Approximately $225 million is paid each year in medical payments for injured workers. An additional $120 million is paid annually in Permanent Partial Disability awards. The Medical Management Claims Rule, (or Rule 20), established by the West Virginia Legislature, is intended to give structure and discipline to both of these areas.

Rule 20 establishes the process for medical management of workers' compensation claims and awards of disabilities including, but not limited to:

-Reasonable and standardized guidelines and parameters for appropriate treatment
-Expected period of time to reach maximum medical improvement
-Range of permanent partial disability (PPD) awards for common injuries and diseases
-Establishment of limits on various types of treatment.

Treatment guidelines are also included for management of musculoskeletal injuries, eye injuries, chemical exposures, hearing loss and occupational pneumoconiosis, as well as multidisciplinary pain management, long-term opioid therapy and interventional pain treatments.

A section is also included that addresses special concerns about certain classes of medications and restrictions on the use of medications that are considered potentially dangerous or of questionable value in the treatment of injured workers.

Under this rule, medical providers are required to submit invoices for payment within six months of the date of service. This is required to improve tracking of expenses and better manage claims. In addition, medical providers must also provide clear documentation to support additional treatment beyond the standard guidelines for injured workers – changing from "clear and convincing" evidence to "a preponderance of the evidence."