Worker Compenstation - Detailed review - 3

What should occur when a medical provider’s bill is received by the payer?


Workers’ compensation payers must respond to all medical bills. For each medical bill received for which no first report of injury has been issued, the payer 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 and the patient so he/she has the option of filing a Form 18 if he/she feels that an injury has occurred.

What should occur when a denial of payment is received by the provider because no workers’ compensation claim exists?


When a claim is denied because the payer has no report of injury (Form 18 or Form 19), the medical provider should send a copy of the bill and the denial (which shall include the reason for the denial) to the employer and patient and direct the patient to the Industrial Commission website for information on filing a workers’ compensation claim. The medical provider may then bill the patient or employer as appropriate.

What about workers’ compensation medical treatment involving a PPO?


The employer/carrier/insurer/administrator that contracts with a PPO or any third party for the payment or processing of medical bills shall ensure that such PPO or third party complies with the procedures articulated in this document. Ultimate responsibility for compliance rests with the employer/carrier/insurer/administrator that contract with a PPO or applicable third party.

What reimbursement amount will a medical provider receive for treatment of workers’ compensation patients?

A medical provider will be reimbursed ONLY the amount approved in the NCIC Medical Fee Schedule unless the provider has contracted with the payer for a lesser rate of reimbursement. In cases wherein a specific code or procedure is not included in the NCIC Medical Fee Schedule, the parties may privately contract for a mutually agreeable payment amount. N.C.G.S. §97-26

How are medical providers reimbursed for new procedures or CPT codes NOT included in the NCIC Medical Fee Schedule?


If reimbursement has not been set by the Industrial Commission, these services should be paid by agreement between the medical provider and payer.


Are there special requirements to be reimbursed for consultation codes?

Yes, check AMA and other coding guides, but it is essential that the consultative physician report findings back to the requesting party or physician. When the treating physician transfers the complete care to another physician the Commission considers this a referral and not a consultation. Then, the new physician should bill a new patient visit.

Who is entitled to receive a patient’s medical records related to their workers’ compensation claim.


The new provisions of N.C.G.S. §97-25.6 set forth under what circumstances an employer or insurer may communicate with a medical provider as follows:

1. Any employer or insurer paying medical compensation to a provider rendering treatment may obtain records of the treatment without authorization of or notice to the employee.
2. An employer or insurer in a denied claim or in a claim that has not yet been accepted or denied may, with written notice to the employee, obtain directly from a medical provider medical records restricted to a current injury or condition for which the employee is claiming compensation. This request does not require the authorization of the employee but does require that the employee receive notice of the request.
3. Upon written request from the employer or insurer, the employee or their attorney shall provide medical records or reports in their possession restricted to conditions related to the injury or illness for which the employee is seeking compensation.
4. An employer or insurer paying compensation for an admitted claim or paying compensation without prejudice may communicate with an employee’s medical provider in writing limited to the attached questions adopted by the North Carolina Industrial Commission.

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