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
TO: | Hospital and Facility Providers of Workers Compensation Services |
FROM: | Jennifer Gudac, Chief Medical Fee Examiner |
SUBJECT: | Revision of Mandatory Billing Requirements |
CC: | Processors of Workers Compensation Medical Bills |
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-92 (HCFA-1450) form. These requirements are in lieu of the previously submitted memorandum dated November 30, 1999. The effective date for these billing requirements shall be February 1, 2000.
Element Description | UB-92 Form Locator No. |
Employees name | Field 12 |
Date of Injury | Field 32 a or b through 35 a or b |
Social Security Number | Field 60 |
Employers Name | 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 | Upon Request |
Due to UB-92 formats, the employees phone number, date of service per line item, and provider representative name will not be required at this time.
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