(a) When services
are rendered by outpatient providers who are reimbursed under the Medicare Part
B Program pursuant to the Medicare fee schedule, the payment under the act
shall be calculated using the Medicare fee schedule as a basis. The fee
schedule for determining payments shall be the transition fee schedule as
determined by the Medicare carrier.
(b) The insurer shall pay the provider for
the applicable Medicare procedure code even if the service in question is not a
compensated service under the Medicare Program.
(c) If a Medicare allowance does not exist
for a reported HCPCS code, or successor codes, the provider shall be paid
either 80% of the usual and customary charge or the actual charge, whichever is
lower.
(d) When calculating payment
for all services rendered on and before December 31, 1995, all rate increases,
periodic adjustments and modifications incorporated into the Medicare Part B
Fee Schedule shall be used. The effective date of these changes under Medicare
shall also be the effective date of the fee changes under the act, as provided
in §
127.151 (relating to medical fee
updates prior to January 1, 1995-generally).
(e) Fee updates subsequent to December 31,
1994, shall be in accordance with §§
127.152 and
127.153 (relating to medical fee
updates on and after January 1, 1995-generally; and medical fee updates on and
after January 1, 1995-outpatient providers, services and supplies subject to
the Medicare fee schedule).
