NORTH CAROLINA INDUSTRIAL COMMISSION

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MEDICAL FEE SCHEDULE

Section 16: Forms

Note: Please see the ADDENDUM at the end of this document.

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Forms for Reporting and Billing; Return to Work;
Annual Report of Medical Only & Lost Time Cases

For a complete listing of Forms please visit http://www.ic.nc.gov/forms.html

Forms may be also obtained by writing the North Carolina Industrial Commission, 4340 Mail Service Center, Raleigh, NC 27699-4340.

Medical providers and attorneys should mail all bills to the employer or insurance company to be processed by them or forwarded to the Industrial Commission for review. Please do not send your bills directly to the Industrial Commission, as this will delay your payment.

See Addendum for more information.

Provider Forms

Medical Provider (Professional) Use HCFA (CMS) Form 1500
Medical Provider (Facility) Use HCFA (CMS) Form UB-04
Dental Provider Use ADA Form (American Dental Association)

Drug Form—Form 25P

This form should be submitted to the employer/and or insurance company. The employee or insurance company can complete this form. The employee should retain a copy before submitting to the payer. If form is completed/submitted by pharmacy or carrier, it is not mandatory for the employee to sign.

Bills may be paid by insurance company or self-insurer and copies retained in their file. It is not necessary to submit these bills to the North Carolina Industrial Commission for approval. Please do not send your bills directly to the Industrial Commission, as this will delay your payment.

Travel Form—Form 25T

The employee should submit this form to the employer and/or insurance company. The employee should retain a copy.

Bills may be paid by insurance company or self-insurer and copies retained in their file. It is not necessary to submit these bills to the North Carolina Industrial Commission for approval. Please do not send your bills directly to the Industrial Commission, as this will delay your payment.

Trial Return to Work—Form 28U

Under the Commission’s Trial Return to Work program, the treating physician must certify whether or not the employee is prevented from continuing the trial return to work due to the employee’s injury for which workers’ compensation is being paid.

N.C. Gen. Stat. §97-32.1

North Carolina General Statute §97-32.1 provides as follows:

97-32.1 Trial Return to work. Notwithstanding the provisions of N.C.G.S. §97-32, the employee may attempt a trial return to work for a period not to exceed nine months. During a trial return to work period, the employee shall be paid any compensation which may be owed for partial disability pursuant to N.C.G.S. §97-30. If the trial return to work is unsuccessful, the employee’s right to continuing compensation under N.C.G.S. §97-29 shall be unimpaired unless terminated or suspended thereafter pursuant to the provisions of the Article. (1993 {Reg. Sess., 1994}, c.679, s.4.1)

Rating Form—Form 25R

Evaluation for Permanent Disability and Amputation Chart

This form and related medical record should be completed by the physician at the end of the healing period and should be sent to the insurance carrier or self-insurer.

Employee’s Application for Additional Medical Compensation Pursuant to N.C. Gen. Stat. §97-25.1Form 18M

For injuries occurring on or after July 5, 1994, the employee may use the Form 18M to request additional medical compensation as long it has been less than two years since the last payment of medical or indemnity compensation. The original and one copy of the Form 18M must be filed with the Industrial Commission’s Office of the Executive Secretary, one copy must be provided to the employer or insurance company/administrator, and one copy must be provided to the attorney of record for the insured, if any.

Physicians should be aware that a space is provided on the Form 18M for their professional statement.

Annual Consolidated Fiscal Report of Medical Only or Lost Time Cases—Form 51

This form is included in the Fee Schedule for the benefit of insurance companies and self-insurers who have to file it annually. The form should be filed with the Statistics Section of the North Carolina Industrial Commission. Insurance companies or self-insurers who directly apply the Fee Schedule should file this report to document the medical compensation processed and paid. 

To the Medical Provider:

Information to be included in Reports of Special Examinations

For your information and as a guide in completing reports of special examinations, the following information is essential and should be incorporated in your written reports.

  1. History of case as obtained from you from the injured (note any pre-existing injuries or diseases).
  2. Injured’s symptoms and complaints as obtained by you.
  3. Physical findings (this is to include laboratory, x-ray, etc.). Include measurements of function according to accepted standard of the American Medical Association Guides.
  4. Diagnosis of condition or conditions found.
  5. Your opinion as to the relation between condition or conditions diagnosed and the injured’s alleged injury or occupational exposure, with your reasons for your opinion.
  6. Whether any temporary disability exists; if so, whether it is total or partial, and its probable duration.
  7. What physical impairment, if any, can be expected.
  8. Where permanent disability has resulted and the case is ready for permanent disability rating, the extent of impairment should be given in detail. Where measurements can be taken and can be related to the corresponding opposite measurement, both measurements should be given as a fraction of injured over uninjured. If both sides are involved in the injury, then any estimate of the normal measurement should be given. If a part of the disability is attributable to a prior injury or disability, the extent to which the present impairment is affected by the prior condition must be given and may be expressed as a percentage; i.e., 50% of impairment due to injury; 50% due to preexisting factors.
  9. What treatment, if any, is indicated, including type, frequency, and probable duration.
  10. Any other medical information that you believe pertinent to the case, to assist in making an equitable adjustment.
  11. Give date patient in your opinion should be able to return to work or actual date of return if known.

Information to be included in Progress Reports

  1. Date of most recent examination.
  2. Present condition and progress since last report.
  3. Measurements of function.
  4. X-ray or laboratory report since last examination.
  5. Treatment—type, duration.
  6. Work status—patient working or estimated date of return to work.
  7. Permanent impairment to be anticipated.

ADDENDUM

  • The North Carolina Industrial Commission will continue to accept physician and professional practice billing on a HCFA 1500 or and Industrial Commission Form 25M. However, the 25M Form was not revised and will be phased out of use. Likewise, the 25D Form for dental claims was not updated and will also be phased out of use. Eventually all physician/professional medical charges will be submitted on the HCFA 1500 Form and all dental claims will be submitted on the American Dental Association’s standard billing form.
  • Hospital/Facility/Home Health Agency providers should use Form UB-04 for billing.
  • Ambulatory Surgery facility fee services performed at a hospital will be billed on the UB-04 Form with the identifying 490 revenue code. Freestanding licensed Ambulatory Surgical Centers may bill on the HCFA 1500 and 25M utilizing the code 490 FF (for facility fee). Reimbursement of the ambulatory surgery facility fees for either the hospital or the freestanding licensed center is to be paid in full of charges.
  • Effective February 1, 2000, the North Carolina Industrial Commission has made the following Provider and Payor requirements regarding Medical Billing and Reimbursement Procedures.

Provider Requirements

  • When submitting medical bills, the professional provider must include:

Description Form 25M HCFA 1500
Employee’s (Patient’s) Name Field 2 Field 2
Employee’s Phone Number Field 2 Field 5
Social Security Number Field 2 Field 1a
Employer’s Name Field 3 Field 7
Date of Injury Field 1 Field 14
Date of Service per line item Field 7 Field 24a
Procedure code(s) and charges Field 7 Field 24d
Copy of Authorization or Record of Verbal Authorization, if available
Medical Notes or Operative Report
Name of Provider Representative designated to receive notice when claim is denied
  • In recognition of the distinct differences in professional and facility billing, the North Carolina Industrial Commission issues the following requirements for providers that submit workers’ compensation billing using the UB-04 form. The effective date for these billing requirements shall be February 1, 2000. Due to UB-04 formats, the employee’s phone number, date of service per line item, and provider representative name will not be required at this time.

Facility Provider Billing

Element Description UB-04 Form Locator No.
Employee’s name Field 12
Date of Injury Field 32 a or b through 35 a or b
Social Security Number Field 60
Employer’s Name Field Field 65
Revenue Codes to Identify Charges Field 42
Description of Revenue Codes Field 43
HCPCS not required
Copy of Authorization (Written or Verbal), if available
Medical Notes or Operative Reports
  • For more specific instructions on completing the HCFA 1500 or UB-04 Forms, please consult the appropriate HCFA manuals.

Payor Requirements

  • When the carrier or other payor is submitting payment, the payor must provide on the explanation of payment the following information:

Patient’s Name

Social Security Number

Account Number, if available

Date of Injury

Date of Service per line item

Procedure Code(s)

Amount Charged and Amount Paid for each Procedure Code (Data fields should include Workers’ Compensation Fee Schedule reductions, PPO discounts or other contract reductions, and non-covered charges. Charges that are denied should be identified along with reason for denial or non-payment.)

Language required by Industrial Commission (including dispute resolution, contact information, and late penalty rules)

Carrier’s Name and Address

Carrier’s Fax Number

Employer’s Name

When a Claim Is Denied by the Payor

  • When liability for payment of compensation is denied, the proper party (i.e., insurance carrier, third party administrator, or self-insured employer) 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 within its facility or practice to receive the Form 61 for workers’ compensation cases. This designated person shall be identified on the original medical bill.

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.


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