North Carolina > Workers Comp
Annual Consolidated Fiscal Report Of Medical Only Or Lost Time Cases 51 - North Carolina
| Annual Consolidated Fiscal Report Of Medical Only Or Lost Time Cases Form. This is a North Carolina form and can be used in Workers Comp . |
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North Carolina Industrial Commission ANNUAL CONSOLIDATED FISCAL REPORT OF Emp. Code #MEDICAL ONLY AND LOST TIME CASES Carrier Code # The Use Of This Form Is Required Under The Provisions of The Workers Compensation Act It is the responsibility of the Carrier, Self-Insured Employer, Group Self-Insured as certified by the N. C. Department of Insurance. and Statutory Self-Insured (State Agencies and Political Subdivisions) to submit a consolidated fiscal report yearly to the N.C. Industrial Commission on medical expenses paid without prior submission of the billings to the Commission, due to (1) the charges having been incurred in "medical only" cases, (2) application of the Commissions Fee Schedule by an approved firm, or (3) payment pursuant to a contract with a Managed Care Organization exempt from the Fee Schedule. An MCO, Third Party Administrator, or service company may file on behalf of these parties. A Form 51 covering the preceding July 1 - June 30 shall be submitted on or before July 30 of each year. Name and Code # of Carrier, Self-Insured Employer, Group Self-Insured as certified by the North Carolina Department of Insurance, or Statutory Self-Insured (State Agencies and Political Subdivisions) All Must Complete The Following 1. Total Number Of Medical Only Cases: 2. Total Amount Paid Medical Only Cases: $ Complete The Following Section Only If You Are A Managed Care Insurer Or Are Directly Applying The Industrial Commission Medical Fee Schedule To Submitted Medical Bills: (Exclude "Medical Only") 3. Total Number Of Lost Time Cases: 4. Total Hospital -- Outpatient paid: $ 5. Total Hospital -- Inpatient paid: $ 6. All other Providers, excluding Rehabilitation: $ 7. Total Amount Paid For Rehabilitation: $ 8. Total Medical Comp. Paid (Add lines 4-7): $ Address Of Submitting Office: REPORTING YEAR: JULY 1, 20 THROUGH JUNE 30, 20 MAIL TO: NCIC - S TATISTICS S ECTION 4334 MAIL S ERVICE CENTER FORM 51 R ALEIGH, NC 27699-4334 7/02 MAIN TELEPHONE: (919) 733-4820 PAGE 1 OF 1 FORM 51 OMBUDSMAN: (800) 688-8349
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