Chapter 	12-15 	is 	based
substantially upon 	Chapter 12-13 	[Eff 8/13/71; 	am
1/1/73, 	am 1/1/74,am 1/1/75, 	am 1/1/76, 	am 1/1/77,
am 1/1/78, 	am 1/1/79,am 1/1/80, 	am 1/1/81, 	am
1/1/82, 	am 1/1/83, 	am 1/1/84, 	am 11/29/85, 	am
11/19/87, 	am 11/24/89, 	am 11/23/92; 	R 1/1/96) 	Chapter
12-15 	[Eff 1/1/96; 	am 1/1/97, 	am 11/22/97, 	am
12/17/01, 	am 12/13/04, 	am 11/6/06, 	am 12/14/07,
am 2/28/11, 	am 12/30/13, 	am 12/28/17]
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SUBCHAPTER 1
GENERAL PROVISIONS
§12-15-1 Definitions. 	As 	used in this 	chapter:
"Advisory panel" means 	the advisory panel of
health care providers appointed by the director
pursuant to section 386-27, 	HRS.
"Appellate board" 	shall be as defined in section
386-1, 	HRS.
"Attending physician" 	shall be as defined in section
386-1, 	HRS.
"Bad faith," 	for 	the purposes of section 386-27,
HRS, 	and this chapter, 	requires a 	finding of a
fraudulent, 	malicious, 	dishonest, 	or 	frivolous 	act or
omission. 	Mere 	carelessness, 	bad judgment, 	or ordinary
negligence, 	in and of themselves, 	do not constitute bad
faith.
"Department" 	shall be as defined in section 386-1,
HRS.
"Director" 	shall be as defined in section 386-1,
HRS.
"Disability" 	shall be as defined in section 386-1,
HRS.
"Disqualified health care provider" means a 	health
care provider barred under section 386-27, 	HRS, 	from
providing health care 	services to a person who 	has
suffered a 	work injury.
"Emergency medical 	services" 	shall be as
defined in section 386-1, 	HRS.
"Employee" 	shall be as defined in section 386-1,
HRS.
"Employer," as defined in section 386-1, 	HRS,
includes a ?elf-insured employer or the self-insured
employer's adjuster or designated 	representative unless
clearly indicated otherwise, 	the 	insurer of an employer,
or an employer who has 	failed 	to comply with section 386-
121, 	HRS.
"Employer's designated representative," 	for 	the
purpose of 	section 386-3l(b) (1), 	HRS, 	shall 	include:
(1) 	A self-insured employer's adjuster or
attorney of 	record;
(2) 	An insured employer's 	insurer, 	adjuster, 	or
attorney of 	record; 	or
(3) 	The adjuster or attorney of record of an
uninsured employer.
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"Guide" or 	"guidelines" 	shall be as defined in
section 386-1, 	HRS.
"Health care provider" 	shall be as defined in
section 386-1, 	HRS.
"Medical care," 	"medical services," or 	"medical
supplies" 	shall be as defined in section 386-1, 	HRS.
"Medical Fee Schedule" 	refers 	to the Medicare
Resource Based Relative Value Scale System applicable
to Hawaii 	and the Workers' 	Compensation Supplemental
Medical 	Fee Schedule, 	Exhibit A, 	at 	the end of this
chapter.
"Physician" 	shall be as defined in section 386-1,
HRS.
"Provider of 	service" means any person or entity who
is licensed, 	certified, 	recognized, 	or registered with
the Department of Commerce and Consumer Affairs and who
renders medical 	care, 	medical 	services, 	or medical
supplies 	in accordance with chapter 386, 	HRS.
"Specialist" means a 	physician or surgeon who
holds 	a 	certification as a 	diplomate 	issued by a
specialty board approved by the American Medical
Association or the American Dental Association.
"Therapist" means a duly licensed physical
therapist or a 	duly registered occupational 	therapist
certified by the National 	Board for Certification in
Occupational Therapy, 	who 	renders 	therapy prescribed
by a 	physician.
"This statute" 	or "the statute" means chapter 386,
HRS, 	unless otherwise specified.
"Treatment" 	is defined as a 	visit to a
provider of service 	for 	the 	~njury excluding
consultations.
"Unqualified health care provider" means a
health care provider who is not qualified by tpe
director under section 386-27, 	HRS, 	to provide
health care services to a person who has 	suffered a
work injury.
"Work injury" 	shall be as defined in section 386-1,
HRS. 	(Eff 1/1/96, 	am 12/13/04; 	am 2/28/11;
comp 	DEC 27 2025 	l 	(Auth: 	HRS §§386-21, 	386-26,
386-27, 	386-72) 	(Imp: 	HRS §§386-1, 	386-2, 	386-21,
386-23, 	386-27)
§§12-15-2 	to 	12-15-11 	(Reserved)
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SUBCHAPTER 2
HEALTH CARE PROVIDERS
§12-15-12 Qualification of health care
providers. 	(a) 	Any 	heal th 	care 	provider 	licensed
or 	certified 	by 	the department 	of 	commerce 	and
consumer 	affairs 	to 	practice 	in the 	State 	of 	Hawaii
is deemed a 	qualified health care provider under the
statute.
(b) 	Continued 	qualification 	shall 	be
contingent 	upon 	compliance with sections 386-26
and 386-27, 	HRS, 	and any 	related 	rules 	and
decisions 	adopted 	and 	issued 	by 	the 	director
pursuant to 	the 	statute. 	[Eff 	1/1/96;
comp 	DEC272025 	] 	(Auth: 	HRS 	§§386-27,
386-72) 	(Imp: 	HRS §§386-26, 	386-27)
§12-15-13 	Health 	care 	provider 	standards. 	Any
health care 	provider 	who 	is 	found 	to 	be 	in
violation 	of 	any 	one or more of the 	following
standards 	shall, 	after hearing, 	be subject to 	the
sanctions and penalties pursuant 	to section 12-15-14
or 	any 	other 	applicable 	provision 	in 	the 	statute:
(1) 	Failure, 	neglect, 	or 	refusal 	to
submit 	complete, 	adequate, 	and
detailed reports as defined in the
statute;
(2) 	Failure, 	neglect, 	or 	refusal 	to 	respond
to 	the 	director's 	written . request 	for
additional 	reports;
(3) 	Failure, 	neglect, 	or refusal 	to observe
and comply with the 	statute;
(4) 	Failure, 	neglect, 	or refusal 	to comply
with the department's 	written 	rules,
determinations, 	or decisions;
(5) 	Persistent 	refusal 	to 	consider the
recommendations of board certified or
qualified health care providers 	in 	the
provider's 	specialty 	field 	who have
examined the 	injured 	employee, 	without
providing 	adequate 	reasons 	for 	such
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refusal;
(6) 	Repeated 	submission 	of 	false 	or 	misleading
reports;
(7) 	Collusion with any other person in the
submission of 	false 	or misleading
information;
(8) 	Submission 	of 	inaccurate, 	misleading, 	or
duplicate bills;
(9) 	Persistent submission of 	false 	or
erroneous 	diagnosis;
(10) 	Use 	of 	treatment 	that 	is:
(A) 	Contraindicated 	or 	hazardous; 	or
(B) 	Excessive 	in 	frequency 	or 	duration;
(11) 	Charging or attempting to charge any fee
to an 	industrially injured employee for
the care of the 	industrial 	injury or
billing the employer more 	than the fee
allowed under section 12-15-90;
(12) 	Charging fees 	to an injured employee
which have been disallowed or
forfeited;
(13) 	Prescription of narcotic, 	addictive,
habituating, 	or dependency inducing drugs
in any way other than for 	therapeutic
purposes;
(14) 	Acts of gross misconduct in the
practice of the profession;
( 15) 	Failure 	to 	treat 	a 	work 	injury 	for other
than ethical or other valid
considerations under the statute;
(16) 	Failure, 	neglect, 	or 	refusal 	to insure
compliance by a 	provider of service under
the health care provider's direction as
required under this 	chapter. 	[Eff 1/1/96;
comp n!='r. 2·7 2025 	] 	(Auth: 	HRS §§38 6-27,
386- ~~/ 	{Imp: 	HRS §386-27)
§12-15-14 Sanctions 	and fines. 	Should a
heal th 	care 	provider 	be 	found 	to 	be 	in 	violation
of 	any 	provision 	of the 	statute 	or 	any 	related
rules, 	the 	director, 	in consideration of the degree
of harm inflicted on an 	injured employee or an
employer, 	of the number of previous violations, 	and
of the presence of evidence 	of bad faith 	violations,
shall, 	after hearing and at 	the director's
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discretion, 	do any one or a 	combination of the
following:
(1) 	Issue a 	reprimand, 	provided the
severity does 	not warrant 	additional
sanctions;
(2) 	Disallow fees 	for 	services 	rendered
to 	the 	injured employee, 	or 	require a
forfeiture 	of payment 	for 	services
rendered, 	or both;
(3) 	Levy a 	fine 	of not more 	than $1,000 	for 	each
violation, 	or suspend the 	health care
provider as a 	qualified health care
provider 	for 	a 	period not 	to exceed one
year, 	or both;
(4) 	Revak~ the 	health care provider's
qualification to practice under the
statute. 	[Eff 1/1/96; 	comp 	oEr 27 2n?li
(Auth: 	HRS §§386-27, 	386-72) 	1Imp: ™s
§386-27)
§12-15-15 	Filing 	complaints. 	(a) 	Whenever 	a
health 	care 	provider 	has 	allegedly 	violated 	any
provision 	of sections 	386-26 	or 	38 6- 27, 	HRS, 	or 	any
related 	rules, 	a 	written 	complaint, 	identifying
the health care provider and indicating the date and
nature 	of 	the 	infraction 	with 	related
documentation, 	shall 	be 	filed with the director,
provided 	that 	it 	is 	submitted 	within 	two 	years 	of
the 	date 	of 	the 	alleged 	infraction 	by 	a 	party 	of
interest.
(b) 	The director shall mail a 	copy of the
complaint to 	the 	heal th 	care 	provider 	against 	whom
the 	complaint 	has been 	filed. 	The health care
provider shall 	have 	the 	right 	to 	file 	with the
complainant 	and 	the 	director 	a 	written statement 	in
response 	to 	the 	complaint 	within 	thirty calendar
days 	from 	the 	date 	the 	director 	mails 	the complaint
to 	the health care provider.
(c) 	The director or a duly appointed
representative shall 	investigate 	the 	statements 	of the
complainant and the health care provider 	against 	whom
the 	complaint 	has 	been 	filed 	and 	shall, 	upon 	not
less 	than 	twenty 	calendar 	days 	notice 	to 	the parties
involved, 	hold a 	hearing pursuant to 	section 386-86,
HRS, 	to take 	testimony or hear arguments.
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(d) 	In cases where the 	complaint pertains 	to
services provided to an 	injured employee, 	such as
method of treatment, 	frequency 	of 	treatment,
prognosis, 	and 	diagnosis, 	the director may establish
an advisory panel 	of health care providers pursuant 	to
section 12-15-20. 	[Eff 1/1/96; 	comR 	]
(Auth: 	HRS 	§§386-27, 	386-72) 	(Imp:'J~~7sW~-27)
§12-15-16 Withdrawal 	of 	complaint.
Requests 	for 	withdrawal 	of 	a 	complaint 	shall 	be
submitted 	in 	writing. 	Upon 	receipt of 	this 	request,
the director shall dismiss 	the 	complaint and notify
the health 	care provider 	against whom 	the 	complaint
has 	been 	filed. 	[Eff 	1/1/96; 	comp DEC 27 2025 	]
(Auth: 	HRS §§386-27, 	386-72) 	(Imp: 	HRS 	§386-27)
§12-15-17 	Decision 	and 	order. 	(a) 	The
director 	shall hold 	a 	hearing 	and 	issue 	a 	written
decision. 	The 	decision shall 	order 	sanctions 	or
fines 	or 	both 	if 	the 	director determines 	that 	the
health 	care 	provider 	acted 	in 	bad 	faith 	and
violated 	any 	provision 	of 	sections 	386-26 or 386-
27, 	HRS, 	or any 	related 	rules .
(bl 	The 	decision 	shall 	be 	sent 	to 	the
respective 	parties 	of 	interest. 	If 	the 	health 	care
provider 	is 	sanctioned 	or 	fined, 	the director 	shall
send 	a 	copy of the decision 	to 	the 	department 	of
commerce 	and 	consumer 	affairs.
(c) 	The 	decision 	shall 	be 	final 	unless
appealed 	pursuant 	to 	section 	386-87, 	HRS. 	The
appeal 	shall not 	stay the director's 	decision.
[Eff 1/1/96; 	compQEC 2 7 2025 	] 	(Auth: 	HRS §§386-
27, 	386-72) 	(Imp: 	HRS 	§386-27)
§12-15-18 	(Reserved)
§12-15-19 Reinstatement. 	A health 	care
provider 	whose 	qualification has been revoked may,
upon written application, 	be 	reinstated 	after 	a
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period 	of 	two 	years 	at 	the discretion of the
director provided the health care provider meets 	the
standards prescribed 	in this 	chapter. 	[Eff 	1/1/96;
comp 	DEC272025] 	(Auth: 	HRS§§386-27, 	386-72)
(Imp: 	HRS §386- 27)
§12-15-20 	Advisory 	panel 	of 	health 	care 	providers.
(a) 	When the director determines 	an advisory panel 	is
necessary, 	the director 	shall 	notify 	the 	complainant 	and
the 	health 	care 	provider 	of 	concern. 	The 	complainant
and 	the 	health 	care 	provider 	of concern 	shall 	submit 	the
names 	of 	their 	preferred 	advisory 	panelist 	and 	two
alternates 	to 	the director.
(b) 	The director shall select a health care
provider in the 	relevant specialty area 	to represent
the director on the advisory panel 	for 	the complaint
reviewed. 	The health care provider shall be
available 	to 	the department 	for 	consultation, 	or
panel 	review, 	or both. 	If 	any 	party 	fails 	to 	submit
names 	within 	the time allowed by 	the director, 	the
director may select 	on 	behalf 	of 	that party, 	a
person to 	fill 	that 	party's 	panelist's 	position.
The director 	shall 	then notify the 	selected panel of
the date of 	review and the 	facts 	of the case.
(c) 	If any panelist considers 	the nature of the
case to be within the panelist's 	scope and field of
expertise, 	and does 	not 	represent 	a 	conflict 	of
interest, 	the 	panelist shall notify the director 	of
the 	panelist's 	availability. 	If 	any 	panelist 	is
unable 	to 	attend 	the 	review 	for 	any 	reason, 	the
director 	shall 	notify 	the 	next 	alternate.
(d) 	The advisory panel 	shall be chaired by the
health care 	provider 	appointed 	by 	the 	director 	and
may 	meet 	with the director as deemed 	necessary 	to
review 	the 	complaint. 	[Eff 	1/1/96;
comp 	DEC 27 2025 	] 	(Auth: 	HRS 	§§386-27, 	386-72)
(Imp: 	HRS 	§386- 27)
§12-15-21 Advisory panel function. 	(a) 	The
advisory 	panel 	shall 	have 	the 	right 	to 	request 	or
subpoena 	through the director 	relevant 	information,
such 	as 	x-rays 	and 	chart 	notes 	on 	each 	case. 	The
heal th 	care 	provider 	against 	whom 	the 	complaint
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has 	been 	filed 	shall 	be notified 	of 	the 	heal th 	care
provider's 	right 	to 	appear before the 	advisory panel
at a 	specified time and place 	for 	a 	review of the
complaint.
(b) 	After the 	review, 	the advisory panel 	shall
recommend to 	the 	director 	disposition 	of 	the 	case.
(c) 	Should the health care provider of concern
fail 	or decline 	to appear, 	the advisory panel 	shall
recommend to 	the 	director 	appropriate 	action 	based
on the available evidence.
(d) 	After 	receipt 	of the 	recommendation of the
advisory panel, 	the 	director 	shall 	hold 	a 	hearing
pursuant 	to 	section 	386-86, 	HRS. 	The 	director
shall 	furnish 	the 	health 	care 	provider 	against 	whom
the 	complaint has 	been filed 	and the 	complainant a
copy 	of 	the 	advisory 	panel's 	recommendation
upon 	request. 	[Eff 	1/1 /96; 	comp
(Auth: 	HRS 	§§371-6, 	386-27, 	386-71, Og6,-na0>25
(Imp: 	HRS §386-27)
§12-15-22 	Advisory 	panel 	fees. 	For 	each
complaint 	reviewed, 	the 	special 	compensation 	fund
shall pay $500 	to 	the 	chairperson 	of 	the 	advisory
panel 	and 	$300 	to 	each 	of 	the 	other 	two 	panel
members. 	[Eff 1/1/96; 	comp DEC 27 2025 	] 	(Auth:
HRS 	§§386-27, 	386-72) 	(Imp: 	HRS 	§386-27)
§12-15-23 	Selection 	of 	new 	health 	care 	provider
upon suspension or 	revocation 	of 	qualification. 	(a)
If 	a 	health care provider's 	qualification is suspended
or 	revoked, 	the 	health 	care 	provider 	shall 	provide 	the
director 	a 	list 	of all 	industrially 	injured 	employees
currently 	being 	treated subject 	to 	chapter 	386, 	HRS,
under 	the 	suspended 	or 	revoked health 	care 	provider's
care 	within 	thirty 	calendar 	days 	of the director's
decision.
(b) 	The 	director 	shall 	notify 	all 	injured
employees under 	the 	suspended 	or 	revoked 	heal th 	care
provider's 	care of 	the 	suspension 	or 	revocation 	within
seven 	calendar 	days of 	receipt 	of 	the 	list 	of 	injured
employees. 	The 	injured employee 	shall 	select 	a 	new
health 	care 	provider. 	This 	selection 	shall 	not 	be
considered a 	first 	change as permitted under section 12-
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15-38.
(c) 	If 	the 	suspended 	or 	revoked 	heal th 	care
provider does 	not 	provide 	the 	list 	of 	injured 	employees
after 	thirty calendar 	days 	of 	the 	director's 	decision,
the 	director 	shall notify all 	known 	injured 	employees
under 	the 	suspended 	or 	revoked 	health 	care provider's
care of the 	suspension 	or 	revocation. 	This
notification 	by 	the director 	shall 	not 	absolve 	the
suspended 	or 	revoked 	health care provider of
responsibility under 	this 	section 	for 	providing such 	list
to 	the director.
(d) 	The 	newly 	selected 	health 	care 	provider 	shall
notify 	the 	employer 	and 	the 	director 	in 	writing 	of 	the
health care provider's selection within seven calendar days
of 	selection. 	(Eff 	1/1/96; 	comp 	DEC 2 7 2025 	l 	(Auth:
HRS §§386-27, 	386-72) 	(Imp: 	HRS §386-27)
§§12-15-24 	to 	12-15-29 	(Reserved)
SUBCHAPTER 3
TREATMENT
§12-15-30 	Provider 	of 	service 	responsibilities. 	(a)
The 	rules 	herein apply 	to 	all 	providers 	of 	service.
Additional 	rules 	pertaining 	to 	specialty 	areas 	are
published 	in 	the 	appropriate 	section.
(b) 	The 	total allowed treatments 	shall not be
performed should 	an 	injured 	employee 	recover 	from
the 	injury 	prior 	to 	reaching the maximum allowed.
(c) 	The director may request evidence of
treatment 	efficacy from the provider of service.
(d) 	Frequency 	of 	treatment 	specified 	in 	the
rules 	herein are guidelines 	to 	improve provider of
service accountability 	and 	are 	not 	intended 	to 	be 	an
authoritative prescription for 	health care.
(e) 	All providers 	of service are 	required to
comply with 	reporting 	requirements 	pursuant 	to 	chapter
386, 	HRS, 	and any 	related 	rules.
(f) 	The director may deny compensation to any
provider of service who performs 	services 	in excess
of the 	frequency of treatment guidelines without
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,,I 	- -,

authorization pursuant to 	the 	statute or any
related 	rules. 	[Ef:f 1/1/96;
comp 	DEC 2 7 2025 	] 	(Auth: 	HRS §§386-26, 	386-27,
386-7;0JEC 21'1ni025rns §§386 - 	21, 	386- 26, 	386- 27,
386 - 	94, 	386-96)
§12-15-31 	Who 	may provide 	services. 	(a) 	All
providers 	of 	service deemed qualified by the director
may provide services 	to an 	injured employee.
Treatment 	shall fall 	within 	the 	scope 	of 	the
provider's 	of 	service 	license or 	certification to
practice.
(b) 	Treatment rendered by an unqualified or
disqualified provider 	of 	service 	shall 	not 	be
reimbursed, 	except 	in emergencies.
(c) 	Any 	service 	performed 	by 	a 	provider 	of
service 	who 	is not 	a 	physician 	as 	defined 	in
section 	386-1, 	HRS, 	shall 	be 	referred 	by 	and 	be
under 	the 	direction 	of 	the 	attending 	physician.
Treatment may be rendered on the basis of a 	written
prescription and treatment 	plan approved by 	the
attending 	physician 	as 	specified 	in 	section 	12-15-
34. 	The prescription and treatment 	plan 	shall 	be
individualized 	for 	the 	patient's 	industrial
injury. 	[Eff 	1/1/96; 	comp 	DEC272025 	(Auth:
HRS 	§ § 3 8 6 - 21, 	3 8 6 - 2 6, 	3 8 6- 2 7 , 	3 8 6 - 7 2 ) 	( Imp : 	HRS
§§386-2 1 , 	386-26, 	386-27)
§12-15-32 Physicians. 	(a) 	Frequency and extent
of treatment shall not be more 	than the nature of the
injury and the process of a 	recovery requires.
Authorization is not 	required for 	the initial 	fifteen
treatments of the injury during 	the 	first 	sixty
calendar days.
(b) 	If the physician believes 	treatments 	in
addition to that allowed by subsection 	(a) 	are
required, 	the physician shall 	transmit a 	treatment
plan to the employer by mail 	or 	facsimile 	under
separate cover at least seven calendar days prior to
the 	start of the additional treatments 	to an address
or facsimile number provided by the employer. 	A
treatment plan shall be 	for 	one hundred twenty
calendar days and shall not exceed fifteen 	treatments
14
3 6 1. 9

within that period. 	Treatments provided with 	less 	than
seven 	calendar days 	notice 	are not authorized. 	A
complete treatment plan shall 	contain the 	following
elements:
(1) 	Projected commencement and termination
dates of treatment;
(2) 	A clear statement as 	to 	the impression
or diagnosis;
(3) 	A specific time 	schedule of measurable
objectives to include baseline
measurements at 	the 	start of the treatment
plan and projected goals by the end of the
treatment plan;
(4) 	Number and frequency of treatments;
(5) 	Modalities and procedures to be
used; 	and
(6) 	An estimated total cost of services. 	Treatment
plans 	which do not 	include 	the above 	specified elements
but which are reasonable and necessary may not be denied
by the employer, 	but upon written notification from the
employer, 	the physician shall correct the deficiency(s) 	and
the employer's liability is deferred as long as the treatment
plan remains deficient. 	Neither the injured employee nor the
employer shall be liable for services provided under a
treatment plan that remains deficient. 	Both the front page of
the treatment plan and the envelope in which the plan is
mailed or the cover sheet if the plan is sent by facsimile
shall be clearly identified as a 	"WORKERS' COMPENSATION
TREATMENT PLAN" in capital letters and in no less than ten
point type.
(c) 	A treatment plan shall be deemed received by an
employer when the plan is 	sent by mail or facsimile with
reasonable evidence showing that 	the 	treatment plan was
received.
(d) 	The employer may 	file 	an objection to 	the
treatment plan with documentary evidence supporting the
denial 	and a 	copy of the denied treatment plan with the
director, 	copying the physician and the 	injured employee.
Both the 	front page of 	the denial and the envelope 	in
which the denial 	is 	filed 	shall be 	clearly identified as
a 	"TREATMENT 	PLAN DENIAL" 	in capital 	letters and in no
less than ten point type. 	The employer shall 	be
responsible 	for payment 	for 	treatments provided under a
complete 	treatment 	plan until 	the date 	the objection is
filed with the director. 	Furthermore, 	the employer's
objection letter must explicitly state that 	if the
attending physician or the 	injured employee does 	not
agree 	with the denial, 	they may 	request a 	review by the
15

director of the employer's denial within fourteen
calendar days after postmark of the employer's denial,
and failure 	to do so shall be 	construed as acceptance of
the employer's denial.
(e) 	The attending physician or the injured
employee may request in writing 	that 	the director
review the employer's denial of the treatment plan.
The request 	for 	review shall be 	filed with the
director, 	copying the employer, 	within fourteen
calendar days after postmark of the employer's denial.
A copy of the denied treatment plan shall be submitted
with the 	request for 	review. 	Both the 	front page 	of
the 	request 	for 	review and the envelope in which the
request is 	filed shall be clearly identified as a
"REQUEST FOR REVIEW OF TREATMENT 	PLAN DENIAL" 	in
capital 	letters and in no less than ten point type. 	For
cases not 	under 	the 	jurisdiction of the director at
the time of the 	request, 	the injured employee shall be
responsible to have the case 	remanded to 	the
director's 	jurisdiction. 	Failure 	to 	file 	a 	request 	for
review of the employer's denial with the director
within fourteen calendar days 	after postmark of the
employer's denial shall be deemed acceptance of the
employer's denial.
(f) 	The director shall issue a decision, 	after a
hearing, 	either 	requiring the 	employer to pay the
physician within thirty-one calendar days 	in
accordance with the medical 	fee 	schedule if the
treatments are determined to be 	reasonable and
necessary or disallowing the fees 	for 	treatments
determined to be unreasonable 	or unnecessary.
Disallowed fees 	shall not be charged to the injured
employee.
(g) 	The 	decision 	issued 	pursuant 	to 	subsection
(f) 	shall be final 	unless appealed pursuant to section
386-87, 	HRS. 	The 	appeal 	shall 	not 	stay 	the 	director's
decision.
(h) 	The psychiatric evaluation or psychological
testing with the 	resultant 	reports 	shall be limited to
four hours 	unless the physician submits prior
documentation indicating the necessity for more 	time
and receives 	pre-authorization from the employer. 	Fees
shall be calculated on an hourly basis as allowed under
Medicare.
(i) 	For physical medicine, 	treatments may
include up to four procedures, 	up to four modalities,
or a 	combination of up to 	four 	procedures and
1 6
3 61 	9

modalities, 	and the visit 	shall 	not exceed sixty
minutes per injury. 	When treating more than one
injury, 	treatments may include up to six procedures, 	up
to six modalities, 	or a 	combination of up to 	six
procedures and modalities, 	and the 	entire visit 	shall
not exceed ninety minutes.
(j) 	Any physician who exceeds 	the 	treatment
guidelines without proper authorization shall not be
compensated for 	the unauthorized services.
(k) 	No compensation shall be allowed for
preparing treatment plans and written justification for
treatments which exceed the 	guidelines.
(1) 	Failure to comply with the 	requirements
in this 	section may result 	in denial 	of fees.
(m) 	Treatment, 	prescribed on an in-patient basis
in a 	licensed acute 	care hospital where the 	injured
employee's 	level of care 	is medically appropriate for
an acute 	setting as determined by community standards,
are excluded from the 	frequency of treatment
guidelines 	specifi~CY1~ 25 [Eff 1/1/96; 	am 1/1/97;
am 12/28/17; 	comp 	) 	(Auth: 	HRS §§386-21,
386-21.2, 	386-26, 	386-72) 	(Imp: 	HRS §§386-21, 	386-
21.2, 	386-26, 	386-27)
§12-15-33 	(Reserved)
§12-15-34 Providers of service other than physicians.
(a) 	Frequency and extent of treatment shall 	not be more
than the 	nature of 	the 	injury and the process of a
recovery 	require. 	Any health care treatment or 	service
performed by a 	Hawaii 	licensed or certified provider of
service other than a 	physician shall be directed by the
attending physician based on a 	written prescription
signed, 	dated, 	and approved by the attending physician.
The prescription may authorize up to an initial 	fifteen
treatments of the 	injury during the 	first 	sixty 	calendar
days. 	For therapists, 	the prescription may authorize 	up 	to
an initial 	twenty treatments of 	the 	injury during the
first 	sixty calendar days.
b) 	If the attending physician believes 	treatments 	in
addition to that allowed by subsection 	(a) 	are 	required,
the provider of 	service 	other than a 	physician, 	in lieu of
the attending physician, 	may transmit a 	treatment plan 	for
17

review and approval to the attending physician who 	shall,
after approval, 	transmit the treatment plan to the
employer by mail or facsimile under separate cover at
least seven calendar days prior to the start of the
additional treatments 	to an address or facsimile 	number
provided by the employer. 	A treatment plan shall be for
one hundred twenty calendar days 	and shall not exceed
fifteen 	treatments within that period. 	Treatments provided
with less 	than seven calendar days 	notice are not
authorized. 	A complete treatment plan shall contain the
following 	elements:
(1) 	Projected commencement and termination
dates of treatment;
(2) 	A clear statement as 	to the
impression or diagnosis;
(3) 	A specific time 	schedule of measurable
objectives 	to include baseline
measurements at the 	start of the 	treatment
plan and projected goals by the end of the
treatment plan;
(4) 	Number 	and 	frequency 	of 	treatments;
(5) 	Modalities and procedures 	to be used; 	and
Treatment plans which do not 	include the 	above specified
elements but which are 	reasonable and necessary may not
be denied by the employer, 	but upon written notification
from the employer, 	the physician or the provider of
service, 	with approval by the attending physician, 	shall
correct the deficiency(s) 	and the employer's 	liability
is deferred as 	long as 	the treatment plan remains
deficient. 	Neither the 	injured employee nor the employer
shall be liable 	for 	services provided under a 	treatment
plan that 	remains deficient. 	Both the front page of the
treatment plan and the envelope 	in which the plan is
mailed or the 	cover sheet if the plan is 	sent by
facsimile 	shall be clearly identified as 	a 	"WORKERS'
COMPENSATION TREATMENT PLAN" 	in capital 	letters and in
no less than 	ten point type.
(cl 	A treatment plan shall be deemed received by an
employer when the plan is 	sent by mail or 	facsimile with
reasonable 	evidence showing that 	the 	treatment plan was
received.
(d) 	The employer may file 	an objection to 	the
treatment plan with documentary evidence supporting the
denial and a 	copy of the denied treatment plan with the
director, 	copyihg the attending physician, 	the provider
of service and the injured employee. 	Both the 	front page
of the denial 	and the envelope 	in which the denial 	is
18
3 6 1 9

filed 	shall be clearly identified as a 	"TREATMENT PLAN
DENIAL" 	in capital 	letters and in no 	less than 	ten point
type. 	The employer shall be 	responsible 	for payment 	for
treatments provided under a 	complete treatment plan
until 	the date 	the objection is 	filed with the director.
Furthermore, 	the employer's 	objection letter must
explicitly state that 	if the attending physician or the
injured employee does 	not 	agree with the denial, 	they
may 	request a 	review by the director of the employer's
denial within fourteen calendar days 	after postmark of
the employer's 	denial, 	and failure 	to do so 	shall be
construed as acceptance of the employer's denial.
(e) 	The attending physician or the injured
employee may 	request 	in writing that 	the director
review the employer's denial of the 	treatment plan. 	The
requesi for 	review shall be 	filed with the director,
copying the employer, 	within fourteen calendar days
after postmark of the 	employer's denial. 	A copy of the
denied treatment plan shall be submitted with the
request 	for 	review. 	Both the 	front 	page of the 	request
for 	review and the envelope in which the request 	is
filed shall be 	clearly identified as a 	"REQUEST 	FOR
REVIEW OF TREATMENT PLAN DENIAL" 	in capital 	letters and
in no 	less than ten point type. 	For cases not 	under 	the
jurisdiction of the director at 	the time of the
request, 	the 	injured employee shall be responsible 	to
have 	the case remanded to the 	director's 	jurisdiction.
Failure 	to 	file 	a 	request 	for 	review of 	the
employer's denial with the director within fourteen
calendar days 	after postmark of the 	employer's 	denial
shall 	be deemed acceptance of the employer's 	denial.
(f) 	The director shall 	issue a decision, 	after a
hearing, 	either 	requiring 	the 	employer to pay the
provider of service other than a 	physician within
thirty-one calendar days 	in accordance with the medical
fee 	schedule 	if the 	treatments 	are determined to be
reasonable and necessary or disallowing the 	fees 	for
treatments determined to be unreasonable or
unnecessary. 	Disallowed fees 	shall 	not be charged to
the 	injured employee.
(g) 	The decision issued pursuant to subsection
(f) 	shall be 	final 	unless 	appealed pursuant to 	section
386-87, 	HRS. 	The appeal 	shall 	not 	stay the director's
decision.
(h) 	The provider of 	service other than a
physician shall 	submit reports at least monthly to 	the
attending physician and employer regarding an injured
19
3 6 1 9

employee's progress. 	The preparation and submission of
written reports 	or progress 	notes 	to 	the employer by
the provider of 	service other than a 	physician are an
integral part of the service 	fee.
(i) 	Treatments may include up to four procedures,
up to 	four modalities, 	or a 	combination of up to 	four
procedures and modalities, 	and the visit 	shall not
exceed sixty minutes per injury. 	When treating more than
one injury, 	treatments may include up to six procedures,
up to six modalities, 	or a 	combination of up to 	six
procedures and modalities, 	and the entire visit 	shall
not exceed ninety minutes. 	This 	section applies 	to
providers of service other than physicians 	including
physical 	therapists, 	occupational therapists, 	massage
therapists, 	and acupuncturists.
(j) 	Any provider of service other than a 	physician
who exceeds the 	treatment guidelines without proper
authorization shall not be 	compensated for 	the
unauthorized services.
(k) 	No compensation shall be allowed for 	preparing
treatment plans and written justification for treatments
which exceed the guidelines.
(1) 	Failure to comply with the ·requirements in this
section may result 	in denial 	of 	fees.
(m) 	Therapy by physical 	therapists and
occupational therapists, ·prescribed on an in-patient
basis 	in a 	licensed acute care hospital where the 	injured
employee's level of care 	is medically appropriate 	for an
acute setting as determined by community standards 	or,
prescribed on an out-patient post- surgery basis not to
exceed thirty calendar days, 	are excluded from the
frequency of treatment guidelines 	specified herein.
[Eff 1/1/96; 	am 1/1/97; 	am 12/28/17; 	comp 	DEC 2 7 2025
(Auth: 	HRS §§386-21, 	386- 21.2, 	386-26, 	386-72) 	{Imp:
HRS §§386-21, 	386-21.2, 	386-26,386-27)
§12-15-35· 	(Reserved)
§12-15-36 	Assistants to providers of service. 	{a)
Providers 	of service may have treatment 	in their
discipline 	carried out by persons certified or licensed
to provide such service.
(b) 	Fees 	for 	services provided by licensed
20

physician assistants as 	recognized pursuant to chapter
453, 	and registered nurses as 	recognized pursuant to
chapter 457, 	shall be eighty-five per cent of the 	fees
authorized by section 12- 15-90.
(c) 	Physical 	therapists may have 	treatment in
their discipline carried out by physical therapist
assistants as 	recognized pursuant to 	461J-3(e). 	Physical
therapist assistants must have completed a program
accredited by The Commission on Accreditation in Physical
Therapy Education. 	The physical 	therapist assistants
shall 	be compensated at 	sixty per cent of the fees
authorized by section 12-15-90.
(d) 	Occupational 	therapists may have 	treatment 	in
their discipline carried out by certified occupational
therapy assistants 	as 	recognized pursuant to 	chapter
457G. 	Occupational 	therapy assistants must have
completed a program accredited by the Accreditation
Council 	for Occupational Therapy Education or an
accreditation body recognized by the Accreditation
Council for Occupational Therapy Education. 	The
certified occupational therapy assistants 	shall be
compensated at 	sixty per cent of the 	fees 	authorized by
section 12-15-90.
(e) 	The qualifications of assistants 	to providers
of 	service must be 	identified on the bill 	for 	service
for 	each service performed by an assistant. 	Fees that
fail 	to identify services performed by assistants may be
denied. 	[Eff 	1/1/96; 	am 12/17/01; 	am 12/13/04, 	am
2/28/11; 	comp nEc 27 ?025 	l 	(Auth: 	HRS §§386-21, 	386-
26, 	386-72) 	('!mp: 	HR~ §§386-21, 	386-26)
§12-15-37 	(Reserved)
§12-15-38 	Change 	of physician, 	surgeon,
hospital, 	or 	rehabil~tation 	facility. 	(a) 	In 	the
event 	an 	injured employee 	elects 	to change attending
physicians, 	the 	employee shall 	notify 	the 	employer
prior 	to 	initiating 	the 	change. 	The 	newly 	selected
attending 	physician 	shall 	make 	a 	diligent 	effort 	to
secure 	from 	the 	previous 	physician, 	or from the
employer, 	all 	of 	the 	available 	medical 	information.
The 	previous 	attending 	physician 	shall 	immediately
forward, 	upon 	request, 	all 	requested 	information
21
3 6 1 9 _

and x-rays 	to the new attending 	physician. 	Changes 	in
attending physician by the 	injured employee subsequent
to the 	first 	change 	require prior approval by the
director or employer.
(bl 	On the 	basis 	of 	competent 	medical 	advice, 	the
director shall determine the need for 	or 	sufficiency of
medical 	services 	furnished 	or 	to 	be 	furnished to 	the
employee and may order any 	needed change 	of physician,
surgeon, 	hospital, 	or rehabilitation facility. 	For
this 	purpose, 	"competent 	medical 	advice" 	may
include advice 	from a 	panel of at 	least three physicians
selected by the director after consultation with
organizations such as 	the Hawaii Medical Association and
convened for 	the purpose of this 	subsection. 	Fees 	for
the 	panel 	of physicians 	selected by 	the 	director shall
be paid from funds 	appropriated 	by 	the 	legislature 	for
use 	by 	the 	department.
(c) 	Whenever 	the 	director 	determines 	medical
reports 	submitted on an employee's industrial 	injury are
not sufficiently 	complete 	to 	ascertain 	maximum medical
recovery and 	to 	permit 	rendering 	a 	sound 	decision 	on
the 	extent 	of disability 	suffered 	by 	the 	employee, 	the
director 	shall 	refer 	the 	employee 	to 	another 	physician
or 	surgeon 	for 	further 	examination 	and 	evaluation, 	all
at 	the 	expense 	of the 	employer.
(d) 	Whenever 	the director 	determines 	medical
reports 	submitted on an employee's 	industrial 	injury are
such that 	there 	may 	reasonably 	be 	di verse 	medical
opinions 	on 	the extent 	of 	disability sustained by the
employee 	(but 	for 	all 	other 	purposes 	the 	reports 	are
complete), 	the 	director 	may appoint a 	duly qualified
impartial physician or surgeon to examine 	the employee
and reports. 	The 	fees 	for 	such examinations 	shall be
paid 	from 	funds 	appropriated by the 	legislature 	for 	use
by the department. 	[Eff 	1/1/96; 	comp DEC 27 2025
(Auth: 	HRS 	§§386-26, 	386-72) 	(Imp: 	HRS 	§§386-21,
386-24, 	386-26, 	386-80)
§12-15-39 	(Reserved)
§12-15-40 Concurrent medical 	treatment. 	(a)
One 	attending 	physician shall be 	in charge of the care
of the injured employee. 	However, 	treatment 	by more
22

than 	one 	qualified 	health 	care 	provider may be allowed
if 	the attending physician determines 	the employee's
injury involves more 	than 	one 	body 	system and 	requires
multidiscipline 	care or 	is 	so 	severe 	or 	complex 	that
services 	of 	more 	than 	one qualified 	health 	care
provider 	are 	required.
(bl 	When 	requesting consideration for 	concurrent
treatment, 	the 	attending physician shall obtain
permission from 	the employer 	prior 	to 	initiating 	such
referral. 	The name, 	business 	address, 	discipline, 	and
specialty 	of 	the assisting 	qualified 	health 	care
provider 	and 	the 	reasons 	for 	concurrent 	treatment 	shall
be 	submitted 	in 	writing 	to the 	employer at 	least seven
calendar days 	prior 	to 	referral.
(c) 	In 	the 	event 	of 	concurrent 	treatment, 	the
director and 	the 	employer 	shall 	continue 	to 	recognize
the 	attending physician 	who 	shall 	be 	responsible 	for
directing 	the overall 	treatment 	program 	and 	assuring
that 	copies 	of 	all 	required 	reports 	are 	submitted.
The 	concurrent 	health 	care provider 	shall 	comply 	with
the 	treatment 	requirements pursuant to section 12-15-32.
(d) 	Whenever 	a 	request 	for 	concurrent
treatment 	is 	received, 	the 	employer 	shall 	respond
within 	seven 	calendar days 	after 	postmark 	of 	such
request, 	giving 	authorization, 	or 	stating 	in 	writing
the 	reason 	for 	refusal 	to 	the attending 	physician, 	the
injured 	employee, 	and 	the 	director. 	The employer's
denial 	of concurrent 	treatment 	shall 	be 	supported 	by
health 	care 	recommendations 	and 	shall 	explicitly
state 	that 	failure 	to 	request a 	review by the
director of the 	employer's 	denial within fourteen
calendar 	days 	after 	postmark 	of 	the 	employer's 	denial
shall be 	construed 	as 	acceptance 	of 	the 	employer's
denial. 	If 	a 	request 	for 	concurrent 	medical 	treatment
has 	been 	denied, 	the attending 	physician 	may 	not
resubmit 	the 	same 	request 	for 	concurrent 	care 	with
the 	same 	medical 	specialty 	for 	forty-five 	calendar
days 	after 	postmark 	of the 	employer's 	denial.
Failure 	by the 	employer to respond within 	seven
calendar 	days 	shall 	constitute 	approval of the 	request.
(el 	The 	attending 	physician 	or 	the 	injured
employee may 	request 	in 	writing 	that 	the 	director
review 	the employer's denial of authorization 	for
concurrent 	treatment. 	The 	request 	for 	review 	shall
be 	filed 	with 	the 	director, 	copying 	the 	employer,
within 	fourteen 	calendar 	days 	after 	postmark 	of 	the
employer's 	denial. 	A copy 	of 	the 	denied 	concurrent
23
3 61 	9 ""

treatment 	request 	shall 	be 	submitted 	with 	the 	request
for 	review. 	For 	cases 	not 	under 	the 	jurisdiction 	of
the 	director 	at 	the 	time 	of 	request, 	the 	injured
employee 	shall 	be 	responsible 	to 	have the 	case 	remanded
to 	the director's 	jurisdiction. 	Failure to 	file 	a
request 	for 	review 	of 	the 	employer's 	denial 	to the director
within fourteen 	calendar 	days 	after 	postmark 	of the
employer's 	denial 	shall 	be 	deemed 	acceptance 	of 	the
employer's 	denial, 	and 	the 	attending 	physician may not
resubmit 	the 	same 	request 	for 	concurrent 	care 	with 	the 	same
medical 	specialty for forty-five calendar days after
postmark of the employer's denial.
(f) 	The director shall 	issue a decision after hearing,
approving or denying the 	request 	for 	concurrent
treatment based on the evidence presented 	(inclusive
of 	records 	on 	file).
(g) 	The 	decision 	shall 	be 	final 	unless 	appealed
pursuant 	to 	section 	386-87, 	HRS. 	The 	appeal 	shall
not 	stay the director's decision.
(h) 	If the nature of the 	injury requires 	the
concurrent services of two or more specialists for
treatment, 	then each physician shall be entitled to
the 	listed fee 	for 	services 	rendered. 	[Eff
1/1/96; 	am 1/1/97; 	am 	12/17 /01; 	comIEJEC 2 7 2025
(Auth: 	HRS 	§§386-21, 	386-26, 	386-72) 	(Imp: HRS
§§386-21, 	386-26)
§12-15-41 	(Reserved)
§12-15-42 	Consultations. 	(a) 	A 	consultation
includes those 	services 	rendered 	by 	another 	physician
whose 	opinion or advice . is 	requested in the evaluation
and treatment of an injured employee's 	injury . 	A
consultation 	may 	be 	requested by 	the 	attending
physician, 	the 	injured employee, 	the employer, 	or the
director. 	Consultation 	referrals 	shall be 	to 	a
physician 	with 	expertise 	and 	experience 	on 	the subject
and 	upon 	authorization 	by 	the 	employer 	or 	upon 	order
of 	the 	director. 	The 	attending 	physician shall
provide the consultant with all available medical
information.
(b) 	When 	requesting 	consideration 	for
consultation, 	the attending 	physician 	shall obtain
24

permission 	from the employer 	prior 	to 	initiating 	such
referral. 	The 	name, 	business 	address, 	discipline, 	and
specialty 	of 	the 	consulting 	physician 	and the 	reasons
for 	the consultation shall be submitted in writing to
the employer at 	least seven calendar days prior 	to
referral.
(c) 	Whenever 	a 	request 	for 	consultation 	is
received, 	the 	employer 	shall 	respond 	within 	seven
calendar 	days 	after postmark 	of 	such 	request, 	giving
authorization 	or 	stating in 	writing 	the 	reason 	for
refusal, 	to 	the 	attending physician, 	the 	injured
employee, 	and 	the 	director. 	The 	refusal 	shall
explicitly 	state 	that 	failure 	to 	request 	a 	review
by 	the 	director 	of 	the 	employer's denial 	within
fourteen 	calendar 	days 	after 	postmark 	of 	the
employer's denial 	shall 	be 	construed 	as 	acceptance 	of
the 	employer's 	denial. 	If 	a 	request 	for 	consul tat ion
with 	the 	same medical 	specialty 	has 	been 	denied, 	the
attending 	physician 	may 	not 	resubmit 	the 	same
request 	for 	consultation 	with 	the 	same 	medical
specialty 	for 	forty-five 	calendar 	days 	after 	postmark
of 	the 	employer's 	denial. 	Failure 	by 	the 	employer 	to
respond 	within 	seven 	calendar days 	shall 	constitute
approval 	of 	the 	request.
(d) 	The 	attending 	physician 	or 	the 	injured
employee 	may 	request 	in 	writing 	that 	the 	director
review 	the employer's 	denial 	of 	the 	request 	for
consul tat ion. 	The 	request 	for 	review 	shall 	be 	filed
with 	the 	director, 	copying 	the 	employer, 	within
fourteen 	calendar 	days 	after postmark 	of 	the 	employer's
denial. 	A copy 	of 	the 	denied 	consultation 	request
shall 	be 	submitted 	with 	the 	request 	for 	review.
Failure 	to 	file 	a 	request 	for 	review 	of 	the employer's
denial 	to 	the 	director 	within 	fourteen 	calendar days
after 	postmark 	of 	the 	employer's 	denial 	shall 	be
deemed 	acceptance 	of 	the 	employer's 	denial, 	and 	the
attending 	physician 	may 	not 	resubmit 	the 	same 	request
for 	consultation 	with 	the 	same 	medical 	specialty 	for
forty-five 	calendar 	days 	after 	postmark 	of 	the
employer's 	denial. 	The director 	shall 	hold 	a 	hearing 	on
the 	request 	for 	review, 	and issue a 	decision approving
or denying the 	request 	for 	consultation 	based 	on
the 	evidence 	presented 	( inclusive 	of 	records 	on
file). 	The 	decision 	shall 	be 	final 	unless 	appealed
pursuant 	to 	section 	386-87, 	HRS. 	The 	appeal 	shall
not 	stay 	the 	director's 	decision.
(e) 	When consultation is 	required immediately
25
•
3 6 1 9

because the condition is 	life-threatening or could
cause serious harm, 	the attending 	physician 	shall
notify 	the 	employer 	as 	soon 	as 	possible.
(f) 	The consultant shall provide a 	copy of the
consultation report 	to 	the 	attending 	physician
and 	the 	employer 	within 	fourteen calendar days 	of
the date of the examination.
(g) 	When the 	consulting 	physician assumes 	the
continuing 	care 	of 	the 	patient, 	this 	subsequent
service will 	no 	longer 	be 	considered 	a 	consultation.
If 	the industrial 	injury 	or 	condition 	necessitates
the 	concurrent medical 	services 	and 	skills 	in
accordance with section 12- 15-40 of two or more
physicians, 	each physician 	shall 	be 	entitled 	to 	the
listed 	fee 	for 	services 	rendered.
(h) 	Fees 	for 	consultations 	requested 	by the
attending 	physician, 	the 	injured employee, 	or the
employer shall be paid by the 	employer. 	Fees 	for
consultations 	requested by 	the 	director 	shall be
paid from funds 	appropriated 	by 	the 	legislature 	for
use 	by the department.
(i) 	For groups 	of physicians 	or hospitals 	with
satellite 	clinics, 	when service 	is rendered by a
member of a 	group 	and 	the 	patient 	is 	referred 	to
another 	physician 	in 	the 	group 	for 	consultation,
fees 	for 	such 	consultation may 	be 	allowed. 	[Eff
1/1/96; 	am 1/1/97; 	am 12/17/01; 	comp 	DEC 27 2025 	]
(Auth: 	HRS 	§§386-21, 	386-26, 	386-72) 	(Imp: 	HRS
§§386-21, 	386-26)
§§12-15-43 	to 	12-15-49 	(Reserved)
§12-15-50 Emergency treatment. 	(a) 	In emergency
cases, 	an unqualified health care provider shall be duly
compensated under the provisions 	of section 386-21, 	HRS,
and any related 	rules, 	for 	services rendered to an
injured employee.
(b) 	The unqualified health care provider shall, 	at
the earliest reasonable and practicable time, 	transfer
care of the injured employee to a 	duly qualified
physician. 	Treatment provided by an unqualified health
care provider subsequent to 	such time as deemed
reasonable and practicable shall not be 	reimbursed.
26
3 6 1 9

[Eff 1/1/96, 	am 2/28/11; 	comp DEC 2 7 2025
HRS §§386-26, 	386-72) 	(Imp: 	HRS §§386-21,
386-27))
) 	(Auth:
386-26,
§12-15-51 Surgery. 	(a) 	When 	elective 	surgery
is 	contemplated, 	the attending 	physician 	shall 	obtain
permission 	from 	the employer at 	least seven calendar
days 	prior to 	the date 	of the proposed surgery.
Written 	notification 	shall 	include 	procedure code,
medical documentation 	justifying 	the 	need 	for 	surgery,
the 	estimated 	date 	of 	surgery, 	and 	the 	hospital 	where
the 	surgery 	is 	to be performed. 	The notification 	shall
permit 	the 	employer 	to 	determine 	whether 	the 	injured
employee should 	be 	examined 	by 	a 	physician 	of 	the
employer's 	choice 	as 	provided 	under 	section 	386-79,
HRS. 	Any physician 	who 	performs 	surgery 	in 	a 	manner
which 	denies 	the 	rights 	of 	the 	employer 	as 	provided
under 	section 	386- 79, 	HRS, 	shall 	forfeit 	the
physician's 	right 	to 	fees. 	When 	the 	surgical 	procedure
has 	a 	"BR" 	(by 	report) 	fee, 	the 	estimated 	fee 	shall
be 	submitted with 	the 	request. 	The 	physician's
request 	shall 	also 	specify 	the 	cost 	and 	need 	for 	a 	co-
surgeon 	or 	assistant 	and 	other 	additional 	surgical
procedures, 	if any.
(b) 	Whenever 	a 	request 	for 	elective 	surgery 	is
received, 	the 	employer 	shall 	respond 	within 	seven
calendar days 	after 	postmark 	of 	such 	request, 	giving
authorization or 	stating 	in 	writing 	the 	reason 	for
refusal, 	to 	the attending 	physician, 	the 	injured
employee, 	and 	the 	director. 	The 	employer's 	denial
of 	elective 	surgery 	shall 	be 	supported 	by health
care 	recommendations 	and 	shall 	explicitly 	state 	that
failure 	to 	request a 	review by the 	director 	of 	the
employer's 	denial 	within 	fourteen calendar 	days 	after
postmark 	of 	the 	employer's 	denial 	shall be 	construed
as 	acceptance 	of 	the 	employer's 	denial. 	If 	a 	request
for a 	surgical procedure has been denied, 	the attending
physician may not 	resubmit 	the 	same request 	for 	the 	same
surgical 	procedure 	for 	forty-five 	calendar 	days 	after
postmark 	of 	the 	employer's 	denial. 	Failure 	by 	the
employer 	to 	respond 	within 	seven calendar days 	shall
constitute approval 	of the 	request.
(c) 	The attending physician or the 	injured
employee may 	request 	in writing that 	the director 	review
the employer's 	denial of the 	request 	for 	elective
27
3 G1 9 y 	II

surgery. 	The 	request 	for 	review shall be 	filed with the
director, 	copying the employer, 	within fourteen calendar
days 	after postmark of the employer's denial. 	Failure
to 	file a 	request 	for 	review of the employer's denial 	to
the director within fourteen 	calendar days 	after
postmark of the employer's denial 	shall be deemed
acceptance of the employer's denial, 	and the attending
physician may not 	resubmit the same request 	for 	the 	same
surgical procedure 	for 	forty-five 	calendar days 	after
postmark of the 	employer's denial. 	The director shall
hold a 	hearing on the 	request 	for 	review, 	and issue a
decision approving or denying the 	request 	for 	elective
surgery based on the evidence presented 	(inclusive of
records on file). 	The decision shall be final 	unless
appealed pursuant 	to section 386-87, 	HRS. 	The appeal
shall 	not stay the director's 	decision.
(d) 	Surgery which must be performed immediately or
within fourteen 	calendar days because the 	condition is
life-threatening or could cause serious harm is not
considered elective surgery. 	The attending physician
shall notify the director and the employer as 	soon as
possible when emergency surgery is 	required.
(e) 	When a 	surgical 	fee 	is chargeable, 	no office
or hospital visit 	charge shall be allowed for 	the day on
which this 	surgical fee 	is earned, 	except 	if surgery is
performed on the 	same day as 	the physician's 	first
examination.
{f) 	Listed fees 	for all 	surgical procedures
include the surgery and the 	follow-up 	care 	for 	the
period indicated in days 	in the column headed "Follow-up
Days" 	in the medical 	fee 	schedule. 	Necessary follow-up
care beyond this 	listed period is to be added on a 	fee-
for- 	service basis. 	Where the 	follow-up period is 	listed
as 	zero, 	the listed fee 	is 	for 	the surgical procedure
only, 	and all post-operative care 	is to be added on a
fee-for-service 	basis.
( g) 	When additional 	surgical procedures are
carried out within the 	listed period of 	follow-up 	care
for a 	previous surgery, 	the 	follow-up periods 	shall
continue concurrently to their normal 	terminations.
(h ) 	Certain of the 	listed procedures 	in the
medical 	fee 	schedule as provided in section 12-15-90
are commonly carried out as an integral part of a
total 	service and, 	as 	such, 	do not warrant a 	separate
charge. 	When such a procedure 	is 	carried out as a
separate procedure, 	not 	immediately related to other
services, 	the indicated fee 	is applicable.
2 8
1 	0v

(i) 	When significant time or complexity to patient
care 	results 	from multiple or bilateral surgical
procedures performed at 	the 	same operative session, 	the
total 	fee 	shall be 	the 	fee 	for 	the major procedure plus
fifty 	per cent of the 	fee 	of the 	lesser procedures
unless otherwise 	specified in this 	chapter. 	When an
incidental procedure 	(e.g., 	incidental appendectomy,
lysis 	of adhesions, 	excision of previous 	scar) 	is
performed through 	the same 	incision, 	the 	fee 	shall 	be
that of the major procedure only.
(j) 	One attending physician shall be in charge of
the care of the 	injured employee. 	However, 	if the
nature of the 	injury 	requires the 	concurrent services of
two or more specialists 	for 	treatment, 	then each
physician shall 	be 	entitled to 	the 	listed fee 	for
services 	rendered.
(k) 	Lacerations ordinarily require no aftercare
except 	removal 	of 	sutures. 	The 	removal 	is considered
a 	routine part of an office or hospital visit.
(1) 	For those 	fees 	not covered by Medicare,
bills 	for 	services 	for 	injured employees who have had
major 	surgery or 	treatment 	for major 	fractures 	and are
later 	treated by another physician for 	follow-up 	care
shall 	be limited to 	the 	fee 	schedule during the 	entire
follow-up period as 	follows:
(1) 	The operating surgeon shall submit a 	fee,
reducing 	it accordingly 	if aftercare 	is
not 	rendered.
(2) 	The physician providing 	follow-up
care 	shall 	submit 	the 	fee 	for 	the
aftercare.
(3) 	It 	shall be the 	responsibility 	of the
operating 	surgeon to advise 	the director or
employer of the apportionment 	of 	the
respective 	fees. 	[Eff 	16lL96; 	am
1 / 1 / 9 7 ; 	am 	12 / 1 7 / 0 1 ; 	comp 	I: C 2 7 2025
(Auth: 	HRS 	§§386-26,386-72) 	(Imp: 	HRS
§§386-21, 	386-26, 	386-79)
§12-15-52 	Anesthesia services. 	(a) 	A base
unit 	is 	listed for 	all procedures 	in the medical 	fee
schedule 	in accordance with section 12-15-90. 	This
includes the base unit of all anesthesia 	services except
the value of the actual 	time spent administering the
anesthesia or 	in unusual detention with the patient.
29
3 G1 9 _:,

(b) 	As allowed under Medicare, 	the anesthesia
charges are equal 	to the sum of the base and time 	units
for 	the service multiplied by a 	geographically adjusted
anesthesia-specific conversion factor.
(c) 	The total value 	for 	anesthesia services
includes pre- and post-operative visits, 	the
administration of the anesthetic, 	and the administration
of 	fluids 	or blood incident, 	or both, 	to the anesthesia
or surgery.
(d) 	The time units are 	computed by dividing the
total 	anesthesia time by fifteen minutes.
(e) 	Calculated values 	for anesthesia 	services shall
be used when the anesthesia 	is administered by a
licensed physician or certified registered nurse
anesthetist and a 	fee 	shall be paid only for 	the
individual anesthetic service.
(f) 	If 	the 	general 	or 	regional 	anesthetic 	is
administered by the attending 	surgeon, 	the 	value shall be
fifty per cent of the calculated value.
(g) 	Necessary drugs and materials provided by the
anesthesiologist or certified registered nurse
anesthetist may be charged for 	separately in accordance
with section 12-15-55.
(h) 	When unusual detention with the patient is
essential for the safety and welfare of the patient, 	the
necessary time will be valued on the same basis 	as
indicated for 	anesthesia time.
(i) 	No additional 	fee 	shall be allowed for 	local
infiltration or digital block anesthesia administered by
the operating surgeon.
(j) 	When either a hypothermia or a pump oxygenator,
or both, 	are employed in conjunction with an anesthetic,
the anesthetic "basic" value will be equal 	to that of
procedure code 00560.
(k) 	Where anesthesia 	is administered for dental
services; 	if the above 	rules 	are not applicable, 	a 	fee
equal to that of procedure code 00120 	for 	inhalation
anesthesia and equal 	to 	that of procedure code 00102 by
an intravenous 	route will be allowed. 	[Eff 1/1/96, 	am
2/28/11; 	comp 	DEC 27 2025 	J 	(Auth: 	HRS §§386-21,
386- 72) 	(Imp: 	HRS §386-21)
§12-15-53 Hospital services. 	(a) 	When
hospitalization 	is 	required 	for 	further 	treatment
of 	an 	injured 	employee, 	that 	employee 	shall 	have 	a
30

free 	choice 	of 	a 	licensed hospital 	on 	the 	island
where 	the 	injury 	occurred. 	If 	the employee 	is 	in
critical 	condition 	or 	unable 	to 	express 	a 	choice
or 	requires 	service 	from 	a 	hospital 	not 	located 	on
the 	island 	where 	the 	injury 	occurred, 	then 	the
attending physician 	may 	designate 	the 	hospital 	to
which 	the 	injured employee will be taken.
(b) 	Hospital 	charges 	for 	an injured employee
shall be 	limited 	to 	the 	lowest 	room 	charge 	for 	the
nature 	of 	the 	injury 	at 	the 	hospital 	where 	confined,
except 	if 	the 	nature of the 	injury requires 	private
care, 	intensive 	care, 	or 	isolation, 	as 	determined
by the attending physician, 	in which 	case 	the
prevailing 	private 	rates 	may 	be 	charged.
(c) 	Where 	an injured employee 	is treated in the
emergency facility 	of a 	hospital, 	the allowable 	hospital
charge 	for 	the 	use of 	the 	emergency 	room 	shall 	be 	the
established emergency room 	charge 	for 	that particular
hospital.
(d) 	All hospital 	charges 	shall be 	itemized when a
bill 	is 	submitted. 	[Eff 	1/1/96; 	comp 	DEC 2 7 2025 	l
(Auth: 	HRS 	§§386-21, 	386-72) 	(Imp: 	HRS 	§386-21)
§12-15-54 	Radiology 	services. 	(a) 	Taking 	of
anterior- posterior 	(A-P), 	lateral, 	and 	oblique 	x-
rays 	shall 	be 	discretionary for 	one hundred twenty days
following 	the 	initial 	treatment 	and may 	be 	allowed
without 	authorization. 	Prior 	authorization 	from the
employer 	must 	be 	obtained 	for 	x-rays 	subsequent 	to 	the
initial 	one 	hundred 	twenty 	days 	of 	treatment.
(b) 	Diagnostic 	tests and x-rays 	shall be taken,
reported, 	and 	marked 	for 	identification 	and
orientation 	in accordance with 	the accepted 	standard 	of
radiologic 	practice. 	X-rays 	shall be 	taken 	with
machines 	with 	a 	current 	certification 	by 	the
department of health.
(c) 	Where 	contrast examinations are performed,
fees 	shall 	include 	the 	usual 	contrast 	media. 	When
special 	trays 	or 	materials 	are 	provided 	by 	the
physician, 	rather 	than 	by 	the 	hospital, 	an 	additional
charge 	is 	warranted.
(d) 	Injection procedures, 	including major 	surgery,
for 	the purpose 	of performing needed radiological
studies, 	are 	covered 	in 	the 	section 	on 	surgery. 	The
fee 	shall 	be 	paid to 	the 	physician 	actually 	performing
31
.3 G1 9

the 	service.
(e) 	X-rays 	shall be 	furnished upon request 	to 	the
director or 	the 	employer 	and 	shall 	be 	returned 	upon
review. 	When 	requested 	by 	the 	director 	or 	employer,
the health 	care 	provider 	shall make any x-rays 	in the
health care provider's possession available 	to 	the
consul ting physician. 	The 	injured 	employee 	may 	carry
the 	x-rays 	to the 	consultation. 	When 	there 	is 	a
change 	in 	attending physicians, 	the x-rays 	or 	copies of
good quality shall 	be made 	available 	to 	the 	new
attending 	physician 	at 	no charge. 	Refusal 	of 	a 	health
care 	provider 	to 	provide 	the x-rays upon 	request 	at
any 	time 	shall 	result 	in nonpayment 	of 	the 	fee 	or
credit to the employer's account 	for 	the 	radiological
study.
(f) 	Fees 	shall 	include both the technical and
professional components. 	In the 	absence 	of 	any prior
agreement 	between a 	radiologist and a hospital 	or other
facility furnishing 	technical 	radiology services, 	the
professional 	component 	shall 	be 	thirty-five 	per 	cent
of 	the · scheduled 	radiology 	fee. 	The 	technical
(-TC) 	and professional 	(-26) 	components 	may 	be 	billed
separately using 	the 	appropriate 	modifiers 	as
indicated 	by Medicare. 	Billings 	for x-rays 	are not
reimbursable without a 	report of the findings.
(g) 	Radiotherapy includes 	the 	use of x-ray and
other high energy modalities 	(betatron, 	linear
accelerator, 	etc.), 	radium cobalt, 	and other
radioactive 	substances. 	Fees 	for 	therapy 	include
follow-up 	care, 	and concomitant office visits, 	but not
concomitant 	surgical, 	radiological, 	or 	laboratory
procedures. 	[Eff 	1/1/96; 	am 	1/1/97;
comp 	DEC 2 7 2025 	1 	(Auth: 	HRS 	§§386-26, 	386-72)
(Imp: 	HRS 	§§386-21, 	386-26, 	386-94)
§12-15-55 	Drugs, 	supplies, 	and materials. 	(a)
Charges 	for prescribed drugs, 	supplies, 	or materials
for 	the use of the injured employee shall be
separately listed and certified by the provider, 	or a
duly authorized 	representative, 	that such charges 	for
drugs, 	supplies, 	or materials were 	required and
prescribed for 	the 	industrial 	injury.
(b) 	Dietary supplements such as minerals and
vitamins shall not be reimbursable unless a
specific compensable dietary deficiency has 	been
32
J 	' 	9

clinically established in the injured employee as
a 	result of the 	industrial 	injury.
(c) 	Payment 	for prescriptive drugs will be made at
the average wholesale price listed in the Red Book plus
forty 	per cent when sold by a physician, 	hospital,
pharmacy, 	or provider of service other than a 	physician.
Billings 	for 	prescriptive drugs must include the
national drug code number listed in the current Red Book
followed by the average wholesale price 	listed at 	time
of purchase by the provider of service. 	Approved
generics 	shall be substituted for 	brand name
pharmaceuticals 	unless 	the prescribing physician
certifies no 	substitution is permitted because the
injured employee's 	condition will not tolerate a 	generic
preparation.
(d) 	Payment for supplies, 	which includes shipping
charges, 	shall not exceed cost plus 	forty 	percent
Providers 	are 	allowed to seek reimbursement 	for 	the
applicable Hawaii general excise 	tax.
(e) 	Charges 	for orthotic, 	prosthetic, 	and
durable medical 	equipment 	include 	fees 	for 	adjusting
and fitting 	services and shall 	not exceed one hundred
ten percent of 	fees 	allowed by Medicare's 	fee 	schedule
for durable medical 	equipment applicable 	to Hawaii.
Beginning January 1, 	2005 and each calendar year
thereafter, 	the Medicare 	Fee Schedule in effect as 	of
January 1 of that 	year shall be the effective 	fee
schedule 	for 	that calendar year. 	[Eff 1/1/96; 	am
12/17/01; 	am 12/13/04; 	am 2/28/11; 	comp 	DEC 2 7 2025
(Auth: 	HRS §§386-26, 	386-72) 	(Imp: 	HRS
§§386-21, 	386-26)
§§12-15-56 	to 	12-15-79 	(Reserved)
SUBCHAPTER 4
ADMINISTRATION
§12-15-80 	Reports 	of 	providers 	of 	service.
(a) 	Any 	provider 	of 	service 	required 	by 	chapter
386, 	HRS, 	this 	chapter, 	or any 	related 	rules 	to
33
3 6 1 9 .,,

make and submit 	reports 	of an 	injury and treatment
shall:
(1) 	Submit 	those 	reports 	to 	the 	director 	and
the 	self- 	insured 	employer, 	or 	the 	insurer
of 	the 	employer when the 	employer 	is 	not
self-insured, 	whichever 	is applicable;
and
(2) 	Itemize its 	statement 	of 	services 	rendered
in a manner showing 	the date of injury,
diagnosis, 	date 	of 	each 	visit 	or 	service,
the 	appropriate 	code number 	used 	as 	the
basis 	for 	the 	charge, 	and 	the fee not 	to
exceed 	the 	maximum 	allowed 	under 	the
medical 	fee 	schedule. 	No service 	charge
for preparing and submitting reports 	required
by section 386-96, 	HRS, 	and any related rules
shall be allowed.
(3) 	Interim 	WC-2 	reports 	shall 	be 	submitted
monthly 	with 	the 	corresponding 	billing
invoice, 	if 	applicable, 	to 	the 	employer 	and
shall 	include the 	following:
(A) 	Current 	diagnosis 	and 	prognosis;
(B) 	Complete information as to the 	nature
of the examination(s) 	and treatments
performed, 	dates of those 	treatments,
and the 	results 	obtained within the
current 	reporting period;
(C) 	A complete 	listing of all 	tests
performed within the current 	reporting
period and the 	results of the 	tests;
(D) 	A statement of whether the injured
employee is 	improving, 	worsening, 	or
if 	"medical 	stabilization" has been
reached; 	and
(E) 	Dates 	of disability, 	work restrictions,
if any, 	return to work date
(4) 	When 	an injured 	employee 	is 	returned 	to
full-time, 	regular, 	light, 	part-time, 	or
restricted work, 	the 	attending 	physician
shall 	submit 	a 	report 	to 	the 	employer
within 	seven 	calendar 	days 	indicating 	the
date 	of release 	to work or medical
stabilization.
(b) 	Interim WC-2 	reports 	and 	all 	medical
documentation 	shall 	be 	submitted 	by 	the 	employer
to 	the 	di rector 	upon 	submission 	of 	a 	"Request 	For
Hearing" 	or within 	ten 	calendar 	days 	of 	a 	request 	by
34

the 	director. 	Any party 	who 	fails 	to 	furnish
medical 	reports 	within 	ten calendar days 	after being
requested by the 	director may 	be subject 	to
penalties 	pursuant 	to 	section 	386-97.5, 	HRS.
(c) 	The 	repeated failure 	of a physician, 	surgeon,
hospital, 	or 	provider 	of 	service 	to 	comply 	with
chapter 	386, 	HRS, 	and 	any 	related 	rules 	shall 	be 	a
reasonable 	basis 	for an employer 	to 	refuse 	to 	pay
or 	withhold 	payment 	for 	services 	rendered. 	[Eff
1/1/96; 	am 11/22/97; 	am 	12/17/01; 	am 	12/13/04;
comp 	DEC 2 7 2025] 	(Auth: 	HRS 	§§386-26, 	386-27,
386-72) 	(Imp: 	HRS 	§§386-21, 	386-26, 	386-27, 	386-96)
§§12-15-81 	to 	12-15-84 (Reserved)
§12-15-85 	Rules 	for 	allowable 	fees 	for 	medical,
surgical, 	and 	hospital 	services 	and 	supplies. 	(a)
Under 	no circumstances 	shall 	a 	provider 	of 	service
directly 	charge the 	injured 	employee 	for 	treatments
relating 	to 	the 	industrial 	injury.
(b) 	When all 	the 	required care 	for 	a 	case
reasonably 	falls 	within 	the 	range 	of 	qualifications
of 	one 	physician, 	no other physician may claim a 	fee,
except 	for 	consultation service 	or 	for 	~urgical
assistance. 	For 	groups 	of physicians 	or 	hospitals
with 	satellite 	clinics, 	when 	service 	is 	rendered 	by 	a
group 	member 	of 	the 	same 	specialty, 	the group 	shall
submit 	bills 	as 	though 	one 	physician 	had 	cared for
the patient.
( c) 	Medical, 	surgical, 	or 	hospital 	care 	of 	an
unusual 	type 	or 	unlisted fee may occur which
represents a 	type 	of 	service 	over 	and 	beyond 	listed
procedures. 	Appropriate 	fees 	may 	be 	allowed, 	subject
to 	the 	employer's 	approval 	prior 	to 	the 	service 	being
provided 	and 	after 	submission 	of 	a 	report 	to 	the
employer 	containing at 	least the 	following
information:
(1) 	Diagnosis 	(post-operative);
(2) 	Size, 	location, 	and number of
lesions or procedures where
appropriate;
(3) 	Major surgical procedure and
supplementary procedures;
35
3 6 l 9 ---

(4) 	Estimated 	follow-up 	period.
(d) 	Medical 	conditions 	which 	are 	pre-
existing 	or 	not 	resulting from the injury or
occupational disease 	shall not be compensable.
Palliative 	temporary 	treatment 	of unrelated
conditions 	shall 	be 	allowed, 	provided 	these 	conditions
directly 	retard, 	prevent, 	or 	endanger 	the 	surgical
care 	or 	recovery 	from 	the 	compensable 	injury 	or
illness. 	This 	treatment 	will 	cease 	as 	soon 	as 	it 	no
longer 	exerts 	influence 	on the 	compensable 	condition.
This 	shall be 	adequately 	explained 	in 	the 	physician's
regular 	report.
(e) 	Certain 	of 	the 	listed procedures 	are 	commonly
carried 	out as an 	integral part of a 	total 	service and,
as 	such, 	do 	not 	warrant 	a 	separate 	charge. 	When 	such
a 	procedure 	is 	carried 	out 	as 	a 	separate 	procedure,
not immediately related to other services, 	the 	indicated
fee 	is applicable.
(f) 	Minimal dressings, 	counseling incidental 	to
treatment, 	etc., 	are 	covered 	by 	the 	office 	visit 	fee.
Necessary drugs, 	supplies, 	and materials 	provided 	by
the provider 	of 	service 	may 	be 	charged 	separately 	in
accordance with section 12-15-55 .
(g) 	Fees, 	including office visits and rating
examinations, 	shall 	not 	be 	paid 	for 	more 	than 	one
visit 	per day by the same provider 	of 	service
regardless 	of 	the 	number 	of 	industrial 	injuries 	or
conditions treated.
(h) 	Each provider of service shall certify on the
bill or 	charges 	that 	such 	charges 	are 	in 	accordance
with 	chapter 386, 	HRS, 	and any related rules.
(i) 	Repeated failure 	to comply with chapter
386, 	HRS, 	and any 	related 	rules 	shall be a
reasonable basis 	for 	an employer to refuse to pay o r
withhold payment for 	services 	rendered. 	The
employer shall make payment within sixty calendar
days of compliance with Chapter 386, 	HRS, 	and
related rules. 	[Eff 1/1/96; 	comp 	ni:c ?. 7 ?O?fi
(Auth: 	HRS §§386-21, 	386-72) 	(Imp: 	H1ts 3386"-:21)
§§12-15-86 	to 	12-15-89 	(Reserved)
3 6
3 6 1 9

§12-15-90 	Workers' 	compensation medical fee
schedule. 	(a) 	Charges 	for medical 	services shall 	not
exceed one hundred ten per cent 	of participating fees
prescribed in the Medicare Resource Based Relative
Value 	Scale System fee 	schedule 	(Medicare 	Fee
Schedule) 	applicable 	to HawaiiL or listed in Exhibit
A, 	located at 	the end of this 	chapterL and made a 	part
of this 	chapter, 	entitled "Workers' 	Compensation
Supplemental Medical 	Fee Schedule", 	dated January 	1,
2026. 	The Medicare 	Fee Schedule 	in effect on January
1, 	1995 shall be applicable through June 	30, 	1996.
Beginning July 1, 	1996 and each calendar year
thereafter, 	the Medicare Fee Schedule in effect as 	of
January 1 of 	that 	year shall be the effective fee
schedule for 	that 	calendar year.
(b) 	If maximum allowable 	fees 	for medical 	services
are 	listed in both the Medicare 	Fee Schedule and the
Workers' 	Compensation Supplemental Medical 	Fee Schedule,
dated January 1, 	2026, 	located at 	the end of this
chapter as 	Exhibit A, 	charges 	shall not exceed the
maximum allowable 	fees 	allowed under the Workers'
Compensation Supplemental Medical 	Fee Schedule, 	dated
January 1, 	2026, 	located at the end of 	this 	chapter as
Exhibit A.
(c) 	If 	the charges are not 	listed in the Medicare
Fee Schedule or 	in the Workers' 	Compensation
Supplemental Medical 	Fee Schedule, 	dated January 1,
2026, 	located at the 	end of this 	chapter as 	Exhibit A,
the provider 	of 	service shall 	charge a 	fee 	not 	to exceed
the 	lowest 	fee 	received by the provider of 	service 	for
the same 	service rendered to private patients. 	Upon
request by the director or the employer, 	a 	provider of
service shall 	submit a 	statement 	to the 	requesting
party, 	itemizing the 	lowest fee 	received 	for 	the 	same
health care, 	services, 	and supplies 	furnished 	to any
private patient during 	the one-year period preceding 	the
date of a 	particular charge. 	Requests 	shall 	be
submitted in writing within twenty calendar days 	of
receipt of a 	questionable charge. 	The provider of
service shall 	reply 	in writing within thirty-one
calendar days 	of receipt of the 	request. 	Failure 	to
comply with the 	request of the employer or 	the director
shall 	be 	reason 	for 	the employer or the director 	to deny
payment.
(d) 	Fees 	listed in the Medicare 	Fee 	Schedule shall
be subject to 	the current Medicare Fee Schedule bundling
and global 	rules 	if not specifically addressed in these
37

rules. 	The Health Care 	Financing Administration Common
Procedure Coding System 	(HCPCS) 	alphabet codes adopted
by Medicare will not be 	allowed, 	except for 	injections
and durable medical equipment, 	unless 	specifically
adopted by the director. 	The director may defer 	to 	a
fee 	listed in the Medicare HCPCS 	Fee Schedule when a 	fee
is not 	listed in the Workers' 	Compensation Supplemental
Medical 	Fee Schedule, 	Exhibit A.
(e) 	Providers 	of 	service will be allowed to add
the applicable Hawaii general 	excise tax to their
billing. 	[Eff 1/1/96; 	am 1/1/97; 	am 11/22/97; 	am
12/17/01; 	am 12/13/04; 	am 11/6/06; 	am 12/14/07; 	am
2/28/11; 	am 12/30/13; 	am 12/28/17; 	am and
comp 	DEC 27 2025 	] 	(Auth: 	HRS §§386-21, 	386-26,
386-72) 	(Imp: 	HRS §§386-21, 	386-26)
§12-15-91 	(Reserved)
§12-15-92 	Controverted 	case 	payments. 	(a) 	When
only the question of the 	liable employer in an
industrial 	injury is 	to 	be 	settled, 	and 	medical 	charges
remains 	unpaid, 	the 	last 	employer 	shall 	pay 	such
charges. 	Such 	payment 	shall be made without 	decision
of 	the 	director. 	When 	a 	liability 	determination 	is
made, 	the 	liable employer, 	if not 	the 	last 	employer,
shall 	reimburse 	the 	last 	employer.
(b) 	In 	the 	event 	a 	controverted 	workers'
compensation claim 	is 	deemed 	compensable, 	the
employer 	shall 	pay 	the outstanding charges 	to 	the
providers 	of service 	in accordance 	with 	section 	12-
15-90 	within 	thirty-one 	calendar days of the -decision
of the director. 	Failure 	to make 	payment 	within
thirty-one 	calendar 	days 	will 	increase the balance
due 	by 	one 	per 	cent 	per 	month.
(c) 	In 	the 	event 	a 	controverted 	workers'
compensation claim 	is 	deemed 	compensable 	and 	the
injured 	employee 	has paid 	the 	provider 	of 	service,
the 	employer 	shall 	reimburse the 	injured 	employee the
actual sums paid to 	the provider of service within
thirty-one 	calendar 	days 	of 	the 	decision 	of the
director. 	[Eff 	1/1/96; 	comp 	DEC 27 2025 	] 	(Auth:
HRS 	§386-72) 	(Imp: 	HRS §§386-21, 	386-92)
38
3 6 l 	9

§12-15-93 	(Reserved)
§12-15-94 	Payment 	by 	employer. 	(a) 	The
employer 	shall 	pay 	for 	all medical 	services 	which
the 	nature 	of 	the compensable 	injury 	and 	the 	process
of 	recovery 	require. 	The employer 	is 	not 	required to
pay for 	care unrelated to 	the 	compensable 	injury.
(b) 	When 	a 	provider 	of 	service 	notifies 	or
bills 	an employer, 	the 	employer 	shall 	inform 	the
provider 	within sixty 	calendar 	days 	of 	such
notification 	or 	billing 	should the employer controvert
the 	claim 	for 	services. 	Failure 	of 	the 	employer 	to
notify the provider of service shall make 	the employer
liable 	for 	services 	rendered 	until 	the 	provider 	is
informed 	the 	employer 	controverts 	additional 	services.
(c) 	The 	employer, 	after 	accepting 	liability,
shall 	pay all 	charges 	billed within 	sixty 	calendar
days 	of 	receipt 	of 	such 	charges 	except 	for 	i terns
where 	there 	is 	a 	reasonable 	disagreement. 	If 	more
than 	sixty 	calendar 	days 	lapse between the 	employer's
receipt of 	an undisputed billing and 	date 	of 	payment,
payment 	of 	billing 	shall 	be 	increased 	by 	one 	per
cent 	per 	month 	of 	the 	outstanding 	balance. 	In the
event 	of 	disagreement, 	the 	employer 	shall 	pay 	for 	all
acknowledged 	charges 	and 	shall 	notify 	the 	provider 	of
service, 	copying 	the 	claimant, 	of 	the 	denial 	of
payment 	and 	the 	reason 	for 	denial 	of 	payment
within 	sixty 	calendar days 	of 	receipt. 	Furthermore,
the 	employer's 	denial 	must explicitly 	state 	that 	if
the 	provider 	of 	service 	does 	not agree, 	the provider
of service may 	file 	a 	"BILL DISPUTE REQUEST" 	to 	include
a 	copy 	of 	the 	original 	bill 	with 	the director 	within
sixty 	calendar 	days 	after 	postmark 	of 	the employer's
objection, 	and 	failure 	to 	do 	so 	shall 	be 	construed 	as
acceptance 	of 	the 	employer's denial.
(d) 	In the 	event a 	reasonable 	disagreement
relating 	to 	specific charges 	cannot be 	resolved, 	the
employer or provider 	of service may 	request
intervention by the director 	in writing with notice 	to
the 	other 	party. 	Both 	the 	front 	page 	of 	the 	billing
dispute 	request 	and 	the 	envelope 	in 	which 	the 	request
is 	mailed 	shall 	be 	clearly 	identified 	as 	a 	"BILLING
DISPUTE 	REQUEST" 	in 	capital 	letters 	and 	in 	no 	less
39
3 6 1 9

than 	ten point 	type. 	The 	director 	shall 	send 	the
parties 	a 	notice and 	the 	parties 	shall 	negotiate
during 	the 	thirty-one calendar 	days 	following 	the 	date
of 	the 	notice 	from 	the 	director. 	If 	the 	parties
fail 	to 	come 	to 	an 	agreement 	during 	the 	thirty-one
calendar days, 	then within 	fourteen 	calendar 	days
following 	the 	thirty-one 	day 	negotiating period,
either 	party 	may 	file 	a 	request, 	in 	writing, 	to 	the
director 	to 	review 	the 	dispute 	with 	notice 	to 	the
other party. 	The 	director 	shall 	send 	the parties 	a
second notice 	requesting 	the 	parties 	file 	position
statements, 	with 	substantiating 	documentation 	to
specifically 	include 	the amount 	in dispute and a
description 	of 	actions 	taken 	to 	resolve 	the 	dispute,
within 	fourteen 	calendar 	days 	following the 	date 	of
the 	second 	notice 	from 	the 	director. 	The director
shall 	review 	the positions 	of 	both parties 	and render
an administrative 	decision 	without 	hearing. 	A
service 	fee 	of 	up 	to 	$500 	payable 	to 	the 	State 	of
Hawaii 	General 	Fund 	will 	be 	assessed 	at 	the 	discretion
of 	the director 	against 	either 	or 	both 	parties 	who
fail 	to negotiate 	in 	good 	faith. 	The 	decision 	of 	the
director 	is 	final 	and 	not 	appealable. 	[Eff 	1/1/96;
aml2/17/0l;comp 	nl='C272025 	1 	(Auth:HRS
§§386-21, 	386-26, 	nJt:,-71, 	386-72) 	(Imp: 	HRS
§§386-21, 	386-26)
40
3 6 1 9