La. Admin. Code tit. 40 § I-5111

Current through Register Vol. 50, No. 9, September 20, 2024

Section I-5111 - Billing Instructions

A. The HCFA 1500 Form is to be used by health care providers except dentist, pharmacy, hospital (unless otherwise stated), and for home and vehicle modifications for billing services provided to workers' compensation claimant. Do not use any other form. A sample HCFA 1500 Claim Form and detailed instruction for proper completion of the form follows.

B. Bills for services rendered should be sent directly to the party responsible for reimbursement. Please do not send your bills directly to the Office of Workers' Compensation as this will delay your payments.

C. Instructions for use of HCFA 1500 Form:

1. provide the claimant's full name and address;

2. indicate the Social Security number; this cuts down on errors and helps correlate the billing to the appropriate file;

3. identify correct date of injury, if possible;

4. complete name and address of the employer, not just an individual's name;

5. name of the insurance carrier;

6. the attending physician should indicate the date the claimant's disability should begin;

7. the attending physician should list all diagnoses and claimant's complaints;

8. the date of the visit, the service(s) or procedure(s) performed and charges;

9. provider's complete name and address;

10. provider's identification number, i.e., tax identification number (TIN) or Social Security number.

La. Admin. Code tit. 40, § I-5111

Promulgated by the Department of Labor, Office of Workers' Compensation, LR 19:54 (January 1993), repromulgated LR 19:212 (February 1993), amended LR 20:1299 (November 1994).

AUTHORITY NOTE: Promulgated in accordance with R.S. 23:1034.2.