Bill the correct treating provider
The Colorado Division of Workers’ Compensation (DOWC) does not recognize “incident-to criteria” for advanced practice practitioners.
- The provider who renders the services must provide his or her name, credentials and NPI in Box 24-J of the CMS-1500 form as the treating provider, not the supervising physician.
- The supporting documentation should clearly indicate who performed the services.
Submit documentation for codes with no value
- Supply codes with no value (unlisted codes and by report) require a description on the CMS-1500 form and the supplier’s invoice to be processed for payment.
- Service codes with no value require a separate letter be submitted describing the service provided. The provider must submit medical records along with a suggested comparable code for the service rendered.
Bill appropriately for completing WC164 forms
- Only the authorized treating physician managing the injury can be paid for completing WC164 initial and closing reports (billed with codes Z0750 or Z0752).
- When the initial visit is performed in an emergency department or urgent care clinic, the facility may only be paid for submitting an initial report. Follow-up care must be provided in a medical office setting.
- Progress reports (Z0751) are only payable if Pinnacol requests the provider to complete the WC164 form as a progress report.
Use CPT codes from the prior year
- The DOWC is one year behind adopting new CPT and HCPC codes so always use the previous year’s CPT books for coding.
Don’t automatically rebill
- Pinnacol has 30 days to process a bill for payment once received.
- If you have not received payment after 30 days, log into the Pinnacol Provider Portal to see if the bill is listed. The portal will indicate the status of the bill and payment.
- If the bill is not listed on the portal, resend the bill through the normal channels.
Utilize the provider portal
Pinnacol’s provider portal gives you secure, convenient access to online resources. Once you register, you can:
- Check claims status
- Search bills, bill history, and print EOBs
- Appeal a bill and upload supporting documentation
- Search active Pinnacol policies
- Request bill summary, clinic designation, clinic profiling and opioid prescribing reports (not available to all providers)
- Email Claim and Medical Reviewers from the claims search
Submit an appeal
Per DOWC Rule 16, all appeals must be submitted within 60 days from the date of payment or denial. All bills can be appealed online through the provider portal. After logging in and locating the bill you want to appeal, follow these steps:
- Provide the reason for the appeal and any additional comments in the text box.
- Upload optional supporting documentation as an attachment or fax to 303.361.5820.
- A pop-up indicates the appeal was submitted.
- After submitting, you will receive an email confirming the bill appeal was received.
Pinnacol Assurance periodically reviews medical records to ensure the documentation requirements for billing are met.
Questions? Please contact us at billingsuccess@pinnacol.com or 303.361.4940.
