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Compensation for Occupational Injuries and Diseases Act, 1993 (Act No. 130 of 1993)

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Doctors Gazette 2024

7. COID Requirements with Billing for Medical Services provided to Injured/Diseased Employees

 

1. All service providers should be registered on The Compensation Fund claims processing system in order to capture medical invoices and medical reports.

 

2. Medical reports and medical invoices should ONLY be submitted/transmitted for claims that The Compensation Fund has accepted liability for and reasonable medical expenses are payable.

 

3. Medical Reports:

In terms of Sec 74(1)(2)(3)(4) and (5) of COID Act, submission of Medical Report; Medical service provider are advised to take note of the following:

a. The First Medical Report (W. CL 4), completed after the first consultation must confirm the clinical description of the injury/disease. It must also detail any procedure performed and any referrals to other medical service providers where applicable.
b. All follow up consultations must be completed on a Progress Medical Report (W.CL5). Any operation/procedure performed must be detailed therein and any referrals to other Medical Service Providers where applicable.
i. A progress medical report is considered to cover a period of 30 days, with the exception where a procedure was performed during that period, then an additional operation report will be required.
ii. Only one medical report is required when multiple procedures are done on the same service date.
c. When the injury/disease being treated stabilises, a Final Medical Report must be completed (W.CL 5F).
d. Medical Service Providers are required to keep copies of medical reports which should be made available to The Compensation Commissioner on demand.

 

4. Medical Invoices:
a. The ICD-10 validations will apply as per the national ICD-10 phase 3 and phase 4.1 requirements. Note that these phases were implemented on 01 July 2014 and entail the following:
i. Valid and ICD-10 codes as the SA ICD-10 Master Industry Table
ii. Maximum level of specificity: ICD-10 codes to be valid at the correct 3rd, 4th or 5th
iii. character level.
iv. Valid ICD-10 primary codes, codes not valid as primary will  be rejected
v. Comply with the dagger and asterisk rule
vi. Comply with the sequelae coding rules
vii. Age edits for ICD-10 codes that have age requirements
viii. Gender edits
ix. All injury and poisoning codes must be accompanied by external cause codes
b. The Compensation Fund allows the submission of invoices in 3 different formats:
i. Switching of invoices: Medical invoices should be switched to The Compensation Fund using the approved format/electronic invoicing file layout. It must be noted that the corresponding medical report must be uploaded online prior to the invoice data being switched, to avoid system rejections on receipt.
ii. Direct uploading of invoices onto the processing application (External APP): The processing system has an online guide available to guide Medical Service Providers for the direct uploading of invoice on the application.
iii. Receipt of manual invoices by Labour Centres.

The first two options are encouraged for ease of processing.

c. The progress of claims/invoices may be viewed on The Compensation Funds processing system.
d. If invoices are partially or wholly outstanding with no reason indicated after 60 days of submission, a medical service provider should enquire by completing an Enquiry Form W.CI-20 and submit it ONCE to nearest Labour Centre. Details regarding Labour Centres are available on the website (www.labour.gov.za)

 

5. When a Medical Service Provider claims an amount less than the published tariff amount for a code, The Compensation Fund will pay the claimed amount.

 

6. When a Medical Service Provider claims an amount more than the published tariff amount for a code, The Compensation Fund will pay the Gazetted amount.

 

7. Medical Service Provider are required to keep copies of medical invoices, medical report and any other claim documents and make these available to The Compensation Commissioner on request.

 

8. Medical Service Provider should not generate multiple invoices for services rendered on the same date i.e. one invoice for medication and the second invoice for other services.

 

NOTE:   Medical forms are available on the Department of Employment and Labour website (www.labour.gov.za)

• First Medical Report (W.CL 4)
• Progress/Final Medical Report (W.CL 5)