North Carolina Administrative Code › Title 11 - INSURANCE › Chapter 23 - INDUSTRIAL COMMISSION › Subchapter J - FEES FOR MEDICAL COMPENSATION › Section 0100 - FEES FOR MEDICAL COMPENSATION › Section 23J .0101 - GENERAL PROVISIONS

Current through Register Vol. 39, No. 2, July 15, 2024
(a) Pursuant to
				  G.S.
				  97-26, the Commission adopts a Medical Fee
				  Schedule composed of maximum amounts, reimbursement rates, and payment
				  guidelines, as set out in the rules of this Subchapter. The amounts and
				  reimbursement rates prescribed in the applicable published Medical Fee Schedule
				  shall govern and apply according to
				  G.S.
				  97-26(c).
(b) The Medical Fee Schedule is available on
				  the Commission's website at
http://www.ic.nc.gov/ncic/pages/feesched.asp
and in hardcopy at the offices of the Commission as set forth in
				  11 NCAC
				  23A .0101.
(c) Insurers and managed care organizations,
				  or administrators on their behalf, may review and reimburse charges for all
				  medical compensation, including medical, hospital, and dental fees, without
				  submitting the charges to the Commission for review and approval.
(d) A provider of medical compensation shall
				  submit its bill for services within 75 days of the rendition of the service, or
				  if treatment is longer, within 30 days after the end of the month during which
				  multiple treatments were provided. However, in cases where liability is
				  initially denied but subsequently admitted or determined by the Commission, the
				  time for submission of medical bills shall run from the time the health care
				  provider received notice of the admission or determination of liability. Within
				  30 days of receipt of the bill, the employer, carrier, or managed care
				  organization or administrator on its behalf, shall pay the bill or send the
				  provider written objections to the bill. If an employer, carrier,
				  administrator, or managed care organization disputes a portion of the
				  provider's bill, the employer, carrier, administrator, or managed care
				  organization, shall pay the uncontested portion of the bill and shall resolve
				  disputes regarding the balance of the charges through its contractual
				  arrangement or through the Commission.
(e) When the 10 percent addition to the bill
				  pursuant to
				  G.S.
				  97-18(i) is uncontested,
				  payment shall be made to the provider without notifying or seeking approval
				  from the Commission. When the 10 percent addition to the bill is contested, any
				  party may request a hearing by the Commission pursuant to
				  G.S.
				  97-83 and
				  G.S.
				  97-84.
(f) When the responsible party seeks an audit
				  of hospital charges, and has paid the hospital charges in full, the payee
				  hospital, upon request, shall provide access to and copies of appropriate
				  records, without charge or fee, to the person(s) chosen by the payor to review
				  and audit the records.
(g) The
				  responsible employer, carrier, managed care organization, or administrator
				  shall pay the bills of medical compensation providers to whom the employee has
				  been referred by the treating physician authorized by the insurance carrier for
				  the compensable injury or body part, unless it has requested that the physician
				  obtain authorization for referrals or tests. Compliance with the request shall
				  not unreasonably delay the treatment or service to be rendered to the
				  employee.
(h) Employees are
				  entitled to reimbursement for travel expenses when the travel is medically
				  necessary and the mileage is 20 or more miles, round trip, at the business
				  standard mileage rate set by the Internal Revenue Service per mile of travel
				  and the actual cost of any tolls paid. Employees are entitled to lodging and
				  meal expenses, at the rate established for state employees by the North
				  Carolina Director of Budget, when it is medically necessary that the employee
				  stay overnight at a location away from the employee's usual place of residence.
				  Employees are entitled to reimbursement for the costs of parking or a vehicle
				  for hire, when the costs are medically necessary, at the actual costs of the
				  expenses. The current reimbursement rates referenced in this Paragraph are
				  contained in the Form 25T,
Itemized Statement of Charges for
				  Travel
, which shall be used to claim travel expenses.
(i) Any employer, carrier, or administrator
				  denying a claim in which medical care has previously been authorized is
				  responsible for all costs incurred prior to the date that notice of denial is
				  provided to each health care provider to whom authorization has been previously
				  given.
Authority
					 G.S.
					 97-18(i);
					 97-25;
					 97-25.6;
					 97-26;
					 97-80(a);
					 138-6; S.L. 2013-410;
Eff. January 1, 1990;
Amended Eff. April 1, 2015; July 1, 2014;
					 January 1, 2013; June 1, 2000;
Recodified from
					 04 NCAC
					 10J .0101 Eff. June 1,
					 2018.