Mich. Admin. Code R. 418.10117 - Carrier responsibilities
Rule 117.
(1) The
carrier or its designated agent shall assure that a billing form is completed
properly before making payment to the licensed provider or licensed
facility.
(2) A carrier may
designate a third party to receive provider bills on its behalf. If a carrier
instructs the provider to send the medical bills directly to the third party,
then the 30-day limit of this rule begins when the third party receives the
bill. The carrier is responsible for forwarding bills and medical documentation
when there is a third party reviewing medical bills for the carrier.
(3) A carrier or designated agent shall make
payment of an unadjusted and properly submitted bill within 30 days of receipt
of a properly submitted bill or shall add a self- assessed 3% late penalty to
the maximum allowable payment or the provider's charge, whichever is less, as
required by these rules.
(4) A
carrier or designated agent shall record payment decisions on a form entitled
"Carrier's Explanation of Benefits" using a format approved by the workers'
compensation agency. The carrier or designated agent shall keep a copy of the
explanation of benefits and shall send a copy to the provider and to the
injured worker. The carrier's explanation of benefits shall list a clear reason
for the payment adjustment or amount disputed and shall notify the provider
what information is required for additional payment.
(5) A carrier or designated agent shall make
payment of an adjusted bill or portion of an adjusted bill within 30 days of
receipt of the properly submitted bill. If a carrier or designated agent
rejects a bill in its entirety, then the carrier or designated agent shall
notify the provider of the rejection within 30 days after receipt of a properly
submitted bill.
(6) If a carrier
requests the provider to send duplicated copies of the documentation required
in part 9 or additional medical records not required by these rules, then the
carrier shall reimburse the provider for the copying charges in accord with
R 418.10118.
(7) When the carrier has disputed a case and
has not issued a copy of the formal notice of dispute to the medical provider,
then the carrier's explanation of benefits shall be sent in response to the
provider's initial bill. The carriers' explanation of benefits shall serve as
notice to the provider that nonpayment of the bill is due to the
dispute.
Notes
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