Newsline No. 03-12 printer image Printer friendly
January 13, 2012  

Standardized medical billing form regulations not applicable to medical-legal bills

The Division of Workers’ Compensations has received complaints from qualified medical evaluators (QMEs) that bills are being rejected by claims administrators because they are not on the standardized forms. By statute, medical providers are required to bill using standardized paper billing forms effective Oct. 15, 2011. This is a new requirement for medical treatment bills only.  It does not apply to medical-legal bills. 

The “Medical Billing and Payment Guide 2011” specifically states: “The following forms [which include the Centers for Medicare & Medicaid Services, (CMS) 1500] are the only forms to be used for paper billing of California workers’ compensation medical treatment services and goods unless there is a written contract agreed by the parties specifying something different.” (Medical Billing and Payment Guide, page 11, Appendix A Standard Paper Forms.) 

However, the requirement to use the standardized paper billing forms does not apply to medical-legal billings, such as those performed in panel QME or other official QME or agreed medical evaluator, (AME) cases. Therefore, it is not appropriate to reject or object to a medical-legal bill because it was not submitted on a standardized form.

Title 8, California Code of Regulations section 9792.5.2 subdivision (a) states: “On and after Oct. 15, 2011, all paper bills for medical treatment provided by health care providers and health care facilities shall be submitted on billing forms set forth in the California Division of Workers’ Compensation Medical Billing and Payment Guide.” Title 8, Cal. Code of Regulations section 9792.5.0 defines “health care provider” as follows: “a provider of medical treatment, goods and services provided pursuant to Labor Code section 4600, including but not limited to a physician, a non-physician or any other person or entity who furnishes medical treatment, goods or services in the normal course of business.”

Medical-legal services are governed by Labor Code sections 4620 – 4628. Section 4620 subdivision (a) defines a medical-legal expense: “For purposes of this article, a medical-legal expense means any costs and expenses incurred by or on behalf of any party, the administrative director, the board, or a referee for X-rays, laboratory fees, other diagnostic tests, medical reports, medical records, medical testimony; and, as needed, interpreter's fees, for the purpose of proving or disproving a contested claim.”

The Division of Workers’ Compensation standardized billing regulations and the “Medical Billing and Payment Guide” may be accessed on DWC’s Web site. 

The text of the regulations and the “Medical Billing and Payment Guide” makes the provisions applicable to medical treatment bills. There is no language which requires a medical-legal bill to be submitted on the CMS 1500 form.