Mont. Admin. r. 24.29.1534 - PROFESSIONAL FEE SCHEDULE
(1) An insurer must
pay the fee schedule or the billed charge, whichever is less, for a service
provided within the state of Montana. The fee schedules are available online at
the department's web site and are updated as soon as is reasonably feasible
relative to the effective dates of the medical codes as described below. All
current and prior instruction sets for services provided starting July 1, 2013,
are available on the department's website. The fee schedules are comprised of
the elements listed in
39-71-704, MCA, and the following:
(a) the conversion factors established by the
department in ARM
24.29.1538;
(b) modifiers, listed on the department's web
site;
(c) the Montana unique code,
MT001, described in (9);
(d) the
Montana unique code, MT003, adopted and described in ARM
24.29.1433; and
(e) the Montana unique code, MT009, for
referral to a vocational rehabilitation counselor for on-site job evaluation
with the injured worker to assist in returning him/her to work either to
his/her time of injury job or a new job/position.
(2) The conversion factors, the Current
Procedural Terminology (CPT) codes, and the relative value units (RVU) used
depend on the date the medical service, procedure, or supply is provided. The
reimbursement amount is generally determined by finding the proper CPT code in
the Resource-Based Relative Value Scale (RBRVS) then multiplying the RVU for
that code by the conversion factor.
(3) The insurer shall pay 100 percent of the
usual and customary charges for dental codes. The insurer shall pay a minimum
of 75 percent of the usual and customary charges for dental codes D6010 through
D6199.
(4) Where a permitted
procedure is not covered by these rules or uses a new code, the insurer must
pay 75 percent of the usual and customary fee charged by the provider to
nonworkers' compensation patients.
(5) The maximum fee that an insurer is
required to pay for a particular procedure is listed on the department web site
and was computed using the RVU in the total facility or nonfacility column of
the RBRVS times the conversion factor, except as otherwise provided for in
these rules.
(6) Professionals,
including those who furnish services in a hospital, critical access hospital,
ambulatory surgery center, or other facility setting must bill insurers using
the CMS 1500, with the exception of physical therapy, occupational therapy, and
speech therapy services provided on an outpatient basis and billed on a UB04.
Dental providers may bill insurers using the American Dental Association (ADA)
Dental Claim Form.
(7) Each
provider is to limit services to those which can be performed within the
provider's scope of license. For nonlicensed providers, the insurer is not
required to reimburse above the related CPT codes for appropriate
services.
(8) When billing the
services listed below, the Montana unique code, MT001, must be used and a
separate written report is required describing the services provided. The
reimbursement rate for this code is 0.54 RVUs per 15 minutes with time
documented by the provider. These requirements apply to the following services:
(a) face-to-face conferences with payor
representative(s) to update the status of a patient upon request of the payor;
(b) a report associated with
nonphysician conferences required by the payor;
(c) completion of a job description or job
analysis form requested by the payor; or
(d) written questions that require a written
response from the provider, excluding the Medical Status
Form.
(9) Where a service
is listed as "by report", the fee charged may not exceed the usual and
customary fee charged by the provider to nonworkers' compensation
patients.
(10) It is the
responsibility of the provider to use the proper procedure, service, and supply
codes on any bills submitted for payment. The failure of a provider to do so,
however, does not relieve the insurer's obligation to pay the bill, but it may
justify delays in payment until proper coding of the services provided is
received by the insurer.
(11)
Copies of the RBRVS are available from the publisher. Ordering information may
be obtained from the department.
Notes
AUTH: 39-71-203, MCA IMP: 39-71-704, MCA
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