Physicians treating Workers’ Compensation injuries often deal with various billing forms. Let’s guide you through the billing forms relevant to both patients and medical professionals.
The standard claim form, CMS-1500, managed by the National Uniform Claim Committee (NUCC), is utilized to bill Medicare carriers and durable medical equipment regional carriers (DMERCs) by non-institutional providers or suppliers. This form is employed to bill patients for medical services not covered by insurance, including Centers for Medicare and Medicaid Services (CMS) and health insurers.
Non-institutional providers and vendors, such as ambulance services, clinical social workers, physicians, nurse practitioners, and psychologists, use the CMS-1500 form to submit medical claims. To streamline administrative processes and enhance provider participation, the Workers’ Compensation Board has replaced several forms with the CMS-1500.
Forms like Doctor’s Initial Report, Continuation to Carrier/Employer Billing Section, Doctor’s Progress Report, Ancillary Medical Report, Doctor’s Narrative Report, and more have been replaced. The physician’s initial narrative report necessitates submission of a CMS-1500, a C4 form, and a medical narrative, facilitated by a clearinghouse with an XML submission partner.
This narrative should encompass details like work status, temporary impairment, causation history, objective findings, diagnosis, and a plan for the first three work statuses. The physician’s opinion on causation and an authorization number should be included at the top of the report, along with the patient’s work status details.
The physician’s narrative report should address whether the patient’s condition caused lost time at work, the dates of resuming full or limited employment, the possibility of resuming regular work activities, and any work-related restrictions with expected lengths. Temporary impairment percentage, ranging from zero to 100%, must be determined by the physician.
A distinction is drawn between a clearinghouse and an XML submission partner, where a clearinghouse becomes an XML submission partner upon approval. Physicians can partner with an approved XML submission partner or ensure their clearinghouse has a data-sharing agreement.
The electronic submission process defines how an approved XML submission partner submits the CMS-1500 form to the Board, allowing providers to electronically submit bills and narratives in the required XML format.
Submitting medical bills within 90 days of the last day of service is crucial. An XML submission partner has seven business days to forward bills and narrative reports to the payer and the Board. Timely correction of rejected bills is necessary, with resending to the payer and the Board.
It’s essential to refer to your state’s Workers’ Compensation Board website or consult a Workers’ Compensation attorney for further details.