What are the forms need to submit with worker compensation claims

3.0 Complete Bills;


(a) To be complete a submission must consist of the following:

(1) The correct uniform billing form/format for the type of health care provider.

(2) The correct uniform billing codes for the applicable portion of the OMFS under which the services are being billed.

(3) The uniform billing form/format must be filled out according to the requirements specified for each format in Appendix A and/or the Companion Guide. Nothing in this paragraph precludes the claims administrator from populating missing information fields if the claims administrator has previously received the missing information.

(4) A complete bill includes required reports and supporting documentation specified in subdivision (b).

(b) All required reports and supporting documentation sufficient to support the level of service or code that has been billed must be submitted as follows:

(1) A Doctor?s First Report of Occupational Injury (DLSR 5021), must be submitted when the bill includes Evaluation and Management services and a Doctor?s First Report of Occupational Injury is required under Title 8, California Code of Regulations § 9785.

(2) A PR-2 report or its narrative equivalent must be submitted when the bill is for Evaluation and Management services and a PR-2 report is required under Title 8, California Code of Regulations § 9785.

(3) A PR-3, PR-4 or their narrative equivalent must be submitted when the bill is for Evaluation and Management services and the injured worker?s condition has been declared permanent and stationary with permanent disability or a need for future medical care. (Use of Modifier – 17.)

(4) A narrative report must be submitted when the bill is for Evaluation and Management services for a consultation.

(5) A report must be submitted when the provider uses the following Modifiers – 22, – 23 and – 25.

(6) A descriptive report of the procedure, drug, DME or other item must be submitted when the provider uses any code that is payable “By Report”.

(7) A descriptive report must be submitted when the Official Medical Fee Schedule indicates that a report is required.

(8) An operative report is required when the bill is for either professional or facility Surgery Services fees.

(9) An invoice or other proof of documented paid costs must be provided when required by the OMFS for reimbursement.

(10) Appropriate additional information reasonably requested by the claims administrator or its agent to support a billed code when the request was made prior to submission of the billing. (This does not prohibit the claims administrator from requesting additional appropriate information during further bill processing.)

(11) For paper bills, any written authorization for services that may have been received by the physician.

(c) For paper bills, if the required reports and supporting documentation are not submitted in the same mailing envelope as the bill, then a header or attachement cover sheet as defined in Section One – 7.3 for electronic attachments must be submitted.

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