Worker compensation - Some terms and definition - Part 1


1.0 Standardized Billing / Electronic Billing Definitions;

(a) “Assignee” means a person or entity that has purchased the right to payments for medical goods or services from the health care provider or health care facility and is authorized by law to collect payment from the responsible payer.


(b) “Authorized medical treatment” means medical treatment in accordance with Labor Code section 4600 that was authorized pursuant to Labor Code section 4610 and which has been provided or authorized by the treating physician.


(c) “Balance forward bill” is a bill that includes a balance carried over from a previous bill along with additional services or a summary of accumulated unpaid balances.


(d) “Bill” means:

(1) the uniform billing form found in Appendix A setting forth the itemization of services provided along with the required reports and/or supporting documentation as described in Section One – 3.0 Complete Bills; or

(2) the electronic billing transmission utilizing the standard formats found in Section Two – Transmission Standards 2.0 Electronic Standard Formats, 2.1 Billing, along with the required reports and/or supporting documentation as described in Section One – 3.0 Complete Bills.


(e) “Billing Agent” means a person or entity that has contracted with a health care provider or health care facility to process bills for services provided by the health care provider or health care facility.


(f) “California Electronic Medical Billing and Payment Companion Guide” is a separate document which gives detailed information for electronic billing and payment. The guide outlines the workers? compensation industry national standards and California jurisdictional procedures necessary for engaging in Electronic Data Interchange (EDI) and specifies clarifications where applicable. It will be referred to throughout this document as the “Companion Guide”.


(g) "Claims Administrator" means a self-administered insurer providing security for the payment of compensation required by Divisions 4 and 4.5 of the Labor Code, a self-administered self-insured employer, or a third-party administrator for a self-insured employer, insurer, legally uninsured employer, or joint powers authority.


(h) “Clearinghouse” means a public or private entity, including a billing service, repricing company, community health management information system or community health information system, and "value-added" networks and switches that provides either of the following functions:


(1) Processes or facilitates the processing of health information received from another entity in a nonstandard format or containing nonstandard data content into standard data elements or a standard transaction.



(2) Receives a standard transaction from another entity and processes or facilitates the processing of health information into nonstandard format or nonstandard data content for the receiving entity.


(i) “Complete Bill” means a bill submitted on the correct uniform billing form/format, with the correct uniform billing code sets, filled out in compliance with the form/format requirements of Appendix A and/or the Companion Guide with the required reports and/or supporting documentation as set forth in Section One – 3 0.


(j) “CMS” means the Centers for Medicare and Medicaid Services of the U.S. Department of Health and Human Services.w

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