Medical Services Division
The Medical Division establishes and monitors billing and payment policies for medical services rendered to workers' compensation claimants and publishes the Medical Services Provider Manual. Division personnel are available Monday through Friday from 8:00 a.m. to 5:00 p.m. to answer questions pertaining to medical billing and payment policy.
Injured workers who have concerns about their medical care should contact the Claims Department at 803-737-5723.
Any appropriately-licensed medical provider who is authorized by the employer or insurance carrier may treat workers' compensation claimants. The Medical Services Provider Manual outlines billing and payment policy for physicians and other health care professionals, the current providers and the current schedule of fees. The fee schedule does not cover hospital charges, general dental, or services rendered outside of South Carolina.
Copies of the manual may be purchased for $60.00 each plus $3.60 South Carolina sales tax by sending a check payable to the South Carolina Workers' Compensation Commission at the following address:
S. C. Workers' Compensation Commission
Attn: Medical Services
P. O. Box 1715
Columbia, SC 29202-1715
Payments to Hospitals and Ambulatory Surgical Centers
Effective October 1, 2006,
healthcare facilities will be paid 40% more than what the federal Medicare program pays for inpatient and outpatient services.
The Hospital and Ambulatory Surgical Center Payment Manual describes the billing and payment policy for inpatient hospital stays and outpatient services rendered at a hospital or ambulatory surgical center.
The Hospital and Ambulatory Surgical Center Payment Manual is available for download in PDF format, or
contact the Medical Services Division for a printed copy at no charge.
Effective July 1, 1997, claims for inpatient hospital stays are paid according to a payment system based on diagnosis related groups (DRG). DRG is a system of classifying an inpatient stay based on the patient's diagnosis, medical condition and any procedures performed.
A software package called a DRG grouper is used to determine which of 300 DRG classifications best describes the inpatient stay. Once a DRG classification is assigned, payment is then made according to the methodology outlined in the Hospital and Ambulatory Surgical Center Payment Manual.
Insurance carriers and bill reviewers who do not possess a DRG grouper may submit inpatient hospital claims directly to the Medical Services Division for processing.
The latest DRG Updates are available on this site.
Effective July 1, 1997, claims for outpatient services rendered at a hospital or ambulatory surgical center are paid at a 12.1% discount to charge. When a patient remains in outpatient observation beyond 48 hours the claim is paid according to the inpatient DRG system.
To inquire about the status of a submitted claim, contact the insurance carrier or self-insured employer. If you are unsure who the insurance representative is, call the injured worker's employer or the Commission's Coverage Division at 803-737-5704.
A medical provider who disagrees with a review and payment should contact the insurance carrier or reviewing entity and attempt to resolve the dispute. If a dispute cannot be resolved by contacting the carrier or reviewing entity, the matter then may be referred to the Medical Services Division for review and resolution.
Contact Information
Kandee Johnson
803-737-5743
kjohnson@wcc.sc.gov
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