SECTION .1500 ‑ UNIFORM CLAIM FORMS

11 NCAC 12 .1501             DEFINITIONS

In this Section, unless the context indicates otherwise:

(1)           "CPT‑4 Codes" means the Physician Current Procedural Terminology published by the American Medical Association.

(2)           "Current ADA Dental Claim Form" means the most recent health insurance claim form published by the American Dental Association.

(3)           "Ethnic origin code" is the established Ethnic (Race) Code as used by the Economics and Statistics Administration, Bureau of Labor Statistics, U.S. Department of Commerce.

(4)           "CMS" means Centers for Medicare and Medicaid Services of the U.S. Department of Health and Human Services.

(5)           "CMS Form 1450 (UB-04)" means the health insurance claim form published by the CMS for use by institutional health care providers.

(6)           "CMS Form 1500" means the health insurance claim form published by the CMS for use by individual health care providers.

(7)           "HCPCS" means Healthcare Common Procedure Coding System, a coding system that describes products, supplies, procedures, and health care provider services; and includes the CPT‑4 Codes, alphanumeric codes, and related modifiers. HCPCS includes:

(a)           "HCPCS Level I Codes", which are the CPT‑4 codes and modifiers for professional services and procedures;

(b)           "HCPCS Level II Codes", which are national alphanumeric codes and modifiers for health care products and suppliers, as well as some codes for professional services not included in the CPT‑4 Codes;

(c)           "HCPCS Level III Codes", which are local alphanumeric codes and modifiers for items and services not included in HCPCS Level I or HCPCS Level II.

(8)           "ICD‑9‑CM Codes" means the diagnosis and procedure codes in the International Classification of Diseases, Clinical Modifications, published by the U.S. Department of Health and Human Services.

(9)           "Individual health care provider" includes any individual, who under Chapter 90 of the General Statutes is licensed, registered, or certified to engage in the practice of or performs duties associated with any of the following: medicine, surgery, dentistry, pharmacy, optometry, midwifery, osteopathy, podiatry, chiropractic, radiology, nursing, physiotherapy, pathology, anesthesiology, anesthesia, laboratory analysis, rendering assistance to a physician, dental hygiene, psychiatry, or psychology.

(10)         "Institutional health care provider" includes:

(a)           a hospital defined under G.S. 131E‑176(13);

(b)           an ambulatory surgical facility defined under G.S. 131E-176(1b);

(c)           a health service facility defined under G.S. 131E‑176(9b);

(d)           a home health agency defined under G.S. 131E‑176(12);

(e)           any of the entities listed in G.S. 58‑55‑35.

(11)         "Payor" means an entity that provides a "health benefit plan", as defined in G.S. 58‑3‑171(c).

(12)         "Standard claim form" means the CMS Form 1450 (UB-04), CMS Form 1500, or the current ADA Dental Claim Form.

History Note:        Authority G.S. 58‑2‑40; 58‑3‑171;

Eff. October 1, 1994;

Readopted Eff. May 1, 2020.