Virginia Administrative Code › Title 16 - LABOR AND EMPLOYMENT › Agency 30 - VIRGINIA WORKERS' COMPENSATION COMMISSION › Chapter 16 - ELECTRONIC MEDICAL BILLING › Section 16VAC30-16-20 - Definitions

Current through Register Vol. 40, No. 24, July 15, 2024
The following words and terms when used in this chapter shall
				  have the following meanings unless the context clearly indicates
				  otherwise:
"Business day" means Monday through Friday, excluding days on
				  which a holiday is observed by the Commonwealth of Virginia.
"Clearinghouse" means a public or private entity, including a
				  billing service, repricing company, community health management information
				  system or community health information system, and "value-added" networks and
				  switches, that is an agent of either the payer or the health care provider and
				  that may perform the following functions:
1. Processes or facilitates the processing of medical billing
				  information received from a client in a nonstandard format or containing
				  nonstandard data content into standard data elements or a standard transaction
				  for further processing of a bill related transaction; or
2. Receives a standard transaction from another entity and
				  processes or facilitates the processing of medical billing information into
				  nonstandard format or nonstandard data content for a client entity.
"CMS" means the Centers for Medicare and Medicaid Services of
				  the U.S. Department of Health and Human Services, the federal agency that
				  administers these programs.
"Companion Guide" means the Virginia Workers' Compensation
				  Electronic Billing and Payment Companion Guides, based on International
				  Association of Industrial Accident Boards and Commissions National Companion
				  Guides, a separate document that gives detailed information for electronic data
				  interchange (EDI) medical billing and payment for the workers' compensation
				  industry using national standards and Virginia specific procedures.
"Complete electronic medical bill" means a medical bill that
				  meets all of the criteria enumerated in 16VAC30-16-50 C.
"Electronic" means communication between computerized data
				  exchange systems that complies with the standards enumerated in this
				  chapter.
"Health care provider" means a person or entity,
				  appropriately certified or licensed, as required, who provides medical services
				  or products to an injured worker in accordance with §
									65.2-603
				  of the Code of Virginia.
"Health care provider agent" means a person or entity that
				  contracts with a health care provider establishing an agency relationship to
				  process bills for services provided by the health care provider under the terms
				  and conditions of a contract between the agent and health care provider. Such
				  contracts may permit the agent to submit bills, request reconsideration,
				  receive reimbursement, and seek medical dispute resolution for the health care
				  provider services billed in accordance with §§
									65.2-605
				  and
				  65.2-605.1
				  of the Code of Virginia.
"Payer" means the insurer or authorized self-insured employer
				  legally responsible for paying the workers' compensation medical bills.
"Payer agent" means any person or entity that performs
				  medical bill related processes for the payer responsible for the bill. These
				  processes include reporting to government agencies; electronic transmission,
				  forwarding, or receipt of documents; review of reports; and adjudication of
				  bills and their final payment.
"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.
"Technical Report Type 3 (TR3) Implementation Guide" means an
				  ASC X12 published document for national electronic standard formats that
				  specifies data requirements and data transaction sets, as referenced in
				  16VAC30-16-30.
Statutory Authority: §
											65.2-605.1
					 of the Code of Virginia.