Electronic Bill Attachments
(a) Required reports and/or supporting documentation to support a bill as defined in Complete Bill Section 3.0 shall be submitted in accordance with this section. Unless otherwise agreed by the parties, all attachments to support an electronically submitted bill must either have a header or attached cover sheet that provides the following information:
(1) Claims Administrator – the name shall be the same as populated in the 005010X222, 005010X223, or 005010X224. Loop 2010BB, NM103.
(2) Employer – the name shall be the same as populated in the 005010X222, 005010X223, or 005010X224, Loop 2010BA, NM103.
(3) Unique Attachment Indicator Number – the Unique Attachment Indicator Number shall be the same as populated in the 005010X222, 005010X223, or 005010X224, Loop 2300, PWK Segment: Report Type Code, the Report Transmission Code, Attachment Control Qualifier (AC) and the unique Attachment Control Number. It is the combination of these data elements that will allow a claims administrator to appropriately match the incoming attachment to the electronic medical bill. Refer to the Companion Guide Chapter 2 for information regarding the Unique Attachment Indicator Number Code Sets.
(4) Billing Provider NPI Number – the number must be the same as populated in Loop 2010AA, NM109. If the provider is ineligible for an NPI, then this number is the provider?s atypical billing provider ID. This number must be the same as populated in Loop 2010AA, REF02.
(5) Billing Provider Name.
(6) Bill Transaction Identification Number – This shall be the same number as populated in the ASC 005010X222, 005010X223, or 005010X224 transactions, Loop 2300 Claim Information, CLM01.
(7) Document type – use Report Type codes as set forth in Appendix C of the Companion Guides.
(8) Page Number/Number of Pages the page numbers reported should include the cover sheet.
(9) Contact Name/Phone Number including area code.
(b) All attachments to support an electronically submitted bill shall contain the following information in the body of the attachment or on an attached cover sheet:
(1) Patient?s name
(2) Claims Administrator?s name
(3) Date of Service
(4) Date of Injury
(5) Social Security number (if available)
(6) Claim number (if available)
(7) Unique Attachment Indicator Number
(c) All attachment submissions shall comply with the rules set forth in Section One – 3.0 Complete Bills and Section Three – Security Rules. They shall be submitted according to the protocols specified in the Companion Guide Chapter 8 or other mutually agreed upon methods.
(d) Attachment submission methods:
(1) FAX
(2) Electronic submission – if submitting electronically, the Division strongly recommends using the ASC X12N/005010X210 Additional Information to Support a Health Care Claim or Encounter (275) transaction set. Specifications for this transaction set are found in the Companion Guide Chapter 8. The Division is not mandating the use of this transaction set. Other methods of transmission may be mutually agreed upon by the parties.
(3) E-mail – must be encrypted
(e) Attachment types
(1) Reports
(2) Supporting Documentation
(3) Written Authorization
(4) Misc. (other type of attachment)
How to Submit worker compensation claim
Electronic Bill Attachments
(a) Required reports and/or supporting documentation to bolster a bill as characterized in Complete Bill Section 3.0 should be submitted as per this segment. Unless generally concurred by the gatherings, all connections to bolster an electronically submitted bill should either have a header or joined spread sheet that gives the accompanying data:
(1) Claims Administrator – the name might be the same as populated in the 005010X222, 005010X223, or 005010X224. Circle 2010BB, NM103.
(2) Employer – the name might be the same as populated in the 005010X222, 005010X223, or 005010X224, Loop 2010BA, NM103.
(3) Unique Attachment Indicator Number – the Unique Attachment Indicator Number should be the same as populated in the 005010X222, 005010X223, or 005010X224, Loop 2300, PWK Segment: Report Type Code, the Report Transmission Code, Attachment Control Qualifier (AC) and the one of a kind Attachment Control Number. It is the mix of these information components that will permit a cases manager to suitably coordinate the approaching connection to the electronic doctor’s visit expense. Allude to the Companion Guide Chapter 2 for data with respect to the Unique Attachment Indicator Number Code Sets.
(4) Billing Provider NPI Number – the number must be the same as populated in Loop 2010AA, NM109. In the event that the supplier is ineligible for a NPI, then this number is the provider?s atypical charging supplier ID. This number must be the same as populated in Loop 2010AA, REF02.
(5) Billing Provider Name.
(6) Bill Transaction Identification Number – This might be the same number as populated in the ASC 005010X222, 005010X223, or 005010X224 exchanges, Loop 2300 Claim Information, CLM01.
(7) Document sort – use Report Type codes as put forward in Appendix C of the Companion Guides.
(8) Page Number/Number of Pages the page numbers reported ought to incorporate the spread sheet.
(9) Contact Name/Phone Number including zone code.
(b) All connections to bolster an electronically submitted bill should contain the accompanying data in the body of the connection or on a joined spread sheet:
(1) Patient?s name
(2) Claims Administrator?s name
(3) Date of Service
(4) Date of Injury
(5) Social Security number (if accessible)
(6) Claim number (if accessible)
(7) Unique Attachment Indicator Number
(c) All connection entries might conform to the tenets put forward in Section One – 3.0 Complete Bills and Section Three – Security Rules. They should be submitted by conventions determined in the Companion Guide Chapter 8 or other commonly settled upon strategies.
(d) Attachment accommodation techniques:
(1) FAX
(2) Electronic accommodation – if submitting electronically, the Division emphatically prescribes utilizing the ASC X12N/005010X210 Additional Information to Support a Health Care Claim or Encounter (275) exchange set. Determinations for this exchange set are found in the Companion Guide Chapter 8. The Division is not commanding the utilization of this exchange set. Different strategies for transmission might be commonly settled upon by the gatherings.
(3) E-mail – must be encoded
(e) Attachment sorts
(1) Reports
(2) Supporting Documentation
(3) Written Authorization
(4) Misc. (other kind of connection)
What are the forms need to submit with worker compensation claims
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.
