S.C. Code Regs. 67-1305 - Medical Bill Review

A. Upon receipt of a medical claim, the employer or carrier shall review the bill for compliance with the policies and maximum payments set forth by the Commission.

(1) An employer or insurance carrier who reviews medical claims for payment must apply to the Commission for approval to review and reduce medical bills. An employer who is not an approved reviewer may solicit the services of an approved bill reviewer, but may not rely on the Commission for bill review services.

(2) In cases where the billing involves unusual or complex circumstances the bill may be sent to the Commission's Medical Services Division for initial review.

(3) Whenever a charge is reduced to the Commission's maximum allowable payment, the reviewer shall include on the explanation of benefits (EOB) form a statement which explains the reduction and indicates the provider's right to appeal the reduction as outlined in subsections B and C.

B. A medical provider who disagrees, based on Commission payment policy, with a reduction may appeal the decision directly to the payer/reviewing entity.

C. If the disagreement cannot be resolved between the provider and the payer/reviewer, the matter may then be referred to the Commission's Medical Services Division for review and resolution.

(1) A provider or reviewer may request a review by submitting to the Medical Services Division:

(a) A cover letter outlining the dispute and stating the requesting party's position regarding the correct payment;

(b) A copy of the bill;

(c) A copy of the explanation of benefits (EOB); and

(d) Any supporting documentation.

(2) The Medical Services Division shall review the bill and supporting documentation, using its medical consultant as needed, and shall make a determination regarding correct payment.

(3) The decision of the Medical Services Division shall be final.

D. Any medical provider who discovers an incorrect payment within two years of the original billing date may resubmit the claim to the payer for the correct payment.

E. Any payer who discovers an overpayment made to a provider within two years of the original billing date may request a refund from that provider.

Notes

S.C. Code Regs. 67-1305

Amended by State Register Volume 21, Issue No. 6, Part 2, eff June 27, 1997.