Health care providers (HCPs)play a key role in New Mexico's workers' compensation system. Authorized HCPs are any medical care providers licensed in New Mexico or otherwise approved by the WCA Director, including surgeons, psychologists and physical therapists. In addition to helping injured workers recover from injuries to return to work, the HCP also offers opinions that affect claims and benefits.
Find out more in our Health Care Provider Guide.
Health Care Provider (HCP) Fee Schedules
The WCA's Medical Cost Containment Bureau implements various cost-saving measures for medical services provided to injured or disabled workers. The MCC Bureau, in conjunction with the Economic Research and Policy Bureau, publishes the Health Care Provider Fee Schedule (HCPFS) to set costs for medical procedures. Health care providers are normally limited to receiving payments within the range of the HCPFS. Hospital stays require pre-authorization.
The 2023 Health Care Provider Fee Schedule and Billing Instructions becomes effective January 1, 2023.
Schedules date back to 2017. For copies of schedules from years prior to those posted, contact WCA-PIO@state.nm.us.
In the 2019 Health Care Provider Fee Schedule and Billing Instructions, there was an omission of text on page 14, under "Materials and Supplies." The last statement in that section should read:
"Materials and supplies provided during a hospital inpatient stay, hospital outpatient treatment or surgery, or emergency room visit shall be reimbursed based on the appropriate hospital ratio."
The correction is retroactive to January 1, 2019.
Interested in Becoming an Independent Medical Examiner (IME) on the WCA List?
Independent Medical Examinations (IMEs) are neutral medical exams provided in certain workers' compensation cases when parties dispute a worker's medical treatment or medical issues need clarification. IMEs can be performed by a single physician or a panel of physicians and specialists.
Either party may petition a workers' compensation judge for the worker to be examined by an independent physician(s) who has not previously treated the worker. IMEs can also occur by agreement of the parties. The judge then considers the opinion of that examination in determining the case. IME providers in New Mexico must be licensed health care providers in good standing and must use the most recent American Medical Association's (AMA) Guide (the Guides) to the Evaluation of Permanent Impairment.
IME providers used by a judge must be on the WCA IME provider list, which is approved by the IME Provider Selection Committee. The committee members represent both labor and industry and are appointed by the WCA Advisory Council.
The IME Provider Selection Committee approves providers for independent medical examinations (IMEs) through a process. The application process is open March 1 through May 31 each year and is now closed.
Find the current list of IME providers.
For questions, contact the WCA Medical Cost Containment Bureau at WCA-MCC@state.nm.us.
Provider's Report of Physical Ability (PROPA)
Download the WCA Provider's Report of Physical Ability (PROPA) 2022 revision.
Helpful guidelines for the HCPs filling out the form can be found on the back of the form.
Purpose of the form: Because a prolonged workplace absence is detrimental to a worker's well-being, the WCA asks HCPs to facilitate the recovering worker's safe, efficient return to work by providing interested parties a clear, quantitative description of current claim-related physical restrictions. In this way, you help employers identify suitable work and assign safe work activities.
When/who fills the PROPA out: Based on a reasonable medical probability, the primary treating HCP is encouraged to fill out the PROPA at each appointment. However, reimbursement for the form can only be obtained as indicated in the current HCP Fee Schedule and Billing Instruction page 22, summarized below:
- The PROPA shall be billed for reimbursement if pre-authorization is obtained AND if it is completed at the provider's initial visit or if there is a change in Work Status (section 2 of the PROPA) or Activity Restrictions (section 3 of the PROPA).
- Completion of the PROPA shall be billed as a separate line item along with the appropriate evaluation code for the appointment.
- The PROPA shall be billed using CPT code 99080 and shall be reimbursed $25.00
- For the initial visit, the medical notes must indicate "WCA Provider's Report of Physical Ability Change."
After the HCP fills the PROPA out: The HCP is asked to provide a copy to the worker immediately after each visit. Note -- the PROPA is not intended to substitute a Functional Capacity Evaluation (FCE).
Please note that the PROPA 2022 version replaces all previous version of the PROPA, including the one dated 2018.
For any questions on this form, contact the WCA Medical Cost Containment Bureau at WCA-MCC@state.nm.us
For the method of payment for Freestanding Ambulatory Surgery Centers, please see page 10 of the Fee Schedule and Billing Instructions.
Ratios Effective January 1, 2019 can be found on page 11 of the Fee Schedule and Billing Instructions document.
Release for Health Care Records
In a workers' compensation case, it may be necessary for a worker to allow a HCP to disclose medical records for the purposes of facilitating and evaluating a workers' compensation claim.
Find the form for Authorization for Use and Disclosure of Health Records
Approval of Out of State Health Care Provider
Injured workers may use a health care provider (HCP) in another state to treat their workplace injuries.
An out of state HCP must follow the WCA Act.
Approval is automatic if the insurance company has paid the HCP.
The rules listed below explain the approval process for using an HCP from another state.
To obtain out of state HCP approval prior to receiving treatment, do one of the following:
The HCP can complete the Out of State Health Care Provider Affidavit and return it to the insurer. The insurer may accept the affidavit. This does not need to be sent to the WCA.
The worker or insurer can complete the Out of State Application to Director packet and file it with the WCA Clerk of the Court.
Approval of an out of state HCP means that worker can receive treatment. It does not mean the HCP is an authorized provider.
How do I file my Application to the Director?
The completed and signed Application to Director packet can be mailed or delivered to:
New Mexico Workers' Compensation Administration
Clerk of the Court
2410 Centre Ave. SE
Albuquerque, NM 87106
Parties with questions may call the ombudsman hotline at 505-841-6894 or toll-free at 866-967-5667.
As indicated in NMAC 184.108.40.206 QUALIFICATION OF OUT OF STATE HEALTH CARE PROVIDERS
A. An HCP that is not licensed in the state of New Mexico must be approved by the director to qualify as an HCP under the act.
B. No party shall have recourse to the billing and payment dispute resolution provisions of these rules with respect to the services of an HCP who is not licensed in New Mexico or approved by the director.
C. The director's approval may be obtained by submitting an application to the director and proposed order, supported by an original affidavit of the HCP seeking approval. Nothing in this rule shall prevent the director from entering into agreements with any party or HCP to provide for simplified and expeditious qualification of HCPs in individual cases, provided, however, that all such arrangements shall be considered public records.
D. The director's approval of a health care provider in a particular case, pursuant to the provisions of Section 52-4-1 NMSA 1978 will be deemed given when an out of state health care provider provides services to that injured worker and the employer/insurer pays for those services. Unless otherwise provided, the approval obtained by this method will not apply to the provision of health care by that provider to any other worker, except by obtaining separate approval as provided in these rules.
E. The out-of-state HCP shall comply with the New Mexico HCP Fee Schedule; however, nothing in these rules shall preclude the separate negotiation of fees between an out-of-state provider and a payer within the HCP Fee Schedule for any health care service as set forth in these rules.
F. In lieu of a formal director's approval, the payer may accept an original Out of State Health Care Provider Affidavit, as provided on the WCA website, from an HCP who is licensed by their state and in good standing.
Official Disability Guidelines
On July 1, 2013, the Official Disability Guidelines (ODG)* went into effect in New Mexico for the treatment of workers' compensation injuries. All medical services rendered for recommended treatment contained in the most recent edition of the Official Disability Guidelines (ODG) are presumed reasonable and necessary.
Read more about the Official Disability Guidelines.
Return to Work
The goal after a workplace illness or injury is getting back to work as quickly as possible. Even if an immediate return to the job isn't possible, light or flex duty may be possible, provided the treating health care provider recommends it and the employer has such work available. The longer a worker is out of work, the greater the chance of never returning to the job.
Find out more about Return to Work.