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
January 18, 2000

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.
Employee’s 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 employee’s phone number, date of service per line item, and provider representative name will not be required at this time.


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N.C. Industrial Commission · 4340 Mail Service Center · Raleigh, NC 27699-4340
Main:  (919) 733-4820  ·   Fax:  (919) 715-0282  ·   BBS:  (919) 715-5920
Internet Address:  http://www.ic.nc.gov/