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10:08:55 PM CDT
Thursday, April 17, 2014

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Billings, Medical Payments, and Fee Schedules

Topics Provider Remittance Advice Forms & Publications E/M Documentation Guidelines
Billing and Medical Payments Reconsideration of Billed Charges Explanation of Benefits (EOB) Codes  
Bill Review Department Billing Options Provider Request for Adjustment (M6)  
Payment Delays Fee Schedule Information Fee Schedules  
Advanced Beneficiary Notice of Non-Payment (ABN)   Advanced Beneficiary Notice (ABN)  

Billing and Medical Payments
Bills must be submitted to WSI within one year of the date of service or within one year of the date WSI accepted liability for the work injury or condition.

To assist with timely payment, please follow these guidelines:

  • Bill with the appropriate bill format (CMS 1500 or UB 04)
  • Bill with valid CPT & HCPC codes
  • Follow AMA guidelines for appropriate billing of modifiers
  • Submit supporting documentation for all dates of service being billed
  • Bill each date of service separately
  • Include the injured worker’s name and claim number
  • If billing unlisted codes, provide a description of the service provided
  • If billing anesthesia the number of minutes should be billed as the units
  • List the ICD-9 code for the service being provided
  • Provide the tax identification number of the facility
  • Provide contact information
  • Provide the treating practitioner’s name and NPI number

Bill Review Department
The WSI bill review department employees Certified Professional Coders and follows AMA guidelines for coding. Medical bills are down-coded or denied if appropriate documentation is not submitted supporting the level of code billed. North Dakota Administrative rule requires submission of medical documentation along with the billed charge. Bills are reviewed for:

  • Proper billing of services
  • Medical relatedness and necessity to the accepted injury
  • Associated medical records
  • Actual delivery of billed services
  • Accuracy of charges and codes

Payment Delays
One of the unique qualifiers with workers’ compensation is the compensability of the injury. Factors which may cause a delay in reimbursement are compensability decisions on the claim. Any time a decision of acceptance or denial of a claim has been made the injured worker is notified. The primary physician will also be notified of the decision. WSI accepts a work related injury for a specific ICD-9 diagnosis. If treatment is for other diagnosis there is a potential for the charges to be denied.

WSI relies on documentation to support the billed charges. When supporting documentation is not received, or documentation does not clearly outline the treatment provided, reimbursement will be denied. To ensure correct documentation, providers should always submit the documentation to support the billed charge. Providers should include the following:

  • Area of treatment (lumbar spine)
  • Type of treatment
  • If billing time based codes, include the length of time for the treatment

Provider Remittance Advice
Remittances are sent weekly with the reimbursement check. The remittance advice includes:

  • Patient's name, date of service, procedure billed, submitted amount, and paid amount
  • Reason codes or Explanation of Benefits (EOB) codes, explain reductions in payment of a service or denial of payment.
    • Some EOB codes allow the patient to be billed for the denied charges, or for the balance of reduced charges. These instances are identified by the statement "CONTACT CLAIMANT FOR PAYMENT". When these EOB codes occur, WSI also sends a "NOTICE OF NON-PAYMENT" EOB to the patient regarding the reduced or denied charges, to inform the patient of their responsibility for the charges.
  • If an EOB code does not state the patient may be contacted for payment, any reduction or denial of services is not billable to the patient, the employer, or another insurer.

To access the complete descriptions of the Explanation of Benefits (EOB) Codes.

Reconsideration of Billed Charges
To request reconsideration of medical bills, a Provider Request for Adjustment (M6) form must be completed. This form can be faxed or mailed to WSI, along with any supporting documentation. This form must be completed to request reconsideration for incorrectly processed charges (overpayment or denied charges).

Billing Options
WSI has partnered with Noridian to allow electronic data interchange (EDI) of medical bills. Any provider currently submitting medical bills to BCBSND electronically may utilize their same processor to submit bills electronically to WSI. For questions on how to get started using EDI, can contact Marsha Buchwitz at 1-800-440-3796 ext. 5973 or 1-701-328-5973 or by email at mbuchwitz@nd.gov.

Fee Schedules
North Dakota Century Code authorizes Workforce Safety & Insurance (WSI) to establish medical and hospital fee schedules. The fee schedule is a list that establishes the recommended maximum level of reimbursement for medical services. A fee schedule usually has two components: a relative value scale and a monetary conversion factor. The fee schedule also establishes guidelines for payment of services. These guidelines may include limitations on the number of allowed treatment, restrictions on frequency of service, or requirements for treatment plans. WSI currently has the following fee schedules:

  • Ambulance
  • Ambulatory Surgical Center (ASC)
  • Anesthesia
  • Dental
  • Durable Medical
  • Evaluation & Management
  • Home Health Equipment (DME)
  • Hospital (Inpatient)
  • Hospital (Outpatient)
  • Medicine (includes Chiropractic)
  • Pathology & Lab
  • Radiology
  • Physical & Occupational Therapy
  • Surgery

WSI does utilize the American Medical Association’s (AMA) Physicians Current Procedural Terminology (CPT®) in the reimbursement for medical services. All level I and level II HCPC’s codes are updated annually in accordance to the publication of new or deleted codes by the AMA. WSI does incorporate different reimbursement methodologies for different types of services being performed.

WSI does strive to have a reimbursement system that equitably pays for the services provided to injured workers. To review the full scope of the Fee Schedules, you are required to accept the disclaimer language, as outlined by the AMA.

WSI pays in full any charges submitted that are less than or equal to the maximum allowable fee as designated by the appropriate fee schedule.

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