N.D. Admin. Code 92-01-02-45.1

Current through Supplement No. 394, October, 2024

Section 92-01-02-45.1 - Medical service provider responsibilities and billings

1. A medical service provider shall comp lete the registration process and corresponding forms identified by the organization to receive payments for services.

2. A medical service provider may not submit a charge for a service which exceeds the amount the medical service provider charges for the same service in cases unrelated to workers' compensation injuries.

3. All bills must be fully itemized, including ICD codes, and services must be identified by code numbers found in the fee schedules or as provided in these rules. The definitions of commonality in the guidelines found in the current procedural terminology must be used as guides governing the descriptions of services, except as provided in the fee schedules or in these rules. All bills must be submitted to the organization within one year of the date of service or within one year of the date the organization accepts liability for the work injury or condition.

4. All medical service providers shall submit charges for medical services on the most current version of the UB 04, CMS 1500, or ADA form, or the corresponding electronic versions of each. All pharmacy charges must be submitted electronically to the organization's pharmacy managed care vendor using the current pharmacy transaction standard. Accepted electronic medical billing formats are outlined in section 92-01-02-45.2. Medical service bills may not include charges for more than one workers' compensation claim, and must include the following:

a. The injured employee's full name and address;

b. The injured employee's claim number and social security number;

c. Date and nature of injury;

d. The area of the body treated, with the appropriate ICD-10-CM code, including identification of right or left, as appropriate;

e. Date of service;

f. Facility's name and address and telephone number where the service was rendered;

g. Name of allied health care professional providing the service along with the rendering allied health care professional's national provider identifier (NPI);

h. Billing facility's name, address, zip code, telephone number; medical service provider's NPI and tax identification number; along with the billing facility's NPI;

i. Referring or ordering health care provider's NPI;

j. Place of service;

k. Appropriate procedure code or hospital revenue code;

l. Charge for each service;

m. Units of service;

n. If dental, tooth numbers;

o. Total bill charge.

5. All records submitted by medical service providers, including notes, except those provided by an emergency room health care provider and those on forms provided by the organization, must be typed to ensure that they are legible and reproducible. Copies of office or progress notes are required for all followup visits. Documentation must be authentic to the visit and may not include cloned, copied, or irrelevant documentation for purposes of up-coding a service. Office notes are not acceptable in lieu of requested narrative reports. Communications may not refer to more than one claim. Addendums and late entries to notes or reports must be signed and must include the date they were created. Addendums or late entries to notes or reports created more than sixty calendar days after the date of service may be accepted at the organization's sole discretion.

6. Medical service providers shall submit with each bill a copy of medical records or reports which support the necessity of a service being billed and its relationship to the work injury, including the level, type, and extent of the service provided to injured employees. Documentation required includes:

a. Laboratory and pathology reports;

b. X-ray findings;

c. Operative reports;

d. Office notes, physical therapy, and occupational therapy progress notes;

e. Consultation reports;

f. History, physical examination, and discharge summaries;

g. Special diagnostic study reports; and

h. Special or other requested narrative reports.

7. If the medical service provider does not submit records with a bill, and still does not provide those records upon request of the organization, the charges for which records were not supplied may not be paid by the organization, unless the medical service provider submits the records before the decision denying payment of those charges becomes final. The medical service provider may also be liable for the penalty provided in subsection 6 of North Dakota Century Code section 65-05-07.

8. Disputes arising out of reduced or denied reimbursement are handled in accordance with section 92-01-02-46. In all cases of accepted compensable injury or illness under the jurisdiction of the workers' compensation law, a medical service provider may not pursue payment from an injured employee for treatment, equipment, or products unless an injured employee desires to receive them and has accepted responsibility for payment, or unless the payment for the treatment was denied because:

a. The injured employee sought treatment from that medical service provider for conditions not related to the compensable injury or illness.

b. The injured employee sought treatment from that medical service provider which was not prescribed by the injured employee's primary health care provider. This includes ongoing treatment by the allied health care professional.

c. The injured employee sought treatment from that allied health care professional after being notified that the treatment sought from that allied health care professional has been determined to be unscientific, unproven, outmoded, investigative, or experimental.

d. The injured employee did not follow the requirements of subsection 1 of North Dakota Century Code section 65-05-28 regarding change of health care providers before seeking treatment of the work injury.

e. The injured employee is subject to North Dakota Century Code section 65-05-28.2, and the health care provider requesting payment is not a preferred provider and has not been approved as an alternative health care provider under subsection 2, 3, or 4 of North Dakota Century Code section 65-05-28.2.

9. A medical service provider may not bill for services not provided to an injured employee and may not bill multiple charges for the same service. Rebilling must indicate that the charges have been previously billed.

10. Pursuant to North Dakota Century Code section 65-05-33, a medical service provider may not submit false or fraudulent billings.

11. Only one office visit designation may be used at a time except for those code numbers relating specifically to additional time.

12. When an injured employee is seen initially in an emergency department and is admitted subsequently to the hospital for inpatient treatment, the services provided immediately prior to the admission are part of the inpatient treatment.

13. When an allied health care professional is asked to review records or reports prepared by another allied health care professional, the allied health care professional shall bill review of the records using CPT code 99080 with a descriptor of "record review". The billing must include the actual time spent reviewing the records or reports and must list the allied health care professional's normal hourly rate for the review.

14. When there is a dispute over the amount of a bill or the necessity of services rendered, the organization shall pay the undisputed portion of the bill and provide specific reasons for nonpayment or reduction of each medical service code.

15. If medical documentation outlines that a non-work-related condition is being treated concurrently with the compensable injury and that condition has no effect on the compensable injury, the organization may reduce the charges submitted for treatment. In addition, the allied health care professional must notify the organization immediately and submit:

a. A description or diagnosis of the non-work-related condition.

b. A description of the treatment being rendered.

c. The effect, if any, of the non-work-related condition on the compensable injury. The allied health care professional shall include a thorough explanation of how the non-work-related condition affects the compensable injury when the allied health care professional requests authorization to treat the non-work-related condition. Temporary treatment of a non-work-related condition may be allowed, upon prior approval by the organization, provided the condition directly delays recovery of the compensable injury. The organization may not approve or pay for treatment for a known pre-existing non-work-related condition for which the injured employee was receiving treatment prior to the occurrence of the compensable injury, which is not delaying recovery of the compensable injury. The organization may not pay for treatment of a non-work-related condition when it no longer exerts any influence upon the compensable injury. When treatment of a non-work-related condition is being rendered, the allied health care professional shall submit reports monthly outlining the effect of treatment on both the non-work-related condition and the compensable injury.

16. In cases of questionable liability when the organization has not rendered a decision on compensability, the medical service provider has billed the injured employee or other insurance, and the claim is subsequently allowed, the medical service provider shall refund the injured employee or other insurer in full and bill the organization for services rendered.

17. The organization may not pay for the cost of duplicating records when covering the treatment received by the injured employee. If the organization requests records in addition to those listed in subsection 5 or records prior to the date of injury, the organization shall pay a charge of no more than twenty dollars for the first twenty-five pages and seventy-five cents per page after twenty-five pages. In an electronic, digital, or other computerized format, the organization shall pay a charge of thirty dollars for the first twenty-five pages and twenty-five cents per page after twenty-five pages. This charge includes any administration fee, retrieval fee, and postage expense.

18. The medical service provider shall assign the correct approved billing code for the service rendered using the appropriate provider group designation. Bills received without codes will be returned to the medical service provider.

19. Billing codes must be found in the most recent edition of the physician's current procedural terminology; health care financing administration common procedure coding system; code on dental procedures and nomenclature maintained by the American dental association; or any other code listed in the fee schedules.

20. A medical service provider shall comply within thirty calendar days with the organization's request for copies of existing medical data concerning the services provided, the patient's condition, the plan of treatment, and other issues pertaining to the organization's determination of compensability, medical necessity, or excessiveness or the organization may refuse payment for services provided by that medical service provider.

21. A medical service provider may not bill an injured employee a fee for the difference between the maximum allowable fee set forth in the organization's fee schedule and usual and customary charges, or bill the claimant any other fee in addition to the fee paid, or to be paid, by the organization for individual treatments, equipment, and products.

N.D. Admin Code 92-01-02-45.1

Amended by Administrative Rules Supplement 2014-352, April 2014, effective April 1, 2014. .

Amended by Administrative Rules Supplement 2016-360, April 2016, effective 4/1/2016.

Amended by Administrative Rules Supplement 2017-365, July 2017, effective 7/1/2017.

Amended byAdministrative Rules Supplement 376, April 2020, effective 4/1/2020.

Amended by Administrative Rules Supplement 2021-383, January 2022, effective 1/1/2022.

General Authority: NDCC 65-02-08, 65-02-20, 65-05-07

Law Implemented: NDCC 65-02-20, 65-05-07, 65-05-28.2