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.
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.
IME Provider Applications Now Open for Submissions
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. To apply to be on the list, fill out the application provided in the link below, and send it to the email link provided through the application: WCA Medical Cost Containment Bureau at WCA-MCC@state.nm.us.
Please fill out the IME application with supporting documents and licensing by downloading the form. (The form must be downloaded. Link here for instructions on downloading pdf forms). Deadline to submit is May 31, 2022 at close of business day (5 p.m.)..
Find the current list of IME providers.
AMA Guides Changes
The American Medical Association (AMA) Guides for evaluating impairment have changed. According to the New Mexico Workers’ Compensation Act 52-1-24 NMSA 1978 A, impairment is “based upon the most recent edition of the American Medical Association’s (AMA) Guide (the Guides) to the Evaluation of Permanent Impairment.” This reference can also be found in Workers’ Compensation Administration (WCA) Rules 126.96.36.199 V and 188.8.131.52 G.
Effective July 1, 2021, the AMA considers AMA Guides Sixth 2021 to be the most current version of AMA Guides Sixth. Going forward, the AMA Guides be revised yearly and maintained exclusively online at https://www.amaguides.com
To assist our stakeholders to better understand these changes, you may refer to the following links below which include a prerecorded webinar by the AMA and a synopsis of the changes:
• AMA Guides Sixth 2021 Education Module
• Description of Changes- AMA Guides Sixth 2021
• AMA Guides Medical Seminar (April 2021)
• What’s New to the AMA Guides (2021 and 2022)
• AMA Guides Frequently Asked Questions
You may also refer to the NM WCA Quarterly Bulletin for Summer 2021 on the agency website, attached here: https://workerscomp.nm.gov/sites/default/files/documents/publications/bulletins/Summer2021.pdf
Further, the AMA, in partnership with the New Mexico Medical Society (NMMS), hosted a virtual LIVE webinar especially for the NM legal and medical community which is linked here:
A passcode is needed to view the recording. Access Passcode: A5=IHKSQ
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.
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.
Provider's Report of Physical Ability (PROPA)
The WCA Provider's Report of Physical Ability (PROPA) 2022 revision is available at this link:
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 Forms and Letter
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.
To seek the WCA Director's approval, you may submit the following forms which are downloadable by clicking on the corresponding document.
The forms are also available on our forms page.
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.
*Now by MCG Health, formerly registered trademarks of the Work Loss Data Institute (WLDI). WLDI was acquired by MCG Health, part of the Hearst Health Network, in 2017.
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.