04 NCAC 10F .0107. COMMUNICATION BETWEEN HEALTH CARE PROVIDERS AND PAYERS

(a)  Any communication between the health care provider and the payer related to medical bill processing shall be of sufficient detail to allow the responder to easily identify the information required to resolve the issue or question related to the medical bill.  Generic statements that simply state a conclusion such as "payer improperly reduced the bill" or "health care provider did not document" or other similar phrases with no further description of the factual basis for the sender's position do not satisfy the requirements of this Rule.

(b)  When communicating with the health care provider, agent, or assignee, the payer may utilize the ASC X12 Reason Codes, or the NCPDP Reject Codes, to communicate with the health care provider, agent, or assignee.

(c)  Communication between the health care provider and payer related to medical bill processing shall be made by telephone or electronic transmission unless the information cannot be sent by those media, in which case the sender shall send the information by mail or personal delivery.

 

History Note:        Authority G.S. 97-26(g1); 97-80(a);

Eff. July 1, 2014.