Form Libc 9 PDF Details

In the realm of workers' compensation, the prompt and accurate exchange of medical information between healthcare providers, employers, and insurers is crucial for the seamless processing of claims and ensuring that employees receive the necessary medical care without undue delay. The LIBC-9 form serves as a cornerstone in this exchange, functioning as the Workers’ Compensation Medical Report Form within Pennsylvania. This document is meticulously designed to be filed with the employer or their insurer, with clear instructions provided on the form itself to facilitate smooth operations. It captures essential information ranging from personal details of the employee, such as name, Social Security Number, and date of injury, to specifics about the employer and insurer, including the claim number if already known. Moreover, it outlines the obligations of healthcare providers to submit detailed documentation and billing information using designated forms, such as the HCFA Form 1500 or the UB92 Form, coupled with supporting documentation to substantiate the medical services rendered. The LIBC-9 also details the frequency and timelines for submission, emphasizing the necessity of submitting the initial report within ten days of commencing treatment, followed by monthly updates. Additionally, it addresses the legal consequences of non-compliance by providers and reinforces the confidentiality of patient information throughout the process. Instructions for completing support documentation and billing forms are also provided, ensuring clarity and compliance in the workers’ compensation claims process. This introduction to the Pennsylvania Department of Labor and Industry's form underscores its pivotal role in maintaining the integrity and efficiency of workers' compensation medical reporting and billing.

QuestionAnswer
Form NameForm Libc 9
Form Length2 pages
Fillable?No
Fillable fields0
Avg. time to fill out30 sec
Other namesprintable libc 9 form, HCFA, LIBC-9, libc9 form

Form Preview Example

WORKERS’ COMPENSATION MEDICAL REPORT FORM

THIS FORM IS TO BE FILED WITH THE EMPLOYER OR INSURER ACCORDING TO INSTRUCTIONS PROVIDED ON THIS FORM.

Name of Employee

 

Name of Employer

 

Name of Insurer

 

Claim Number (if known)

Date of Birth

Employee SS#

Date of Injury

Date of Report

 

Provider Name

 

Provider Address

 

Contact Person

Phone #

Health Care Providers shall complete and submit the appropriate HCFA billing form and needed documentation to the Employer. If the employer is covered by an insurer, the bill is to be sent to the insurer. The LIBC-9 form and required accompanying documentation shall be submitted within ten (10) days of commencing treatment and at least once a month thereafter, as long as treatment continues. If a provider does not submit the required medical reports in the prescribed format, the Employer/Insurer is not obligated to pay for such treatment until the required report is received by the Employer/Insurer.

Documentation should include (where pertinent) claimant’s history, diagnosis, description of treatment and services rendered, physical indings and prognosis including whether or not there has been recovery enabling the claimant to return to work with or without limitations, and speciic restrictions, if any, regarding return to work. Bills for follow-up visits should include progress/ofice notes to support diagnosis. (section 127.203 of the Act 44 regulations.)

Providers may not charge for documentation supporting a claim for payment. Providers may charge their usual fee for special reports speciically requested by the Employer/Insurer. All patient information shall be submitted with the knowledge of the patient and must be maintained as conidential by the Employer/Insurer. The insurance plan or program shall not be liable to pay for treatment until the report/claim form has been iled.

Listed on the reverse are guidelines for the completion of billing forms and submission of records.

LIBC-9 REV 7-04 (Page 1) COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF LABOR AND INDUSTRY BUREAU OF WORKERS’ COMPENSATION

BILLING FORM GUIDELINES:

Requests for payment of medical bills shall be made either on the HCFA Form 1500 or the UB92 Form, or any successor forms required by HCFA.

Cost-based providers shall submit a detailed bill including service codes consistent with the service codes submitted to the PA Bureau of Workers’ Compensation on the detailed charge master.

Until a health care provider submits bills on one of the forms speciied above, Employers/Insurers are not required to pay for the treatment billed.

HCFA forms must be signed or typed with the name of the provider. Name and signature (if signature is used) must match.

MEDICAL REPORT FORM GUIDELINES:

The LIBC-9 Medical Report Form is required to be submitted within 10 days of initial treatment and monthly thereafter. The Form must be accompanied by documentation to support the billing.

Suggested Supporting Documentation:

Physicians - Ofice notes

Physical/Occupational Therapists - Daily Treatment Records/Notes with Physician referral

Pharmacies - NDC#, amount dispensed, RX#

DME Vendor - Medicare/HCPC code, Certiicate of medical necessity

Chiropractors - Treatment notes

Ambulance providers - Medicare codes, notes/reports

X-ray/MRI Facilities - Reports

Lab Facilities - Test results

Anesthesia Services - ASA code, base/time units, Anesthesia Record

Hospitals - Records from area providing the service (e.g. Emergency, Outpatient Surgery...)

Inpatient Hospital Admissions - H&P, Discharge Summary, Operative Report (if applicable)

CORFs & Rehab Centers - Daily treatment notes, including physician orders

Ambulatory Surgery Centers - Notes and reports

General for all providers: Use most appropriate and speciic HCFA coding on billing.

When using miscellaneous codes, include detailed description of service.

FRAUD NOTICE: Filing misleading or incomplete information knowingly and with intent to defraud is in violation of Section 1102 of the Pennsylvania Workers’ Compensation Act and may also be subject to criminal and civil penalties through Pennsylvania Act 165 of 1994.

Auxiliary aids and services are available upon request to individuals with disabilities.

Equal Opportunity Employer/Program

LIBC-9 REV 7-04 (Page 2)