North Carolina Administrative Code

SUBCHAPTER 23F –ELECTRONIC BILLING RULES SECTION .0100 –ADMINISTRATION 11 NCAC 23F .0101 Electronic Medical Billing and Payment Requirement Carriers and licensed health care providers shall utilize electronic billing and payment in workers' compensation claims. Carriers and healt…

11 NCAC 23F .0102 DEFINITIONS As used in this Subchapter: (1) "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 sw…

11 NCAC 23F .0103 Formats for Electronic Medical Bill Processing (a) Beginning March 1, 2014, electronic medical billing transactions shall be conducted using the electronic formats adopted under the Code of Federal Regulations, Title 45, part 162, subparts K, N, and P. Whenever …

11 NCAC 23F .0104 Billing Code Sets Billing codes and modifier systems identified below are valid codes for the specified workers' compensation transactions, in addition to any code sets defined by the standards adopted in 11 NCAC 23F .0103: (1) "CDT-4 Codes" that refers to the c…

11 NCAC 23F .0105 Electronic Medical Billing, Reimbursement, and Documentation (a) Payers and payer agents shall: (1) accept electronic medical bills submitted in accordance with the standards adopted in this Subchapter; (2) transmit acknowledgments and remittance advice in compl…

11 NCAC 23F .0106 Employer, Insurance Carrier, Managed Care Organization, or Agents' Receipt of Medical Bills from Health Care Providers (a) Upon receipt of medical bills submitted in accordance with the rules in this Subchapter, a payer shall evaluate each bill's conformance wit…

11 NCAC 23F .0107 Communication Between Health Care Providers and Payers (a) Any communication between the health care provider and the payer related to medical bill processing shall be of sufficient detail to allow the responder to easily identify the information required to res…

11 NCAC 23F .0108 Effective Date This Chapter applies to all medical services and products provided on or after March 1, 2014. For medical services and products provided prior to March 1, 2014, medical billing and processing shall be in accordance with the rules in effect at the …

SUBCHAPTER 23G – NORTH CAROLINA INDUSTRIAL COMMISSION RULES FOR MEDIATED SETTLEMENT AND NEUTRAL EVALUATION CONFERENCES SECTION .0100 – MEDIATION AND SETTLEMENT 11 NCAC 23G .0101 ORDER FOR MEDIATED SETTLEMENT CONFERENCE (a) Mediation Upon Agreement of the Parties. If the parties t…

11 NCAC 23G .0102 SELECTION OF MEDIATOR (a) By Agreement of Parties. The parties in a workers' compensation case or a state tort claims case may, by agreement, select a mediator certified by the North Carolina Dispute Resolution Commission within 55 days of the filing of a Form 3…

11 NCAC 23G .0103 THE MEDIATED SETTLEMENT CONFERENCE (a) Where Conference Is to Be Held. Unless all parties in a workers' compensation case or a state tort claims case and the mediator otherwise agree, the mediated settlement conference shall be held in the county where the case …

11 NCAC 23G .0104 DUTIES OF PARTIES, REPRESENTATIVES, AND ATTORNEYS (a) Attendance. The following persons shall attend the mediated settlement conference: (1) all individual parties; (2) in a workers' compensation case, a representative of the employer at the time of injury if: (…

11 NCAC 23G .0105 SANCTIONS (effective july 1, 2014) If a person or party whose attendance at a mediated settlement conference is required by Rule.0104 of this Subchapter fails to attend or cancels, without Commission approval in accordance with Paragraph (f) of Rule .0101 of thi…

11 NCAC 23G .0106 AUTHORITY AND DUTIES OF MEDIATORS (a) Control of Conference. The mediator shall at all times be in control of the mediated settlement conference and the procedures to be followed. Except as otherwise set forth in the Rules in this Subchapter with regard to the f…

11 NCAC 23G .0107 COMPENSATION OF THE MEDIATOR (a) By Agreement. When the mediator is stipulated to by the parties, compensation shall be as agreed upon between the parties and the mediator. (b) By Commission Order. When the mediator is appointed by the Commission, the mediator's…

11 NCAC 23G .0108 MEDIATOR CERTIFICATION AND DECERTIFICATION (a) Party Selection. The parties may, by mutual consent, select any North Carolina Dispute Resolution Commission-certified mediator, with or without the qualifications in Paragraph (b) of this Rule, as the parties' medi…

11 NCAC 23G .0109 NEUTRAL EVALUATION (a) Nature of Neutral Evaluation. As used in this Subchapter, neutral evaluation is an abbreviated presentation of facts and issues by the parties to a neutral evaluator at an early stage of the case. The neutral evaluator is responsible for e…

11 NCAC 23G .0110 WAIVER OF RULES In the interests of justice or to promote judicial economy, the Commission may, except as otherwise provided by the rules in this Subchapter, waive or vary the requirements or provisions of any of the rules in this Subchapter in a case pending be…

11 NCAC 23G .0111 MOTIONS Unless otherwise indicated by the Rules in this Subchapter or an applicable order by the Commission in the interests of justice or judicial economy, motions pursuant to the Rules in this Subchapter shall be addressed to the Commission's Dispute Resolutio…

11 NCAC 23G .0112 MISCELLANEOUS Throughout the Rules in this Subchapter any reference to the number of days within which any act may be performed shall mean and refer to calendar days, and shall include Saturdays, Sundays and holidays established by the State Personnel Commission…

SUBCHAPTER 23H – RULES OF THE INDUSTRIAL COMMISSION RELATING TO THE PUBLIC SAFETY EMPLOYEES' DEATH BENEFITS ACT section .0100 – administration 11 NCAC 23H .0101 LOCATION OF OFFICES AND HOURS OF BUSINESS For purposes of this Subsection, the offices of the North Carolina Industrial…

SECTION .0200 - RULES OF COMMISSION 11 NCAC 23H .0201 DETERMINATION OF CLAIMS BY THE COMMISSION (a) Upon application for an award under the provisions of the Public Safety Employees' Death Benefits Act, the Commission shall determine whether sufficient evidence is contained in th…

11 NCAC 23H .0202 HEARINGS BEFORE THE COMMISSION (a) The Commissioner or Deputy Commissioner before whom a case regarding the Public Safety Employees' Death Benefits Act is set for hearing, shall order the parties to participate in a pre-trial conference. This conference shall be…

11 NCAC 23H .0203 APPOINTMENT OF GUARDIAN AD LITEM (a) Infants or incompetents may bring an action under this Subchapter only through their guardian ad litem. The Commission shall appoint a person as guardian ad litem if the Commission determines it to be in the best interest of …

11 NCAC 23H .0204 WRITTEN OR RECORDED STATEMENT (a) Upon the request of the employer or his agent to take a written or a recorded statement in an action pursuant to Article 12A of Chapter 143 of the General Statutes, the employer or his agent shall advise any person eligible for …

11 NCAC 23H .0205 REVIEW BY THE FULL COMMISSION (a) A party may request a review of an award filed by a Deputy Commissioner in an action pursuant to Article 12A of Chapter 143 of the General Statutes by filing a letter expressing a request for review to the Full Commission within…

11 NCAC 23H .0206 WaIVER of Rules In the interests of justice or to promote judicial economy the Commission may, except as otherwise provided by the rules in this Subchapter, waive or vary the requirements or provisions of any of the rules in this Subchapter in a case pending bef…

SUBCHAPTER 23I - CHILDHOOD VACCINE-RELATED INJURY RULES OF THE NORTH CAROLINA INDUSTRIAL COMMISSION SECTION .0100 –ADMINISTRATION 11 NCAC 23I .0101 Locations of Offices and Hours of BUSINESS For purposes of this Subsection, the offices of the North Carolina Industrial Commission …

11 NCAC 23I .0102 OFFICIAL FORMS The use of any printed forms related to Childhood Vaccine-Related Injury claims, other than those provided by the Commission is prohibited, except that insurance carriers, self-insurers, attorneys and other parties may reproduce forms for their ow…

section .0200 – rules of commission 11 NCAC 23I .0201 PROCEDURE When a claim is filed in accordance with G.S. 130A-425(b), the respondent shall determine and report its position to the claimant and the Commission on the issues listed in G.S. 130A-426(a) within 90 days. If the res…

11 NCAC 23I .0202 ATTORNEYS' FEES An attorney seeking fees pursuant to G.S. 130A-427(a)(4) shall submit to the Commission a copy of the fee agreement, a request for payment of fee, and an affidavit or itemized statement in support of an award of attorneys' fees. History Note: Aut…

11 NCAC 23I .0203 WAIVER of Rules In the interests of justice or to promote judicial economy the Commission may, except as otherwise provided by the rules in this Subchapter, waive or vary the requirements or provisions of any of the rules in this Subchapter in a case pending bef…

11 NCAC 23I .0204 SANCTIONS (a) The Commission may, on its own initiative or motion of a party, impose a sanction against a party or attorney or both when the Commission determines that such party, or attorney, or both failed to comply with the Rules in this Subchapter. The Commi…

SUBCHAPTER 23J – FEES FOR MEDICAL COMPENSATION SECTION 0100 – FEES FOR MEDICAL COMPENSATION 11 NCAC 23J .0101 GENERAL PROVISIONS (a) Pursuant to G.S. 97-26, the Commission adopts a Medical Fee Schedule composed of maximum amounts, reimbursement rates, and payment guidelines, as s…

11 NCAC 23J .0102 FEES FOR PROFESSIONAL SERVICES (a) Except as otherwise provided in this Rule, maximum allowable amounts payable to health care providers for professional services shall be based on the current year's Medicare Part B Fee Schedule for North Carolina ("the Medicare…

11 NCAC 23J .0103 Fees for INSTITUTIONAL SERVICES [Effective April 1, 2015] (a) Except where otherwise provided, maximum allowable amounts for inpatient and outpatient institutional services shall be based on the current federal fiscal year's facility-specific Medicare rate estab…

section .0500 – rules of the commission 11 NCAC 23K .0501 WAIVER of Rules History Note: Authority G.S. 143-293; 143B-426.50; 143B-426.52(d); Temporary Adoption Eff. December 3, 2013 and shall expire on the earlier of the date all claims made under this section are finally adjudic…

SUBCHAPTER 23L – INDUSTRIAL COMMISSION FORMS SECTION .0100 – WORKERS’ COMPENSATION FORMS 11 NCAC 23L .0101 FORM 21 – AGREEMENT FOR COMPENSATION FOR DISABILITY (a) The parties to a workers' compensation claim shall use the following Form 21, Agreement for Compensation for Disabili…

11 NCAC 23L .0102 FORM 26 – SUPPLEMENTAL AGREEMENT AS TO PAYMENT OF COMPENSATION (a) If the parties to a workers' compensation claim have previously entered into an approved agreement on a Form 21, Agreement for Compensation for Disability, or a Form 26A, Employer's Admission of …

11 NCAC 23L .0103 FORM 26A – EMPLOYER'S ADMISSION OF EMPLOYEE'S RIGHT TO PERMANENT PARTIAL DISABILITY (EFFECTIVE DECEMBER 1, 2020) (a) The parties to a workers' compensation claim shall use the following Form 26A, Employer's Admission of Employee's Right to Permanent Partial Disa…

11 NCAC 23L .0104 FORM 36 – SUBPOENA (a) The parties to a claim shall use the following Form 36, Subpoena, to subpoena a person(s) to appear and testify and/or produce documents for inspection before the Commission. The Form 36, Subpoena, shall read as follows: STATE OF NORTH CAR…

11 NCAC 23L .0105 Form T-42 – Application for Appointment of Guardian Ad Litem (a) Persons seeking to appear on behalf of an infant or incompetent shall apply on a Form T-42, Application for Appointment of Guardian Ad Litem, in accordance with Rule 11 NCAC 23B .0203. The Form T-4…

subChapter 23M – RULES FOR THE UTILIZATION OF OPIOIDS, RELATED PRESCRIPTIONS, AND PAIN MANAGEMENT TREATMENT IN WORKERS' COMPENSATION CLAIMS section .0100 – GENERAL PROVISIONS 11 NCAC 23M .0101 PURPOSE AND APPLICABILITY OF THE RULES (a) The rules in this Subchapter address the uti…

11 NCAC 23M .0102 DEFINITIONS As used in this Subchapter: (1) "Acute phase" means 12 weeks of treatment for pain following an injury by accident, occupational disease, surgery for an injury by accident or occupational disease, or subsequent aggravation of an injury by accident or…

11 NCAC 23M .0103 WAIVER OF RULES In the interests of justice or to promote judicial economy, the Commission may, except as otherwise provided by the rules in this Subchapter, waive or vary the requirements or provisions of any of the rules in this Subchapter in a case pending be…

SECTION .0200 – UTILIZATION RULES FOR OPIOID AND OTHER PHARMACOLOGICAL PAIN MANAGEMENT TREATMENT 11 NCAC 23M .0201 FIRST PRESCRIPTION OF MEDICATION FOR PAIN in AN acute phase (a) This Rule applies to the first prescription of any medication to an employee for pain in an acute pha…

11 NCAC 23M .0202 PRESCRIPTION OF MEDICATION FOR PAIN IN AN ACUTE PHASE following the first prescription (a) This Rule applies to prescriptions for medication to an employee for pain during an acute phase that are written after a first prescription as described in Rule .0201 of t…

11 NCAC 23M .0203 PRESCRIPTION OF MEDICATION FOR PAIN IN A CHRONIC PHASE (a) This Rule applies to prescriptions for medication to an employee for pain during a chronic phase. (b) Before prescribing a targeted controlled substance, a health care provider shall document his or her …

SECTION .0300 – UTILIZATION RULES FOR OPIoid AntagonistS 11 NCAC 23M .0301 CO-PRESCRIPTION OF OPIOID ANTAGONIST (a) A health care provider prescribing a targeted controlled substance shall consider co-prescribing an opioid antagonist to the following: (1) employees taking benzodi…

SECTION .0400 – UTILIZATION RULES FOR non-PHARMACOLOGICAL TREATMENT FOR PAIN 11 NCAC 23M .0401 NON-PHARMACOLOGICAL TREATMENT FOR PAIN (a) A health care provider shall consider and may prescribe non-pharmacological treatments for pain. Examples of these treatments include the foll…