reglab/statecodes huggingface dataset:
Louisiana Administrative Code › Title 40 - LABOR AND EMPLOYMENT › Part I - Workers' Compensation Administration › Subpart 2 - Medical Guidelines › Chapter 29 - Pharmacy Reimbursement Schedule, Billing Instruction and Maintenance Procedures › Section I-2909 - Noncovered Services

Current through Register Vol. 50, No. 6, June 20, 2024
A. The workers'
				  compensation insurer will not make payment for:
1. over-the-counter (OTC) drugs and supplies
				  unless prescribed by the treating physician of record. All over-the-counter and
				  Schedule V preparations must be prescribed by a medical practitioner licensed
				  to write prescriptions. Approved OTC drugs are reimbursed the same as legend
				  drugs;
2. drugs or disposable
				  needles and syringes dispensed while a patient in a hospital, nursing home, or
				  other institution;
3. experimental
				  or investigative drugs which have not been approved by FDA;
4. vitamins, vitamin injections, or vitamin
				  therapy of any kind;
5. diet pills
				  or drugs for the purpose of weight reduction unless the treating physician can
				  provide prior justification;
6.
				  charges for any prescription, or item of merchandise or service, not related to
				  the qualifying illness or injury;
7. pharmacy charges incurred in conjunction
				  with non-work related conditions; or
8. items or services which are furnished
				  gratuitously without regard to the individual's ability to pay, and without
				  expectation of payment from any source.
Louisiana Administrative Code › Title 40 - LABOR AND EMPLOYMENT › Part I - Workers' Compensation Administration › Subpart 2 - Medical Guidelines › Chapter 29 - Pharmacy Reimbursement Schedule, Billing Instruction and Maintenance Procedures › Section I-2915 - Billing Instructions

Current through Register Vol. 50, No. 6, June 20, 2024
A.
				  Pharmaceutical billing must occur on either the CMS 1500 or a company invoice.
				  Billing document will include the following minimum information:
1. claimant name;
2. claimant address;
3. unique claimant identifier;
4. date prescription was filled;
5. n ational drug code;
6. drug name;
7. drug quantity;
8. total charge;
9. number of days prescribed;
10. prescribing providers name;
11. prescribing providers NPI;
12. pharmacists I.D.;
13. dispensing facility address;
14. dispensing facility phone
				  number;
15. medication charge;
				  and
16. dispensing fee
				  charge.
Louisiana Administrative Code › Title 40 - LABOR AND EMPLOYMENT › Part I - Workers' Compensation Administration › Subpart 2 - Medical Guidelines › Chapter 31 - Vision Care Services, Reimbursement Schedule, Billing Instruction and Maintenance Procedures › Section I-3115 - Covered Services

Current through Register Vol. 50, No. 6, June 20, 2024
A. Only optical
				  services necessitated by an occupational injury or illness are covered. Such
				  services are provided as a result of damage to the eye(s) due to a work injury
				  or exposure. In addition, frames, lenses and contact lenses not originally
				  purchased by the carrier/self-insured employer will be replaced if damaged or
				  broken in a work-related accident, in accordance with the provisions of
				  R.S.
				  23:1203.
B.
1. There
				  are three distinct types of services provided:
a. professional service;
b. optical fitting service; and
c. eye appliance.
Louisiana Administrative Code › Title 40 - LABOR AND EMPLOYMENT › Part I - Workers' Compensation Administration › Subpart 2 - Medical Guidelines › Chapter 31 - Vision Care Services, Reimbursement Schedule, Billing Instruction and Maintenance Procedures › Section I-3117 - Benefit Detail and Limitations

Current through Register Vol. 50, No. 6, June 20, 2024
A.
				  Certain items are not payable by the carrier/self-insured employer unless
				  specifically justified on medical grounds or as a replacement for eyewear of
				  like-quality damaged in an occupational accident. In other words, upgrades such
				  as daily wear to extended wear contact lenses, or ordinary frames to designer
				  frames are not reimbursable. If the claimant desires an upgrade, the
				  carrier/self-insured employer should be billed for the frames or lenses which
				  approximates the original item and the claimant must pay the
				  difference.
B. The items subject to
				  this limitation are:
1. sunglasses;
2. scratch resistant lenses;
3. antireflectant lenses;
4. photosensitive lenses; and
5. oversized lenses.
Louisiana Administrative Code › Title 40 - LABOR AND EMPLOYMENT › Part I - Workers' Compensation Administration › Subpart 2 - Medical Guidelines › Chapter 33 - Hearing Aid Equipment and Services Reimbursement Schedule, Billing Instructions and Maintenance Procedures › Section I-3325 - Covered Services

Current through Register Vol. 50, No. 6, June 20, 2024
A. The
				  carrier/self-insured employer will pay for a hearing aid to correct
				  trauma-induced hearing loss. The purchase and use of the hearing aid must be
				  shown to improve the claimant's hearing ability and must be prescribed by an
				  ear, nose and throat specialist or by a physician possessing a certificate of
				  clinical competence in audiology (CCCA).
B. Definitions
1.
Covered Hearing Aid
				  Expense
. Covered Hearing Aid Expense includes charges incurred for
				  audiometric examinations, hearing aid evaluation tests, and hearing aids to the
				  extent that charges are reasonable and customary as set forth below:
a. audiometric examination performed by a
				  physician or audiologist;
b.
				  hearing aid evaluation test performed by a physician or audiologist, which may
				  include the trial and testing of various makes and models of hearing aids to
				  determine which make and model will best compensate for the loss of hearing
				  acuity but only when indicated by the most recent audiometric
				  examination;
c. hearing aids of the
				  following functional design: in-the-ear, behind-the-ear and on-the-body, but
				  only if:
i. the hearing aid is prescribed
				  based upon the most recent audiometric examination and most recent hearing aid
				  evaluation test; and
ii. the
				  hearing aid provided by the dealer is the make and model prescribed by the
				  physician or audiologist and is certified as such by the physician or
				  audiologist.
In order for the charges for services and supplies
					 described in
					 §3325. B.1
					 .a and b above to be covered, the audiometric
					 examination must result in a determination that a hearing aid would compensate
					 for the loss of hearing acuity.
Louisiana Administrative Code › Title 40 - LABOR AND EMPLOYMENT › Part I - Workers' Compensation Administration › Subpart 2 - Medical Guidelines › Chapter 33 - Hearing Aid Equipment and Services Reimbursement Schedule, Billing Instructions and Maintenance Procedures › Section I-3327 - Physician Dispensing of Hearing Aids

Current through Register Vol. 50, No. 6, June 20, 2024
A. Hearing aid evaluation tests are billable
				  only when the evaluation is performed by a provider other than the hearing aid
				  dispenser or if the test results indicate no hearing aid is needed.
AUTHORITY NOTE:
					 Promulgated in accordance with
					 R.S.
					 23:1034.2.
Louisiana Administrative Code › Title 40 - LABOR AND EMPLOYMENT › Part I - Workers' Compensation Administration › Subpart 2 - Medical Guidelines › Chapter 35 - Nursing/Attendant Care and Home Health Services Reimbursement Schedule, Billing Instruction and Maintenance Procedures › Section I-3507 - Prior Authorization

Current through Register Vol. 50, No. 6, June 20, 2024
A.
1. All nursing services and personal care
				  services described herein, except those specifically noted, must have prior
				  written authorization of the carrier/self-insured employer before reimbursement
				  will be made. Claimants should be notified of this requirement in writing upon
				  the initiation of the claim.
2.
				  Each authorization request must include a prescription or statement of need
				  from the treating physician of record. The information provided by the
				  prescribing physician must include, at a minimum:
a. in addition to the medical report and
				  written justification required above, a description of needed nursing or other
				  attendant services, as well as specifying the level of nursing care (R.N.,
				  L.P.N., sitter/nonprofessional); and
b. estimated period of need, including
				  daily/hourly requirements for each level of nursing care.
Louisiana Administrative Code › Title 40 - LABOR AND EMPLOYMENT › Part I - Workers' Compensation Administration › Subpart 2 - Medical Guidelines › Chapter 35 - Nursing/Attendant Care and Home Health Services Reimbursement Schedule, Billing Instruction and Maintenance Procedures › Section I-3511 - Maximum Allowable Reimbursement

Current through Register Vol. 50, No. 6, June 20, 2024
A. Payment for nursing/attendant care
				  services, (not to include home infusion therapy) will be made for the least of:
1. the provider's usual and customary
				  fee;
2. a pre-negotiated amount
				  between the provider and carrier/self-insured employer; or
3. the maximum allowable amounts as
				  established by these rules.
Louisiana Administrative Code › Title 40 - LABOR AND EMPLOYMENT › Part I - Workers' Compensation Administration › Subpart 2 - Medical Guidelines › Chapter 37 - Home and Vehicle Modification Reimbursement Schedule, Billing Instructions and Maintenance Procedures › Section I-3707 - Prior Authorization

Current through Register Vol. 50, No. 6, June 20, 2024
A. Requests
				  for home or vehicle modifications will most often originate from the claimant
				  or a vocational rehabilitation consultant.
B. A request for modification or repair of a
				  dwelling must be substantiated by detailed estimates listing the following:
1. exact nature of work to be done;
2. itemized cost of materials; and
3. total cost of labor broken down by total
				  hours and hourly rate.
Louisiana Administrative Code › Title 40 - LABOR AND EMPLOYMENT › Part I - Workers' Compensation Administration › Subpart 2 - Medical Guidelines › Chapter 37 - Home and Vehicle Modification Reimbursement Schedule, Billing Instructions and Maintenance Procedures › Section I-3709 - Home Modifications

Current through Register Vol. 50, No. 6, June 20, 2024
A. The main
				  objective of the carrier/self-insured employer is to maintain the claimant in a
				  home environment, thus avoiding prolonged or repeated
				  hospitalization.
B. Written
				  authorization detailing the approved modifications and their exact cost must be
				  issued prior to the initiation of work to be done.
C. When a request for modification or repair
				  of a dwelling is considered, the request must contain verification that the
				  dwelling is owned by the claimant or that there is an agreement with the owner
				  for long-term residence. Modifications and repairs will be made after a
				  determination by carrier/self-insured employer staff as to needs in accordance
				  with the following guidelines.
1. Home
				  modifications considered by the carrier/self-insured employer will be limited
				  to the interior of a residence with the exception of ramps, lifts, and porches
				  necessary for access to and exit from the home. However, when the existing
				  residence is constructed in such a manner as to severely limit the claimant's
				  mobility, the carrier/self-insured employer may consider additional exterior
				  modifications. Items that may not be included in a bid for a room addition
				  include medicine cabinets, special lighting, special doorways (double doors,
				  sliding glass doors, etc.) decks or porches (wider than what is necessary for
				  accessibility).
2. When it is
				  determined that the reasonable rearrangement of existing furniture, fixtures,
				  appliances, etc. will eliminate barriers and make the dwelling accessible, the
				  carrier/self-insured employer will not approve any interior
				  modification.
Louisiana Administrative Code › Title 40 - LABOR AND EMPLOYMENT › Part I - Workers' Compensation Administration › Subpart 2 - Medical Guidelines › Chapter 37 - Home and Vehicle Modification Reimbursement Schedule, Billing Instructions and Maintenance Procedures › Section I-3711 - Vehicle Modifications

Current through Register Vol. 50, No. 6, June 20, 2024
A. The
				  carrier/self-insured employer will authorize modifications to vehicles only on
				  the basis of medical necessity. Modifications will be limited to the following:
1. installation of hand controls;
				  and
2. van modifications when
				  transfers into and out of a sedan type vehicle are not possible.
Louisiana Administrative Code › Title 40 - LABOR AND EMPLOYMENT › Part I - Workers' Compensation Administration › Subpart 2 - Medical Guidelines › Chapter 37 - Home and Vehicle Modification Reimbursement Schedule, Billing Instructions and Maintenance Procedures › Section I-3715 - Schedule of Maximum Allowances

Current through Register Vol. 50, No. 6, June 20, 2024
A.
				  The reimbursement allowances for home and vehicle modifications are determined
				  by obtaining bids for the specific modifications. Maximum allowable
				  reimbursement schedules cannot be preset or predetermined. A minimum of three
				  bids should be obtained by the carrier/self-insured employer whenever
				  possible.
B. The payment agreed to
				  by the carrier/self-insured employer represents the maximum allowance and
				  constitutes payment in full for the services. No additional charge to the
				  claimant is allowed. No charge shall be submitted to the carrier/self-insured
				  employer before the service has been performed. All home and vehicle
				  modifications require prior authorization.
AUTHORITY NOTE:
					 Promulgated in accordance with
					 R.S.
					 23:1034.2.
Louisiana Administrative Code › Title 40 - LABOR AND EMPLOYMENT › Part I - Workers' Compensation Administration › Subpart 2 - Medical Guidelines › Chapter 39 - Medical Transportation Reimbursement Schedule, Billing Instructions, and Maintenance Procedures › Section I-3909 - Ambulance Services

Current through Register Vol. 50, No. 6, June 20, 2024
A. Levels of
				  Care. Transportation by ground ambulance has been determined to be of two
				  levels of care: either basic life support (BLS) or advanced life support (ALS).
				  The ALS level of care cannot be charged unless the services meet the
				  requirements stated in the ALS definition below. The BLS level of care will be
				  billed when the ALS level of care does not apply.
B. Definitions
1. Advanced Life Support. The advanced life
				  support (ALS) base rate may be billed when the following requirements are met.
				  For the trip being billed, at least one ALS service must have been provided.
				  ALS services are defined as:
a.
				  administration of intravenous solutions by an emergency medical
				  technician;
b. airway management by
				  an emergency medical technician or paramedic;
c. endotracheal airway management by an
				  emergency medical technician or paramedic;
d. advanced cardiac life support performed by
				  a paramedic;
e. administration of
				  drugs by a paramedic; and
f.
				  performance of any of the above by a registered nurse or physician.
Louisiana Administrative Code › Title 40 - LABOR AND EMPLOYMENT › Part I - Workers' Compensation Administration › Subpart 2 - Medical Guidelines › Chapter 39 - Medical Transportation Reimbursement Schedule, Billing Instructions, and Maintenance Procedures › Section I-3911 - Schedule of Maximum Allowances

Current through Register Vol. 50, No. 6, June 20, 2024
A.
				  This document provides the basis for identification of procedures to be
				  reimbursed to transportation vendors. The coding source is the health care
				  financing administration common procedure coding system (HCPCS). No other
				  coding methodology will be accepted by the carrier/self-insured employer.
				  Please do not bill using any of the modifiers. Modifiers will not affect
				  payment and may cause your bill to be unnecessarily delayed.
B. This fee schedule provides the basis for
				  reimbursement of medical transportation. Reimbursement is limited to the least
				  of:
1. the provider's usual and customary
				  charge;
2. a reimbursement amount
				  previously negotiated by the provider and the carrier/self-insured employer;
				  or
3. the maximum allowable
				  reimbursement as determined by the following schedule.
State of Louisiana
Office of Workers' Compensation
Schedule of Maximum Allowances for Medical
								Transportation
HCPCS
Description
Maximum
Allowable
A0140
Nonemergency Transportation and Air Travel
								(Private or Commercial), Intra or Interstate
B.R.
A0999
Unlisted Ambulance Service
B.R.
A0380
Emergency Ambulance Service, BLS per Mile, One Way
$6
A0390
Emergency Ambulance Service, (ALS) Per Mile, One
								Way
$7
A0420
Ambulance Service, Waiting Time, One Half (1/2)
								Hour Increments, Rate per Unit (See Table Below)
$42
A0422
Ambulance Service, Oxygen, Administration and
								Supplies, Life Sustaining Situation
B.R.
A0427
Emergency Ambulance Service, Advanced Life Support
								(ALS) Base Rate, All Inclusive Services, One Way
$375
A0428
Nonemergency Transportation, Ambulance, Base Rate,
								One Way
$169
A0429
Emergency Ambulance Service, BLS Rate One Way
$258
A0430
Ambulance Service, Conventional Air Service One
								Way
B.R.
A0431
Ambulance Service, Air, Helicopter, v
B.R.
Louisiana Administrative Code › Title 40 - LABOR AND EMPLOYMENT › Part I - Workers' Compensation Administration › Subpart 2 - Medical Guidelines › Chapter 41 - Durable Medical Equipment and Supplies Reimbursement Schedule, Billing Instructions, and Maintenance Procedures › Section I-4111 - Durable Medical Equipment

Current through Register Vol. 50, No. 6, June 20, 2024
A. Durable
				  medical equipment (DME) refers to those items which can withstand repeated use,
				  are primarily used to serve a medical purpose, are generally not useful to a
				  person in the absence of illness, injury or disease, and are appropriate for
				  use in the claimant's home.
1. Covered
				  Services. The carrier/self-insured employer reimburses for the purchase or
				  rental of certain medical equipment and accessories and the purchase of certain
				  medical supplies for the claimant's use in a noninstitutional setting. Supplies
				  and equipment for nursing home claimants are restricted by the terms of any
				  negotiated agreement between the nursing home and the carrier/self-insured
				  employer, except as detailed herein. All items must be prescribed by the
				  claimant's treating physician.
Note: Allowances pertaining to oxygen and other
					 respiratory equipment and services can be found in both this manual and the
					 respiratory services manual. procedure codes and billing instructions for
					 braces and supplies related to prosthetic devices may be found in the manual
					 for prosthetic/orthopedic equipment. hearing aid information is found in the
					 hearing aid equipment and services manual.
2. Noncovered Services. In general, only
				  those supply and equipment items listed in the section of this manual entitled
				  "maximum allowances" will be reimbursed. The use of otherwise unlisted HCPCS
				  codes may be covered when medical necessity is documented.
3. Nonlisted Items and Individual
				  Consideration. Occasionally, there may be a workers' compensation claim where
				  the HCPCS code either does not appear on the schedule of maximum allowances or
				  is designated as "by report (BR)." In these instances, where medical necessity
				  has been documented, the carrier/self-insured employer should contact three DME
				  Suppliers in the geographic area from which the claim originated and obtain
				  charge information for the specific HCPCS code billed. The carrier will use the
				  average of the three responses as the maximum allowance for the specific HCPCS
				  code. This procedure may be repeated when necessary for other codes which fall
				  into this category.
Louisiana Administrative Code › Title 40 - LABOR AND EMPLOYMENT › Part I - Workers' Compensation Administration › Subpart 2 - Medical Guidelines › Chapter 41 - Durable Medical Equipment and Supplies Reimbursement Schedule, Billing Instructions, and Maintenance Procedures › Section I-4113 - Equipment Rental/Purchase Guidelines

Current through Register Vol. 50, No. 6, June 20, 2024
A. Whenever the total of prospective rental
				  payments for the period of medical need as stated by the prescribing physician
				  equals or exceeds the maximum purchase price as set by the Office of Workers'
				  Compensation Administration, the DME provider, prescribing physician and
				  carrier/self-insured employer should recommend purchase instead of rental when
				  communicating with the claimant. All items with a maximum allowable rate of
				  $150 or less will be allowed as purchases only, regardless of the expected
				  period of medical need. If, however, a definite period of medical need cannot
				  be determined at the time of the initial prescription, a rental authorization
				  will be granted with following condition.
1.
				  Rented DME is considered purchased equipment once the Monthly Rental Allowance
				  equals the Purchase Allowance. The DME is then owned by the claimant and
				  neither claimant, nor insurer, nor employer can be billed.
Louisiana Administrative Code › Title 40 - LABOR AND EMPLOYMENT › Part I - Workers' Compensation Administration › Subpart 2 - Medical Guidelines › Chapter 41 - Durable Medical Equipment and Supplies Reimbursement Schedule, Billing Instructions, and Maintenance Procedures › Section I-4115 - Equipment Warranty and Repair Information

Current through Register Vol. 50, No. 6, June 20, 2024
A. Benefits are not provided for equipment
				  repair or maintenance by the carrier/self-insured employer. The repair or
				  maintenance of rented DME is the responsibility of the DME supplier at no
				  additional charge to the claimant. The carrier/self-insured employer is
				  responsible for DME repair and maintenance of purchased equipment (subject to
				  warranty provisions).
B. For
				  purchased DME, the DME supplier must provide a one-year warranty agreement to
				  the claimant. If the warranty agreement requires some nominal monetary fee, it
				  is billable to the carrier/self-insured employer. The DME supplier must always
				  inform the claimant about any DME warranty provided by the
				  manufacturer.
AUTHORITY NOTE:
					 Promulgated in accordance with
					 R.S.
					 23:1034.2.
Louisiana Administrative Code › Title 40 - LABOR AND EMPLOYMENT › Part I - Workers' Compensation Administration › Subpart 2 - Medical Guidelines › Chapter 41 - Durable Medical Equipment and Supplies Reimbursement Schedule, Billing Instructions, and Maintenance Procedures › Section I-4117 - Billing Instructions

Current through Register Vol. 50, No. 6, June 20, 2024
A. All
				  initial claims for the rental or purchase of DME must be filed with a statement
				  of medical necessity. The authorized physician should supply the durable
				  medical equipment provider with a prescription stating the medical necessity
				  for such services with the claimant's diagnosis, prognosis, and expected time
				  span for which the equipment or supplies will be required. The recommended form
				  for this information is on the following page. The form should be presented to
				  the DME Supplier by the claimant and must be attached to the initial claim form
				  for the rental or purchase of DME.
B. DME Certification Form
Click Here
					 To View Image
AUTHORITY NOTE:
					 Promulgated in accordance with
					 R.S.
					 23:1034.2.
Louisiana Administrative Code › Title 40 - LABOR AND EMPLOYMENT › Part I - Workers' Compensation Administration › Subpart 2 - Medical Guidelines › Chapter 43 - Prosthetic and Orthopedic Equipment › Section I-4311 - Covered Services

Current through Register Vol. 50, No. 6, June 20, 2024
A.
				  Prosthetic/Orthotic Appliances
1. The
				  carrier/self-insured employer will pay only for those orthotic or prosthetic
				  devices prescribed by an authorized physician for a recognized occupational
				  injury or illness. The device must be described in commonly recognized language
				  in accordance with the Schedule of Maximum Allowances included in this
				  document.
2. Repairs and
				  modifications to achieve satisfactory adjustment of an appliance shall be made
				  within 60 days of initial fitting without additional charge by the supplier of
				  the orthotic or prosthetic device. The provider should attach a signed
				  statement from the claimant acknowledging receipt of the item whenever
				  submitting invoices to the carrier/self-insured employer for prosthetic
				  appliances.
3. Neither a
				  myoelectric (bionic) prosthetic appliance or a cosmetic prosthetic appliance
				  will be approved unless the standard, functional version of the prosthesis has
				  been used on a 6-month trial basis. Both versions will not be reimbursed
				  simultaneously.
4. Appliances
				  purchased in connection with a compensable injury may be replaced if medically
				  necessary.
Note: Please consult the Vision Care Services Fee Schedule
					 for information concerning the billing of artificial eyes. A separate fee
					 schedule is also published with billing instructions and rates for durable
					 medical equipment and supplies as well as hearing aid equipment and
					 services.
Louisiana Administrative Code › Title 40 - LABOR AND EMPLOYMENT › Part I - Workers' Compensation Administration › Subpart 2 - Medical Guidelines › Chapter 43 - Prosthetic and Orthopedic Equipment › Section I-4313 - Nonlisted Items and Individual Consideration

Current through Register Vol. 50, No. 6, June 20, 2024
A. Occasionally, there may be a workers'
				  compensation claim where the HCPCS code either does not appear on the Schedule
				  of Maximum Allowances or is designated as "By Report (BR)." In these instances
				  where medical necessity has been documented, the carrier/self-insured employer
				  should contact three prosthetic and orthotic equipment suppliers in the
				  geographic area from which the claim originated and obtain charge information
				  for the specific HCPCS code billed. The carrier will use the average of the
				  three responses as the maximum allowance for the specific HCPCS code. This
				  procedure may be repeated when necessary for other codes which fall into this
				  category.
AUTHORITY NOTE:
					 Promulgated in accordance with
					 R.S.
					 23:1034.2.
Louisiana Administrative Code › Title 40 - LABOR AND EMPLOYMENT › Part I - Workers' Compensation Administration › Subpart 2 - Medical Guidelines › Chapter 43 - Prosthetic and Orthopedic Equipment › Section I-4315 - Noncovered Services

Current through Register Vol. 50, No. 6, June 20, 2024
A. In general,
				  only those equipment items listed in the section of this manual entitled
				  "Maximum Allowances" will be reimbursed. The use of otherwise unlisted HCPCS
				  codes may be covered when medical necessity is documented.
AUTHORITY NOTE:
					 Promulgated in accordance with
					 R.S.
					 23:1034.2.
Louisiana Administrative Code › Title 40 - LABOR AND EMPLOYMENT › Part I - Workers' Compensation Administration › Subpart 2 - Medical Guidelines › Chapter 43 - Prosthetic and Orthopedic Equipment › Section I-4317 - Billing Instructions

Current through Register Vol. 50, No. 6, June 20, 2024
A. In
				  addition to the HCFA 1500 Form, the completed Medical Certification Form
				  (LDOL-WC-3002) must be submitted for all initial claims either rental or
				  purchase.
B. DME 3002 Form
Click Here
					 To View Image
AUTHORITY NOTE:
					 Promulgated in accordance with
					 R.S.
					 23:1034.2.
Louisiana Administrative Code › Title 40 - LABOR AND EMPLOYMENT › Part I - Workers' Compensation Administration › Subpart 2 - Medical Guidelines › Chapter 43 - Prosthetic and Orthopedic Equipment › Section I-4339 - Schedule of Maximum Allowances and Procedural Codes

Current through Register Vol. 50, No. 6, June 20, 2024
A. This maximum allowable reimbursement
				  schedule provides the basis for identification of prosthetic and orthopedic
				  equipment reimbursable to providers. the coding system used is the health care
				  financing administration common procedure coding system (HCPCS). No other
				  coding methodology will be accepted for this program. Invoices submitted to the
				  carrier/self-insured employer should be billed at the providers usual and
				  customary rate, not the maximum allowable charge designated in this fee
				  schedule. Reimbursement is limited to the least of:
1. the provider's usual and customary charge;
				  or
2. a previously negotiated
				  amount by the provider and carrier/self-insured employer; or
3. the allowable reimbursement
				  schedule.
Louisiana Administrative Code › Title 40 - LABOR AND EMPLOYMENT › Part I - Workers' Compensation Administration › Subpart 2 - Medical Guidelines › Chapter 45 - Respiratory Services Reimbursement Schedule, Billing Instructions, and Maintenance Procedures › Section I-4507 - Prior Authorization

Current through Register Vol. 50, No. 6, June 20, 2024
A. Except
				  in documented emergencies, all equipment, supplies and services described
				  herein, except those specifically noted, must have prior written authorization
				  of the carrier/self-insured employer before reimbursement will be made.
				  Claimants should be notified of this requirement in writing upon the initiation
				  of the claim. Each authorization request must include a prescription or
				  statement of need from the treating physician of record.
B. Prior authorization requests will be
				  approved, denied, or amended and approved by the carrier/self-insured employer.
				  Occasionally, some requests may be returned for further information,
				  explanation, or reports. Once a request is approved, please take great care to
				  bill only for those procedures or services specifically authorized by the
				  carrier/self-insured employer. In addition, please attach the authorization
				  letter to the invoice or enter the prior authorization number in the
				  appropriate field on the invoice.
C. The following must be taken into account
				  when making a prior authorization request.
1.
				  The prescription or the letter of justification from the claimant's physician
				  is the key factor in obtaining prior authorization of the carrier/self-insured
				  employer and reimbursement. For oxygen requests, the type and amount, the
				  frequency, and method of delivery also must be specified. In addition, the
				  physician should list the estimated requirements for ancillary
				  supplies.
2. For approved rentals
				  and supplies, a specific period of authorization will be established based on
				  the recommendation of the physician who issues the prescription. At the end of
				  this initial period, if there is a continuing need for equipment or supplies,
				  it is the provider's responsibility to obtain a new prescription, the prognosis
				  and a new estimate of the period of need. The provider should make the
				  continuing authorization request and attach the prescription.
3. For equipment rental and purchase request,
				  the item's model and serial number and a description of the warranty coverage
				  must be included with the request. The carrier/self-insured employer is
				  authorized to require a consultation prior to approval of any equipment or
				  supplies.
Louisiana Administrative Code › Title 40 - LABOR AND EMPLOYMENT › Part I - Workers' Compensation Administration › Subpart 2 - Medical Guidelines › Chapter 45 - Respiratory Services Reimbursement Schedule, Billing Instructions, and Maintenance Procedures › Section I-4509 - Covered Services

Current through Register Vol. 50, No. 6, June 20, 2024
A. All
				  equipment, supplies and related services must be pre-authorized for
				  reimbursement to be made. Services and equipment must be provided by providers
				  who have qualified professional support staff to install and monitor the
				  equipment, such as registered nurses, licensed practical nurses, or certified
				  respiratory therapists. The claimant's authorized physician must prescribe
				  continuous oxygen based upon the physician's interpretation of a blood oxygen
				  report (i.e., arterial blood gas or oximetry) that was performed no more than
				  12 months prior to the authorization request. On occasion, a pulmonologist
				  consultation may be requested. An annual blood oxygen analysis report is
				  recommended for continued authorization of oxygen therapy.
B. Standard Oxygen Systems Versus Oxygen
				  Concentrators. Oxygen concentrators will be considered only for claimants who
				  require continuous daily oxygen for a minimum of 8 hours in a 24-hour period.
				  Prior authorization requests to deliver more than standard amounts of oxygen
				  will be reviewed by the carrier/self-insured employer with the requesting
				  physician to determine if an oxygen concentrator would be a better
				  option.
C. Portable Oxygen. At the
				  request of the prescribing physician, the carrier/self-insured employer may
				  authorize portable oxygen in three instances:
1. as a back up to an oxygen concentrator for
				  claimants on continuous oxygen who need oxygen to go for routine medical
				  treatment or visits;
2. for those
				  claimants whose record documents eight or more hours of daily activity;
				  and
3. when requested by the
				  attending physician and approved by the carrier/self-insured employer for
				  certain rehabilitation and recreational uses.
Louisiana Administrative Code › Title 40 - LABOR AND EMPLOYMENT › Part I - Workers' Compensation Administration › Subpart 2 - Medical Guidelines › Chapter 45 - Respiratory Services Reimbursement Schedule, Billing Instructions, and Maintenance Procedures › Section I-4511 - Noncovered Services

Current through Register Vol. 50, No. 6, June 20, 2024
A. Only those
				  services specifically listed in the section of this manual entitled "Maximum
				  Reimbursement Allowances" are covered. Charges billed under the code for
				  unlisted services or equipment will be reviewed prior to any pricing. Charges
				  for items under this code that were not pre-authorized will be disallowed.
				  Noncovered professional services include but are not limited to:
1. any service considered investigational or
				  experimental, such as membrane diffusion capacity;
2. services not ordered by a physician or
				  administered under the direction of a physician or by qualified medical staff;
				  and
3. services not consistent with
				  the patient's diagnosis, treatment or respiratory problems.
Louisiana Administrative Code › Title 40 - LABOR AND EMPLOYMENT › Part I - Workers' Compensation Administration › Subpart 2 - Medical Guidelines › Chapter 45 - Respiratory Services Reimbursement Schedule, Billing Instructions, and Maintenance Procedures › Section I-4537 - Maximum Reimbursement Allowance

Current through Register Vol. 50, No. 6, June 20, 2024
A. Maximum allowable reimbursement for
				  compensable professional respiratory therapy services will be based upon the
				  lesser of the provider's charge or the allowance indicated in the Office of
				  Workers' Compensation administration's CPT code reimbursement manual listing of
				  medical procedures.
B. Maximum
				  allowable reimbursement for respiratory therapy supplies, equipment and related
				  services will be the least of:
1. the
				  provider's usual and customary fee;
2. a pre-negotiated amount between the
				  provider and carrier/self-insured employer; or
3. the amount indicated in the maximum
				  allowable reimbursement schedule.
Louisiana Administrative Code › Title 40 - LABOR AND EMPLOYMENT › Part I - Workers' Compensation Administration › Subpart 2 - Medical Guidelines › Chapter 47 - Miscellaneous Claimant Expenses Reimbursement Schedule, Billing Instruction and Maintenance Procedures › Section I-4733 - Schedule of Maximum Allowances

Current through Register Vol. 50, No. 6, June 20, 2024
A.
				  General Guidelines
1. Maximum reimbursement
				  allowances have been established for most of the services required by workers'
				  compensation claimants. The maximum allowable reimbursement can generally be
				  found in one of the following manuals:
a.
CPT Code Reimbursement Manual
- this manual contains
				  reimbursement allowances for services described by CPT-4 codes, i.e., dental,
				  surgical, radiology, pathology, and medical procedures;
b. pharmacy reimbursement manual;
c. vision care services reimbursement
				  manual;
d. vocational
				  rehabilitation services reimbursement manual;
e. home and vehicle modification
				  reimbursement manual;
f. hospital
				  reimbursement manual;
g. hearing
				  aid equipment reimbursement manual;
h. respiratory services reimbursement
				  manual;
i. durable medical
				  equipment reimbursement manual;
j.
				  nursing attendant care reimbursement manual;
k. prosthetic and orthopedic equipment
				  reimbursement manual;
l. medical
				  transportation reimbursement manual.
Louisiana Administrative Code › Title 40 - LABOR AND EMPLOYMENT › Part I - Workers' Compensation Administration › Subpart 2 - Medical Guidelines › Chapter 49 - Vocational Rehabilitation Consultant Reimbursement Schedule, Billing Instruction and Maintenance Procedures › Section I-4911 - Covered Services

Current through Register Vol. 50, No. 6, June 20, 2024
A. The
				  carrier/self-insured employer authorizes private rehabilitation firms to
				  provide professional services including consultation, assessment, and follow-up
				  to assist claimants in returning to suitable gainful employment, as provided by
				  R.S.
				  23:1226.
B. The professional service fee includes
				  costs related to the rendering of professional services, i.e., clerical
				  support, postage and the preparation of correspondence. No additional charges
				  are allowed for the activities which constitute professional
				  services.
C. Waiting time, mileage,
				  and long distance phone calls are reimbursed separately.
AUTHORITY NOTE:
					 Promulgated in accordance with
					 R.S.
					 23:1034.2.
Louisiana Administrative Code › Title 40 - LABOR AND EMPLOYMENT › Part I - Workers' Compensation Administration › Subpart 2 - Medical Guidelines › Chapter 49 - Vocational Rehabilitation Consultant Reimbursement Schedule, Billing Instruction and Maintenance Procedures › Section I-4913 - Noncovered Services

Current through Register Vol. 50, No. 6, June 20, 2024
A. No duplicate
				  payment will be made for medical reports prepared by physicians and submitted
				  through the counselor. Such reports are requested from the treating physician
				  by the counselor and payment for these reports is made by the
				  carrier/self-insured employer.
B.
				  No payment will be made for any activity after notification by the
				  carrier/self-insured employer of case closure.
AUTHORITY NOTE:
					 Promulgated in accordance with
					 R.S.
					 23:1034.2.
Louisiana Administrative Code › Title 40 - LABOR AND EMPLOYMENT › Part I - Workers' Compensation Administration › Subpart 2 - Medical Guidelines › Chapter 49 - Vocational Rehabilitation Consultant Reimbursement Schedule, Billing Instruction and Maintenance Procedures › Section I-4915 - Schedule of Maximum Allowances

Current through Register Vol. 50, No. 6, June 20, 2024
A.
				  This reimbursement schedule indicates maximum allowances which constitute
				  payment in full for the services. No additional charge to the claimant is
				  allowed. No charge shall be submitted to the carrier/self-insured employer
				  before the service has been performed. All procedures require prior
				  authorization.
Professional fee, per hour
$80*
Travel time/wait time, per hour
$80*
Mileage, per mile
**
Long distance calls
At Cost
Local calls
$0.25
*When appropriate, a pro rata billing of this amount
					 should be made at the rate of $1.3333 per minute. (i.e., 15 minutes should be
					 billed as $20.00; 20 minutes as $26.67; 30 minutes as $40.00; 40 minutes as
					 $53.33, etc.)
**IRS Standard Mileage Rate in effect at the time services
					 are rendered.
AUTHORITY NOTE:
					 Promulgated in accordance with
					 R.S.
					 23:1034.2.
Louisiana Administrative Code › Title 40 - LABOR AND EMPLOYMENT › Part I - Workers' Compensation Administration › Subpart 2 - Medical Guidelines › Chapter 49 - Vocational Rehabilitation Consultant Reimbursement Schedule, Billing Instruction and Maintenance Procedures › Section I-4917 - Billing Code Instructions

Current through Register Vol. 50, No. 6, June 20, 2024
A. For
				  billing Vocational Rehabilitation Consultant Services, the following locally
				  assigned HCPCS codes will be used.
Code
Description
X0710
Professional fee, per hour
X0720
Professional Fee (Travel Time/Wait Time), per hour
X0730
Mileage, per mile
X0740
Long Distance Calls
X0750
Local Calls
B.
				  Additional codes may be assigned by the Office of Workers' Compensation as the
				  need arises.
AUTHORITY NOTE:
					 Promulgated in accordance with
					 R.S.
					 23:1034.2.
Louisiana Administrative Code › Title 40 - LABOR AND EMPLOYMENT › Part I - Workers' Compensation Administration › Subpart 2 - Medical Guidelines › Chapter 51 - Medical Reimbursement Schedule › Section I-5103 - Introduction

Current through Register Vol. 50, No. 6, June 20, 2024
A. This document is
				  primarily intended to facilitate the establishment of the maximum allowable
				  reimbursement for all physician, chiropractic, physical and occupational
				  therapy, pharmacy, hospital, vision care, hearing aid equipment,
				  nursing/attendant care and home health, home and vehicle modification, medical
				  transportation, durable medical equipment, prosthetic, and orthopedic
				  equipment, respiratory, miscellaneous claimant expenses, vocational
				  rehabilitation and dental care services.
B. For an overview of the Workers'
				  Compensation Program and all policies and procedure concerning treatment of
				  compensable work related injuries and illnesses, please refer to the
				  carrier/self-insured employer.
AUTHORITY NOTE:
					 Promulgated in accordance with
					 R.S.
					 23:1034.2.
Louisiana Administrative Code › Title 40 - LABOR AND EMPLOYMENT › Part I - Workers' Compensation Administration › Subpart 2 - Medical Guidelines › Chapter 51 - Medical Reimbursement Schedule › Section I-5105 - Verification of Coverage

Current through Register Vol. 50, No. 6, June 20, 2024
A. The
				  carrier/self-insured employer is responsible for 100 percent of the maximum
				  allowable reimbursement rate for covered services rendered for treatment of
				  compensable conditions. The claimant is not required to contribute a co-payment
				  and does not have to meet any deductibles.
1.
				  Prior to the provision of medical services, supplies, or other non-medical
				  services the determination that the illness, injury, or condition, is work
				  related must be made, and must be accomplished in the following manner:
a. carrier/self-insured employer should be
				  contacted for verification of coverage/liability;
b. the name and title of the individual
				  verifying coverage/liability must be recorded in the claimant's
				  records;
c. denial of
				  coverage/liability must be immediately communicated to the claimant.
Louisiana Administrative Code › Title 40 - LABOR AND EMPLOYMENT › Part I - Workers' Compensation Administration › Subpart 2 - Medical Guidelines › Chapter 51 - Medical Reimbursement Schedule › Section I-5107 - Other Payer Liabilities

Current through Register Vol. 50, No. 6, June 20, 2024
A. Whenever
				  a claimant is eligible for Medicare or payment from another third party payer
				  and is also eligible for workers' compensation medical benefits, the
				  carrier/self-insured employer is always the primary payer, the payer of first
				  resort. Services related to compensable conditions should be billed to the
				  carrier/self-insured employer before attempting to collect from the third party
				  payer.
B. If a claimant is
				  receiving treatment for both compensable and noncompensable medical conditions,
				  only those services provided in treatment of compensable conditions should be
				  listed on claims and invoices submitted to the carrier/self-insured employer.
				  In addition, payments from private payers for noncompensable conditions should
				  not be listed on invoices submitted to the carrier/self-insured
				  employer.
C. Charges for
				  noncompensable conditions are collectible by the provider from any other third
				  party payer, subject to the limitations and exclusions contained in the third
				  payer's policy.
AUTHORITY NOTE:
					 Promulgated in accordance with
					 R.S.
					 23:1034.2.
Louisiana Administrative Code › Title 40 - LABOR AND EMPLOYMENT › Part I - Workers' Compensation Administration › Subpart 2 - Medical Guidelines › Chapter 51 - Medical Reimbursement Schedule › Section I-5109 - Prior Authorization

Current through Register Vol. 50, No. 6, June 20, 2024
A. The
				  Louisiana Workers' Compensation Statutes (R.S.
				  23:1142) establishes a monetary limit for
				  nonemergency medical care. The statute further provides significant penalties
				  for a carrier/self-insured employer's arbitrary and capricious refusal to
				  approve necessary care beyond that limit. (See Chapter 27 Utilization Review
				  Procedu§2715.
				  A and B). In addition to all other rules and
				  procedures, the provider or practitioner who provide care under the "medical
				  emergency" exception must demonstrate that it was a "medical emergency" as
				  outlined in the Utilization Review Procedures, cited above. For additional
				  instructions, please refer to the respective section of the schedule.
In addition, the
					 following Sections of this Chapter are applicable and shall be used for the
					 other chapters in this Part governing reimbursement. These specific Chapters
					 are: Chapter 31, Vision Care Services; Chapter 33, Hearing Aid Equipment and
					 Services; Chapter 35, Nursing Attendant Care and Home Health Services; Chapter
					 39, Medical Transportation; Chapter 41, Durable Medical Equipment and Supplies;
					 Chapter 43, Prosthetic and Orthopedic Equipment; Chapter 45, Respiratory
					 Services; Chapter 47, Miscellaneous Claimant Expenses; and Chapter 49,
					 Vocational Rehabilitation Consultant.
AUTHORITY NOTE:
					 Promulgated in accordance with
					 R.S.
					 23:1034.2.