Mich. Admin. Code R. 418.101203 - Carrier's technical health care review program
Rule 1203. Under the technical health care review program, the carrier shall do all of the following:
(a) Determine the accuracy of the procedure
coding. If the carrier determines, based upon review of the bill and any
related material which describes the procedure performed, that the procedure is
incorrectly or incompletely coded, then the carrier may re-code the procedure,
but shall notify the provider of the reasons for the recoding within 30 days of
receipt of the bill under part 13 of these rules.
(b) Determine that the amount billed for a
procedure does not exceed the maximum allowable payment established by these
rules. If the amount billed for a procedure exceeds the maximum allowable
payment, then the carrier shall reimburse the maximum allowable payment for
that procedure.
(c) Identify those
bills and case records which, under
R 418.101205, shall be subject to
professional health care review.
Notes
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