Worker compensation claim - standard terms - Part 3

(s) “NCPDP” means the National Council for Prescription Drug Programs.


(t) Official Medical Fee Schedule (OMFS) means all of the fee schedules found in Article 5.3 of Subchapter 1 of Chapter 4.5 of Title 8, California Code of Regulations (Sections 9789.10 - 9789.111), adopted pursuant to Section 5307.1 of the Labor Code for all medical services, goods, and treatment provided pursuant to Labor Code Section 4600. These include the following schedules: Physician?s services; Inpatient Facility; Outpatient Facility; Clinical Laboratory; Durable Medical Equipment, Prosthetics, Orthotics and Supplies (DMEPOS); Ambulance; and Pharmaceutical.


(u) “Physician” has the same meaning specified in Labor Code Section 3209.3: physicians and surgeons holding an M.D. or D.O. degree, psychologists, acupuncturists, optometrists, dentists, podiatrists, and chiropractic practitioners licensed by California state law and within the scope of their practice as defined by California state law.

(1) "Psychologist" means a licensed psychologist with a doctoral degree in psychology, or a doctoral degree deemed equivalent for licensure by the Board of Psychology pursuant to Section 2914 of the Business and Professions Code, and who either has at least two years of clinical experience in a recognized health setting or has met the standards of the National Register of the Health Service Providers in Psychology.

(2) "Acupuncturist" means a person who holds an acupuncturist's certificate issued pursuant to Chapter 12 (commencing with Section 4925) of Division 2 of the Business and Professions Code.


(v) "Required report" means a report which must be submitted pursuant to title 8, California Code of Regulations sections 9785 – 9785.4 or pursuant to the OMFS. These reports include the Doctor?s First Report of Injury, PR-2, PR-3, PR-4 and their narrative equivalents, as well as any report accompanying a “By Report” code billing.


(w) “Supporting Documentation” means those
documents, other than a required report, necessary to support a bill. These include, but are not limited to an invoice required for payment of the DME item being billed. For paper bills, supporting documentation includes any written authorization for services that may have been received by the physician.


(x) “Treating Physician” means the primary treating physician or secondary physician as defined by section 9785(a)(1), (2).


(y) “Uniform Billing Forms” are the CMS 1500, UB-04, NCPDP Universal Claim Form and the ADA 2006 set forth in Appendix A.


(z) “Uniform Billing Codes” are defined as:

(1) “California Codes” means those codes adopted by the Administrative Director for use in the Physician?s Services section of the Official Medical Fee Schedule (Title 8, California Code of Regulations §§ 9789.10-11).

(2) "CDT-4 Codes" means the current dental codes, nomenclature, and descriptors prescribed by the American Dental Association in “Current Dental Terminology, Fourth Edition.”

(3) "CPT-4 Codes" means the procedural terminology and codes contained in the “Current Procedural Terminology, Fourth Edition,” as published by the American Medical Association and as adopted in the appropriate fee schedule contained in sections 9789.10-9789.100.

(4) “Diagnosis Related Group (DRG)” or “Medicare Severity-Diagnosis Related Codes” (MS-DRG) means the inpatient classification schemes used by CMS for hospital inpatient reimbursement. The DRG/MS-DRG systems classify patients based on principal diagnosis, surgical procedure, age, presence of co-morbidities and complications and other pertinent data.

(5) "HCPCS" means CMS? Healthcare Common Procedure Coding System, a coding system which describes products, supplies, procedures and health professional services and includes, the American Medical Association?s (AMA's) Physician “Current Procedural Terminology, Fourth Edition,” (CPT-4) codes, alphanumeric codes, and related modifiers.

(6) "ICD-9-CM Codes" means the diagnosis and procedure codes in the International Classification of Diseases, Ninth Revision, Clinical Modification published by the U.S. Department of Health and Human Services.

(7) "NDC" means the National Drug Codes of the Food and Drug Administration.

(8) “Revenue Codes” means the 4-digit coding system developed and maintained by the National Uniform Billing Committee for billing inpatient and outpatient hospital services, home health services and hospice services.

(9) "UB-04 Codes" means the code structure and instructions established for use by the National Uniform Billing Committee (NUBC).

(aa) “Working days” means Mondays through Fridays but shall not include Saturdays, Sundays or the following State Holidays. (1) January 1st (“New Year?s Day”.)
(2) The third Monday in January ("Dr. Martin Luther King, Jr. Day.")
(3) The third Monday in February (“Washington Day” or “President?s Day.”)
(4) March 31st ("Cesar Chavez Day.")
(5) The last Monday in May (“Memorial Day.”)
(6) July 4th (“Independence Day.”)
(7) The first Monday in September (“Labor Day.”)
(8) November 11th ("Veterans Day.")
(9) The third Thursday in November (“Thanksgiving Day.”)
(10) The Friday After Thanksgiving Day
(11) December 25th (“Christmas Day.”)
(12) If January 1st, March 31st, July 4th, November 11th, or December 25th falls upon a Sunday, the Monday following is a holiday. If November 11th falls upon a Saturday, the preceding Friday is a holiday.

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