11 NCAC 23F .0102          DEFINITIONS

As used in this Subchapter:

(1)           "Clearinghouse" means a public or private entity, including a billing service, repricing company, community health management information system or community health information system, and "value-added" networks and switches, that is an agent of either the payer or the provider and that may perform the following functions:

(a)           Processes or facilitates the processing of medical billing information received from a client in a nonstandard format or containing nonstandard data content into standard data elements or a standard transaction for further processing of a bill related transaction; or

(b)           Receives a standard transaction from another entity and processes or facilitates the processing of medical billing information into nonstandard format or nonstandard data content for a client entity.

(2)           "Complete electronic bill" submission means a medical bill that meets all of the criteria enumerated in this Subchapter.

(3)           "Electronic" refers to a communication between computerized data exchange systems that complies with the standards enumerated in this Subchapter.

(3)           "Health Care Provider" is as set forth in G.S. 97-2(20).

(4)           "Health Care Provider Agent" is a person or entity that contracts with a health care provider establishing an agency relationship to process bills for services provided by the health care provider under the terms and conditions of a contract between the agent and health care provider. Such contracts may permit the agent to submit bills, request reconsideration, receive reimbursement, and seek medical dispute resolution for the health care provider services.

(5)           "Implementation guide" is a published document for national electronic standard formats as defined in this Subchapter that specifies data requirements and data transaction sets.

(6)           "National Provider Identification Number" or "NPI" means the unique identifier assigned to a health care provider or health care facility by the Secretary of the United States Department of Health and Human Services.

(7)           "Payer" means the insurance carrier, third-party administrator, managed care organization, or employer responsible for paying the workers' compensation medical bills.

(8)           "Payer agent" means any person or entity that performs medical bill related processes for the payer responsible for the bill.  These processes include reporting to government agencies, electronic transmission, forwarding or receipt of documents, review of reports, adjudication of bill, and final payment.


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

Eff. January 1, 1996;

Recodified from 04 NCAC 10F .0101 Eff. July 1, 2014;

Amended Eff. July 1, 2014;

Recodified from 04 NCAC 10F .0102 Eff. June 1, 2018.