(a) is submitted on a standard form prescribed by the Department based on the most recent Universal Billing (UB) form and Health Care Financing Administration (HCFA) 1500 billing form pursuant to 452 CMR 6.05;
(b) is signed by the provider, as defined in 452 CMR 6.02, performing such service (or by that provider's authorized representative or signature stamp), accompanied by a detailed description of the service rendered, the name and licensure number of the provider performing such service, as required by MGL c. 152, § 13; where the request for reimbursement is for hospital outpatient services, including but not limited to, restorative services, the signature, name, and licensure number of the practitioner, as defined in 452 CMR 6.02, actually performing the service shall be placed on the detailed description accompanying the request, and
(c) contains, at a minimum, the following:
1. employee name,
2. date of injury,
3. date(s) of service,
4. itemized services rendered,
5. where applicable, International Classification of Diseases-9 (ICD-9) code(s), diagnosis code(s), Current Procedural Terminology (CPT) code(s), administrative and all other procedure code(s) promulgated by the Rate Setting Commission,
6. in the case of restorative and chiropractic services, the applicable Current Procedural Terminology (CPT) code(s) for utilization descriptive purposes; and applicable charges for each service.
Standard Workers' Compensation Premium , as used in MGL c. 152, § 65 and 452 CMR 7.00, shall mean the direct written premium equal to the product of payroll by class code and the currently applicable manual rates multiplied by any applicable experience modification factor.