How can providers find correct insurance carrier information for mailing billing claims forms?
Carrier contact information can be found through the South Carolina Workers' Compensation Commission's website at the following link: Verify Coverage Online. The Commission does not accept and will not forward claim forms to employers/insurance carriers.
Verifying authorization to treat between provider and payers.
Medical providers must receive authorization from the employer or insurance carrier prior to providing treatment, except for emergency care when the carrier cannot be reached. An employer who authorizes treatment, whether verbally or in writing, enters into a contract with the provider and is responsible for paying for that service, even if it is determined later than the injury was not work related. When getting authorization, every effort should be made to verify as specifically as possible what services the provider is proposing. Whenever possible, approve services by CPT® codes(s). If possible obtain written authorization for all treatment.
When is payment to a medical provider due?
By South Carolina Law, payment to a medical provider must be made within 30 days of the tender of the payment request to the employer's representative. The only exception to the 30-day requirement may occur in rare cases when the Commission has accepted a properly filed request from the payer or provider to resolve a billing dispute (SC Code of Law 42-9-360; SC Code of Regulations 67-1305).
Which Forms Should I Use To File A Request For Payment?
For Inpatient Facility Charges, Outpatient Facility Charges, and Ambulatory Surgery Center Facility Charges, A “UB04” Form Should Be Used To Request Payment. For Physician Charges And Clinic Office-Based Charges, A “HCFA 1500” Form Should Be Used To Request Payment.
What is the reimbursement for medical testimony by deposition or testimony by appearance for physicians?
Effective April 1, 2021: Deposition testimony is Code SC004 ($400.00) for initial hour and Code SC005 ($100.00) to report each additional quarter hour. Time is measured based on the actual time spent in deposition. Appearance Testimony is Code SC001 ($600) for initial hour and code SC002 ($150) to report each additional quarter hour. Payment is based on the time spent "in court" only.
When should providers submit claims for payment?
Claims should be completed and filed with the appropriate payer as soon as possible after the initial visit or treatment and at reasonable and regular intervals throughout the course of treatment.
What is the Maximum Allowable Payment (MAP) for an independent medical evaluation (IME)?
IMEs conducted on or after December 15, 2009 will not be subject to a maximum allowable payment. However, IME costs will continue to be reviewed in each case and listed on the Form 61 for approval by the Commission.
How should services not listed in the fee schedule be billed?
These services are based on the usual and customary charges, and the reimbursement should be negotiated with the insurance company/third party administrator.
What are the charges for copies of reports and records?
Effective April 1, 2021: Providers are required to include supporting documentation when submitting claims, or when required by an insurance carrier, self-insured employer, or the Commission to submit substantiating documentation, and may not charge for these required reports (see Regulation 67-1302 B(2). However, when the records or reports are not for the purposes listed above, providers may charge for copying costs. Copying charges for electronic format are $0.65 per page for the first 30 pages in an electronic format, and $0.50 per page thereafter provided in an electronic format, which may not exceed $150.00 per request, inclusive of a clerical and handling fee of $25 plus tax and actual postage costs. Copying charges for printed format are $0.65 per page for the first 30 printed pages, and $0.50 per printed page thereafter, which may not exceed $200.00 per request, inclusive of a clerical and handling fee of $25 plus tax and actual postage costs. Providers must respond to a request for copies within fourteen days of receipt or face a penalty of up to $200 (SC Code of Law 42-15-95.)
What is the payment and purpose for the Physician’s Statement (Form 14-B)?
Payment is $70.00 for completing the Commission’s Form 14B. Prepayment for form or report completion is prohibited. The purpose of WCC Form 14B Physician’s Statement is to consolidate medical information, already existing in the patient’s medical file, onto a single, easily referenced document. The Form 14B is a summary of information generated from the patient’s previous medical exams, including the diagnosis, date of maximum medical improvement, permanent impairment, work restrictions, retained hardware, and need for future medical care and treatment.
What is the payment policy for services rendered outside of the state of South Carolina?
The MAP amounts listed in this manual are not applicable to medical services rendered outside of the State of South Carolina even when the services are provided under the South Carolina Workers’ Compensation Act. Therefore, insurers and self-insureds should inquire about and negotiate rates with out-of-state providers prior to authorizing care, except in emergency situations.