North Carolina
Industrial Commission

In an effort to bring more efficiency to the medical billing and reimbursement process, the N.C. Industrial Commission requires that the following items be included in each medical bill submitted for payment and in each Explanation of Payment issued with payment. These requirements initially resulted from the discussions of the 1999 Task Force of Medical Provider and Carrier Representatives and were recently updated in 2005 and 2006 by the NCIC Advisory Council Medical Bill Task Force comprised of provider, carrier, self-insured, PPO, plaintiffs’ and defendants’ bar representatives.

Provider Requirements
See attached chart* for appropriate field locations for the UB 92 and CMS 1500 forms.

*Numbers correspond to attached chart.

When submitting medical bills, the provider must include*:

1. Entity’s name
    
2. Entity’s tax ID
    
3. Employee’s (patient’s) name
    
4. Employee’s (patient’s) phone number
    
5. Employee’s (patient’s) social security number or ID number
    
6. Patient account number as assigned by the provider
    
7. Employer’s name
    
8. Carrier/payor name
    
9. Date of injury
    
10. Date(s) of service per line item
     
11. Procedure codes per line item
     
12. Diagnosis codes
     
13. Admission date
     
14. Discharge date
     
15. Billed charges per procedure code
     
16. Medical notes or operative report
     
17. Phone number and name of provider representative, position, or department designated to receive notice when claim is denied

When submitting medical bills, to expedite claims processing, the provider should include, if available:

18. IC number
     
19. Carrier claim number
     
20. Authorization code

Medical bills must be submitted within 75 days of the rendition of the service, or if the treatment lasts longer than 30 days, within 30 days after the end of the month during which multiple treatments were provided, or within such other reasonable period of time as allowed by the Industrial Commission. In cases where liability is initially denied but subsequently admitted or determined by the Industrial Commission, the time for submission of medical bills shall run form the time the provider received notice of the admission or determination of liability.

Payor Requirements
See attached chart for additional information.

When the carrier or other payor is submitting payment, the payor must provide:

• Entity name
   
• Entity tax ID
   
• Employee’s (patient’s) name
   
• Employee’s social security number
   
• Employer’s name
   
• Patient account number
   
• Date of injury
   
• Date(s) of service per line item
   
• Procedure code(s) by line item
   
• Amount charged and amount paid for each procedure code (data fields should include Workers’ Compensation Fee Schedule reductions, PPO discounts or other contract reductions, adjustments, and non-covered charges. Charges that are denied should be identified along with reason for denial or non-payment)
   
• Language required by NCIC (including dispute resolution, contact information, and late payment penalty rules)
   
• Carrier’s name, address, and contact information (including telephone number and the name or title of the appropriate individual or position to contact regarding the claim)
   
• Where applicable, PPO’s name, address, and contact information (including telephone number and the name of the appropriate individual or position to contact regarding the claim)
   
• Explanation of Payment with the check

When submitting payment, the payor should include, if available:

• Carrier claim number
   

• IC number
   

• Authorization Code

To ensure your company is in compliance with North Carolina Industrial Commission standards, please submit a sample of your current “Explanation of Payment” statement to the Industrial Commission by September 1, 2006. All correspondence should be directed to the Chief Medical Fee Examiner (see name and address below).

When a Bill Is Received by the Payor

Workers’ compensation payors must respond to all medical bills. For each medical bill received for which no first report of injury has been issued, the payor must follow up by telephone with the employer to verify the existence of a workers’ compensation claim. If no claim is verified, the medical bill shall be returned to the medical provider with a letter stating that no claim exists. This letter shall be signed by the carrier representative and shall include the representative’s phone number. This letter shall be copied to the employer and the patient so he/she has the option of filing a Form 18 if he/she feels that an injury has occurred.

Certain bills do not require North Carolina Industrial Commission approval. Please be advised that the Industrial Commission does not process the following bills, which should be paid as follows:

• Travel bills—$0.445 per mile effective January 1, 2006; tracks IRS standard mileage reimbursement rate.
   
• Drug bills—Pay in full.
   
• Ambulance bills—Pay in full.
   
• Out-of-State bills and claims—Pay in full.
   
• Minor medical ($2,000 or less) bills—Pay per fee schedule or contracted rate (also, should include on Form 51 at year end).
   
• Nursing bills (private duty and home health)—Pay in full.
   
• Nursing home bills—Pay in full or per your agreement with insurance carrier/self-insurer.
   
• Pain clinic bills—Pay per your agreement with insurance carrier/self-insurer.
   
• Industrial rehabilitation (“work hardening programs” and “psychological services”) bills—Pay per your agreement with the insurance carrier/self-insurer.
   
• Rehabilitation professional bills—New rule effective January 1, 1993—Include copy of bill and IC number.

When a Claim Is Denied by the Payor

When liability for payment of compensation is denied initially or subsequent to a payment without prejudice, the proper party (i.e., insurance carrier, third party administrator, or self-insured employer), within 14 days of receipt of the claim, shall provide a copy of the Form 61 denial to the Commission, to the claimant, to the claimant’s attorney (if any), and to all known health care providers. To ensure that health care providers are made aware of denials, the health care provider must designate an individual, position, or department within its facility or practice to receive the Form 61 for workers’ compensation cases. This designation shall be identified on the original medical bill.

When a Denial Is Received by the Provider

When a claim is denied because the payor has no report of injury (Form 18 or Form 19), the medical provider should send a copy of the bill and the denial (which shall include the reason for the denial) to the employer and patient and direct the patient to the Industrial Commission website for information on filing a workers’ compensation claim. The medical provider may then bill the patient or employer as appropriate.

All other denials may be appealed to the Medical Billing Section.

Compliance

Compliance with the foregoing is mandatory and will be enforced by the Industrial Commission. The employer/carrier/insurer/administrator that contracts with a PPO or any third party for the payment or processing of medical bills shall ensure that such PPO or third party complies with the procedures articulated in this document. Ultimate responsibility for compliance rests with the employer/carrier/insurer/administrator that contract with a PPO or applicable third party.

Payments of “clean claims” (where liability has been admitted and the proper information as stated above is provided on or with the claim) shall be paid in accordance with N.C. Gen. Stat. §97-18(i) and Rule 407. If a clean claim is not paid within 60 days after it has been approved by the Commission and returned to the responsible party, or within 60 days after it was properly submitted to an insurer or managed care organization responsible for direct reimbursement, the Industrial Commission will automatically assess an amount equal to ten (10) percent of the unpaid medical bill unless such late payment is excused by the Commission.

The Industrial Commission may enforce compliance by audits of all payors. Complaints should be directed to the chief medical fee examiner:

Ms. Christine Williams
Chief Medical Fee Examiner
N.C. Industrial Commission
Medical Billing Section
4337 Mail Service Center
Raleigh, NC 27699-4337
(919) 807-2614
Williamc@ind.commerce.state.nc.us