1. (1) The following approved standardized reimbursement forms shall be used by providers as indicated below. Each form shall be completed in its entirety and shall comply with the Alabama Maximum Fee Schedule coding, if available.

   1. (a) Providers: physicians; optometrists; chiropractors; durable medical equipment suppliers; diagnostic facilities; laboratory facilities; independently based speech therapy, physical therapy, and occupational therapy centers; home health providers; and other professional medical services. Professional medical services provided pursuant to Rule 480-5-5-.20(2)(e),e.g., medical doctors, physical therapists, etc.

      1. 1. Form: HCFA 1500 as currently revised with all subsequent revisions. Office notes and/or supporting documentation directly relating to the services provided are required to be attached to the HCFA 1500.

   2. (b) Providers: hospitals and ambulatory surgical centers. Hospital outpatient technical services or facility fees provided in support of professional services as stated in Rule 480-5-5-.20(2)(e).

      1. 1. Form: UB-92 as currently revised with all subsequent revisions and itemized billing.

   3. (c) Providers: licensed pharmacists dispensing pharmaceutical to their patients for pharmaceutical claims.

      1. 1. Form: The current Pharmacy Universal Claim Form or the National Council for Prescription Drug Programs (NCPDP) form and subsequent revisions or any form which contains the data as outlined in Rule 480-5-5-.21(2)(a)3.

   4. (d) Providers: dentists.

      1. 1. Form: J510 (ADS85) Dental Form as currently revised and all subsequent revisions with chart notes.
2. (2) This rule is not intended to and shall not be deemed to supersede any agreement or other arrangements between providers and payors for the submission of claims, medical records, and any other claims related data.

Author: Worker's Compensation Medical Services Board

Statutory Authority: Code of Ala. 1975, §§25-5-3 and 25-5-293.

History: New Rule: Filed August 9 1996; effective September 13, 1996. Amended: Filed February 25, 1998; effective April 30, 1998.