Workers' Compensation Knowledge Center

Alabama

How much time do you have to file?

• Initial bill: One year from date of service
• Appeal: One year from date of service

How is reimbursement calculated? 

• Inpatient: Per diem with a stop-loss for more higher-cost claims
• Outpatient: Percent of billed charges (based on a ratio given to each hospital)

How do payers reimburse for out-of-state patients?
The patient’s home state has jurisdiction.

How much time does the payer have to send payment?
25 days from receipt of clean claim or the payer faces a 10% penalty on the amount due.

• Alabama Self-Insurers Association (ASIA) – Workers’ compensation

Alaska

How much time do you have to file?

• Initial bill: 180 days from date of service
• Appeal: 60 days after receiving notice of denial

How is reimbursement calculated? 

• Inpatient: Medicare-based with hospital uplift (184%)
• Outpatient: Medicare-based
• Critical Access Hospital (CAH): 100% of billed charges
• Inpatient Rehab Facility (IRF): 100% of billed charges
• Long Term Care Hospital (LTCH): 100% of billed charges

How to bill for implants?

• Inpatient: Paid separately if the cost is above $25,000. Invoices are required for submission. Reimbursement amount is (invoice cost- 25,000) x 10%.
• Outpatient: Paid at cost x 10%.

How do payers reimburse for out-of-state patients? 
The jurisdiction with the lower expected payment is used.

How much time does the payer have to send payment?
30 days or the payer owes 25% in interest.

Arkansas

How much time do you have to file?

• Initial bill: Two years from date of injury
• Appeal: Two years from date of injury or one year from last payment

How is reimbursement calculated? 

• Inpatient: Paid by hospital peer group rates (per diem)
• Outpatient: Medicare-based

How to bill for implants?

• Inpatient and outpatient: Paid at 120% of cost. Invoices required.

How do payers reimburse for out-of-state patients? 
Arkansas rules apply.

How much time does the payer have to send payment? 30 days with 18% penalty.

• Arkansas Self-Insurers Association (ASIA) – Workers’ compensation

Arizona

How much time do you have to file?

• Initial bill: One year from date of service
• Appeal: 90 days from notice of denial

How is reimbursement calculated? 
There are no formal reimbursement rules. The amount paid for inpatient and outpatient medical services are based on what providers in the geographic area usually charge for the same or similar medical service.

How do payers reimburse for out-of-state patients? N/A

How much time does the payer have to send payment?
30 days with interest.

California

How much time do you have to file?

• Initial bill: 12 months from date of discharge
• Appeal: 30 days from receipt of EOB

How is reimbursement calculated? 

• Inpatient: 120% of Medicare
• Outpatient: 117.8% of Medicare

How to bill for implants?

• Inpatient and outpatient: Not reimbursable in most situations.

How do payers reimburse for out-of-state patients? 
Out-of-state hospitals are exempt from the CA fee schedule. The amount paid for inpatient and outpatient medical services are UCR based on what providers in the geographic area usually charge for the same or similar medical service.

How much time does the payer have to send payment?
45 working days (60 for government employees) at 25% penalty.

• California Applicants’ Attorneys Association (CAAA) – Workers’ compensation
• California Self-Insurers Association (CSIA) – Workers’ compensation
• California Workers’ Compensation Institute (CWCI)
• Commission on Health and Safety and Workers’ Compensation (CHSWC)
• State Compensation Insurance Fund (SCIF) – Workers’ compensation
• Workers’ Compensation Appeals Board (WCAB)
• Workers’ Compensation Insurance Rating Bureau (WCIRB)

Colorado

How much time do you have to file?

• Initial bill: 120 days from date of service
• Appeal: 60 days from written notice of denial

How is reimbursement calculated? 

• Inpatient: 185% of Medicare
• Outpatient: State specific modified APC tables (Medicare based)

How to bill for implants?

• Inpatient and outpatient: Not separately payable.

How do payers reimburse for out-of-state patients? 
Colorado rules apply.

How much time does the payer have to send payment?
30 days from receipt of clean claim.

• Pinnacol – Provider of workers’ compensation insurance

Connecticut

How much time do you have to file?

• Initial bill: 180 days from date of service
• Appeal: 60 days from EOB date

How is reimbursement calculated? 

• Inpatient: 174% of Medicare
• Outpatient: 210% of Medicare
• Non-hospital Ambulatory Surgery Center (ASC): 195% of Medicare

How to bill for implants?

• Inpatient and outpatient: Additional reimbursement given by exception only at 130% of cost.

How do payers reimburse for out-of-state patients? 
Usual, customary and reasonable.

How much time does the payer have to send payment?
28 days with a 20% penalty.

• Connecticut Workers’ Compensation Commission (CWCC)

Washington DC

How much time do you have to file?

• Initial bill: 1 year from date of injury
• Appeal: 60 days from EOB date

How is reimbursement calculated? 

• Inpatient and outpatient: 113% of Medicare

How to bill for implants?

• Inpatient and outpatient: Not separately paid

How do payers reimburse for out-of-state patients? 
Washington D.C. rules apply.

How much time does the payer have to send payment?
14 days at 10% penalty.

Delaware

How much time do you have to file?

• Initial bill: 30 days from discharge
• Appeal: N/A

How is reimbursement calculated? 

• Inpatient and outpatient: Medicare-based with percent of contingency

How to bill for implants?

• Inpatient and outpatient: N/A

How do payers reimburse for out-of-state patients? 
The jurisdiction with the lower expected payment is used.

How much time does the payer have to send payment?
30 days at 1% interest.

• Delaware Compensation Rating Bureau (DCRB) – Workers compensation

Florida

How much time do you have to file?

• Initial bill: N/A
• Appeal: N/A

How is reimbursement calculated? 

• Inpatient: Per diem
• Outpatient: Rate is based by county

How to bill for implants?

• Inpatient and outpatient: Paid separately at 130% of cost. Invoices required.

How do payers reimburse for out-of-state patients? 
Either by negotiation or hospital location.

How much time does the payer have to send payment?
45 days.

• Florida Self-Insurers Guaranty Association (FSIGA) – Workers compensation

Georgia

How much time do you have to file?

• Initial bill: 1 year from date of injury
• Appeal: 120 days from EOB

How is reimbursement calculated? 

• Inpatient and outpatient: Medicare-based

How to bill for implants?

• Inpatient and outpatient: Paid at cost. Invoices required.

How do payers reimburse for out-of-state patients? 
The patient’s home state has jurisdiction.

How much time does the payer have to send payment?
30 days with increasing penalties.

• Georgia Self-Insurers Guaranty Trust Fund (SIGTF) – Workers compensation
• Georgia State Board of Workers’ Compensation

Hawaii

How much time do you have to file?

• Initial bill: 2 years from date of injury
• Appeal: N/A

How is reimbursement calculated? 

• Inpatient and outpatient: Usual, Customary and Reasonable. Paid at billed charges.

How to bill for implants?

• Inpatient and outpatient: N/A

How do payers reimburse for out-of-state patients? 
There are no out-of-state rules in place.

How much time does the payer have to send payment?
60 days with a 1-5% penalty per month.

• Hawaii Employers Mutual Insurance Company (HEMIC) – Provider of workers’ compensation insurance

Iowa

How much time do you have to file?

• Initial bill: N/A
• Appeal: N/A

How is reimbursement calculated? 

• Inpatient and outpatient: Usual, Customary and Reasonable

How to bill for implants?

• Inpatient and outpatient: N/A

How do payers reimburse for out-of-state patients? 
There are no out of state rules in place.

How much time does the payer have to send payment?
There are no rules in place for payment deadlines and penalties.

Idaho

How much time do you have to file?

• Initial bill: 120 days from date of service
• Appeal: 30 days from EOB date of issue

How is reimbursement calculated? 

• Inpatient: DRG with outlier
• Outpatient: Medicare-based APC rate

How to bill for implants?

• Inpatient and outpatient: 110% of cost only if the cost exceeds $500.

How do payers reimburse for out-of-state patients? 
Idaho rules apply.

How much time does the payer have to send payment?
30 days. If missed, the payer is not allowed to dispute charges.

• Idaho State Insurance Fund (ISIF) – Provider of workers’ compensation insurance

Illinois

How much time do you have to file?

• Initial bill: N/A
• Appeal: N/A

How is reimbursement calculated? 

• Inpatient: DRG-based with trauma add-on and outlier
• Outpatient: Regional-based fee schedule

How to bill for implants?

• Inpatient and outpatient: 125% of cost with pass-through items paying at 65% of charges.

How do payers reimburse for out-of-state patients? 
The jurisdiction with the lower expected payment is used.

How much time does the payer have to send payment?
30 days at 1% interest.

Indiana

How much time do you have to file?

• Initial bill: N/A
• Appeal: N/A

How is reimbursement calculated? 

• Inpatient and outpatient: 200% of Medicare

How to bill for implants?

• Inpatient and outpatient: Not separately paid.

How do payers reimburse for out-of-state patients? 
Indiana rules apply.

How much time does the payer have to send payment?
90 days with no penalty.

• Indiana Compensation Rating Bureau (ICRB) – Workers’ compensation
• Indiana Workers’ Compensation Board
• Indiana Workers’ Compensation Institute (IWCI)

Kansas

How much time do you have to file?

• Initial bill: N/A
• Appeal: 30 days for first appeal and 60 days for second

How is reimbursement calculated? 

• Inpatient: DRG-based with trauma add-on or stop-loss
• Outpatient: Paid via peer group rates

How to bill for implants?

• Inpatient: If the cost is less than $5000, pay at 50% of cost. If the cost is greater than $5000, pay at 125% of cost.
• Outpatient: 125% of cost

How do payers reimburse for out-of-state patients? 

• Inpatient: Reimbursed via Peer Group 2 of the KS fee schedule
• Outpatient: Reimbursed at 80% of charges

How much time does the payer have to send payment?
60 days with no penalty.

• Kansas Division of Workers Compensation
• Kansas Self-Insurers Association (KSIA) – Workers’ compensation

Kentucky

How much time do you have to file?

• Initial bill: 45 days
• Appeal: 14 days from EOB date

How is reimbursement calculated? 

• Inpatient and outpatient: Paid via cost-to-charge ratio that is updated annually

How to bill for implants?

• Inpatient and outpatient: Not reimbursed separately

How do payers reimburse for out-of-state patients? 
Kentucky rules apply.

How much time does the payer have to send payment?
30 days.

Louisiana

How much time do you have to file?

• Initial bill: 1 year
• Appeal: 60 days

How is reimbursement calculated? 

• Inpatient: Per diem with stop-loss/outlier
• Outpatient: Lesser of state fee schedule reimbursement amount (MRA) or 90% of billed charges

How to bill for implants?

• Inpatient and outpatient: 120% of cost. Invoices required.

How do payers reimburse for out-of-state patients? 

A patient may receive medical services in Louisiana for injuries incurred in an out-of-state accident.

• If the patient is receiving treatment under the Workers’ Compensation Law of another state, the state fee schedule manual may not apply.
• If the patient is receiving care and treatment in Louisiana pursuant to the Louisiana Act, the reimbursement is subject to the requirements and amount of the manual regardless of the site of injury.

How much time does the payer have to send payment?
E-bill is 30 days. Any other bill is 60 days at 12% of balance or $50/day.

• Louisiana Association of Self Insured Employers (LASIE) – Workers’ compensation

Massachusetts

How much time do you have to file?

• Initial bill: 90 days from date of service
• Appeal: 12 months from date of service

How is reimbursement calculated? 

• Inpatient and outpatient: Percent of charges (hospital PAF)

• PAF is a state published hospital account factor. It represents the fee schedule amount for Massachusetts but the maximum they are obligated to pay if another rate hasn’t been established.

How to bill for implants?

• Inpatient and outpatient: Paid via PAF.

How do payers reimburse for out-of-state patients? 

The Massachusetts DIA Reviewing Board ruled in Tedeschi v. S&F Concrete, 6 Mass. Workers’ Comp. Rep. 120 (1992) that out-of-state providers are bound by the rates set by the Division.

1. Payment to out of state Acute Hospitals that provide inpatient services is based on the Acute Median PAF. If the Hospital is a Non-Acute Hospital the Non-Acute Median PAF will be used.
2. Payment is determined by multiplying the applicable PAF by total Charges for services.

How much time does the payer have to send payment?
There are no rules in place for payment deadlines and penalties.

• Massachusetts’ Department of Industrial Accidents (MDIA) – Workers’ compensation
• Massachusetts Workers’ Compensation Advisory Council (WCAC)
• Workers’ Compensation Rating and Inspection Bureau of Massachusetts (WCRIBMA)

Maryland

How much time do you have to file?

• Initial bill: N/A
• Appeal: N/A

How is reimbursement calculated? 

• Inpatient and outpatient: Each hospital admission is grouped into one of 320 APR-DRGs that classify patients into clinically cohesive categories based on their medical condition and the severity of their illness. The 320 APR-DRGs are separated into four “severity of illness” levels. The number of cases, the average charge per case, and the average charge per day by Maryland acute hospitals all impact charges.

• “Average Charge per Case” is the average charge for cases in the APR-DRG at each hospital after the charge has been weighted by the statewide severity distribution for the APR-DRG (this creates a severity-adjusted average charge). This average charge does not include physician fees.
• “Average Charge per Day” is the severity adjusted average charge divided by the average length of stay for patients in an APR-DRG at each hospital. Each hospital’s average charge can be affected by a number of factors, including: Patients’ severity of illness, Wage levels and the price of goods and services in its locality, The amount of teaching it does, the amount of uncompensated care it provides to patients.
• The above factors are reflected in the amount that Maryland hospitals are allowed to charge for services. In addition, the average charge for each APR-DRG is weighted by the statewide severity distribution for that category.

How to bill for implants?

• Inpatient and outpatient: Paid at cost plus shipping.

How do payers reimburse for out-of-state patients? 

• Inpatient: MD has stated they do not have jurisdiction over the reimbursement of out of state hospitals. We should either negotiate a payment or use the hospital’s home state fee schedule as a starting point for payment due.
• Outpatient: An out-of-State hospital, except a hospital located in the District of Columbia, shall be reimbursed per the MD fee schedule rules.

How much time does the payer have to send payment?
45 days.

Maine

How much time do you have to file?

• Initial bill: N/A
• Appeal: N/A

How is reimbursement calculated? 

• Inpatient: Payments for inpatient services in an acute care hospital are based on the MS-DRG system. The payment is calculated by multiplying the base rate times the MS-DRG weight.
• Outpatient: Payments for outpatient services in an outpatient hospital or an ambulatory surgical center are based on the APC system. The payment must be calculated by multiplying the base rate times the APC weight.

How to bill for implants?

• Inpatient and outpatient: Where an implant exceeds $10,000 in cost, acute care hospitals may seek additional reimbursement beyond the maximum allowable charge. Reimbursement is set at the actual amount paid plus 20% or $500.00, whichever is less. When an acute care hospital seeks additional reimbursement pursuant to this rule, the implantable charge is excluded from any calculation for an outlier payment. Handling and freight charges must be included in the acute care hospital’s invoiced cost and are not to be reimbursed separately.

How do payers reimburse for out-of-state patients? 
Maine rules apply.

How much time does the payer have to send payment?
30 days.

• Maine Workers’ Compensation Board (MWCB)

Michigan

How much time do you have to file?

• Initial bill: One year
• Appeal: N/A

How is reimbursement calculated? 

• Inpatient or observation care; Emergency department services; Occupational, physical, and speech therapy services; Outpatient surgeries; Laboratory services and outpatient services: The maximum payment ratio methodology (CCR) applies. If a carrier pays a properly submitted bill or unadjusted portion of the bill…

• …within 30 days of receipt, then the payment is calculated by multiplying the charges times the hospital’s maximum payment ratio times a multiplier of 107%.

• (Appropriate charges * hospital ratio for the date of service * 107%)

• …after 30 days, then the multiplier shall be 110% allowing for a 3% late fee.

• (Appropriate charges * hospital ratio for the date of service * 110%)

• If applying the ratio methodology results in an amount greater than the hospital’s charge, the carrier shall reimburse the hospital’s charge. The only time a carrier shall pay in excess of the charge is if a properly submitted bill was not paid within 30 days and, in that instance, the carrier shall reimburse the charge plus a 3% late fee.

How to bill for implants?

• Inpatient and outpatient: Not billed separately

How do payers reimburse for out-of-state patients? 
When a hospital outside the state of Michigan submits a bill for facility services, the carrier may initially process payment by using the method described in subrule (1) of this rule, applying the average maximum payment ratio, as published in the health care services manual. Subrule 1: If the facility located outside of Michigan does not accept reimbursement according to Michigan health care services rules, then the carrier shall negotiate the charges with the out-of-state facility or reimburse the facility according to the laws of the state where the facility is located.

How much time does the payer have to send payment?
30 days at 3% of the amount owed.

• Michigan Self-Insurers’ Association (MSIA) – Workers’ compensation

Minnesota

How much time do you have to file?

• Initial bill: 180 days from discharge
• Appeal: One year

How is reimbursement calculated? 

• Inpatient: 200% of Medicare with stop-loss exceptions
• Outpatient: CMS-based fee schedule

How to bill for implants?

• Inpatient and outpatient: Paid at 85% of hospital Usual, Customary and Reasonable

How do payers reimburse for out-of-state patients? 
Minnesota rules apply.

How much time does the payer have to send payment?
30 days or the payer owes 25% of the amount owed in penalties.

Missouri

How much time do you have to file?

• Initial bill: N/A
• Appeal: N/A

How is reimbursement calculated? 

• Inpatient and outpatient: Usual, customary and reasonable

How to bill for implants?

• Inpatient and outpatient: Usual, customary and reasonable

How do payers reimburse for out-of-state patients? 
There are no out of state rules in place.

How much time does the payer have to send payment?
There are no rules in place for payment deadlines and penalties.

• Missouri Self-Insurers Association (MSIA) – Workers’ compensation

Mississippi

How much time do you have to file?

• Initial bill: 30 days from date of service
• Appeal: 30 days from EOB date

How is reimbursement calculated? 

• Inpatient: 200% of Medicare
• Outpatient: Reimbursement for all hospital-based outpatient and freestanding ASC services are based on the APC system using relative weights and a base rate

How to bill for implants?

• Inpatient and outpatient: Not reimbursed separately.

How do payers reimburse for out-of-state patients? 
Mississippi rules apply.

How much time does the payer have to send payment?
30 days at 1.5% a month.

• Mississippi Workers’ Compensation Commission (MWCC)

Montana

How much time do you have to file?

• Initial bill: N/A
• Appeal: N/A

How is reimbursement calculated? 

• Inpatient: Paid via Montana DRG
• Outpatient: Paid via Montana APC system

How to bill for implants?

• Inpatient and outpatient: Implants costing less than $10,000 are bundled into the Montana MS-DRG reimbursement (invoices not required). If costs are more than $10,000, additional reimbursement is sought through Montana-specific code MT003. Invoices are required when seeking additional payment from the Montana MS-DRG and Outlier. Reimbursement is calculated at Cost + 15%.

How do payers reimburse for out-of-state patients? 
Montana rules apply.

How much time does the payer have to send payment?
60 days at $200 penalty.

Nebraska

How much time do you have to file?

• Initial bill: N/A
• Appeal: N/A

How is reimbursement calculated? 

• Inpatient and outpatient: Paid via tiered system based on hospital size

How to bill for implants?

• Inpatient and outpatient: 125% of cost

How do payers reimburse for out-of-state patients? 
Paid via tier one reimbursement rates.

How much time does the payer have to send payment?
30 days no penalty.

Nevada

How much time do you have to file?

• Initial bill: N/A
• Appeal: N/A

How is reimbursement calculated? 

• Inpatient: Per diem model
• Outpatient: State-specific fee schedule

How to bill for implants?

• Inpatient and outpatient: Between 120% and 140% of cost depending on implant type

How do payers reimburse for out-of-state patients? 
Nevada rules apply.

How much time does the payer have to send payment?
45 days from bill approval.

New Hampshire

How much time do you have to file?

• Initial bill: N/A
• Appeal: N/A

How is reimbursement calculated? 

• Inpatient and outpatient: Usual, customary and reasonable.

How to bill for implants?

• Inpatient and outpatient: Usual, customary and reasonable

How do payers reimburse for out-of-state patients? 
There are no out of state rules in place.

How much time does the payer have to send payment?
There are no rules in place for payment deadlines and penalties.

New Jersey

How much time do you have to file?

• Initial bill: 2 years
• Appeal: 2 years

How is reimbursement calculated? 

• Inpatient and outpatient: Usual, customary and reasonable. Hospital bills paid at billed charges or negotiated rate.

How to bill for implants?

• Inpatient and outpatient: Usual, customary and reasonable

How do payers reimburse for out-of-state patients? 
Exclusive jurisdiction for any disputed medical charge arising from any claim for compensation for a work-related injury or illness shall be vested in the division.

How much time does the payer have to send payment?
There are no rules in place for payment deadlines and penalties.

New Mexico

How much time do you have to file?

• Initial bill – inpatient: 60 days
• Initial bill – outpatient: 30 days
• Appeal: 30 days

How is reimbursement calculated? 

• Inpatient and outpatient: Paid via hospital specific ratio.

How to bill for implants?

• Inpatient and outpatient: 125% of cost. Invoices required.

How do payers reimburse for out-of-state patients? 
Paid via out of state hospital ratio (37% on 2023).

How much time does the payer have to send payment?
30 days.

• New Mexico Workers’ Compensation Administration (WCA)

New York

How much time do you have to file?

• Initial bill: 90 days from date of service
• Appeal: 60 days from EOB date

How is reimbursement calculated? 

• Inpatient and outpatient: 150% of Medicaid

How to bill for implants?

• Inpatient and outpatient: Not reimbursed separately.

How do payers reimburse for out-of-state patients? 
New York rules apply.

How much time does the payer have to send payment?
45 days with penalties to payer.

• New York Compensation Insurance Rating Board (NYCIRB) – Workers’ Compensation
• New York State Workers’ Compensation Board (NYSWCB)

North Carolina

How much time do you have to file?

• Initial bill: 75 days
• Appeal: 30 days

How is reimbursement calculated? 

• Inpatient: 160% of Medicare.
• Outpatient: 200% of Medicare.

How to bill for implants?

• Inpatient and outpatient: Not paid separately.

How do payers reimburse for out-of-state patients? 
Paid via location of provider.

How much time does the payer have to send payment?
60 days at 10%.

• North Carolina Self-Insurance Guaranty Association (NCSIGA) – Workers’ Compensation

North Dakota

How much time do you have to file?

• Initial bill: One year from date of service
• Appeal: 30 days from EOB date

How is reimbursement calculated? 

• Inpatient: Paid via Medicare DRG.
• Outpatient: Paid via Medicare APC rates.

How to bill for implants?

• Inpatient and outpatient: Not payable.

How do payers reimburse for out-of-state patients? 
North Dakota rules apply.

How much time does the payer have to send payment?
There are no rules in place for payment deadlines and penalties.

Ohio

How much time do you have to file?

• Initial bill: 1 year
• Appeal: 1 year

How is reimbursement calculated? 

• Inpatient and outpatient: Medicare-based fee schedule

How to bill for implants?

• Inpatient and outpatient: Not paid separately.

How do payers reimburse for out-of-state patients? 
Ohio rules apply with some U & C consideration.

How much time does the payer have to send payment?
30 days.

• Ohio Bureau of Worker’s Compensation (OBWC)
• Ohio Self-Insurers Association (OSIA) – Workers’ Compensation

Oklahoma

How much time do you have to file?

• Initial bill: N/A
• Appeal: N/A

How is reimbursement calculated? 

• Inpatient and outpatient: Medicare-inspired fee schedule published by Fair Health.

How to bill for implants?

• Inpatient and outpatient: Always paid separately at 105% of cost.

How do payers reimburse for out-of-state patients? 
Oklahoma rules apply.

How much time does the payer have to send payment?
45 days.

Oregon

How much time do you have to file?

• Initial bill: 60 days
• Appeal: N/A

How is reimbursement calculated? 

• Inpatient and outpatient: Paid via Oregon fee schedule rates published in bulletin 290.

How to bill for implants?

• Inpatient and outpatient: Not paid separately.

How do payers reimburse for out-of-state patients? 
Oregon rules apply.

How much time does the payer have to send payment?
45 days.

• Oregon Ombudsman for Injured Workers (OOIW) – Workers’ Compensation
• Oregon Self-Insurers Association (OSIA) – Workers’ Compensation
• Oregon Workers’ Compensation Board (OWCB)
• Oregon Workers’ Compensation Division (OWCD)

Pennsylvania

How much time do you have to file?

• Initial bill: N/A
• Appeal: N/A

How is reimbursement calculated? 

• Inpatient: Paid via PA 1994 version-12 DRG
• Outpatient: Paid via PA charge master
• Trauma claims: Paid at 100% of charges in PA

How to bill for implants?

• Inpatient and outpatient: Not paid separately

How do payers reimburse for out-of-state patients? 
Pennsylvania rules apply.

How much time does the payer have to send payment?
30 days at 10% interest.

• Pennsylvania Compensation Rating Bureau (PCRB) – Workers’ Compensation
• Pennsylvania Self-Insurers’ Association (PSIA) – Workers’ Compensation

• Rhode Island Division of Workers’ Compensation

South Carolina

How much time do you have to file?

• Initial bill: N/A
• Appeal: 2 years

How is reimbursement calculated? 

• Inpatient and outpatient: Paid at 140% of Medicare

How to bill for implants?

• Inpatient and outpatient: Not paid separately

How do payers reimburse for out-of-state patients? 
Rates should be negotiated.

How much time does the payer have to send payment?
30 days.

• South Carolina State Accident Fund – Workers’ Compensation

South Dakota

How much time do you have to file?

• Initial bill: N/A
• Appeal: N/A

How is reimbursement calculated? 

• Inpatient: Codes listed in appendix B of the FS paid at 80% of charges. Codes not listed paid at 100% of charges.
• Outpatient: Codes listed in appendix B of the FS paid at 80% of charges. Codes not listed paid at 100% of charges.

How to bill for implants?

• Inpatient and outpatient: Not paid separately

How do payers reimburse for out-of-state patients? 
Cannot exceed South Dakota rules.

How much time does the payer have to send payment?
30 days

• South Dakota Division of Labor and Management

Tennessee

How much time do you have to file?

• Initial bill: N/A
• Appeal: One year

How is reimbursement calculated? 

• Inpatient: Paid via per diem with stop-loss
• Outpatient: 150% of Medicare

How to bill for implants?

• Inpatient and outpatient: Not paid separately

How do payers reimburse for out-of-state patients? 
Tennessee rules apply.

How much time does the payer have to send payment?
30 days.

• Tennessee Workers’ Compensation Division

Texas

How much time do you have to file?

• Initial bill: 95 days from date of service
• Appeal: 10 months from date of service

How is reimbursement calculated? 

• Inpatient: 143% of Medicare if no request for separate implant reimbursement. !08% of Medicare if there is a request for separate reimbursement.
• Outpatient: 200% of Medicare if there is no request for separate implant reimbursement. 130% if there is a request for separate Implant reimbursement.

How to bill for implants?

• Inpatient and outpatient: N/A

How do payers reimburse for out-of-state patients? 
Texas rules apply.

How much time does the payer have to send payment?
45 days.

Utah

How much time do you have to file?

• Initial bill: 1 year
• Appeal: 1 year

How is reimbursement calculated? 

• Inpatient: Usual, Customary and Reasonable
• Outpatient: Usual, Customary and Reasonable

How to bill for implants?

• Inpatient and outpatient: N/A

How do payers reimburse for out-of-state patients? 
There are no out of state rules in place.

How much time does the payer have to send payment?
45 days for initial bill and 30 days for appeal payment.

• Utah Division of Industrial Accidents – Workers’ Compensation

Vermont

How much time do you have to file?

• Initial bill: N/A
• Appeal: N/A

How is reimbursement calculated? 

• Inpatient and outpatient: Paid at 83% of charges

How to bill for implants?

• Inpatient and outpatient: Not paid separately

How do payers reimburse for out-of-state patients? 
Vermont rules apply.

How much time does the payer have to send payment?
30 days.

• Vermont Workers’ Compensation Division

Virginia

How much time do you have to file?

• Initial bill: N/A
• Appeal: N/A

How is reimbursement calculated? 

• Inpatient and outpatient: Paid via regional fee schedule

How to bill for implants?

• Inpatient and outpatient: Implant Rev Codes 274-278 are payable but are required to have a CPT/HCPCS code listed with the Rev Code. They are paid at a percent of billed charges. No documents relating to the cost of the implant, such as the invoice, shall be required. If no CPT/HCPCS code is billed, then the allowed amount will be zero and a corrected claim should be requested unless the charges are already below our workable threshold.

How do payers reimburse for out-of-state patients? 
Virginia rules apply.

How much time does the payer have to send payment?
60 days.

• Virginia Workers’ Compensation Commission (VWCC)

Washington

How much time do you have to file?

• Initial bill: 1 year
• Appeal: 90 days

How is reimbursement calculated? 

• Inpatient and outpatient: Paid either via state fund or percent of allowed charge factor

How to bill for implants?

• Inpatient and outpatient: Paid via POAC. Invoices are required.

How do payers reimburse for out-of-state patients?
Paid via POAC factor of 64.2% of charges.

How much time does the payer have to send payment?
60 days.

West Virginia

How much time do you have to file?

• Initial bill: 180 days
• Appeal: N/A

How is reimbursement calculated? 

• Inpatient: Paid at 135% of Medicare
• Outpatient: Paid at 135% of Medicare

How to bill for implants?

• Inpatient and outpatient: Not paid separately

How do payers reimburse for out-of-state patients? 
West Virginia rules apply with exceptions.

How much time does the payer have to send payment?
There are no rules in place for payment deadlines and penalties.

• West Virginia Self-Insurers Association (WVSIA) – Workers’ Compensation
• West Virginia Workers’ Compensation Commission (WVWCC)

Wisconsin

How much time do you have to file?

• Initial bill: One year
• Appeal: Six to nine months, depending on situation

How is reimbursement calculated? 

• Inpatient: Paid either via certified database or WI DRG rate.

• Outpatient: Paid either via certified database or hospital locality.

How to bill for implants?

• Inpatient and outpatient: Not paid separately

How do payers reimburse for out-of-state patients? 
Wisconsin does not regulate out-of-state rates.

How much time does the payer have to send payment?
60 days.

Wyoming

How much time do you have to file?

• Initial bill: N/A
• Appeal: 15 days from EOB date

How is reimbursement calculated? 

• Inpatient and outpatient: 130% of Medicare

How to bill for implants?

• Inpatient and outpatient: 130% of cost

How do payers reimburse for out-of-state patients? 
Wyoming rules apply.

How much time does the payer have to send payment?
There are no rules in place for payment deadlines and penalties.

• Wyoming Workers’ Safety and Compensation Division