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Question | Answer |
---|---|
Form Name | Form Libc 9 |
Form Length | 2 pages |
Fillable? | No |
Fillable fields | 0 |
Avg. time to fill out | 30 sec |
Other names | printable libc 9 form, HCFA, LIBC-9, libc9 form |
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 |
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Name of Employer |
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Name of Insurer |
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Claim Number (if known) |
Date of Birth |
Employee SS# |
Date of Injury |
Date of Report |
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Provider Name |
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Provider Address |
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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
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
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.
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.
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
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
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