NDAC 92-01-02-48
Elements of filing
Cite as N.D. Admin. Code § 92-01-02-48
1.
For purposes of this section, unless the context otherwise requires:
a.
"Appropriate record" means a legible medical record or report from a provider, or any
other relevant and material information, substantiating the type, nature, extent, and
work-relatedness of an injury, which is adequate to verify the level, type, and extent of
services provided.
b.
"Bill" means a provider's statement of charges and services rendered for treatment of a
work-related injury.
c.
"Bill review" means the review or audit of medical bills and any associated medical
records by workforce safety and insurance and may include review for duplications,
omissions, actual delivery of billed services and items, accuracy of charges and
associated coding, and improper concurrent bills for services involving evaluation or
treatment of work-related and non-work-related problems.
d.
"Wage verification" means federal and state income tax returns; W-2 forms; daily, weekly,
biweekly, semimonthly, or monthly employer payroll statements; and income statements
prepared in accordance with generally accepted accounting practices.
2.
The elements of filing for an application for workers' compensation benefits are satisfied when
the organization has received:
a.
The first report of injury form completed and signed by the injured employee or someone
acting on the injured employee's behalf. The employer's report may be deemed admitted
pursuant to North Dakota Century Code sections 65-01-16 or 65-05-01.4;
b.
Wage verification as requested by the organization, if disability benefits are claimed; and
c.
Appropriate records from the provider necessary to determine the type, nature, extent,
and potential work-relatedness of the injury or disability.
3.
The elements of filing for a reapplication are satisfied when the organization is in receipt of:
a.
The C4 form or other correspondence requesting benefits signed by the employee;
b.
Wage verification as requested by the organization, if disability benefits are claimed; and
c.
Appropriate records from the provider.
4.
The elements of filing for payment of a medical bill are satisfied when a bill review is
completed and after the organization has received:
a.
A bill from the provider or employee; and
b.
Appropriate records from the provider or employee.
5.
If the organization requests additional information from the employee needed to process an
application or a reapplication and the employee does not provide the information, elements of
filing are not satisfied until the employee provides the requested information.
6.
The organization may waive elements of filing in conjunction with programs established for the
expedited processing of selected claims.