This Billing Guide outlines California’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 DWC required forms for compliant paper and electronic workers’ comp billing in California.

Choosing the Correct Form

The California Division of Workers’ Compensation (DWC) uses four separate forms for paper billing, and bills submitted electronically use the equivalent electronic protocol to transmit the billing information.

The following are the four separate forms used for California workers’ comp billing:

1. Form CMS-1500 is for use by healthcare providers.
2. Form UB-04 or CMS-1450 is the NUBC health insurance claim form for use by health facilities and institutional care providers as well as home health providers.
3. The American Dental Association Dental Claim Form is for—you guessed it—dentists.
4. The NCPDP Workers’ Compensation/Property & Casualty Claim Form is the claim form adopted by the National Council for Prescription Drug Programs, Inc. for pharmacy bills for workers’ compensation.

It is important to use the correct version of each form, too. As an example, the DWC switched to a different version of CMS-1500 for bills issued on or after April 1, 2014. This updated form resembles the previous form. For the CMS-1500, check for the correct version number (02-12) on the bottom right corner:

Definition of a Complete Bill

To be complete, a bill submission must meet certain requirements set forth by the California Division of Workers’ Compensation (DWC). Per the California DWC Medical and Billing Payment Guide, complete bill submissions must include all of the following:

1. The correct form (if submitted on paper), or the correct format (if submitted electronically).
2. The correct UBC codes for the appropriate OMFS, including the correct ICD code.
3. Fields filled out according to the requirements for each format, as specified in Appendix A of the most recent CA DWC Medical Billing and Payment Guide and/or the Companion Guide to the same. See this article for more information on how to correctly fill out workers’ comp bills.
4. Required reports and supporting documentation.

State-Mandated Physician Reporting Requirements

California requires the physician to submit the following reports to document injured worker status.

Incomplete Bills Denied

A claims administrator may refuse to pay a bill if the bill is incomplete as defined by the DWC.  However, if a claims administrator determines that a bill is incomplete, it must return an Explanation Of Review (EOR) within 30 days which specifies any missing or invalid information.

Filling Out Work Comp Bills

daisyBill’s Revenue Cycle Management software walks users through the CMS-1500 or NCPDP form step-by-step to ensure completeness and compliance. Should you need to manually fill out a billing form, do not handwrite in fields for these forms. Instead, use a typewriter or printer for original bills. This is a DWC requirement.

The California’s Division of Workers’ Compensation has directions for filling out all the fields in work comp forms. Find these directions in the CA DWC Medical Billing and Payment Guide, on the Field Tables in Appendix A to Section One. There are four sections, each covering one of the standard paper billing forms.

Specifically:

Electronic Billing Mandate

The California Division of Workers’ Compensation regulates e-billing and paper billing in the state with rules in its Medical Billing and Payment Guide (PDF). Healthcare providers in the state have the option of filing either electronic bills or paper forms.

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