DEPARTMENT OF LABOR & INDUSTRY BUREAU OF WORKERS222 COMPENSATION WORKERS222 COMPENSATION002 MEDICAL REPORT FORM002 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 WCAIS claim number Date of birth Employee SS# XXX-XX-Date of injury Or WC ID number Date of report Provider name Provider address Contact person Telephone Health care providers shall complete and submit the appropriate HCFA billing form and needed American LegalNet, Inc. www.FormsWorkFlow.com 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/CMS. Forms must be signed or typed with the name of the provider. Name and signature (if signature is used) must match. Cost-based providers shall submit a detailed bill including service codes and rev codes consistent with the service codes and rev codes submitted to the Bureau of Workers222 Compensation on the detailed charge master. are not required to pay for the treatment billed. MEDICAL REPORT FORM GUIDELINES: This form must be submitted within 10 days of initial treatment and monthly thereafter, and must be accompanied by documentation to support the billing. Suggested supporting documentation: Physical/Occupational therapists 227 Daily treatment records/notes with physician referral Pharmacies 227 NCD#, amount dispensed, RX# Chiropractors 227 Treatment notes Ambulance providers 227 Medicare codes, notes/reports X-ray/MRI facilities 227 Reports Lab Facilities 227 Test results Anesthesia services 227 ASA code, base/time units, anesthesia record Hospitals 227 Records from area providing the service (e.g. emergency, outpatient surgery...) Inpatient hospital admissions 227 H&P, discharge summary, operative report (if applicable) CORFs & Rehabilitation Centers 227 Daily treatment notes, including physician orders Ambulatory surgery centers 227 Notes and reports When using miscellaneous codes, include detailed description of services. 77 P.S. 2471039.2, and may also be subject to criminal and civil penalties under 18 Pa. C.S.A. 2474117 (relating to insurance fraud). Employer Information Services 717.772.3702 Claims Information Services toll-free inside PA: 800.482.2383 local & outside PA: 717.772.4447 Hearing Impaired Email ra-li-bwc-helpline@pa.gov *9*002 Auxiliary aids and services are available upon request to individuals with disabilities.002 Equal Opportunity Employer/Program002 American LegalNet, Inc. www.FormsWorkFlow.com