Mont. Admin. r. 24.29.1402 - PAYMENT OF MEDICAL CLAIMS
(1) Payment of
medical claims must be made in accordance with the schedule of facility and
professional medical fees adopted by the department.
(a) Payment of medical claims must also be
made in accordance with the utilization and treatment guidelines adopted by the
department in ARM Title 24, chapter 29, subchapter 16.
(b) The department may assess a penalty on
insurers for neglect or failure to use the correct fee schedule. It is the
insurer's responsibility to ensure that the correct fee schedule is used by a
third-party agent.
(c) A provider
of medical treatment or services shall only be paid for services under this
chapter if the bill for medical treatment or services is timely received by the
employer or appropriate payer. Absent a showing of good cause, a bill for
treatment or services is timely received by the employer or appropriate payer
when it is actually received within 365 days of the later of:
(i) the date of service; or
(ii) the date the provider of medical
treatment or services knew the treatment or services was related to a claim for
benefits under this chapter.
(2) The insurer shall make timely payments of
all medical bills for which liability is accepted. For services provided on or
after July 1, 2013, the department may assess a penalty on an insurer that
without good cause neglects or fails to pay undisputed medical bills on an
accepted liability claim within 60 days of receipt of the bill(s). The insurer
must document receipt date of the bill(s) or the receipt date will be three
days after the bill(s) was sent by the provider.
(3) For purposes of coding interest billing
on unpaid charges, providers must bill the interest amount using the Montana
unique code MT005 established by this rule.
(4) Payment of private room charges shall be
made only if ordered by the treating physician.
(5) Special nurses shall be paid only if
ordered by the treating physician.
(6) For claims arising on or after July 1,
1993, no fee or charge is payable by the injured worker for treatment of
injuries sustained if liability is accepted by the insurer, other than:
(a) the co-payment provided by
39-71-704, MCA. The decision
whether to require a co-payment rests with the insurer, not the medical
provider. If the insurer does not require a co-payment by the worker, the
provider may not charge or bill the worker any fee. The insurer must give
enough advance notice to known medical providers that it will require
co-payments from a worker so that the provider can make arrangements with the
worker to collect the co-payment;
(b) the charges for a nonpreferred provider,
after notice is given as provided in
39-71-1102, MCA;
(c) the charges for medical services obtained
from other than a managed care organization, once an organization is designated
by the insurer as provided in
39-71-1101, MCA; or
(d) the charges for medical services denied
by the insurer on the basis that the services meet both of the following
criteria:
(i) the medical services do not
return the injured worker to employment; and
(ii) the medical services do not sustain
medical stability.
(7) For compensable services provided on or
after July 1, 2013, if the injured worker pays for the initial medical service
prior to acceptance of the claim by the insurer, the injured worker must be
reimbursed the entire amount they paid out-of-pocket within 30 days of
acceptance.
(a) If the insurer pays the
provider, the provider must reimburse the injured worker.
(b) Otherwise, the insurer must reimburse the
injured worker.
Notes
AUTH: 39-71-203, MCA IMP: 39-71-107, 39-71-203, 39-71-510, 39-71-704, MCA
State regulations are updated quarterly; we currently have two versions available. Below is a comparison between our most recent version and the prior quarterly release. More comparison features will be added as we have more versions to compare.
No prior version found.