8 AAC 55.010 - Benefits
(a) To be eligible
for benefits from the fund, a person must be a fisherman who, at the time an
injury is sustained, is licensed in the person's own name by the state to
engage in commercial fishing under
AS
16.05.480 or AS 16.43, and who is actually so
engaged in Alaska water or is occupied in the state preparing or dismantling
boats or gear used in commercial fishing.
(b) Unless required as a result of accidental
bodily injury caused by the fishing endeavor, benefits may not be awarded for
(1) the services of a dentist;
(2) dental prosthetic appliances or the
fitting of them;
(3) eye
refractions and hearing examinations;
(4) eye glasses or the fitting of them;
or
(5) hearing aids or the fitting
of them.
(c) Benefits may
not be awarded for an injury
(1) if the
injury does not arise out of an accident directly connected with commercial
fishing;
(2) caused by the
fisherman's willful intent to injure or kill self or another;
(3) caused by the fisherman's intoxication,
or caused by the fisherman being under the influence of drugs unless the drugs
were taken as prescribed by a treating physician; in this paragraph,
(A) "drugs" has the meaning given in
AS
23.30.395;
(B) "intoxication" has the meaning given in
8
AAC 20.010; or
(4) if the fisherman has knowingly falsified
a material fact directly connected with the fisherman's claim against the
fund.
(d) Benefits may
not be awarded unless the following conditions are either met or, in a review
under AS
23.35.040(a)(1), excused by
the council for just cause:
(1) the fisherman
receives initial treatment not later than 120 days after the date of injury;
the initial treating provider shall submit a Physician's Report (Form 07-6126),
unless the department accepts an alternate format that provides the same data
in a form that the department can easily use;
(2) the claim is submitted no later than one
year after the date of initial treatment;
(3) the fisherman responds no later than 90
days after receipt of an inquiry seeking clarification of any item on a claim,
or of any item on a billing for services performed or goods supplied;
(4) there is no unexplained gap in treatment
of more than three months;
(5) the
provider submits price lists and fee determinations to the administrator no
later than 30 days after receipt of a request.
(e) Transportation to return a fisherman to
the fisherman's home may be allowed to the extent that the costs are in
addition to those that the fisherman would normally have encountered had the
fisherman not been injured.
(f) The
department may require information regarding insurance coverage, including an
insurance benefits statement, and may hold a claim in abeyance pending the
receipt of required information. Insurance benefit statements must be received
by the department not later than 180 days after a fisherman receives an inquiry
seeking clarification.
(g) A vessel
owner may not recover reimbursement for a protection and indemnity insurance
policy deductible payment unless the administrator receives
(1) proof of direct payment of medical
benefits to or on behalf of the fisherman by the vessel owner, together with a
copy of the declaration page of the policy setting out the policy coverage and
limits; or
(2) proof of direct
payment of medical benefits to or on behalf of the fisherman by the vessel
owner's protection and indemnity insurance company, together with
(A) proof of payment of the policy deductible
to the protection and indemnity insurance company by the vessel owner;
and
(B) a copy of the declaration
page of the policy setting out the policy coverage and limits.
(h) Provider bills must
be submitted to the department in a format approved by the United States
Department of Health and Human Services, Centers for Medicare and Medicaid
Services (CMS), unless the department accepts an alternate format that provides
the same data in a form that the department can easily use.
(i) Provider bills must be accompanied by
signed and dated chart notes.
(j)
If an injury requires continuing and multiple treatments of a similar nature,
the standards for payment for outpatient treatment for the injury are as
follows:
(1) payment for a course of
treatment may not exceed more than three treatments per week for the first
month, two treatments per week for the second and third months, one treatment
per week for the fourth and fifth months, and one treatment per month for the
sixth through 12th months;
(2) a
provider shall furnish a written treatment plan if the course of treatment will
require more frequent outpatient treatment than allowed under this
subsection;
(3) the treatment plan
shall be furnished to the administrator no later than 14 days after treatment
begins;
(4) the treatment plan must
include objectives, modalities, frequency of treatments, and reasons for the
frequency of treatments.
Notes
Authority:AS 23.35.050
AS 23.35.070
AS 23.35.100
AS 23.35.145
AS 23.35.150
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