Louisiana Administrative Code
Title 40 - LABOR AND EMPLOYMENT
Part I - Workers' Compensation Administration
Subpart 2 - Medical Guidelines
Chapter 51 - Medical Reimbursement Schedule
Section I-5111 - Billing Instructions

Universal Citation: LA Admin Code I-5111

Current through Register Vol. 50, No. 9, September 20, 2024

A. The HCFA 1500 Form is to be used by health care providers except dentist, pharmacy, hospital (unless otherwise stated), and for home and vehicle modifications for billing services provided to workers' compensation claimant. Do not use any other form. A sample HCFA 1500 Claim Form and detailed instruction for proper completion of the form follows.

B. Bills for services rendered should be sent directly to the party responsible for reimbursement. Please do not send your bills directly to the Office of Workers' Compensation as this will delay your payments.

C. Instructions for use of HCFA 1500 Form:

1. provide the claimant's full name and address;

2. indicate the Social Security number; this cuts down on errors and helps correlate the billing to the appropriate file;

3. identify correct date of injury, if possible;

4. complete name and address of the employer, not just an individual's name;

5. name of the insurance carrier;

6. the attending physician should indicate the date the claimant's disability should begin;

7. the attending physician should list all diagnoses and claimant's complaints;

8. the date of the visit, the service(s) or procedure(s) performed and charges;

9. provider's complete name and address;

10. provider's identification number, i.e., tax identification number (TIN) or Social Security number.

AUTHORITY NOTE: Promulgated in accordance with R.S. 23:1034.2.

Disclaimer: These regulations may not be the most recent version. Louisiana may have more current or accurate information. We make no warranties or guarantees about the accuracy, completeness, or adequacy of the information contained on this site or the information linked to on the state site. Please check official sources.
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