114 CMR, § 40.04 - Provisions Affecting Eligible Providers

(1) Facility Rate. If a procedure other than those listed in 114.3 CMR 40.06 with a PC and TC fee is performed at a site other than the provider's office and is also properly billed by another health care provider, each provider will be reimbursed at 50% of the listed fee.

(2) Out-of-state Providers. An insurer may pay out-of-state provider for services at the payment rates set forth in 114.3 CMR 40.00.

(3) Individual Consideration (I.C.). Services that are authorized but for which there are no established rates are designated as I.C. items. The purchaser under M.G.L. c. 152 will determine an appropriate payment rate. Unless otherwise provided in 114.3 CMR 40.05, the payment will be determined in accordance with all of the applicable following standards and criteria:

(a) The amount of time required to perform the procedure,

(b) The degree of skill required to perform the procedure,

(c) The severity or complexity of the patient's disease, disorder or disability,

(d) The policies, procedures and practices of other third party insurers,

(e) A copy of the current invoice from the supplier for items if the provider cost exceeds $500.00. The provider is responsible for maintaining invoices for any items that cost less than $500.00 for a minimum of three years from the date of the original bill to the carrier.

(4) Utilization Standard. The DIA Healthcare Services Board publishes treatment guidelines pertaining to work place injury and illness that define appropriate care deemed medically necessary. All services provided under the Workers' Compensation Act must be delivered within the scope of these guidelines.

Notes

114 CMR, § 40.04