Information for Carriers
Important News Regarding Ambulatory
Surgery Fee Schedule
Rules and Public Comment Meeting on October 3, 2016
On August 9, 2016, Superior Court Judge Paul Ridgeway entered a Decision invalidating the ambulatory surgery center provisions of the workers’ compensation medical fee schedule that became effective April 1, 2015. Please click here to read that decision. The decision has been stayed pursuant to a September 2, 2016 Order by Judge Ridgeway. Click here to view the Order.
The Industrial Commission will hold a non-mandatory public comment meeting on October 3, 2016, to consider appropriate steps for the Industrial Commission to take in light of the August 9, 2016 Decision. Please click here to view the meeting notice. Please click here for the cost analyses published by NCCI and NCRB that are referenced in the meeting notice. The cost analyses may be used by the public in formulating any comments or proposals prior to or following the public comment meeting.
The Industrial Commission received the following proposals on September 26, 2016. As stated in the meeting notice, members of the public may attend the meeting on October 3, 2016, to address oral comments on these proposals to the Commission. Additionally, any person may present written comments in response to the proposals by October 10, 2016, as described in the meeting notice referenced above. In accordance with the meeting notice, the Commission is posting all proposals received. The proposals are listed in chronological order of receipt.
- Proposal from Surgical Care Affiliates, LLC. Please click here.
- Proposal from 21 employer, insurance, and third-party administrator organizations. Please click here.
- Proposal from the National Association of Mutual Insurance Companies. Please click here.
- Proposal from the North Carolina Hospital Association. Please click here.
ICD-10 Diagnosis Codes Required as of October 1, 2015
Beginning October 1, 2015, pursuant to N.C. Gen. Stat. § 97-26(g1) and in alignment with federal regulations, the applicable administrative standard for diagnosis code sets for medical billing and reporting in North Carolina workers’ compensation cases will transition to the International Classification of Diseases, 10th Edition, Clinical Modification and Procedure Coding System (ICD-10), from the 9th Edition (ICD-9).
Although there have been previous delays in the implementation of the ICD-10 code sets, the Industrial Commission will continue to follow the timeframe set by the Centers for Medicare and Medicaid Services (CMS).
All medical services provided on or after October 1, 2015, must be billed with ICD-10 diagnosis and procedure codes. Medical services provided before October 1, 2015 must continue to be billed with ICD-9 diagnosis and procedure codes. Health care providers should follow CMS’s guidelines for billing claims that overlap the ICD-10 implementation date.
For more information about the transition, please visit the CMS website at http://www.cms.gov/Medicare/Coding/ICD10/Index.html.
Medical Fee Schedule Changes, Effective July 1, 2015
Please click here for a notice regarding the changes to the Workers’ Compensation Medical Fee Schedule that are effective July 1, 2015. The notice links to Frequently Asked Questions that provide information and guidance regarding the changes to the Medical Fee Schedule.
Medical Fee Schedule Changes, Effective April 1, 2015
Please click here for a notice regarding changes to the Workers' Compensation Medical Fee Schedule, effective April 1, 2015. The notice links to Frequently Asked Questions that provide information and guidance regarding the changes to the Medical Fee Schedule.
Rule 1001 Medical Practice Guidelines and Peer Reviewer Profiles
The North Carolina Industrial Commission offers a secure FTP site (ftp://22.214.171.124/), so that insurance companies and other entities may upload Rule 1001 Medical Practice Guidelines, Rule 1001 Peer Reviewer Profiles, and related documents and correspondence for the Commission to view. Click here for complete instructions on how to use this FTP site.
If you have questions related to Rule 1001 Medical Practice Guidelines or Rule 1001 Peer Reviewer Profiles that you have submitted or general questions about Rule 1001 submissions, please contact the Executive Secretary's office by e-mailing firstname.lastname@example.org. Someone from our office will respond.
If you have problems uploading or questions about the FTP site itself, please e-mail the NCIC IT Section at NCICIT@ic.nc.gov; or you may call the IT Section at (919) 807-2590 between the hours of 8:00 a.m. and 4:00 p.m. EST/EDT Monday-Friday.
Announcement Regarding Medical Bill Reporting Electronic Data Interchange (EDI)
In response to requests from employers, carriers, and third-party administrators, the Industrial Commission will delay the mandatory implementation date for Medical Bill Reporting via EDI from March 1, 2014, to July 1, 2014. This purpose of this postponement is to allow these stakeholders additional time for preparation and necessary programming. No additional extensions will be granted.
Announcement Regarding Electronic Medical Billing and Payment
Pursuant to N.C. Gen. Stat. §97-26(g1), the Industrial Commission was directed to adopt rules requiring electronic medical billing and payment processes. The Industrial Commission subsequently adopted Electronic Billing Rules 101-109 in 2012. These rules were then held in abeyance in conjunction with other rule making efforts and to allow the Commission to develop an implementation guide. The Electronic Billing and Payment Companion Guide is now in final form and ready for publication. Click here for access to the guide. This guide can also be accessed on the Commission’s webpages for Carriers and for Medical Providers.
The date for implementation of electronic medical billing in the adopted rules referenced above is March 1, 2014. The Commission received and considered feedback and multiple requests for extensions of the March 1, 2014 deadline from employers, carriers, third-party administrators, and medical billing companies. In order to allow these stakeholders additional time for preparation, the Commission will not require compliance with the Electronic Billing Rules until July 1, 2014, with regard to electronic medical billing processes. The rules and portions of the companion guide that govern and require electronic medical payment processes will not be mandatory until January 1, 2015. No additional extensions will be granted.
Update Regarding Medical Fee Schedule
On January 1, 2013, the Industrial Commission enacted 04 NCAC 10J .0101 Fees for Medical Compensation. This new rule revised the payment structure for medical treatment under the Commission’s Medical Fee Schedule and Hospital Fee Schedule. These adjustments were made on staggered dates: (1) January 1, 2013; (2) February 1, 2013; and (3) April 1, 2013. The Industrial Commission has provided three notices regarding these changes and encourages all insurance carriers, self-insured groups and administrators, and managed care organizations to make timely and accurate payment for medical services in accordance with the rule and guidance provided in the following notices:
- January 16, 2013 announcement for January 1, 2013 changes: http://www.ic.nc.gov/011613notice.pdf
- January 30, 2013 announcement for February 1, 2013 changes: http://www.ic.nc.gov/013013notice.pdf
- March 22, 2013 announcement for April 1, 2013 changes: http://www.ic.nc.gov/ncic/pages/032213notice.pdf
The following are answers to some of the most commonly asked questions from insurers about North Carolina Workers’ Compensation.
I am an adjuster for an insurer. Is there a form I should use to deny a workers’ compensation claim?
Yes. Pursuant to N.C. Gen. Stat. §97-18(c) and (d), a Form 61 must be filed with the N.C. Industrial Commission and a copy sent to the employee or the employee’s attorney of record, if any, and also to all known medical service providers. The adjuster should provide a detailed statement describing the grounds for denying compensability or liability either on the Form 61 or on an attached letter.
I am an out-of-state medical provider. Am I required to accept medical rates as established by the N.C. Medical Fee Schedule when I treat patients for a N.C. claim?
No. You are allowed to bill charges in full or based on a prior agreement if one has been established. If one has not been established, expect reimbursement pursuant to your state’s fee schedule.
Do I need permission to suspend or terminate Temporary Total benefits under workers’ compensation?
Yes, unless there has been a return to work as explained in the paragraph below. A Form 24 must be filed with the N.C. Industrial Commission and sent to the employee or the employee’s attorney of record, if any, and payments may be stopped only after a decision by the Commission.
You may terminate Temporary Total benefits [N.C. Gen. Stat. §97-29] when an employee has returned to work for the same or different employer subject to Trial-Return to Work provisions [N.C. Gen. Stat. §97-32.1] or when the employer contests a claim pursuant to Payment Without Prejudice [N.C. Gen. Stat. §97-18(d)] within ninety (90) days (unless an extension has been granted by the Industrial Commission).
Otherwise, you should submit a Form 24 - Application to Terminate or Suspend Payments of Compensation pursuant to N.C. Gen. Stat. §97-18.1, to the Industrial Commission. The Industrial Commission shall approve or deny the Form 24. You should receive approval from the Industrial Commission prior to the termination of compensation benefits. If payments are suspended prematurely, and the Special Deputy Commissioner disallows the Form 24 request, the insurer must pay full retroactive benefits to the employee.
Are there any penalties if payment of compensation benefits are not paid within fourteen (14) days after it has become due when the injured worker is being paid ongoing compensation?
Yes. Pursuant to N.C. Gen. Stat. §97-18(g), there shall be added to such unpaid installment an amount equal to ten per cent (10%), which shall be paid at the same time as, but in addition to, such installment, unless such nonpayment is excused by the Industrial Commission after a showing by the employer that owing to conditions over which he had no control such installment could not be paid within the period prescribed for payment. There is a Penalty Memo available from the Industrial Commission for more information.
Which forms should I submit to the Industrial Commission when a claimant has returned to work?
You should use the Form 28 - Return to Work Report, when the claimant has returned to work with no working restrictions, or the Form 28-T - Notice of Termination of Compensation by Reason of Trial-Return to Work Pursuant to N.C. Gen. Stat. §97-18.1(b) and §97-32.1, when the claimant has working restrictions.