Submission of Medical Reports
| • | In terms of section 74(1)-(5) of the Compensation for Occupational Injuries and Diseases Act, 1993 (COID Act), every Medical Service Provider shall submit the prescribed medical reports when claiming from the Compensation Fund. |
| • | The First Medical Report (W.CL 4), completed after the initial consultation, shall: |
| o | Confirm the clinical description of the injury or disease. |
| o | Detail all procedures performed; and |
| o | Record all referrals to other medical service providers, where applicable. |
| • | All follow up consultations shall be recorded on a Progress Medical Report (W.CL 5). Any procedure or operation performed during the reporting period shall be clearly detailed, including all referrals, where applicable. |
| • | A Progress Medical Report shall cover a maximum period of thirty (30) days, except where a procedure has been performed during that period, in which case an additional operation report shall be submitted. |
| • | Where multiple procedures are performed on the same date of service, only one medical report shall be submitted in respect of that service date. |
| • | Upon stabilisation of the injury or disease, a Final Medical Report (W.CL 5F) shall be completed and submitted |
| • | Medical Service Providers shall attach a medical report or other appropriate medical documentation to every claim submitted to the Compensation Fund. |
| • | Medical Service Providers shall retain copies of all submitted medical reports and shall make such records available to the Compensation Commissioner upon request. |
| • | With effect from 1 April 2025, ALL medical practitioners shall submit relevant patient records together with medical invoices for services rendered. (This includes hospitals, anaesthetists, and any other practitioners that have not previously been required to do so) |
Submission of Medical Invoices
| • | Medical invoices shall be submitted only in respect of claims for which liability has been formally accepted by the Compensation Fund and where payment of reasonable medical expenses has been authorised. |
| • | The submission of medical invoices without the required accompanying medical documentation shall be strictly prohibited and shall result in rejection of the invoice. |
| • | Duplicate invoices shall not be submitted under any circumstances. |
| • | Running accounts or statements shall not be accepted and shall be rejected at system level. |
Minimum Information Requirements for Medical Invoices
Every medical invoice submitted to the Compensation Fund shall, at a minimum, include the following information:
| • | The allocated Compensation Fund claim number. |
| • | The full name, surname, and identity number of the employee. |
| • | The name and Compensation Fund registration number of the employer, as reflected on the Employer's Report of Accident (W.CL 2); |
| • | The date(s) of service rendered. |
| • | The Medical Service Provider's BHF practice number. |
| • | The VAT registration number of the Medical Service Provider, where applicable. |
| • | The applcable tariff code(s) as published in the approved tariff gazettes. |
| • | The amount claimed per tariff code, quantity, total amount claimed including the correct sequencing of modifiers where applicable. |
| • | A unique invoice number. |
(Medical invoices that do not comply with the prescribed minimum information requirements shall be rejected and shall not be processed for payment).
VAT and Tariff Application
| • | Published tariff amounts shall be assessed exclusive of VAT. |
| • | VAT shall be applied only where the Medical Service Provider is a registered VAT vendor and has supplied a valid VAT registration number on the invoice. |
| • | Where no VAT registration number is provided, the Medical Service Provider shall be regarded as a non-VAT vendor and VAT shall not be applied. |
| • | Notwithstanding the above, the following tariffs shall be processed as VAT inclusive: |
| • | Per diem tariffs applicable to private hospitals; and |
| • | VAT exempt tariff codes applicable to private ambulance services. |
Pharmaceuticals and Referrals
| • | All pharmaceutical claims shall be submitted in accordance with the NAPPI file and shall be accompanied by the original prescription(s). |
| • | Where a referral is required, the referring practitioner's referral letter shall accompany the medical invoice. |
Enforcement and Non-Compliance
| • | The Compensation Fund shall withhold payment of any medical invoice that fails to comply with the billing and submission requirements prescribed in this document and as published in the Government Gazette. |
| • | Noncompliance with these billing requirements shall result in rejection of claims and may result in further remedial or enforcement action by the Compensation Fund. |
