reglab/statecodes huggingface dataset:
Michigan Administrative Code › Department - Labor and Economic Opportunity › Workers Compensation Agency › Workers' Compensation Health Care Services Rules › Part 9 - BILLING › Subpart A - PRACTITIONER BILLING › Section R. 418.10923 - Hospital billing for practitioner services

Current through Vol. 24-12, July 15, 2024
Rule 923.
(1) A
					 hospital billing for practitioner services, including a certified registered
					 nurse anesthetist, a certified anesthesiologist assistant, a physician, a nurse
					 who has a specialty certification, and a physician's assistant, shall submit
					 bills on a CMS 1500 form and the hospital shall use the appropriate procedure
					 codes adopted by these rules. A hospital shall bill for professional services
					 provided in the hospital clinic setting as practitioner services on a CMS 1500
					 form using outpatient hospital for the site of service. A hospital or hospital
					 system-owned office practice shall bill all office services as practitioner
					 services on a CMS 1500 form using office or clinic for the site of service. A
					 hospital or hospital system-owned industrial or occupational clinic providing
					 occupational health services for injured workers shall bill all clinic services
					 as practitioner services on a CMS 1500 using office or clinic for the site of
					 service. A hospital or hospital system-owned industrial or occupational clinic
					 shall not use emergency department evaluation and management procedure codes.
					 Radiology and laboratory services may be billed as facility services on the
					 UB-04.
(2) A hospital billing for
					 the professional component of a medical service, excluding physical medicine,
					 occupational medicine, or speech and hearing services shall bill the service on
					 a CMS 1500 claim form adding modifier -26 identifying the bill is for the
					 professional component of the service. The bill shall indicate outpatient
					 hospital for the site of service. The carrier shall pay the maximum allowable
					 fee listed in the manual for the professional component of the procedure. If
					 the professional component is not listed, then the carrier shall pay 40% of the
					 maximum allowable fee.
(3) A
					 hospital billing for a radiologist's or pathologist's services shall bill the
					 professional component of the procedure on the CMS 1500 claim form and shall
					 place modifier -26 after the appropriate procedure code to identify the
					 professional component of the service. The carrier shall pay the maximum
					 allowable fee listed in the manual for the professional component of the
					 procedure. If the professional component is not listed, then the carrier shall
					 pay 40% of the maximum allowable fee.
(4) A hospital billing for a certified
					 registered nurse anesthetist or certified anesthesiologist assistant shall bill
					 only time units of an anesthesiology procedure and use modifier -QX with the
					 appropriate anesthesia code, except when billing for a certified registered
					 nurse anesthetist in the absence of medical direction from a supervising
					 anesthesiologist.
Michigan Administrative Code › Department - Labor and Economic Opportunity › Workers Compensation Agency › Workers' Compensation Health Care Services Rules › Part 9 - BILLING › Subpart A - PRACTITIONER BILLING › Section R. 418.10923b - Billing for ambulatory surgery center (ASC) or freestanding surgical outpatient facility (FSOF)

Current through Vol. 24-12, July 15, 2024
Rule 923b.
(1)
					 An ASC or FSOF shall be licensed by the Michigan department of licensing and
					 regulatory affairs under part 208 of the code or if it has an agreement with
					 the centers for Medicare and Medicaid services (CMS) to participate in
					 Medicare. The owner or operator of the facility shall make the facility
					 available to other physicians, dentists, podiatrists, or providers who comprise
					 its professional staff. The following apply:
(a) When a surgery procedure is appropriately
					 performed in the ASC or FSOF and CMS has not assigned a payment code for that
					 procedure, the procedure shall be considered BR.
(b) The ASC or FSOF shall be reimbursed the
					 maximum allowable paid for the payment code, taking into consideration the
					 multiple procedure rule for facilities as defined by CMS.
Michigan Administrative Code › Department - Labor and Economic Opportunity › Workers Compensation Agency › Workers' Compensation Health Care Services Rules › Part 9 - BILLING › Subpart A - PRACTITIONER BILLING › Section R. 418.10925 - Billing requirements for other licensed facilities

Current through Vol. 24-12, July 15, 2024
Rule 925.
(1) A
					 licensed facility, other than a hospital or freestanding surgical outpatient
					 facility, shall bill the facility services on the UB-04 national uniform
					 billing claim form and shall include the revenue codes contained in the
					 Official UB-04 Data Specifications Manual, ICD-10-CM and ICD-10-PCS coding for
					 diagnoses and procedures, and CPT procedure codes for surgical, radiological,
					 laboratory, and medicine and evaluation and management services.
(2) Only the technical component of a
					 radiological service or a laboratory service shall be billed on the
					 standardized UB-04 national uniform billing claim form.
(3) All bills for the professional services
					 shall be billed on a CMS 1500 claim form, using the appropriate CPT procedure
					 code and modifier.
(4) A report
					 describing the services provided and the condition of the patient shall be
					 included with the bill.
Michigan Administrative Code › Department - Labor and Economic Opportunity › Workers Compensation Agency › Workers' Compensation Health Care Services Rules › Part 9 - BILLING › Subpart A - PRACTITIONER BILLING › Section R. 418.10926 - Billing for air and ground ambulance services

Current through Vol. 24-12, July 15, 2024
Rule 926.
(1)
					 Air ambulance providers shall bill procedure codes A0430, A0431, A0435, and
					 A0436 as appropriate from the HCPCS codebook, as adopted by reference in
					 R 418.10107.
(2) Ground ambulance providers shall bill
					 procedure codes A0425-A0429 and A0432-A0434 as appropriate from the HCPCS
					 codebook, as adopted by reference in
					 R 418.10107.
(3) A hospital-owned air or ground ambulance
					 provider billing with the same tax identification number as the hospital shall
					 submit charges for ambulance services on a UB-04 form. All other ambulance
					 providers shall submit charges for ambulance services on a CMS-1500
					 form.
(4) Air ambulance services
					 are considered reasonable when a medical condition, in whole or in part, is
					 such that transportation by either basic or advanced life support ground
					 ambulance would constitute a threat to the patient's life or seriously endanger
					 the patient's health.
(5) Ground
					 ambulance services are considered reasonable when a medical condition is such
					 that use of other forms of transportation are contraindicated and would
					 endanger the patient's health.
(6)
					 A properly submitted air or ground ambulance bill shall include documentation
					 indicating the necessity of air or ground ambulance services.
(7) An air ambulance service shall be covered
					 only to the nearest facility capable of furnishing the required level and type
					 of care for the injury or illness involved.
(8) The ambulance point of pick up shall be
					 reported by its 5-digit ZIP code. Charges for services and mileage shall be
					 based on documented loaded patient mileage only. If the patient is pronounced
					 dead by a legally authorized professional after the air ambulance has taken off
					 or the ground ambulance is dispatched, but before being loaded onto the
					 ambulance for transport, then the MAP is the appropriate base rate, with no
					 amount allowed for mileage or for a rural adjustment.
(9) Ambulance origin and destination
					 modifiers listed in the HCPCS Level II codebook, as adopted by reference in
					 R 418.10107, shall be used on the
					 bill as appropriate and will be listed on the agency website at
www.michigan.gov/wca
.
(10) All items and services associated with
					 the ambulance transport are included in the maximum allowable payment and shall
					 not be unbundled and billed separately.
(11) Ground ambulance services are reimbursed
					 based on the level of services performed, not the type of vehicle
					 responding.
Michigan Administrative Code › Department - Labor and Economic Opportunity › Workers Compensation Agency › Workers' Compensation Health Care Services Rules › Part 10 - REIMBURSEMENT › Subpart A - Eligibility for premium tax credit › Section R. 418.101001 - General rules for practitioner reimbursement

Current through Vol. 24-12, July 15, 2024
Rule 1001.
(1) A
					 provider that is authorized to practice in the state of Michigan shall receive
					 the maximum allowable payment in accordance with these rules. A provider shall
					 follow the process specified in these rules for resolving differences with a
					 carrier regarding payment for appropriate health care services rendered to an
					 injured worker. Reimbursement shall be based upon the site of service. The
					 agency shall publish the maximum allowable payment for a procedure performed in
					 the non-facility setting and the maximum allowable payment for a procedure
					 performed in the facility setting.
(2) A carrier shall not make a payment for a
					 service unless all required review activities pertaining to that service are
					 completed.
(3) A carrier's payment
					 shall reflect any adjustments in the bill made through the carrier's
					 utilization review program.
(4) A
					 carrier shall pay, adjust, or reject a properly submitted bill within 30 days
					 of receipt. The carrier shall notify the provider on a form entitled "Carrier's
					 Explanation of Benefits" in a format specified by the agency. A copy shall be
					 sent to the injured worker.
(5) A
					 carrier shall not make a payment for any service that is determined
					 inappropriate by the carrier's professional health care review
					 program.
(6) The carrier shall
					 reimburse the provider a 3% late fee if more than 30 calendar days elapse
					 between a carrier's receipt of a properly submitted bill and a carrier's
					 mailing of the payment.
(7) If a
					 procedure code has a maximum fee of "by report," the provider shall be paid its
					 usual and customary charge or the reasonable amount, whichever is less. The
					 carrier shall provide an explanation of its determination that the fee is
					 unreasonable or excessive in accordance with these rules.
Michigan Administrative Code › Department - Labor and Economic Opportunity › Workers Compensation Agency › Workers' Compensation Health Care Services Rules › Part 10 - REIMBURSEMENT › Subpart A - Eligibility for premium tax credit › Section R. 418.101002 - Conversion factors for practitioner services

Current through Vol. 24-12, July 15, 2024
Rule 1002.
(1)
					 The agency shall determine the conversion factors for medicine, evaluation and
					 management, physical medicine, surgery, pathology, and radiology procedures.
					 The conversion factor is used by the agency for determining the maximum
					 allowable payment for medical, surgical, and radiology procedures. The maximum
					 allowable payment is determined by multiplying the appropriate conversion
					 factor by the relative value unit assigned to a procedure. The relative value
					 units are provided for the medicine, surgical, and radiology procedure codes
					 separate from these rules on the agency's website,
www.michigan.gov/leo/bureaus-agencies/wdca
.
					 The relative value units are updated by the agency using codes adopted from
					 "Current Procedural Terminology (CPT)" as adopted by reference in
					 R 418.10107. The agency shall
					 determine the relative values by using information found in the "Medicare
					 RBRVS: The Physicians' Guide" as adopted by reference in
					 R 418.10107.
(2) The conversion factor for medicine,
					 radiology, and surgical procedures is $47.66 for the year 2023 and is effective
					 for dates of service on or after the effective date of these rules.
Michigan Administrative Code › Department - Labor and Economic Opportunity › Workers Compensation Agency › Workers' Compensation Health Care Services Rules › Part 10 - REIMBURSEMENT › Subpart A - Eligibility for premium tax credit › Section R. 418.101003 - Reimbursement for "by report" and ancillary procedures

Current through Vol. 24-12, July 15, 2024
Rule 1003.
(1)
					 If a procedure code does not have a listed relative value, or is noted BR, then
					 the carrier shall reimburse the provider's usual and customary charge or
					 reasonable payment, whichever is less, unless otherwise specified in these
					 rules.
(2) The following ancillary
					 services are by report and the provider shall be reimbursed either at the
					 practitioner's usual and customary charge or reasonable payment, whichever is
					 less:
(a) Dental services.
(b) Vision and prosthetic optical services.
(c) Hearing aid
					 services.
(d) Home health
					 services.
Michigan Administrative Code › Department - Labor and Economic Opportunity › Workers Compensation Agency › Workers' Compensation Health Care Services Rules › Part 10 - REIMBURSEMENT › Subpart A - Eligibility for premium tax credit › Section R. 418.101003a - Reimbursement for dispensed medications

Current through Vol. 24-12, July 15, 2024
Rule 1003a.
(1)
					 Prescription medication must be reimbursed at the average wholesale price (AWP)
					 minus 10%, as determined by Red Book or Medi-Span, adopted by reference in
					 R 418.10107, plus a dispense fee.
					 All of the following apply to reimbursements: The dispense fee for a brand name
					 drug is $3.50. The dispense fee for a generic drug is $5.50.
(c) Reimbursement for repackaged
					 pharmaceuticals is at a maximum reimbursement of AWP minus 10% based on the
					 original manufacturer's NDC number, as determined by Red Book or Medi-Span,
					 adopted by reference in
					 R 418.10107, plus a dispensing fee
					 of $3.50 for brand name and $5.50 for generic.
(d) All pharmaceutical bills submitted for repackaged products
					 must include the original manufacturer or distributer stock package national
					 drug code or NDC number.
(e) When
					 an original manufacturer's NDC number is not available in either Red Book or
					 Medi-Span, as adopted by reference in
					 R 418.10107, and a pharmaceutical
					 is billed using an unlisted or not otherwise specified code, the payer shall
					 select the most closely related NDC number to use for reimbursement of the
					 pharmaceutical.
Michigan Administrative Code › Department - Labor and Economic Opportunity › Workers Compensation Agency › Workers' Compensation Health Care Services Rules › Part 10 - REIMBURSEMENT › Subpart A - Eligibility for premium tax credit › Section R. 418.101003b - Reimbursement for biologicals, durable medical equipment, and supplies

Current through Vol. 24-12, July 15, 2024
Rule 1003b.
(1)
					 The carrier shall reimburse durable medical equipment (DME), supplies, and
					 biologicals at Medicare plus 5%. The health care services division shall
					 provide the maximum allowable payments for DME, supplies, and biologicals
					 separate from these rules on the agency website,
www.michigan.gov/leo/bureaus-agencies/wdca
.
					 Biologicals that have NDC numbers must be billed and reimbursed under
					 R 418.10912.
(2) Rented DME must be identified on the
					 provider's bill by RR. Modifier NU identifies the item as purchased,
					 new.
(3) If a DME, supply, or
					 biological exceeding $35.00 is not listed in the fee schedule, has no maximum
					 allowable payment (MAP) value in the fee schedule, or is billed with a not
					 otherwise specified code, then reimbursement must be the provider's acquisition
					 cost, plus a percent mark-up as follows, for purchased DME:
(a) Invoice cost of $35.01 to $100.00 must
					 receive cost plus 50%.
(b) Invoice
					 cost of $100.01 to $250.00 must receive cost plus 30%.
(c) Invoice cost of $250.01 to $700.00 must
					 receive cost plus 25%.
(d) Invoice
					 cost of $700.01 or higher must receive cost plus 20%.
Michigan Administrative Code › Department - Labor and Economic Opportunity › Workers Compensation Agency › Workers' Compensation Health Care Services Rules › Part 10 - REIMBURSEMENT › Subpart A - Eligibility for premium tax credit › Section R. 418.101004 - Modifier code reimbursement

Current through Vol. 24-12, July 15, 2024
Rule 1004.
(1)
					 Modifiers may be used to report that the service or procedure performed has
					 been altered by a specific circumstance but does not change the definition of
					 the code. This rule lists procedures for reimbursement when certain modifiers
					 are used. A complete listing of modifiers are listed in Appendix A of "Current
					 Procedural Terminology CPT 2023 Professional Edition," and the "HCPCS 2023
					 Level II Professional Edition" as adopted by reference in
					 R 418.10107.
(2) When modifier code -25 is added to an
					 evaluation and management procedure code, reimbursement must only be made when
					 the documentation provided supports the patient's condition required a
					 significant separately identifiable evaluation and management service, other
					 than the other service provided or beyond the usual preoperative and
					 postoperative care.
(3) When
					 modifier code -26, professional component, is used with a procedure, the
					 professional component must be paid.
(4) If a surgeon uses modifier code -47 when
					 performing a surgical procedure, anesthesia services that were provided by the
					 surgeon and the maximum allowable payment for the anesthesia portion of the
					 service must be calculated by multiplying the base unit of the appropriate
					 anesthesia code by $42.00. No additional payment is allowed for time
					 units.
(5) When modifier code -50
					 or -51 is used with surgical procedure codes, the services must be paid
					 according to the following, as applicable:
(a)
					 The primary procedure at not more than 100% of the maximum allowable payment or
					 the billed charge, whichever is less.
(b) The secondary procedure and the remaining
					 procedure or procedures at not more than 50% of the maximum allowable payment
					 or the billed charge, whichever is less.
(c) When multiple injuries occur in different
					 areas of the body, the first surgical procedure in each part of the body must
					 be reimbursed 100% of the maximum allowable payment or billed charge, whichever
					 is less, and the second and remaining surgical procedure or procedures must be
					 identified by modifier code -51 and be reimbursed at 50% of the maximum
					 allowable payment or billed charges, whichever is less.
(d) When modifier -50 or -51 is used with a
					 surgical procedure with a maximum allowable payment of BR, the maximum
					 allowable payment must be 50% of the provider's usual and customary charge or
					 50% of the reasonable amount, whichever is less.
Michigan Administrative Code › Department - Labor and Economic Opportunity › Workers Compensation Agency › Workers' Compensation Health Care Services Rules › Part 10 - REIMBURSEMENT › Subpart A - Eligibility for premium tax credit › Section R. 418.101005 - Reimbursement for home health services

Current through Vol. 24-12, July 15, 2024
Rule 1005.
(1)
					 Home health services are reimbursed "by report," requiring submission of a
					 report with the charges on the UB-04 claim form. The carrier shall reimburse
					 the home health agency according to each "by report" procedure listed on the
					 UB-04, billed with the appropriate HCPCS code in accord with
					 R
					 418.10909.
(2) Home health services shall be reimbursed
					 by the carrier at either the provider's usual and customary charge as defined
					 by these rules or reasonable amount, whichever is less.
(3) Services listed in the HCPCS Level II
					 codebook, as adopted by reference in
					 R 418.10107, as per diem shall be
					 reimbursed per diem or per visit in accord with the description of the code.
					 The per diem visit shall be either at the provider's usual and customary charge
					 or reasonable amount, whichever is less.
(4) Supplies and durable medical equipment
					 (DME) shall be reimbursed pursuant to these rules.
Michigan Administrative Code › Department - Labor and Economic Opportunity › Workers Compensation Agency › Workers' Compensation Health Care Services Rules › Part 10 - REIMBURSEMENT › Subpart A - Eligibility for premium tax credit › Section R. 418.101006 - Reimbursement for mental health services

Current through Vol. 24-12, July 15, 2024
Rule 1006.
(1) A
					 carrier shall only reimburse procedure code 90792 and add on procedure codes
					 90833, 90836, and 90838 when billed by a psychiatrist who is either a medical
					 doctor (M.D.) or a doctor of osteopathy (D.O.).
(2) A licensed psychologist or a limited
					 license psychologist billing for a diagnostic procedure shall be paid the
					 maximum allowable payment or the practitioner's usual and customary fee,
					 whichever is less.
(3) A licensed
					 psychologist billing for a therapeutic service shall use modifier -AH and shall
					 be paid the maximum allowable payment or the practitioner's usual and customary
					 charge, whichever is less.
(4) For
					 the following providers, therapeutic mental health services shall be reimbursed
					 at 85% of the maximum allowable payment, or the practitioner's usual and
					 customary charge, whichever is less. If a procedure code has a maximum
					 allowable payment of "by report," the maximum allowable payment shall be 85% of
					 the reasonable payment, or the practitioner's usual and customary charge,
					 whichever is less:
(a) -AL limited license
					 psychologist.
(b) -AJ certified
					 social worker.
(c) -LC licensed
					 professional counselor.
(d) -MF
					 licensed marriage and family therapist.
Michigan Administrative Code › Department - Labor and Economic Opportunity › Workers Compensation Agency › Workers' Compensation Health Care Services Rules › Part 10 - REIMBURSEMENT › Subpart A - Eligibility for premium tax credit › Section R. 418.101007 - Reimbursement for anesthesia services

Current through Vol. 24-12, July 15, 2024
Rule 1007.
(1)
					 The carrier shall determine the maximum allowable payment for anesthesia
					 services by adding the base units to the time units. The carrier shall
					 reimburse anesthesia services at either the maximum allowable payment, or the
					 practitioner's usual and customary charge, whichever is less. Each anesthesia
					 base unit shall be multiplied by $42.00 to determine payment for the base
					 procedure.
(2) Anesthesia base
					 units shall only be paid to an anesthesiologist, a surgeon who provides the
					 anesthesia and performs the surgery, or a certified registered nurse
					 anesthetist providing anesthesia without medical direction of the
					 anesthesiologist. Only 1 practitioner shall be reimbursed for base units,
					 documented by the anesthesia record.
(3) The carrier shall reimburse the time
					 units by the total minutes listed in the "days" or "units" column and the alpha
					 modifier added to the procedure code. Time units are reimbursed in the
					 following manner:
(a) Increments of 15
					 minutes or portions thereof, for administration of the anesthesia.
(b) Increments of 30 minutes or portions
					 thereof, for supervision or direction of a CRNA or certified anesthesiologist
					 assistant.
(c) In no instance shall
					 less than 1 time unit be reimbursed.
Michigan Administrative Code › Department - Labor and Economic Opportunity › Workers Compensation Agency › Workers' Compensation Health Care Services Rules › Part 10 - REIMBURSEMENT › Subpart A - Eligibility for premium tax credit › Section R. 418.101008 - Reimbursement for opioid treatment for chronic, non-cancer pain

Current through Vol. 24-12, July 15, 2024
Rule 1008.
(1)
					 For purposes of these rules, chronic pain is pain unrelated to cancer or is
					 incident to surgery and that persists beyond the period of expected healing
					 after an acute injury episode. It is pain that persists beyond 90 days
					 following the onset of the pain. The payer shall reimburse for opioids used in
					 the treatment of chronic pain resulting from work-related conditions.
(2) This rule is applicable to opioid
					 treatment of chronic pain for the following:
(a) Injury dates on or after June 26,
					 2015.
(b) Beginning December 26,
					 2015, all other injury dates.
Michigan Administrative Code › Department - Labor and Economic Opportunity › Workers Compensation Agency › Workers' Compensation Health Care Services Rules › Part 10 - REIMBURSEMENT › Subpart A - Eligibility for premium tax credit › Section R. 418.101008a - Required documentation for reimbursement of treatment for chronic, non-cancer pain with opioids

Current through Vol. 24-12, July 15, 2024
Rule 1008a.
(1)
					 In order to receive reimbursement for opioid treatment beyond 90 days, the
					 physician seeking reimbursement shall submit a written report to the payer not
					 later than 90 days after the initial opioid prescription fill for chronic pain
					 and every 90 days thereafter. The written report shall include all of the
					 following:
(a) A review and analysis of the
					 relevant prior medical history, including any consultations that have been
					 obtained, and a review of data received from an automated prescription drug
					 monitoring program in the treating jurisdiction, such as the Michigan Automated
					 Prescription System (MAPS), for identification of past history of narcotic use
					 and any concurrent prescriptions.
(b) A summary of conservative care rendered
					 to the worker that focused on increased function and return to work.
(c) A statement on why prior or alternative
					 conservative measures were ineffective or contraindicated.
(d) A statement that the attending physician
					 has considered the results obtained from appropriate industry accepted
					 screening tools to detect factors that may significantly increase the risk of
					 abuse or adverse outcomes including a history of alcohol or other substance
					 abuse.
(e) A treatment plan that
					 includes all of the following:
(i) Overall
					 treatment goals and functional progress.
(ii) Periodic urine drug screens.
(iii) A conscientious effort to reduce pain
					 through the use of non-opioid medications, alternative non-pharmaceutical
					 strategies, or both.
(iv)
					 Consideration of weaning the injured worker from opioid use.
(f) An opioid treatment agreement
					 that has been signed by the worker and the attending physician. This agreement
					 shall be reviewed, updated, and renewed every 6 months. The opioid treatment
					 agreement shall outline the risks and benefits of opioid use, the conditions
					 under which opioids will be prescribed, and the responsibilities of the
					 prescribing physician and the worker.
Michigan Administrative Code › Department - Labor and Economic Opportunity › Workers Compensation Agency › Workers' Compensation Health Care Services Rules › Part 10 - REIMBURSEMENT › Subpart A - Eligibility for premium tax credit › Section R. 418.101008b - Denial of reimbursement for prescribing and dispensing opioid medications used to treat chronic, non-cancer pain

Current through Vol. 24-12, July 15, 2024
Rule 1008b. Reimbursement for prescribing and dispensing
						opioid medications may be denied, pursuant to the act. Denial of reimbursement
						may occur if the physician reporting and treatment plan requirements as stated
						in
						R 418.101008a are not met. Denial
						of reimbursement shall occur only after a reasonable period of time is provided
						for the weaning of the injured worker from the opioid medications, and
						alternative means of pain management have been offered.
Michigan Administrative Code › Department - Labor and Economic Opportunity › Workers Compensation Agency › Workers' Compensation Health Care Services Rules › Part 10 - REIMBURSEMENT › Subpart A - Eligibility for premium tax credit › Section R. 418.101009 - Reimbursement for custom compounded topical medication

Current through Vol. 24-12, July 15, 2024
Rule 1009.
(1)
					 Six months after the effective date of this rule, a custom compound topical
					 medication, as defined in
					 R418.10108, must be reimbursed only
					 when the compound meets all of the following standards:
(a) There is no readily available
					 commercially manufactured equivalent product.
(b) No other United States Food and Drug
					 Administration (FDA) approved alternative drug is appropriate for the
					 patient.
(c) The active ingredients
					 of the compound each have an NDC number and are components of drugs approved by
					 the FDA.
(d) The drug has not been
					 withdrawn or removed from the market for safety reasons.
(e) The prescriber is able to demonstrate to
					 the payer that the compound medication is clinically appropriate for the
					 intended use.
Michigan Administrative Code › Department - Labor and Economic Opportunity › Workers Compensation Agency › Workers' Compensation Health Care Services Rules › Part 10 - REIMBURSEMENT › Subpart A - Eligibility for premium tax credit › Section R. 418.101010 - Reimbursement for air and ground ambulance services

Current through Vol. 24-12, July 15, 2024
Rule 1010.
(1)
					 Reimbursement for air and ground ambulance services, when not provided by a
					 hospital owned air or ground ambulance provider billing with the same tax
					 identification number as the hospital, shall be determined by using the
					 reimbursement rate published by CMS. The formula for determining the maximum
					 allowable paid (MAP) for ambulance services is determined by multiplying the
					 (Medicare rate) X (1.40). The MAP shall be published in the health care
					 services fee schedule and shall utilize the practice expense (PE) of the
					 geographical information (GPCI), which shall be a melded average using 60% of
					 the figures published for the city of Detroit added to 40% of the figures
					 published for the rest of this state.
(2) The MAP for procedure codes A0425, A0430,
					 A0431, A0435, and A0436 shall list 2 values for each procedure code, an urban
					 and a rural MAP. Reimbursement is based on the zip code at the ambulance point
					 of pick up and based on documented loaded patient mileage only. Urban or rural
					 designations for each zip code shall be based on CMS and indicated on the
					 agency website at
www.michigan.gov
.
(3) The MAP for procedure codes A0426-A0429
					 and A0432-A0434 shall list 3 values for each procedure code, an urban, a rural,
					 and a super-rural MAP. Reimbursement is based on the zip code at the ambulance
					 point of pick up and based on documented loaded patient mileage only. Urban,
					 rural, and super-rural designations for each zip code shall be based on CMS
					 definitions and indicated on the agency website at
www.michigan.gov
.
(4) Mileage shall be reimbursed per
					 documented loaded patient miles and is expressed in statute mile.
(a) For trips totaling up to 100 covered
					 miles, the mileage shall be rounded up to the nearest tenth of a
					 mile.
(b) For trips totaling 100
					 covered miles or greater, mileage shall be rounded up to the nearest whole
					 number mile without use of a decimal.
Michigan Administrative Code › Department - Labor and Economic Opportunity › Workers Compensation Agency › Workers' Compensation Health Care Services Rules › Part 10 - REIMBURSEMENT › Subpart A - Eligibility for premium tax credit › Section R. 418.101015 - General rules for facility reimbursement

Current through Vol. 24-12, July 15, 2024
Rule 1015.
(1) A
					 facility licensed by this state shall receive the maximum allowable payment in
					 accordance with these rules. The facility shall follow the process specified in
					 these rules for resolving differences with a carrier regarding payment for the
					 appropriate health care services rendered to an injured worker.
(2) The carrier or its designated agent shall
					 assure that the UB-04 national uniform billing claim form is completed
					 correctly before payment. A carrier's payment shall reflect any adjustments in
					 the bill made through the carrier's utilization review program.
(3) A carrier shall pay, adjust, or reject a
					 properly submitted bill within 30 days of receipt, sending notice on a form
					 entitled "Carrier's Explanation of Benefits" in a format specified by the
					 agency. The carrier shall reimburse the facility a 3% late fee if more than 30
					 days elapse between a carrier's receipt of a properly submitted bill and a
					 carrier's mailing of the payment.
(4) Submission of a correctly completed UB-04
					 claim form shall be considered to be a properly submitted bill. The following
					 medical records shall also be attached to the facility charges as applicable:
(a) Emergency room report.
(b) The initial evaluations and progress
					 reports every 30 days whenever physical medicine, speech, and hearing services
					 are billed by a facility.
(c) The
					 anesthesia record whenever the facility bills for the services of a CRNA,
					 certified anesthesiologist assistant, or anesthesiologist.
Michigan Administrative Code › Department - Labor and Economic Opportunity › Workers Compensation Agency › Workers' Compensation Health Care Services Rules › Part 10 - REIMBURSEMENT › Subpart A - Eligibility for premium tax credit › Section R. 418.101016 - Reimbursement; payment ratio methodology

Current through Vol. 24-12, July 15, 2024
Rule 1016.
(1) A
					 hospital licensed in Michigan billing facility services shall be reimbursed
					 using the maximum payment ratio methodology for the following services:
(a) Inpatient or observation care.
(b) Emergency department services.
(c) Occupational, physical, and speech
					 therapy services.
(d) Outpatient
					 surgeries.
(e) Laboratory services
					 and outpatient services. If a carrier pays a properly submitted bill or
					 unadjusted portion of the bill within 30 days of receipt, then the payment is
					 calculated by multiplying the charges times the hospital's maximum payment
					 ratio times a multiplier of 107%. If a carrier pays the bill after 30 days,
					 then the multiplier shall be 110% allowing for a 3% late fee.
Michigan Administrative Code › Department - Labor and Economic Opportunity › Workers Compensation Agency › Workers' Compensation Health Care Services Rules › Part 10 - REIMBURSEMENT › Subpart A - Eligibility for premium tax credit › Section R. 418.101022 - Facility reimbursement excluding hospital or freestanding surgical outpatient facility

Current through Vol. 24-12, July 15, 2024
Rule 1022.
(1)
					 When the following licensed facilities provide services to an injured worker
					 and bill the carrier, the billed services shall be considered by report:
(a) Nursing home.
(b) County medical care facility.
(c) Hospice.
(d) Hospital long-term care unit.
(e) Intermediate care facility or skilled
					 nursing facility.
Michigan Administrative Code › Department - Labor and Economic Opportunity › Workers Compensation Agency › Workers' Compensation Health Care Services Rules › Part 10 - REIMBURSEMENT › Subpart A - Eligibility for premium tax credit › Section R. 418.101023 - Reimbursement for ASC or FSOF

Current through Vol. 24-12, July 15, 2024
Rule 1023.
(1)
					 Reimbursement for surgical procedures performed in an ASC or FSOF shall be
					 determined by using the ASC rate published by CMS. The formula for determining
					 the maximum allowable paid (MAP) for a surgical procedure in an ASC or FSOF is
					 determined by multiplying the (Medicare ASC rate) X (1.30). The MAP shall be
					 published in the health care services fee schedule.
(2) When 2 or more surgical procedures are
					 performed in the same operative session, the facility shall be reimbursed at
					 100% of the maximum allowable payment or the facility's usual and customary
					 charge, whichever is less, for the procedure classified with the highest
					 payment rate. Any other surgical procedures performed during the same session
					 shall be reimbursed at 50% of the maximum allowable payment or 50% of the
					 facility's usual and customary charge, whichever is less, unless the procedure
					 is not subject to the multiple procedure discount as indicated by CMS in the
					 health care services ASC fee schedule. A facility shall not unbundle surgical
					 procedure codes when billing the services.
(3) When an eligible procedure is performed
					 bilaterally, each procedure shall be listed on a separate line of the claim
					 form and shall be identified with LT for left and RT for right. At no time
					 shall modifier 50 be used by the facility to describe bilateral
					 procedures.
(4) Implants are
					 included in the maximum allowable paid unless the CMS list it as a pass through
					 item. Pass through items will be provided on the agencys website,
www.michigan.gov/wca
. If an
					 item is implanted during the surgical procedure and the ASC or FSOF bills the
					 implant and includes the copy of the invoice, then the implant shall be
					 reimbursed at the cost of the implant plus a percent markup as follows:
(a) Cost of implant: $1.00 to $500.00 shall
					 receive cost plus 50%.
(b) Cost of
					 implant: $500.01 to $1000.00 shall receive cost plus 30%.
(c) Cost of implant: $1000.01 and higher
					 shall receive cost plus 25%.
Michigan Administrative Code › Department - Labor and Economic Opportunity › Workers Compensation Agency › Workers' Compensation Health Care Services Rules › Part 11 - HOSPITAL PAYMENT RATIO › Section R. 418.101101 - Calculation and revision of payment ratio for Michigan hospitals

Current through Vol. 24-12, July 15, 2024
Rule 1101.
(1) The
				  workers' compensation agency shall annually calculate and revise, under the
				  provisions of
1969 PA 306, MCL
				  24.201
				  et seq
. the payment ratios for all Michigan hospitals. The calculation
				  shall be made using a hospital's most recent fiscal year information that is
				  submitted to the Michigan department of health and human services, hospital and
				  clinic reimbursement division, preceding each annual calculation. The
				  information used shall be that reported to the Michigan department of health
				  and human services on the hospital's statement of patient revenues and
				  operating expenses, G2 worksheet. The workers' compensation agency shall
				  complete the payment ratio calculation when the figures are available from the
				  Michigan department of health and human services and shall annually provide the
				  hospital ratio calculations on the agencys website,
www.michigan.gov/wca
.
(2) The workers' compensation agency shall
				  calculate a hospital's cost-to-charge ratio by dividing each hospitals total
				  operating expenses by total patient revenues as reported on the hospital's
				  statement of patient revenues and operating expenses, G2 worksheet.
Michigan Administrative Code › Department - Labor and Economic Opportunity › Workers Compensation Agency › Workers' Compensation Health Care Services Rules › Part 11 - HOSPITAL PAYMENT RATIO › Section R. 418.101102 - Calculation and revision of payment ratio for hospitals outside Michigan

Current through Vol. 24-12, July 15, 2024
Rule 1102. The workers' compensation agency shall annually
					 calculate and revise, under the provisions of 1969 PA 306, as amended, being
					 §
										24.201et
					 seq. of the MCL, at the same time as calculating Michigan hospitals' payment
					 ratios, a weighted state average payment ratio to be used for hospitals that
					 are located outside the state of Michigan. The payment ratio shall be
					 calculated by dividing the total hospital operating expenses for Michigan by
					 the total hospital patient revenues for Michigan as reported under R
					 418.1101(1).
Michigan Administrative Code › Department - Labor and Economic Opportunity › Workers Compensation Agency › Workers' Compensation Health Care Services Rules › Part 11 - HOSPITAL PAYMENT RATIO › Section R. 418.101103 - Adjustments to hospital's payment ratio

Current through Vol. 24-12, July 15, 2024
Rule 1103.
(1) A
				  hospital may apply to the agency for an adjustment of the hospital's maximum
				  payment ratio.
(2) The hospital
				  shall apply for an adjustment on a form and in a manner prescribed by the
				  workers' compensation agency.
(3)
				  If the agency determines that a hospital's ratio of total operating expenses to
				  total patient revenues, as reported on the hospital's statement of patient
				  revenues and operating expenses, G2 worksheet, for a hospital's most recent
				  fiscal year is higher than the payment ratio calculated according to R
				  418.1101, so that the amount of underpayment is more than $100,000.00 or is
				  equal to or greater than 2/10 of 1% of the hospital's operating expenses for
				  the year, then the agency shall revise the payment ratio and shall notify the
				  hospital and all carriers of the revised payment ratio within 45 days after the
				  receipt of a properly submitted request for an adjustment.
(4) If a hospital's request for an adjustment
				  to the hospital's payment ratio is denied by the workers' compensation agency,
				  then a hospital may request reconsideration and appeal of the agency's action
				  regarding the hospital's request for adjustment of its payment ratio.
Michigan Administrative Code › Department - Labor and Economic Opportunity › Workers Compensation Agency › Workers' Compensation Health Care Services Rules › Part 11 - HOSPITAL PAYMENT RATIO › Section R. 418.101104 - Request for adjustment to hospital's maximum payment ratio; agency's response

Current through Vol. 24-12, July 15, 2024
Rule 1104.
(1)
				  Within 60 days of the agency's receipt of a hospital's request for adjustment
				  to the hospital's maximum payment ratio, the workers' compensation agency shall
				  notify the hospital of the action on the adjustment request and shall notify
				  the hospital of the hospital's right to provide additional information to
				  request reconsideration of the agency's action.
(2) The workers' compensation agency shall
				  also furnish the hospital with an appeal form. The appeal form shall include an
				  explanation of the appeal process.
Michigan Administrative Code › Department - Labor and Economic Opportunity › Workers Compensation Agency › Workers' Compensation Health Care Services Rules › Part 11 - HOSPITAL PAYMENT RATIO › Section R. 418.101105 - Agency's action on request for adjustment of maximum payment ratio; hospital's appeal

Current through Vol. 24-12, July 15, 2024
Rule 1105.
(1) If
				  a hospital is in disagreement with the action taken by the workers'
				  compensation agency on its request for adjustment of the hospital's maximum
				  payment ratio, then a hospital may, within 30 days of receipt of the agency's
				  action on the hospital's request for adjustment to its maximum payment ratio,
				  deliver or mail an appeal of the agency's action to the agency. The appeal
				  shall include a detailed statement of the reasons for disagreement and shall
				  request reconsideration of the agency's action on the hospital's request for
				  adjustment.
(2) The workers'
				  compensation agency shall hold a hearing within 30 days of the receipt of a
				  hospital's appeal under section 847 of the act.
Michigan Administrative Code › Department - Labor and Economic Opportunity › Workers Compensation Agency › Workers' Compensation Health Care Services Rules › Part 12 - CARRIER'S PROFESSIONAL HEALTH CARE REVIEW PROGRAM › Section R. 418.101201 - Carrier's health care review program

Current through Vol. 24-12, July 15, 2024
Rule 1201.
(1) The
				  carrier shall have both a technical health care review program and a
				  professional health care review program.
(2) Health care review shall be conducted in
				  a reasonable manner on bills submitted by a provider for health care services
				  furnished because of a covered injury or illness arising out of and in the
				  course of employment.
Michigan Administrative Code › Department - Labor and Economic Opportunity › Workers Compensation Agency › Workers' Compensation Health Care Services Rules › Part 12 - CARRIER'S PROFESSIONAL HEALTH CARE REVIEW PROGRAM › Section R. 418.101203 - Carrier's technical health care review program

Current through Vol. 24-12, July 15, 2024
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.
Michigan Administrative Code › Department - Labor and Economic Opportunity › Workers Compensation Agency › Workers' Compensation Health Care Services Rules › Part 12 - CARRIER'S PROFESSIONAL HEALTH CARE REVIEW PROGRAM › Section R. 418.101204 - Carrier's professional health care review program

Current through Vol. 24-12, July 15, 2024
Rule 1204.
(1) A
				  carrier may have another entity perform professional health care review
				  activities on its behalf.
(2) The
				  agency shall certify a carrier's professional health care review program
				  pursuant to
				  R 418.101206.
(3) The carrier shall submit a completed form
				  entitled "Application for Certification of the Carrier's Professional Health
				  Care Review Program" to the agency. If the carrier is a selfinsured employer or
				  self-insured group fund, then the service company information shall be included
				  on the form in addition to the carrier and review company information. In
				  addition to the completed form, the carrier shall submit all of the following:
(a) The methodology used to perform
				  professional review.
(b) A listing
				  of the licensed, registered, or certified health care professionals reviewing
				  the health care bills or establishing guidelines for technical review. In
				  addition, the proof of current licensure and qualifications for the health care
				  professionals shall be included with the completed application.
(c) A list of the carrier's peer review
				  staff, including specialty.
Michigan Administrative Code › Department - Labor and Economic Opportunity › Workers Compensation Agency › Workers' Compensation Health Care Services Rules › Part 12 - CARRIER'S PROFESSIONAL HEALTH CARE REVIEW PROGRAM › Section R. 418.101205 - Scope of professional health care review

Current through Vol. 24-12, July 15, 2024
Rule 1205.
(1) The
				  carrier, or it's review company, shall review case records and health-service
				  bills, or both, under the professional health care review program as follows:
(a) A case where health care service
				  payments, excluding inpatient hospital care, exceed $20,000.00.
(b) A case involving inpatient hospital
				  care.