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Billing Guide

This Billing Guide outlines Utah’s workers' compensation billing requirements and DaisyBill’s resources for filing compliant medical bills.

Billing Form Requirements

This table is a guide to DaisyBill's resources on the required forms for compliant paper and electronic workers’ comp billing in Utah.

Forms

Services

DaisyBill Resources

CMS-1500 (HCFA)

Physician Services

Durable Medical Equipment

Dispensed Pharmaceuticals

CMS-1500 Instructions

UB-04

Facility

NCPDP

Pharmacy

ADA

Dental

Proprietary: [Form]

[Services]

[Form] Instructions

Reporting Requirements

This table is a guide to DaisyBill's resources on the reporting forms required for compliant paper and electronic workers’ comp billing in Utah.

Service

Attachment Description

Days until Due

 Form (PDF)

Initial Report

Physician's Initial Report of Injury

7 days

Form 123

When the employee is leaving the state

Attending Physician's Statement

When requested by employee

Form 043

Electronic Billing Mandate

The Utah Labor Commission has not issued electronic billing regulations or rules for medical bills. Accordingly, contact the payer to determine if workers’ comp bills can be submitted electronically.

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