North Carolina Administrative Code › Title 11 - INSURANCE › Chapter 23 - INDUSTRIAL COMMISSION › Subchapter A - WORKERS' COMPENSATION RULES › Section .0600 - CLAIMS ADMINISTRATION AND PROCEDURES › Section 23A .0614 - HEALTH CARE PROVIDER FEE DISPUTE PROCEDURE

Current through Register Vol. 39, No. 2, July 15, 2024
(a) Health
				  care providers seeking to resolve a dispute regarding payment of charges for
				  medical compensation shall make an inquiry directly to the employer or
				  employer's workers compensation insurance carrier responsible for the payment
				  of medical fees by using an Industrial Commission Form 26I
Medical
				  Provider Dispute Resolution Questionnaire
.
(b) The Commission shall assist a health care
				  provider who has been unsuccessful in obtaining carrier contact information. No
				  information regarding a specific claim shall be provided by the Commission to
				  the health care provider.
(c) When
				  an employer or carrier does not respond to a health care provider's Form 26I
Medical Provider Dispute Resolution Questionnaire
inquiry
				  regarding a medical fee dispute within 20 days, or denies liability as a Form
				  26I
Medical Provider Dispute Resolution Questionnaire
response, the health care provider may file a written request seeking
				  assistance from the Commission regarding the fee dispute.
(d) The Commission shall conduct a conference
				  between the health care provider and the employer or carrier in an effort to
				  resolve the dispute.
(e) When the
				  health care provider, with assistance from the Commission is unable to resolve
				  the dispute, the health care provider may request limited intervention in the
				  workers' compensation claim for the sole purpose of resolving the fee
				  dispute.
(f) A health care provider
				  seeking limited intervention in a workers' compensation claim shall file a
				  motion to intervene with the Commission. The Motion to Intervene must include
				  the following:
(1) the Commission file
				  number, if known;
(2) the
				  employee's name, address, and last four digits of his or her social security
				  number;
(3) the date of injury and
				  a description of the workplace injury, including the body parts known to be
				  affected;
(4) an itemized list of
				  the medical fees in dispute, including CPT codes relating specific charges to
				  the Workers' Compensation Medical Fee Schedule, and explanations directly
				  relating each charge to the employee's workplace injury;
(5) a copy of the Form 26I
Medical
				  Provider Dispute Resolution Questionnaire
submitted by the health care
				  provider, including all accompanying materials, and any response received back
				  by the health care provider from the employer or carrier contacted;
(6) a copy of the written request for
				  assistance submitted to the Medical Fees Section of the Commission;
(7) a copy of the written summary by the
				  Medical Fees Section of the informal resolution process and outcome;
(8) a sworn affidavit by the health care
				  provider that states:
(A) the health care
				  provider has treated the employee;
(B) the medical fees itemized by the health
				  care provider are current and unpaid; and
(C) the health care provider reasonably
				  believes that the employer or carrier named on the Form 26I
Medical
				  Provider Dispute Resolution Questionnaire
is obligated to pay the fees
				  under the Workers' Compensation Act; and
(9) a certification of service upon both the
				  employee and the employer or carrier named on the Form 26I
Medical
				  Provider Dispute Resolution Questionnaire
.