Mich. Admin. Code R. 418.10108 - Definitions; A to I
Rule 108. As used in these rules:
(a) "Acquisition cost" means the provider's
purchase cost established by an invoice detailing the line-item cost to the
provider from a manufacturer or wholesaler net of any rebates or
discounts.
(b) "Act" means the
worker"s disability compensation act of 1969, 1969 PA 317, MCL
418.101 to
418.941.
(c) "Adjust" means that a carrier or a
carrier's agent reduces a healthcare provider's request for payment to the
maximum fee allowed by these rules, to a provider's usual and customary charge,
or, when the maximum fee is by report, to a reasonable amount. "Adjust" also
means when a carrier re-codes a procedure or reduces payment as a result of
professional review.
(d) "Agency"
means the workers' disability compensation agency.
(e) "Ambulatory surgical center" (ASC) means
an entity that operates exclusively for providing surgical services to patients
not requiring hospitalization and has an agreement with the centers for
Medicare and Medicaid services (CMS) to participate in Medicare.
(f) "Appropriate care" means healthcare that
is suitable for a particular individual, condition, occasion, or
place.
(g) "Biologics" or
"biologicals" include drugs or other products that are derived from life forms.
Biologics are biology-based products used to prevent, diagnose, treat, or cure
disease or other conditions in humans and animals. Biologics generally include
products such as vaccines, blood, blood components, allergenics, somatic cells,
genes, proteins, DNA, tissues, skin substitutes, recombinant therapeutic
proteins, microorganisms, antibodies, immunoglobins, and others, including, but
not limited to, those that are produced using biotechnology and are made from
proteins, genes, antibodies, and nucleic acids.
(h) "BR" or "by report" means that the
procedure is not assigned a relative value unit or a maximum fee and requires a
written description.
(i) "Carrier"
means an organization that transacts the business of workers' compensation
insurance in this state and that may be any of the following:
(i) A private insurer.
(ii) A self-insurer.
(iii) One of the funds in chapter 5 of the
act, MCL 418.501 to
418.561.
(iv) The Christopher R. Slezak first
responder presumed coverage fund.
(j) "Case" means a covered injury or illness
that occurs on a specific date and is identified by the worker's name and date
of injury or illness.
(k) "Case
record" means the complete healthcare record that is maintained by a carrier
and pertains to a covered injury or illness that occurs on a specific
date.
(l) "Complete procedure"
means a procedure that contains a series of steps that are not billed
separately.
(m) "Covered injury or
illness" means an injury or illness for which treatment is mandated by section
315 of the act, MCL
418.315.
(n) "Current Procedural Terminology (CPT)"
means a listing of descriptive terms and identifying codes and provides a
uniform nationally accepted nomenclature for reporting medical services and
procedures. The CPT codebook provides instructions for coding and claims
processing.
(o) "Custom compound"
means a customized topical medication prescribed or ordered by a duly licensed
prescriber for the specific patient that is prepared in a pharmacy by a
licensed pharmacist in response to a licensed practitioner"s prescription or
order, by combining, mixing, or altering of ingredients, but not
reconstituting, to meet the unique needs of an individual patient.
(p) "Dispute" means a disagreement between a
carrier or a carrier's agent and a healthcare provider on the application of
these rules.
(q) "Durable medical
equipment" means specialized equipment that is designed to stand repeated use,
is used to serve a medical purpose, and is appropriate for home use.
(r) "Emergency condition" means that a delay
in treating a patient would lead to a significant increase in the threat to the
patient's life or to a body part.
(s) "Established patient" means a patient
whose medical and administrative records for a particular covered injury or
illness are available to the provider.
(t) "Expendable medical supply" means a
disposable article that is needed in quantity on a daily or monthly
basis.
(u) "Facility" means an
entity licensed by this state pursuant to the public health code, 1978 PA 368,
MCL 333.1101 to
333.25211. The office of an
individual practitioner is not considered a facility.
(v) "Focused review" means the evaluation of
a specific healthcare service or provider to establish patterns of use and
dollar expenditures.
(w) "Follow-up
days" means the days of care following a surgical procedure that are included
in the procedure's maximum allowable payment, but does not include care for
complications. The health care services division shall provide the follow-up
days for surgical procedures separate from these rules on the agency's website,
www.michigan.gov/leo/bureaus-agencies/wdca.
(x) "Free standing outpatient facility"
(FSOF) means a facility, other than the office of a physician, dentist,
podiatrist, or other private practice, offering a surgical procedure and
related care that in the opinion of the attending physician can be safely
performed without requiring overnight inpatient hospital care.
(y) "Healthcare organization" means a group
of practitioners or individuals joined together to provide healthcare services
and includes any of the following:
(i) Health
maintenance organization.
(ii)
Industrial or other clinic.
(iii)
Occupational healthcare center.
(iv) Home health agency.
(v) Visiting nurse association.
(vi) Laboratory.
(vii) Medical supply company.
(viii) Community mental health
board.
(z)"Healthcare
review" means the review of a healthcare case or bill, or both, by a carrier,
and includes technical healthcare review and professional healthcare
review.
(aa) "Incidental surgery"
means a surgery that is performed through the same incision, on the same day,
by the same doctor of dental surgery, doctor of medicine, doctor of osteopathy,
or doctor of podiatry, that is not related to diagnosis.
(bb) "Independent medical examination" means
an examination and evaluation that is requested by a carrier or an employee,
that is conducted by a different practitioner than the practitioner who
provides care.
(cc) "Industrial
medicine clinic," also referred to as an "occupational health clinic," means an
organization that primarily treats injured workers. The industrial medicine
clinic or occupational health clinic may be a healthcare organization or may be
a clinic owned and operated by a hospital for the purposes of treating injured
workers.
(dd) "Insured employer"
means an employer who purchases workers' compensation insurance from an
insurance company that is licensed to write insurance in this state.
Notes
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