Worker Compensation review - Part 2

What information must the medical provider include on the UB 92 or CMS 1500 forms submitted to the payer?

When submitting medical bills, the provider must include*:
Entity’s name
Entity’s tax ID
Employee’s (patient’s) name
Employee’s (patient’s) phone number
Employee’s (patient’s) social security number or ID number
Patient account number as assigned by the provider
Employer’s name
Carrier/payer name
Date of injury
Date(s) of service per line item
Procedure codes per line item
Diagnosis codes
Admission date
Discharge date
Billed charges per procedure code
Medical notes or operative report
Phone number and name of provider representative, position, or department designated to receive notice when claim is denied
When submitting medical bills, to expedite claims processing, the provider should include, if available:
IC number
Carrier claim number
Authorization code

How long does a payer have to reimburse a medical provider for authorized treatment?

Payments of "clean claims" (where liability has been admitted and the proper information as stated above is provided on or with the claim) shall be paid in accordance with N.C. Gen. Stat. 97-18(i) and Rule 407. If a clean claim is not paid within 60 days after it has been approved by the Commission and returned to the responsible party, or within 60 days after it was properly submitted to an insurer or managed care organization responsible for direct reimbursement, the Industrial Commission will automatically assess an amount equal to ten (10) percent of the unpaid medical bill unless such late payment is excused by the Commission.

How may medical providers resolve disputes with payers regarding reimbursement amounts?

The medical provider should first attempt to resolve billing disputes directly with the payer. Unresolved disputes should be submitted to the North Carolina Industrial Commission Medical Fees Section with a carbon copy to the payer. Submitted information should include the following:
Cover letter explaining dispute
Copies of bill
Copies of medical reports related to dispute
Copy of the payer’s previous explanation of payment
Any additional documentation felt to be related to issue

May a medical provider ever directly bill a patient for medical services related to an alleged workers’ compensation claim?

"A health care provider shall not pursue a private claim against an employee for all or part of the costs of medical treatment provided to the employee by the provider unless the employee’s claim or the treatment is finally adjudicated not to be compensable or the employee fails to request a hearing after denial of liability by the employer."

If a claim is denied by the workers’ compensation payer and the injured worker appeals to the Commission, the provider must wait until a decision is reached regarding the Commission’s determination of compensability of the patient’s claim and medical bills. If the Commission agrees that the claim and/or medical treatment are not compensable, then the provider may bill the injured worker

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