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.