Worker compensation - Some standard definition - Part 2

k) “Duplicate bill” means a bill that is exactly the same as a bill that has been previously submitted with no new services added, except that the duplicate bill may have a different “billing date.”


(l) "Electronic Standard Formats" means the ASC X12N standard formats developed by the Accredited Standards Committee X12N Insurance Subcommittee of the American National Standards Institute and the retail pharmacy specifications developed by the National Council for Prescription Drug Programs (“NCPDP”) identified in Section Two - Transmission Standards, which have been and adopted by the Secretary of Health and Human Services under HIPAA.. See the Companion Guide for specific format information.


(m) “Explanation of Review” (EOR) means the explanation of payment or the denial of the payment using the standard code set found in Appendix B – 1.0. EORs use the following standard codes:

(1) DWC Bill Adjustment Reason Codes provide California specific workers? compensation explanations of a payment, reduction or denial for paper bills. They are found in Appendix B – 1.0 DWC Bill Adjustment Reason Code / CARC / RARC Matrix Crosswalk.

(2) Claims Adjustment Group Codes represent the general category of payment, reduction, or denial for electronic bills. The most current, valid codes should be used as appropriate for workers? compensation. These codes are obtained from the Washington Publishing Company http://www.wpc-edi.com.

(3) Claims Adjustment Reason Codes (CARC) represent the national standard explanation of payment, reduction or denial information. These codes are obtained from the Washington Publishing Company http://www.wpc-edi.com. A subset of the CARCs is adopted for use in responding to electronic bills in workers? compensation in Appendix B – 1.0 DWC Bill Adjustment Reason Code / CARC / RARC Matrix Crosswalk.

(4) Remittance Advice Remark Codes (RARC) represent supplemental explanation for a payment, reduction or denial. These are always used in conjunction with a Claims Adjustment Reason Code. These codes are obtained from the Washington Publishing Company http://www.wpc-edi.com. A subset of the RARCs is adopted for use in responding to electronic bills in workers? compensation in Appendix B – 1.0 DWC Bill Adjustment Reason Code / CARC / RARC Matrix Crosswalk.



(n) "Health Care Provider" means a provider of medical treatment, goods and services, including but not limited to a physician, a non-physician or any other person or entity who furnishes medical treatment, goods or services in the normal course of business.


(o) “Health Care Facility” means any facility as defined in Section 1250 of the Health and Safety Code, any surgical facility which is licensed under subdivision (b) of Section 1204 of the Health and Safety Code, any outpatient setting as defined in Section 1248 of the Health and Safety Code, any surgical facility accredited by an accrediting agency approved by the Licensing Division of the Medical Board of California pursuant to Health and Safety Code Sections 1248.15 and 1248.4, or any ambulatory surgical center or hospital outpatient department that is certified to participate in the Medicare program under Title XVIII (42 U.S.C. Sec. 1395 et seq.) of the federal Social Security Act.


(p) “Itemization” means the list of medical treatment, goods or services provided using the codes required by Section One – 3.0 to be included on the uniform billing form.


(q) “Medical Treatment” means the treatment, goods and services as defined by Labor Code Section 4600.


(r) “National Provider Identification Number” or “NPI” means the unique identifier assigned to a health care provider or health care facility by the Secretary of the United States Department of Health and Human Services.

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