How to Submit worker compensation claim
(a) Required reports and/or supporting documentation to bolster a bill as characterized in Complete Bill Section 3.0 should be submitted as per this segment. Unless generally concurred by the gatherings, all connections to bolster an electronically submitted bill should either have a header or joined spread sheet that gives the accompanying data:
(1) Claims Administrator - the name might be the same as populated in the 005010X222, 005010X223, or 005010X224. Circle 2010BB, NM103.
(2) Employer - the name might be the same as populated in the 005010X222, 005010X223, or 005010X224, Loop 2010BA, NM103.
(3) Unique Attachment Indicator Number - the Unique Attachment Indicator Number should be the same as populated in the 005010X222, 005010X223, or 005010X224, Loop 2300, PWK Segment: Report Type Code, the Report Transmission Code, Attachment Control Qualifier (AC) and the one of a kind Attachment Control Number. It is the mix of these information components that will permit a cases manager to suitably coordinate the approaching connection to the electronic doctor's visit expense. Allude to the Companion Guide Chapter 2 for data with respect to the Unique Attachment Indicator Number Code Sets.
(4) Billing Provider NPI Number – the number must be the same as populated in Loop 2010AA, NM109. In the event that the supplier is ineligible for a NPI, then this number is the provider?s atypical charging supplier ID. This number must be the same as populated in Loop 2010AA, REF02.
(5) Billing Provider Name.
(6) Bill Transaction Identification Number – This might be the same number as populated in the ASC 005010X222, 005010X223, or 005010X224 exchanges, Loop 2300 Claim Information, CLM01.
(7) Document sort – use Report Type codes as put forward in Appendix C of the Companion Guides.
(8) Page Number/Number of Pages the page numbers reported ought to incorporate the spread sheet.
(9) Contact Name/Phone Number including zone code.
(b) All connections to bolster an electronically submitted bill should contain the accompanying data in the body of the connection or on a joined spread sheet:
(1) Patient?s name
(2) Claims Administrator?s name
(3) Date of Service
(4) Date of Injury
(5) Social Security number (if accessible)
(6) Claim number (if accessible)
(7) Unique Attachment Indicator Number
(c) All connection entries might conform to the tenets put forward in Section One – 3.0 Complete Bills and Section Three – Security Rules. They should be submitted by conventions determined in the Companion Guide Chapter 8 or other commonly settled upon strategies.
(d) Attachment accommodation techniques:
(1) FAX
(2) Electronic accommodation – if submitting electronically, the Division emphatically prescribes utilizing the ASC X12N/005010X210 Additional Information to Support a Health Care Claim or Encounter (275) exchange set. Determinations for this exchange set are found in the Companion Guide Chapter 8. The Division is not commanding the utilization of this exchange set. Different strategies for transmission might be commonly settled upon by the gatherings.
(3) E-mail – must be encoded
(e) Attachment sorts
(1) Reports
(2) Supporting Documentation
(3) Written Authorization
(4) Misc. (other kind of connection)
