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Billing for providers new to workers’ compensation — FAQ

FAQ for medical providers who are billing for workers' compensation service for the first time.
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When medical providers are billing for workers' compensation service for the first time, they often have questions about the forms, codes, and payments. These frequently asked questions and answers provide resources and tips to assist you. 

I’ve been told I should bill on a CMS1500 form. Where can I find one?

CMS forms may be purchased online or you can download one here for free. Instructions for completing the forms are available online. Colorado workers’ compensation rules require the CMS1500 (formerly called HCFA) to be used to bill workers’ compensation services.

What is required on the CMS1500 form?

The CMS1500 should include the injured worker’s claim number, employer name, ICD10 codes, dates of service, place of service code, CPT/HCPCS/Z code(s), billed units, billed amounts, tax ID number, legible name and NPI. For more information, see CMS1500 do’s and don’ts here.

One of my claims came back with a denial: “Disallowed — we could not locate the claim number associated with this bill. Please verify this patient has an on-the-job injury claim filed with Pinnacol Assurance as the payer.” What do I do?

If you need to confirm which insurance covers the injured worker, you can go to the Colorado Division of Workers’ Compensation website, find “Insurance Coverage” and select "Verification of Coverage".

If Pinnacol is the insured but the claim has not been filed by the employer or there is no claim number assigned, refer to the instructions found here.

I received a denial stating my W-9 was not on file with Pinnacol. What is a W-9 and what should I do?

A W-9 is an IRS tax form that lists your taxpayer identification number, which tells Pinnacol how your company is registered and operating. Before Pinnacol can pay you, we must have your company’s W-9 in order to report to the IRS the payments made to you. You can find the form and instructions online here. Fax the completed W-9 form to Pinnacol at 303.361.5955.

What is the WC164 form? Where can I get this form?

The WC164 is a Colorado DOWC form used by the designated provider (authorized treating physician) to document the status, progress and medical treatment of an injured worker. The work status, limitations and follow-up care are documented along with the date of maximum medical improvement and any impairments. The report is required for initial and closing visits. A copy of the completed report is provided to Pinnacol and the injured worker. The form can be found on Colorado’s DOWC website.

I’ve never billed CPT codes before. How do I know which codes to bill?

CPT guidelines are updated yearly and can be purchased through the American Medical Association and other organizations. Many professional websites have codes and coding information available online. Additional billing and coding guidelines can be found in the Colorado DOWC Rule 18.

How much will you reimburse for my codes?

Colorado workers’ compensation has its own state fee schedule. Although many of the CPT codes used by Medicare and commercial insurance are the same, our fee schedule is unique. The fee schedule and instructions for looking up codes are on the Colorado DOWC website.

Where do I send my claim, and how long does it take before I get paid?

Bills must be submitted within 120 days from the date of service to meet the timely filing requirement. Paper claims can be submitted via fax to 303.361.5820 or 888.240.2389 or sent to Pinnacol Assurance, PO Box 469013, Denver, CO 80246. To get paid faster, we encourage you to bill electronically. Click here for more information on submitting electronic bills.

Per Colorado statute, bills must be processed within 30 days.

How can I follow up on my bill or appeal the determination on my bill?

To determine the status of a submitted bill, log in to the Provider Portal. In the portal you can check on the status of a bill or claim. Click here to register and click on “Register for the Provider Portal now.”

To file an appeal, you can submit the appeal online through the Provider Portal or fax the appeal to 303.361.5820.

Does workers’ comp allow “incident to” billing?

No, workers’ compensation billing does not follow Medicare or commercial guidelines for nonphysician practitioners. NPI numbers are required on the bill unless the provider is exempt from this requirement. The rendering provider’s NPI and place of service must be on the CMS1500. For the signature requirements and billing arrangements, click here.

For more assistance, please email billingsuccess@pinnacol.com or call 303.361.4940 or 888.852.2289.

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