Haw. Code R. § 16-23-115 - Workers' compensation medical fee schedule
(a)
Charges for medical services shall not exceed one hundred ten per cent of
participating fees prescribed in the Medicare Resource Based Relative Value
Scale System applicable to Hawaii (Medicare Fee Schedule) or Exhibit A at the
end of Title 12, Chapter 15, entitled "Workers' Compensation Supplemental
Medical Fee Schedule" (Exhibit A). The Medicare Fee Schedule and Exhibit A,
together herein referred to as the "medical fee schedule," is made a part of
this chapter and shall be used to determine the maximum allowable fees using
the procedure codes and unit values established by the department of labor and
industrial relations pursuant to section
386-21,
HRS. Any subsequent amendment by the department of labor and industrial
relations to the Medicare fee schedule and Exhibit A, shall be incorporated
into this chapter by reference.
(b)
If the maximum allowable fees for medical services are listed in both the
Medicare Fee Schedule and Exhibit A, charges shall not exceed the maximum
allowable fees allowed under Exhibit A.
(c) For the purposes of this section "private
patient" means a patient not covered by insurance. If the charges are not
listed in the medical fee schedule or in Exhibit A, the health care provider
shall charge a fee not to exceed eighty per cent of the health care or
alternative care provider's usual and customary fee for the same service
rendered to a private patient. Upon request by the insurer, a health care or
alternative care provider shall submit a statement itemizing the lowest fee
charged for the same health care, services, and supplies furnished to any
private patient during a one-year period preceding the date of the particular
charge. Requests shall be submitted in writing within twenty calendar days of
receipt of a charge allegedly in excess of the allowable amount. The health
care or alternative care provider shall reply in writing within ten calendar
days of receipt of the request. Failure to comply with the request of the
insurer shall be reason for the insurer to deny payment.
(d) Fees listed in the Medicare Fee Schedule
shall be subject to the current Medicare Fee Schedule correct coding initiative
("CCI") and follow-up rules. The Health Care Financial Administration Common
Procedure Coding System alphabet codes adopted by Medicare shall not be allowed
unless specifically adopted by the director of labor.
Notes
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