Medical Billing and E-Billing Requirements
Labor Code section 4603.4, enacted as part of AB 749 in 2002 and amended in SB 228 in 2003, calls for the administrative director of the DWC to adopt regulations that require:
1) workers’ compensation medical providers to submit medical bills on standardized forms; and
2) claims administrators to accept electronic medical bills from medical providers who choose to submit them electronically.
More than six years ago, the DWC began developing the regulations to establish standards for workers’ compensation medical billings submitted on paper forms and in electronic formats. The proposed regulations are intended to improve provider/payer interactions and streamline billing/review processes. California was the first state to begin developing such standards, just ahead of Texas, which has since adopted many of the standards drafted by California. During this process, regulators from both states worked closely with the International Association of Industrial Accident Boards and Commissions (IAIABC) to develop electronic billing standards for workers’ compensation that can be adopted nationally.
Earlier this month, the DWC announced a 15-day comment period on modifications to its proposed regulations – one of the final steps in the formal regulatory path to adoption. The regulations incorporate the 5010 version of the national electronic billing transaction standards for exchanging medical billing data that will become mandatory next year under federal Health Insurance Portability and Accountability Act (HIPAA) provisions (Note: workers’ compensation is exempt from HIPAA, but LC 4603.4 requires the standards "to the extent feasible" to be "consistent with existing standards under the Health Insurance Portability and Accountability Act of 1996").
CWCI and others have worked closely with the DWC on these regulations, and many of our suggestions have been integrated into the latest version. After gathering and responding to public comments submitted during the current 15-day comment period, the Division expects to finalize and adopt the regulations later this year. California workers’ compensation medical providers will then have 90 days to meet the new medical billing requirements. Payers will have 18 months after the regulations are adopted to ensure they have systems in place to receive and process electronic bills and to pay them within 15 working days in accordance with the standards.
The latest version of the medical billing and e-billing standards, guides, and associated information, are available in the Regulation section of the CWCI website, http://www.cwci.org/regulation.html?id=7. CWCI is compiling member input and will comment on the latest version by the Jan. 28 deadline (this Friday). In the meantime, you may want to review the regulations to see how your current systems align with the proposed standards and to assess the impact on workflow and programming — starting with whether your system can meet the requirements for processing paper and electronic bills, and a timetable for implementation.
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