126.1 Each provider of medical care or services pursuant to the Act shall use a standard coding system for reports and bills generated pursuant to this chapter, in accordance with § 125.4.

126.2 Medical care and services shall be billed at the rate established in the medical fee schedule adopted by the Program. This fee schedule shall be based on one hundred-thirteen percent (113%) of Medicare's reimbursement amounts.

126.3 Unless the procedure is needed for emergency care, medical providers shall seek prior authorization in accordance to guidelines to be published by the Program.

126.4 Where a medical provider intends to bill for a procedure where prior authorization is required, that provider must request such authorization from the Program. All medical bills submitted to the Program lacking a required prior authorization will be automatically denied.

126.5 All charges for medical and surgical treatment, appliances or supplies furnished to injured employees, except for treatment and supplies provided by nursing homes, shall be supported by medical evidence as provided in § 125.2. The Program may withhold payment for services until such report or evidence is provided. The physician or provider shall itemize the charges on Form M1 (for professional services or medicinal drugs dispensed in the office), Form M2 (for hospitals), an electronic or paper-based bill that includes required data elements (for pharmacies) or other forms as warranted and accepted by the Program, and submit the form promptly to the Program.

126.6 No bill will be paid for expenses incurred if the bill is submitted more than one year beyond the end of the calendar year in which the expense was incurred or the service or supply was provided, or more than one year beyond the end of the calendar year in which the claim was first accepted as compensable by the Program, whichever is later.

SOURCE: Final Rulemaking published at 28 DCR 2307 (May 22, 1981); as amended by Emergency and Proposed Rulemaking published at 57 DCR 9540 (October 8, 2010)[EXPIRED]; as amended by Final Rulemaking published at 57 DCR 12224, 12229 (December 24, 2010); as amended by Final Rulemaking published at 59 DCR 8766, 8771 (July 27, 2012); as amended by Final Rulemaking published at 64 DCR 6325 (July 7, 2017).