Current Version Of CMS-1500 – The provider shall use the most current version of the CMS-1500

CMS-1500 Line-Item Number 24A (Date(s) of Service) – The provider should enter the beginning date of service in month, day, and year format. BWC will not accept any medical bill containing more than one (1) service date per line item. Line items that contain a different “From” and “To” date will be denied with the following: “EOB 269 – Payment is denied as BWC allows only one date of service per line item.”

CMS-1500 Line-Item Numbers 24I, 24J, 25 & 33 – The provider should pay special attention to instructions for completing line-item numbers 24I, 24J, 25, and 33, which are used in determining provider eligibility in bill processing and financial reporting to the IRS.

CMS-1500 Line-Item Numbers 14, 21, 24F, 24I, 24J, & 33B – The provider should complete the form in its entirety to ensure the provider follows the BWC-specific instructions for the items listed below (Note: The numbers listed below correspond with the line-item numbers on the form):

Registering National Provider Identifier – The provider must register the provider’s National Provider Identifier with BWC before submitting bills with National Provider Identifier. Billing a provider using the same National Provider Identifier for multiple locations must ensure that BWC has the accurate address information on file for each billing location.

Changing Provider Information In BWC Records – To make any changes, additions or corrections to the provider information as it is recorded in BWC’s records, the provider must submit a written request on company letterhead to Ohio BWC Provider Enrollment at fax number (614) 621-1333 or the following address:

Ohio BWC Provider Enrollment

P.O. Box 15249

Columbus, OH 43218-2031

Cross Reference ANSI X12 ASC 937 – Please use cross references to the ANSI X12 ASC 837 (i.e., American National Standard Institute (ANSI) X12 Accredited Standards Committee (ASC) 837 (i.e., standard format for transmitting health care claims electronically)) standard in the National Uniform Claim Committee (NUCC) instructions as the guideline for submitting electronic bills. Click here to obtain contact information for electronic transmission to the MCO.

Line Items:

Line-item Number 14 - Date of current illness, injury or pregnancy (LMP)

Line-item Number 21 - Diagnosis of nature of illness or injury: Enter the International Classification or Diseases-Clinical Modification (ICD-CM) code(s) that correspond(s) to the conditions treated, in accordance tich National Correct Coding guidelines. The billed diagnoses must be related to the services billed.

Line-item Number 24F - Charges: Enter your usual, customary and reasonable charge for the procedure performed. If more than one unit of service is billed, make sure your charges reflect this in the total.

Line-item Number 24I- ID qualifier (ID QUAL): If using the 11-digit BWC provider number, use qualifier G2 or LU in the non-National Provider Identifier qualifier field.

Line-item Number 24J- Rendering Provider ID #: The MCO and BWC can only accept one rendering provider ID per bill.

Line-item Number 33B- Other ID: Enter the billing provider’s 11-digit BWC Provider Number.

Hospital & UB-04 – BWC will only accept UB-04 form from a hospital. Other provider types that may be able to bill Medicare or Medicaid on a UB-04 should refer to the Provider Bill Type Form REquirements list noted in Section II of this chapter.

National Provider Identifier Number & BWC 11 Digit Provider Number – A hospital should use the UB-04 when submitting bills for workers’ compensation services.

The hospital may use the hospital’s National Provider Identifier number or BWC’s 11 digit provider number when billing.

Coding Clinic Of The American Hospital Association – A hospital must submit hospital bills in accordance with the correct coding guidelines per the CodingClinic of The American Hospital Association. Failure to do so may result in an incorrect reimbursement calculation.

Medical Documentation Requirements – See Chapter 2 medical documentation requirements.

Split Cycle Bills – Split cycle bills with overlapping dates of service will not be accepted.

UB-04 Line-Item Numbers 14, 21, 24F, 24I, 24J, & 33B – The provider should complete the form in its entirety ensuring that it follows the BWC-specific instructions for the items listed below (Note: The numbers listed below correspond with the line-item numbers on the form).