Information for Carriers
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.
Do the forms have to be color-coded?
Because we scan all forms and documents and convert them to electronic files, at this time, the Industrial Commission is using white paper for all forms and correspondence. This makes them easier to scan.
Do insurers and self-insurers have to send all bills to the Industrial Commission?
No, they do not. Insurers and self-insurers may pay the following bills without submitting them to the Industrial Commission for approval.
- Medical Travel bills (the mileage rate increased to $.55 per mile, effective 27 January 2009).
- Minor medical bills of $2,000 or less.
- Pharmacy bills—pay in full or per agreement.
- Ambulance bills—pay in full or per agreement.
- Out-of-state claims or providers—pay in full or per agreement or by your state’s fee schedule.
- Private-duty-nursing bills—pay in full or per agreement.
- Nursing-home bills (per agreement with nursing home).
- Pain-clinic bills (per agreement with pain clinic).
- Industrial rehabilitation bills for "work hardening programs" and "psychological services" (per agreement with service provider).
- Rehabilitation nurse bills—pay in full or per agreement (per Industrial Commission rule effective January 1, 1993). Please send a copy of these bills, with the I.C. Number indicated, to the Industrial Commission for its files. It is no longer necessary to send reports unless they have been requested.