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

Chairman and Commissioners · 4336 Mail Service Center · Raleigh, North Carolina 27699-4336
Telephone: (919) 733-4820 · Fax: (919) 715-0282 · BBS: (919) 715-5920
Internet Address: http://www.comp.state.nc.us/

 

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:

PAYOR REQUIREMENTS

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

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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Chairman and Commissioners   ·  N.C. Industrial Commission  ·  4336 Mail Service Center  ·  Raleigh, NC 27699-4336
Main:  (919) 733-4820 
·  Fax:  (919) 715-0282  ·  BBS:  (919) 715-5920
Internet Address:  http://www.comp.state.nc.us/