Free LIBC-9 REV 7-04.indd - Pennsylvania

WORKERS' COMPENSATION MEDICAL REPORT FORM
THIS FORM IS TO BE FILED WITH THE EMPLOYER OR INSURER ACCORDING TO INSTRUCTIONS PROVIDED ON THIS FORM. Name of Employee _______________________________________________________________ Name of Employer _______________________________________________________________ Name of Insurer _________________________________________________________________ _______________________________________________________________ Claim Number (if known)____________________________ Employee SS#_____________________________________ Date of Report_____________________________________ Provider Name __________________________________________________________________ _______________________________________________________________ Provider Address_________________________________________________________________ _______________________________________________________________ _________________________________________________________________ Contact Person ____________________________________ Phone #____________________ Date of Birth ________________ Date of Injury _______________

Health Care Providers shall complete and submit the appropriate HCFA billing form and needed documentation to the Employer. If the employer is covered by an insurer, the bill is to be sent to the insurer. The LIBC-9 form and required accompanying documentation shall be submitted within ten (10) days of commencing treatment and at least once a month thereafter, as long as treatment continues. If a provider does not submit the required medical reports in the prescribed format, the Employer/Insurer is not obligated to pay for such treatment until the required report is received by the Employer/Insurer. Documentation should include (where pertinent) claimant's history, diagnosis, description of treatment and services rendered, physical findings and prognosis including whether or not there has been recovery enabling the claimant to return to work with or without limitations, and specific restrictions, if any, regarding return to work. Bills for follow-up visits should include progress/office notes to support diagnosis. (section 127.203 of the Act 44 regulations.) Providers may not charge for documentation supporting a claim for payment. Providers may charge their usual fee for special reports specifically requested by the Employer/Insurer. All patient information shall be submitted with the knowledge of the patient and must be maintained as confidential by the Employer/Insurer. The insurance plan or program shall not be liable to pay for treatment until the report/claim form has been filed. Listed on the reverse are guidelines for the completion of billing forms and submission of records.

LIBC-9 REV 7-04 (Page 1) COMMONWEALTH OF PENNSYLVANIA

DEPARTMENT OF LABOR AND INDUSTRY

BUREAU OF WORKERS' COMPENSATION

BILLING FORM GUIDELINES: Requests for payment of medical bills shall be made either on the HCFA Form 1500 or the UB92 Form, or any successor forms required by HCFA. Cost-based providers shall submit a detailed bill including service codes consistent with the service codes submitted to the PA Bureau of Workers' Compensation on the detailed charge master. Until a health care provider submits bills on one of the forms specified above, Employers/Insurers are not required to pay for the treatment billed. HCFA forms must be signed or typed with the name of the provider. Name and signature (if signature is used) must match. MEDICAL REPORT FORM GUIDELINES: The LIBC-9 Medical Report Form is required to be submitted within 10 days of initial treatment and monthly thereafter. The Form must be accompanied by documentation to support the billing. Suggested Supporting Documentation: Physicians - Office notes Physical/Occupational Therapists - Daily Treatment Records/Notes with Physician referral Pharmacies - NDC#, amount dispensed, RX# DME Vendor - Medicare/HCPC code, Certificate of medical necessity Chiropractors - Treatment notes Ambulance providers - Medicare codes, notes/reports X-ray/MRI Facilities - Reports Lab Facilities - Test results Anesthesia Services - ASA code, base/time units, Anesthesia Record Hospitals - Records from area providing the service (e.g. Emergency, Outpatient Surgery...) Inpatient Hospital Admissions - H&P, Discharge Summary, Operative Report (if applicable) CORFs & Rehab Centers - Daily treatment notes, including physician orders Ambulatory Surgery Centers - Notes and reports General for all providers: Use most appropriate and specific HCFA coding on billing. When using miscellaneous codes, include detailed description of service. FRAUD NOTICE: Filing misleading or incomplete information knowingly and with intent to defraud is in violation of Section 1102 of the Pennsylvania Workers' Compensation Act and may also be subject to criminal and civil penalties through Pennsylvania Act 165 of 1994.

Auxiliary aids and services are available upon request to individuals with disabilities. Equal Opportunity Employer/Program
LIBC-9 REV 7-04 (Page 2)