Note: The following constitutes the proposed
changes in this Rule. Added language appears in bold italic script, and
proposed deletions are indicated by strikeout. The changes will not go
into effect until further notice by the Industrial Commission.
Rule 407
Fees for Medical Compensation
(1) Subject to the provisions of N.C. Gen. Stat. § 97-25.3, "Preauthorization," the Industrial Commission shall adopt and publish a Fee Schedule, pursuant to the provisions of N.C. Gen. Stat. § 97-26(a), fixing maximum fees, except for hospital fees pursuant to N.C. Gen. Stat. § 97-26(b), which may be charged for medical, surgical, nursing, dental, and rehabilitative services, and medicines, sick travel, and other treatment, including medical and surgical supplies, original artificial members as may reasonably be necessary at the end of the healing period and the replacement of such artificial members when reasonably necessitated by ordinary use or medical circumstances. The fees prescribed in the applicable published Fee Schedule shall govern and apply in all cases. However, in special hardship cases where sufficient reason is demonstrated to the Industrial Commission, fees in excess of those so published may be allowed. Persons who disagree with the allowance of such fees in any case may make application for and obtain a full review of the matter before the Industrial Commission as in all other cases provided. Copies of this published Fee Schedule may be obtained from the Industrial Commission’s authorized vendor.
(2) A provider of medical compensation shall submit its statement for
services within seventy-five 75 days of the rendition of the service or
if treatment is longer, within thirty 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. However, 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 from the time the health care provider
received notice of the admission or determination of liability. Within thirty
30 days of receipt of the statement, the employer, or carrier, or managed care
organization, or administrator on its behalf, shall pay or submit the statement to the
Industrial Commission for approval or send the provider written objections to the
statement. If an employer, carrier/ administrator or managed care organization disputes a
portion of the provider’s bill, it shall pay the uncontested portion of the bill and
shall resolve disputes regarding the balance of the charges through its contractual
arrangement or through the Industrial Commission. If any bill for medical compensation
services is not paid within sixty 60 days after it has been approved by
the Industrial Commission and returned to the responsible party, or, when the employee is
receiving treatment through a managed care organization, within sixty 60
days after the bill has been properly submitted to an insurer or managed care
organization, there shall be added to such unpaid bill an amount equal to ten
percent 10%, which shall be paid at the same time as, but in addition to, such
bill, unless late payment is excused by the Industrial Commission. When the ten
percent 10% addition to the bill is uncontested, payment shall be made to the
provider without notifying or seeking approval from the Industrial Commission. When the ten
percent 10% addition to the bill is contested, any party may request a hearing by
the Industrial Commission pursuant to N.C. Gen. Stat. § 97-83, and N.C. Gen. Stat. §
97-84.
(3) When the responsible party seeks an audit of hospital charges, and has paid the hospital charges in full, the payee hospital, upon request, shall provide all reasonable access and copies of appropriate records, without charge or fee, to the person(s) chosen by the payor to review and audit the records.
(4) The responsible employer or carrier/administrator shall pay the statements of medical compensation providers to whom the employee has been referred by the authorized treating physician, unless said physician has been requested to obtain authorization for referrals or tests; provided, that compliance with such request does not unreasonably delay the treatment or service to be rendered to the employee.
(5) It is the responsibility of the carrier, self-insured employer, group insured as certified by the North Carolina Department of Insurance, and statutory self-insured (state agency or political subdivision) to submit on a yearly basis a Form 51, Consolidated Fiscal Annual Report of "Medical Only" and "Lost Time" Cases.
(6) Employees shall be entitled to reimbursement for sick travel when
the travel is medically necessary and the mileage is twenty 20 or more
miles, round trip, at a rate to be established periodically by the Industrial Commission
in its Minutes. Employees shall be entitled to lodging and meal expenses, at a rate to be
periodically established by the Industrial Commission in its Minutes, when it is medically
necessary that the employee stay overnight at a location away from the employee’s
usual place of residence. An employee shall be entitled to reimbursement for the costs of
parking or a vehicle for hire, when the costs are medically necessary, at the actual costs
of the expenses, unless the Industrial Commission determines the expenses were not
reasonable.
(7) The Amendments to this Rule are effective March 15,
1995.
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