Source: http://register.dls.virginia.gov/details.aspx?id=7295
Timestamp: 2019-01-21 01:42:23
Document Index: 361359783

Matched Legal Cases: ['§ 65', '§ 65', '§ 65', '§ 65', '§ 65', '§ 65', '§ 65']

Vol. 35 Iss. 10 (Final Regulation) 16VAC30-16, Electronic Medical Billing January 07, 2019
Title of Regulation: 16VAC30-16. Electronic Medical Billing (adding 16VAC30-16-10 through 16VAC30-16-80).
Statutory Authority: § 65.2-605.1 of the Code of Virginia.
Agency Contact: James J. Szablewicz, Chief Deputy Commissioner, Virginia Workers' Compensation Commission, 333 East Franklin Street, Richmond, VA 23219, telephone (804) 205-3097, FAX (804) 823-6936, or email james.szablewicz@workcomp.virginia.gov.
Pursuant to Chapter 621 of the 2015 Acts of Assembly, the regulation implements infrastructure under which (i) providers of workers' compensation medical services (providers) submit billing, claims, case management, health records, and all supporting documentation electronically to employers or employers' workers' compensation insurance carriers (payers) and (ii) payers return actual payment, claim status, and remittance information electronically to providers that submit billing and required supporting documentation electronically. The regulation establishes standards and methods for electronic submissions and transactions that are consistent with the electronic medical billing and payment guidelines of the International Association of Industrial Accident Boards and Commissions. The regulation does not require any reporting to or enforcement by the Virginia Workers' Compensation Commission or any other governmental agency.
Changes since the proposed regulation (i) made December 31, 2018, a voluntary compliance date and moved the mandatory compliance date to July 1, 2019; (ii) adjusted the small provider exemption; and (iii) increased the time period within which a payer must either reject or complete an incomplete medical bill.
This chapter applies to all medical services and products provided on or after [ December 31, 2018 July 1, 2019 ]. For medical services and products provided prior to [ December 31, 2018 July 1, 2019 ], medical billing and processing shall be in accordance with the rules in effect at the time the medical service or product was provided [ ; however, providers and payers may voluntarily comply with the provisions of this chapter beginning on December 31, 2018 ].
"Supporting documentation" means those documents necessary for the payer to process a bill and includes any written authorization received from the third-party administrator or any other records as required by the Virginia Workers' Compensation Commission.
C. The implementation specifications for the ASC X12N and the ASC X12 Standards for Electronic Data Interchange may be obtained from the ASC X12, 7600 Leesburg Pike, Suite 430, Falls Church, VA 22043; telephone (703) 970-4480; and FAX (703) 970-4488. They are also available online at http://store.x12.org/. A fee is charged for all implementation specifications.
D. The implementation specifications for the retail pharmacy standards may be obtained from the National Council for Prescription Drug Programs, 9240 East Raintree Drive, Scottsdale, AZ 85260; telephone (480) 477-1000; and FAX (480) 767-1042. They are also available online at http://www.ncpdp.org. A fee is charged for all implementation specifications.
8. "National Uniform Billing Committee Codes" are a code structure and instructions established for use by the National Uniform Billing Committee, such as occurrence codes, condition codes, or prospective payment indicator codes. As of [ (insert effective date of final regulation) February 6, 2019 ], these are known as UB04 codes.
1. This section outlines the exclusive process for the initial exchange of electronic medical bill and related payment processing data for professional, institutional or hospital, pharmacy, and dental services [ provided to injured workers in accordance with § 65.2-603 of the Code of Virginia ].
2. [ Payers Unless exempted from this process in accordance with subdivision B 2 of this section, payers ] or their agents shall:
3. Unless exempted from this process in accordance with [ subsection subdivision ] B [ 1 ] of this section, a health care provider shall:
4. Payers shall be able to exchange electronic data by [ December 31, 2018 July 1, 2019, unless exempted from the process in accordance with subdivision B 2 of this section ].
5. Health care providers or their agents shall be able to exchange electronic data by [ December 31, 2018 July 1, 2019 ], unless exempted from the process in accordance with [ subsection subdivision ] B [ 1 ] of this section.
[ 1. ] A health care provider is exempt from the requirement to submit medical bills electronically to a payer if:
[ 1. a. ] The health care provider employs [ 10 15 ] or fewer full-time employees; [ and or ]
[ 2. Treatment or services provided to injured workers to be billed under workers' compensation constitutes less than 10% of the health care provider's practice. b. The health care provider submitted fewer than 250 medical bills for workers' compensation treatment, services, or products in the previous calendar year.
2. A payer is exempt from the requirements to receive and pay medical bills electronically if the payer processed fewer than 250 medical bills for workers' compensation treatment, services, or products in the previous calendar year. ]
7. Acceptance of [ an a complete or ] incomplete medical bill does not satisfy the written notice of injury requirement from an employee or payer as required by §§ 65.2-600 and 65.2-900 of the Code of Virginia.
[ 8. Acceptance of a complete or incomplete medical bill by a payer does begin the time period by which a payer shall accept or deny liability for any alleged claim related to such medical treatment pursuant to § 65.2-605.1 of the Code of Virginia.
9. 8. ] Transmission of an Implementation Acknowledgment under subdivision D 2 of this section and acceptance of a complete, structurally correct file serves as proof of the received date for an electronic medical bill in subsection C of this section.
4. All payments for services [ that have been billed electronically in accordance with this chapter ] are required to be paid via electronic funds transfer unless an alternate [ electronic ] method is agreed upon by the payer and health care provider.
G. Requirements for health care providers exempted from electronic billing. Health care providers exempted from electronic medical billing pursuant to [ subsection subdivision ] B [ 1 ] of this section shall submit paper medical bills for payment in the following formats as applicable:
I. Connectivity. Unless the payer or its agent is exempted from the electronic medical billing process in accordance with [ subsection subdivision ] B [ 2 ] of this section, it should attempt to establish connectivity through a trading partner agreement with any clearinghouse that requests the exchange of data in accordance with 16VAC30-16-30.
1. A payer shall not reject medical bills that are complete, unless the bill is a duplicate bill. [ A payer may subsequently reject a complete medical bill or any portion thereof that is contested or denied in accordance with the requirements of subsection B of § 65.2-605.1 of the Code of Virginia. ]
2. Within [ 21 45 ] calendar days of receipt of an incomplete medical bill, a payer or its agent shall either:
b. Reject the incomplete bill, in accordance with this subsection [ and the requirements of subsection B of § 65.2-605.1 of the Code of Virginia ].
D. A payer shall not reject or deny a medical bill except as provided in subsection A of this section. When rejecting or denying an electronic medical bill, the payer shall clearly identify the reasons for the bill's rejection or denial by utilizing the appropriate codes in the standard transactions found in 16VAC30-16-50 D 3 b [ and shall comply with all requirements of subsection B of § 65.2-605.1 of the Code of Virginia ].
1. For bills submitted electronically, the rejection of the entire bill or the rejection of specific service lines included in the initial bill shall be sent to the submitter [ within two business days of receipt as soon as practicable but not more than 45 calendar days after receipt ].
[ I. A payer shall not reject or deny a medical bill except as provided in subsection A of this section. When rejecting or denying a medical bill, the payer shall also communicate to the health care provider the reasons for the medical bill's rejection or denial. ]
Electronic Billing and Payment Companion Guide, Virginia Workers' Compensation Commission Release 1.0, 12/2018
VA.R. Doc. No. R16-4654; Filed December 20, 2018, 7:30 a.m.