| (a) In addition to the data requirements and standards
adopted under §133.500(a) of this title (relating to Electronic
Formats for Electronic Medical Bill Processing), all professional,
institutional or hospital, and dental electronic medical bills submitted
before January 1, 2012, must contain:
(1) the telephone number of the submitter;
(2) the workers' compensation claim number assigned
by the insurance carrier or, if that number is not known by the health
care provider, a default value of "UNKNOWN";
(3) the injured employee's Social Security number as
the subscriber member identification number;
(4) the injured employee's date of injury;
(5) the rendering health care provider's state provider
license number;
(6) the referring health care provider's state provider
license number;
(7) the billing provider's state provider license number,
if the billing provider has a state provider license number;
(8) the attending physician's state medical license
number, when applicable;
(9) the operating physician's state medical license
number, when applicable;
(10) the claim supplemental information, when electronic
documentation is submitted with an electronic medical bill; and
(11) the resubmission condition code, when the electronic
medical bill is a duplicate, request for reconsideration, or other
resubmission.
(b) In reporting the injured employee Social Security
number and the state license numbers under subsection (a) of this
section, health care providers must follow the data content and format
requirements contained in §133.10 of this title (relating to
Required Billing Forms/Formats).
(c) In addition to the data requirements contained
in the standards adopted under §133.500(c) of this title, all
professional, institutional or hospital, and dental electronic medical
bills submitted on or after January 1, 2012, must contain:
(1) the telephone number of the submitter;
(2) the workers' compensation claim number assigned
by the insurance carrier or, if that number is not known by the health
care provider, a default value of "UNKNOWN";
(3) the injured employee's date of injury;
(4) the claim supplemental information, when electronic
documentation is submitted with an electronic medical bill;
(5) the resubmission condition code, when the electronic
medical bill is a duplicate, request for reconsideration, or other
resubmission; and
(6) for a designated doctor and a health care provider
performing a test or evaluation as a result of a designated doctor's
referral, the assignment number in the prior authorization field.
(d) In addition to the data requirements contained
in the standards adopted under §133.500 of this title, all pharmacy
electronic medical bills must contain:
(1) the dispensing pharmacy's National Provider Identification
number;
(2) the prescribing doctor's National Provider Identification
number; and
(3) for a health care provider performing a test or
evaluation as a result of a designated doctor's referral, the assignment
number in the prior authorization field.
(e) In reporting the resubmission condition code under
this section, the resubmission condition codes must have the definitions
specified in §133.10(j) of this title.
(f) This section does not apply to paper medical bills
submitted for payment under §133.10(b) of this title.
(g) This section is effective for medical bills submitted
on or after June 1, 2024, including medical bills submitted as a result
of an examination that was ordered or referred as the result of an
order issued on or after June 1, 2024.
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