Section .0100 –Administration

Link to law: http://reports.oah.state.nc.us/ncac/title 04 - commerce/chapter 10 - industrial commission/subchapter f/subchapter f rules.html
Published: 2015

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SUBCHAPTER 10F –ELECTRONIC BILLING RULES

 

SECTION .0100 –ADMINISTRATION

 

04 NCAC 10F .0101           Electronic

Medical Billing and Payment Requirement

Carriers and licensed health care providers shall utilize

electronic billing and payment in workers' compensation claims. Carriers and health

care providers shall develop and implement electronic billing and payment

processes consistent with 45 CFR 162.  Carriers and health care providers shall

comply with this Rule on or before March 1, 2014.  45 CFR 162 is hereby

incorporated by reference and includes subsequent amendments and editions.  A

copy may be obtained at no charge from the National Archives and Records

Administration's website, http://ecfr.gpoaccess.gov/cgi/t/text/text-idx?c=ecfr&tpl=/ecfrbrowse/Title45/45cfr162_main_02.tpl,

or upon request, at the offices of the Commission, located in the Dobbs

Building, 430 North Salisbury Street, Raleigh, North Carolina, between the hours

of 8:00 a.m. and 5:00 p.m.

 

History Note:        Authority G.S. 97-26(g1); 97-80;

Eff. July 1, 2014.

04 NCAC 10F .0102           DEFINITIONS

As used in this Subchapter:

(1)           "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 is an agent of either the

payer or the provider and that may perform the following functions:

(a)           Processes or facilitates the processing of

medical billing information received from a client in a nonstandard format or

containing nonstandard data content into standard data elements or a standard

transaction for further processing of a bill related transaction; or

(b)           Receives a standard transaction from another

entity and processes or facilitates the processing of medical billing

information into nonstandard format or nonstandard data content for a client

entity.

(2)           "Complete electronic bill" submission

means a medical bill that meets all of the criteria enumerated in this

Subchapter.

(3)           "Electronic" refers to a communication

between computerized data exchange systems that complies with the standards

enumerated in this Subchapter.

(3)           "Health Care Provider" is as set forth in

G.S. 97-2(20).

(4)           "Health Care Provider Agent" is a person

or entity that contracts with a health care provider establishing an agency

relationship to process bills for services provided by the health care provider

under the terms and conditions of a contract between the agent and health care

provider. Such contracts may permit the agent to submit bills, request

reconsideration, receive reimbursement, and seek medical dispute resolution for

the health care provider services.

(5)           "Implementation guide" is a published

document for national electronic standard formats as defined in this Subchapter

that specifies data requirements and data transaction sets.

(6)           "National Provider Identification Number"

or "NPI" means the unique identifier assigned to a health care

provider or health care facility by the Secretary of the United States

Department of Health and Human Services.

(7)           "Payer" means the insurance carrier,

third-party administrator, managed care organization, or employer responsible

for paying the workers' compensation medical bills.

(8)           "Payer agent" means any person or entity

that performs medical bill related processes for the payer responsible for the

bill.  These processes include reporting to government agencies, electronic

transmission, forwarding or receipt of documents, review of reports,

adjudication of bill, and final payment.

 

History Note:        Authority G.S. 97-26; 97-26(g1); 97-80;

Eff. January 1, 1996;

Recodified from 04 NCAC 10F .0101 Eff. July 1, 2014;

Amended Eff. July 1, 2014.

 

04 NCAC 10F .0103           Formats for Electronic Medical Bill

Processing

(a)  Beginning March 1, 2014, electronic medical billing

transactions shall be conducted using the electronic formats adopted under the

Code of Federal Regulations, Title 45, part 162, subparts K, N, and P. 

Whenever a standard format is replaced with a newer standard, the most recent

standard shall be used.  The requirement to use a new version shall commence on

the effective date of the new version as published in the Code of Federal

Regulations.

(b)  Nothing in this Subchapter shall prohibit payers and health

care providers from using a direct data entry methodology for complying with

these requirements, provided the methodology complies with the data content

requirements of the adopted formats and these Rules.

 

History Note:        Authority G.S. 97-26; 97-26(g1); 97-80;

Eff. January 1, 1996;

Recodified from 04 NCAC 10F .0102 Eff. July 1, 2014;

Amended Eff. July 1, 2014.

 

04 NCAC 10F .0104           Billing Code Sets

Billing codes and modifier systems identified below are

valid codes for the specified workers' compensation transactions, in addition

to any code sets defined by the standards adopted in 04 NCAC 10F .0103:

(1)           "CDT-4 Codes" that refers to the codes

and nomenclature prescribed by the American Dental Association.

(2)           "CPT-4 Codes" that refers to the procedural

terminology and codes contained in the "Current Procedural Terminology,

Fourth Edition," as published by the American Medical Association.

(3)           "Diagnosis Related Group (DRG)" that

refers to the inpatient classification scheme used by CMS for hospital

inpatient reimbursement.

(4)           "Healthcare Common Procedure Coding System"

(HCPCS) that refers to a coding system which describes products, supplies,

procedures, and health professional services and that includes CPT-4 codes,

alphanumeric codes, and related modifiers.

(5)           "ICD-9-CM Codes" that refers to diagnosis

and procedure codes in the International Classification of Diseases, Ninth

Revision, Clinical Modification published by the United States Department of

Health and Human Services.

(6)           "ICD-10-CM/PCS" that refers to diagnosis

and procedure codes in the International Classification of Diseases, Tenth

Edition, Clinical Modification/Procedure Coding System.

(7)           National Drug Codes (NDC) of the United States Food and Drug Administration.

(8)           "Revenue Codes" that refers to 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)           "National Uniform Billing Committee Codes"

that refers to the code structure and instructions established for use by the

National Uniform Billing Committee (NUBC).

 

History Note:        Authority G.S. 97-26(g1); 97-80;

Eff. July 1, 2014.

 

04 NCAC 10F .0105           Electronic

Medical Billing, Reimbursement, and Documentation

(a)  Payers and payer agents shall:

(1)           accept electronic medical bills submitted

in accordance with the standards adopted in this Subchapter;

(2)           transmit acknowledgments and remittance

advice in compliance with the standards adopted in this Subchapter in response

to electronically submitted medical bills; and

(3)           utilize methods to receive electronic

documentation required for the adjudication of a bill.

(b)  A health care provider shall:

(1)           exchange medical bill data in accordance

with the standards adopted in this Subchapter;

(2)           submit medical bills as defined by this

Rule to any payers who have established connectivity with the health care

provider system or clearinghouse;

(3)           submit required documentation in accordance

with Paragraph (d) of this Rule; and

(4)           receive and act upon any acceptance or

rejection acknowledgment from the payer.

(c)  To be considered a complete electronic medical bill,

the bill or supporting transmissions shall:

(1)           be submitted in the correct billing format,

with the correct billing code sets as presented in this Rule;

(2)           be transmitted in compliance with the

format requirements described in this Rule;

(3)           include in legible text all medical reports

and records, including evaluation reports, narrative reports, assessment

reports, progress reports and notes, clinical notes, hospital records and

diagnostic test results that are necessary for adjudication;

(4)           identify the:

(A)          injured employee;

(B)          employer;

(C)          insurance carrier, third party administrator,

managed care organization or its agent;

(D)          health care provider; and

(E)           medical service or product;

(5)           comply with any other requirements as

presented in a companion guide published by the Commission; and

(6)           use current and valid codes and values as

defined in the applicable formats defined in this Subchapter.

(d)  Electronic Acknowledgment:

(1)           Interchange Acknowledgment (TA1) notifies

the sender of the receipt of, and structural defects associated with, an

incoming transaction.

(2)           As used in this Paragraph, Implementation

Acknowledgment (ASC X12 999) transaction is an electronic notification to the

sender of the file that it has been received and has been:

(A)          accepted as a complete and structurally correct

file; or

(B)          rejected with a valid rejection code.

(3)           As used in this Paragraph, Health Care

Claim Status Response (ASC X12 277) or Acknowledgment transaction (detail

acknowledgment) is an electronic notification to the sender of an electronic

transaction (individual electronic bill) that the transaction has been received

and has been:

(A)          accepted as a complete, correct submission; or

(B)          rejected with a valid rejection code.

(4)           A payer shall acknowledge receipt of an

electronic medical bill by returning an Implementation Acknowledgment (ASC X12

999) within one business day of receipt of the electronic submission.

(5)           Notification of a rejected bill shall be transmitted

when an electronic medical bill does not meet the definition of a complete

electronic medical bill as described in this Rule or does not meet the edits

defined in the applicable implementation guide or guides.

(6)           A health care provider or its agent may not

submit a duplicate electronic medical bill earlier than 60 days from the date

originally submitted if a payer has acknowledged acceptance of the original

complete electronic medical bill.  A health care provider or its agent may

submit a corrected medical bill electronically to the payer after receiving

notification of a rejection.  The corrected medical bill shall be submitted as

a new, original bill.

(7)           A payer shall acknowledge receipt of an

electronic medical bill by returning a Health Care Claim Status Response or

Acknowledgment (ASC X12 277) transaction (detail acknowledgment) within two business

days of receipt of the electronic submission.

(8)           Notification of a rejected bill shall be transmitted

in an ASC X12 277 response or acknowledgment when an electronic medical bill

does not meet the definition of a complete electronic medical bill or does not

meet the edits defined in the applicable implementation guide or guides.

(9)           A health care provider or its agent may not

submit a duplicate electronic medical bill earlier than 60 days from the date

originally submitted if a payer has acknowledged acceptance of the original

complete electronic medical bill.  A health care provider or its agent may

submit a corrected medical bill electronically to the payer after receiving

notification of a rejection. The corrected medical bill shall be submitted as a

new, original bill.

(10)         Acceptance of a complete medical bill is not

an admission of liability by the payer.  A payer may subsequently reject an accepted

electronic medical bill if the employer or other responsible party named on the

medical bill is not legally liable for its payment.

(11)         The subsequent rejection shall occur no

later than seven days from the date of receipt of the complete electronic

medical bill.

(12)         The rejection transaction shall indicate

that the reason for the rejection is due to denial of liability.

(13)         Acceptance of an incomplete medical bill

does not satisfy the written notice of injury requirement from an employee or

payer as required in G.S. 97-22.

(14)         Acceptance of a complete or incomplete

medical bill by a payer does not begin the time period by which a payer shall

accept or deny liability for any alleged claim related to such medical

treatment pursuant to G.S. 97-18 and 04 NCAC 10A .0601.

(15)         Transmission of an Implementation

Acknowledgment under Subparagraph (d)(2)of this Rule and acceptance of a

complete, structurally correct file serves as proof of the received date for an

electronic medical bill in this Rule.

(e)  Electronic Documentation

(1)           Electronic documentation, including medical

reports and records submitted electronically that support an electronic medical

bill, may be required by the payer before payment may be remitted to the health

care provider.  Electronic documentation may be submitted simultaneously with the

electronic medical bill.

(2)           Electronic transmittal by electronic mail

shall contain the following information:

(A)          the name of the injured employee;

(B)          identification of the worker's employer, the

employer's insurance carrier, or the third party administrator or its agent

handling the workers' compensation claim;

(C)          identification of the health care provider billing

for services to the employee, and where applicable, its agent;

(D)          the date(s) of service; and

(E)           the workers' compensation claim number assigned by

the payer, if known.

(f)  Electronic remittance notification

(1)           As used in the Paragraph, an electronic

remittance notification is an explanation of benefits (EOB) or explanation of review

(EOR), submitted electronically regarding payment or denial of a medical bill,

recoupment request, or receipt of a refund.

(2)           A payer shall provide an electronic

remittance notification in accordance with G.S. 97-18.

(3)           The electronic remittance notification

shall contain the appropriate Group Claim Adjustment Reason Codes, Claim

Adjustment Reason Codes (CARC) and associated Remittance Advice Remark Codes

(RARC) or, for pharmacy charges, the National Council for Prescription Drugs

Program (NCPDP) Reject Codes, denoting the reason for payment, adjustment, or

denial.

(4)           The remittance notification shall be sent

within two days of:

(A)          the expected date of receipt by the health care provider

of payment from the payer; or

(B)          the date the bill was rejected by the payer.  If a

recoupment of funds is being requested, the notification shall contain the

proper code described in Subparagraph (e)(3) of this Rule and an explanation

for the amount and basis of the refund.

(g)  A health care provider or its agent may not submit a

duplicate paper medical bill earlier than 30 days from the date originally

submitted unless the payer has returned the medical bill as incomplete in

accordance with this Subchapter. A health care provider or its clearinghouse or

agent may submit a corrected paper medical bill to the payer after receiving

notification of the return of an incomplete medical bill.  The corrected

medical bill shall be submitted as a new, original bill.

(h)  A payer shall establish connectivity with any clearinghouse

that requests the exchange of data in accordance with this Subchapter.  A payer

or its agent may not reject a standard transaction on the basis that it contains

data elements not needed or used by the payer or its agent.

(j)  A health care provider that does not send standard transactions

shall use an internet-based direct data entry system offered by a payer if the payer

does not charge a transaction fee.  A health care provider using an Internet-based

direct data entry system offered by a payer or other entity shall use the appropriate

data content and data condition requirements of the standard transactions.

 

History Note:        Authority G.S. 97-26(g1); 97-80;

Eff. July 1, 2014.

 

04 NCAC 10F .0106           Employer,

Insurance Carrier, Managed Care Organization, or Agents' Receipt of Medical

Bills from Health Care Providers

(a)  Upon receipt of medical bills submitted in accordance

with the rules in this Subchapter, a payer shall evaluate each bill's

conformance with the criteria of a complete medical bill.  A payer shall not

return to the health care provider medical bills that are complete, unless the

bill is a duplicate bill.  Within 21 days of receipt of an incomplete medical

bill, a payer or its agent shall either:

(1)           Complete the bill by adding missing health

care provider identification or demographic information already known to the

payer; or

(2)           Return the bill to the sender, in

accordance with this Paragraph.

(b)  The received date of an electronic medical bill is the

date all of the contents of a complete electronic bill are successfully

received by the claims payer.

(c)  The payer may contact the health care provider to

obtain the information necessary to make the bill complete. Any request by the

payer or its agent for additional documentation to pay a medical bill shall:

(1)           be made by telephone or electronic transmission

unless the information cannot be sent by those media, in which case the sender

shall send the information by mail or personal delivery;

(2)           be specific to the bill or the bill's

related episode of care;

(3)           describe with specificity the clinical and

other information to be included in the response;

(4)           be relevant and necessary for the

resolution of the bill;

(5)           be for information that is contained in or

is in the process of being incorporated into the injured employee's medical or

billing record maintained by the health care provider; and

(6)           indicate the reason for which the insurance

carrier is requesting the information.

If the payer or its agent obtains the missing information

and completes the bill to the point it can be adjudicated for payment, the

payer shall document the name and telephone number of the person who supplied

the information. Health care providers and payers, or their agents, shall

maintain, in a reproducible format, documentation of communications related to

medical bill processing.

(d)  A payer shall not return a medical bill except as

provided in this Rule.  When returning an electronic medical bill, the payer

shall identify the reason(s) for returning the bill by utilizing the

appropriate Reason and Rejection Code identified in the standards identified in

this Subchapter.

(e)  The proper return of an incomplete medical bill in

accordance with this section fulfills the obligation of the payer to provide to

the health care provider or its agent information related to the incompleteness

of the bill.

(f)  Payers shall timely reject bills or request additional

information needed to reasonably determine the amount payable as follows:

(1)           For bills submitted electronically, the

rejection of all or part of the bill shall be sent to the submitter within two

days of receipt.

(2)           If bills are submitted in a batch

transmission, only the specific bills failing edits shall be rejected.

(g)  If a payer has reason to challenge the coverage or

amount of a specific line item on a bill, but has no reasonable basis for

objections to the remainder of the bill, the uncontested portion shall be paid

timely, as required in this Rule.

(i)  Payment of all uncontested portions of a complete

medical bill shall be made within 30 days of receipt of the original bill, or

receipt of additional information requested by the payer allowed under the law. 

After 60 days an amount equal to 10 percent shall be added to an unpaid bill.

(j)  A payer shall not return a medical bill except as

provided in this Rule.  When returning a medical bill, the payer shall also

communicate the reason(s) for returning the bill.

 

History Note:        Authority G.S. 97-18(a); 97-26(g1);

97-80;

Eff. July 1, 2014.

 

04 NCAC 10F .0107           Communication Between Health Care

Providers and Payers

(a)  Any communication between the health care provider and

the payer related to medical bill processing shall be of sufficient detail to

allow the responder to easily identify the information required to resolve the

issue or question related to the medical bill.  Generic statements that simply

state a conclusion such as "payer improperly reduced the bill" or

"health care provider did not document" or other similar phrases with

no further description of the factual basis for the sender's position do not

satisfy the requirements of this Rule.

(b)  When communicating with the health care provider,

agent, or assignee, the payer may utilize the ASC X12 Reason Codes, or the

NCPDP Reject Codes, to communicate with the health care provider, agent, or

assignee.

(c)  Communication between the health care provider and

payer related to medical bill processing shall be made by telephone or

electronic transmission unless the information cannot be sent by those media,

in which case the sender shall send the information by mail or personal

delivery.

 

History Note:        Authority G.S. 97-26(g1); 97-80(a);

Eff. July 1, 2014.

 

04 NCAC 10F .0108           Effective Date

This Chapter applies to all medical services and products

provided on or after March 1, 2014.  For medical services and products provided

prior to March 1, 2014, medical billing and processing shall be in accordance

with the rules in effect at the time the health care was provided.

 

History Note:        Authority G.S. 97-26(g1); 97-80;

Eff. July 1, 2014.