Thomas J. Bolch, Commissioner
Laura K. Mavretic, Commissioner
Renée C. Riggsbee, Commissioner
Christopher Scott, Commissioner
Dianne C. Sellers, Commissioner
| Bernadine S. Ballance,
Commissioner Thomas J. Bolch, Commissioner Laura K. Mavretic, Commissioner Renée C. Riggsbee, Commissioner |
|
James B. Hunt Jr., Governor Christopher Scott, Commissioner Dianne C. Sellers, Commissioner |
North Carolina
Industrial Commission
MEMORANDUM
TO: All
Workers’ Compensation Carriers, Third Party Administrators, Medical Bill Review
Agencies, and Providers of Medical Services to Workers’ Compensation Claimants
FROM: Bernadine S. Ballance, Commissioner
Thomas J. Bolch, Commissioner
Laura K. Mavretic, Commissioner
Renée C. Riggsbee, Commissioner
Christopher Scott, Commissioner
Dianne C. Sellers, Commissioner
DATE: November 30, 1999
SUBJECT: New Mandatory Medical Billing and Reimbursement Procedures
In an effort to bring more efficiency to the medical billing and reimbursement process, the 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 resulted from the discussions of the Task Force of Medical Provider and Carrier Representatives. As of February 1, 2000 the following procedures must be followed:
PROVIDER REQUIREMENTS
When submitting medical bills, the provider must include:
- Employee’s (Patient’s) Name
- Employee’s Phone Number
- Social Security Number
- Employer’s Name
- Date of Injury
- Date of Service per line item
- Procedure code(s) and charges
- 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
PAYOR REQUIREMENTS
When the carrier or other payor is submitting payment, the payor must provide:
- 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
- Employer’s Name
To ensure that 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 February 1, 2000. All correspondence should be directed to the Chief Medical Fee Examiner (see name and address below).
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 [in PDF form] 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.
Compliance with the foregoing is mandatory. The Industrial Commission will enforce compliance by random audits of all payors. Please direct responses or inquiries to:
Ms. Jennifer Gudac
Chief Medical Fee Examiner
North Carolina Industrial Commission
4337 Mail Service Center
Raleigh, NC 27699-4337
(919) 733-1999
gudaca@ind.commerce.state.nc.us
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