reglab/statecodes huggingface dataset:
Code of Maine Rules › 90 - INDEPENDENT AGENCIES › 351 - WORKERS' COMPENSATION BOARD › Chapter 3 - FORM FILING › LIST OF APPENDICES

Current through 2024-29, July 17, 2024
90-351
Maine Workers' Compensation Board
Rule Chapter 3 Electronic Filing
List of Appendices
I. Instructions and
Maine Workers' Compensation Board (MWCB)
Claims Release 3 (CR 3), First Report of Injury
				  (FROI),
Element Requirement Table
II. MWCB CR 3, FROI, Conditional Requirement
				Table
III. MWCB CR 3, Subsequent
				Report of Injury (SROI), Element Requirement Table
IV. MWCB CR 3, SROI, Conditional Requirement
				Table
V. IAIABC CR 3, Data
				Dictionary, 01/01/2010 Edition
VI.
				MWCB Proof of Coverage Element Requirement Table
VII. MWCB Proof of Coverage Conditional
				Requirement Table
VIII. IAIABC
				Proof of Coverage Release 2.1 Data Dictionary, 06/01/07 Edition
Copies of the Appendices may be requested by contacting the
				  Workers' Compensation Board:
Workers' Compensation Board
27 State House Station
Augusta ME 04333-0027
Tel: 207-287-3818 or online at:
http://www.maine.gov/sos/cec/rules/90/chaps90-.htm
Code of Maine Rules › 90 - INDEPENDENT AGENCIES › 351 - WORKERS' COMPENSATION BOARD › Chapter 4 - INDEPENDENT MEDICAL EXAMINER › Section 351-4-1 - Creation of Independent Medical Examiner System Pursuant to 39-A M.R.S.A. section 312

Current through 2024-29, July 17, 2024
1. To be eligible
				to participate in the Board appointed independent medical examiner program,
				health care providers must meet the criteria of this subsection.
A. The provider must be licensed/certified by
				the State of Maine.
B.
(1) The provider must have an active,
				treating practice, or have had an active treating practice within the
				twenty-four (24) months period preceding appointment as an examiner in an
				individual case;
(2) Be Board
				certified; and
(3) Demonstrate
				experience in the treatment of work-related injuries.
For purposes of this chapter, "active, treating practice"
				  means the provider has direct involvement in evaluation, diagnosis and
				  treatment of patients on a frequent and regular basis in their specific field
				  of expertise.
C.
				The provider must demonstrate superior qualifications and experience in their
				particular fields of expertise.
Code of Maine Rules › 90 - INDEPENDENT AGENCIES › 351 - WORKERS' COMPENSATION BOARD › Chapter 4 - INDEPENDENT MEDICAL EXAMINER › Section 351-4-2 - Assignment of Independent Medical Examiners Pursuant to 39-A M.R.S.A. section 312

Current through 2024-29, July 17, 2024
1. If the parties
				agree to the selection of a particular independent medical examiner, they shall
				file a form prescribed by the Board with the Office of Medical/Rehabilitation
				Services, Workers' Compensation Board, 27 State House Station, Augusta, Maine
				04333. If the employee is unrepresented by counsel, the independent medical
				examiner agreed upon must be chosen from the Board's list of independent
				medical examiners or approved by the Executive Director or the Executive
				Director's designee.
2. If the
				parties do not agree to the selection of a particular independent medical
				examiner, the requesting party shall file a Request for Independent Medical
				Examination (WCB M-2) with the Office of Medical/ Rehabilitation Services,
				Workers' Compensation Board, 27 State House Station, Augusta, Maine 04333 and
				follow the procedures contained in section
				3 of this rule. The Executive Director
				or the Executive Director's designee shall assign an examiner from the list of
				qualified examiners. If the list does not contain a qualified examiner, the
				Executive Director or the Executive Director's designee may select a qualified
				medical examiner of his/her choice. An Administrative Law Judge may also
				request an independent medical examination. The requesting party must:
A. Complete Board Form M-2 and file it with
				the Office of Medical/ Rehabilitation Services, Workers' Compensation Board, 27
				State House Station, Augusta, Maine 04333.
B. Attach to Board Form M-2 a joint medical
				stipulation containing all medical records and other pertinent information,
				including an index of all treating health care providers and examinations
				performed under
				39-A
				M.R.S.A. §207 since the date of
				injury.
Code of Maine Rules › 90 - INDEPENDENT AGENCIES › 351 - WORKERS' COMPENSATION BOARD › Chapter 4 - INDEPENDENT MEDICAL EXAMINER › Section 351-4-4 - Fees for Independent Medical Examinations under 39-A M.R.S.A. section 312

Current through 2024-29, July 17, 2024
1. Independent
				medical examinations will have a maximum charge of $300.00 per hour up to a
				maximum of five hours for review of records and information, the performance of
				any necessary examinations, and the preparation of the written report. This
				charge does not include such diagnostic testing as may be necessary. Additional
				charges may be allowed with the consent of both parties or by the Executive
				Director or the Executive Director's designee for good cause shown. The fee for
				the examination and report must be paid by the employer. In the event the exam
				is scheduled to determine apportionment of responsibility between employers,
				the employer/insurer that requested the exam shall pay for the examination and
				report, unless otherwise agreed to by the requesting employer/insurer and any
				other employer/insurer that is a party to the proceeding. If an employee
				requests the exam, all employers/insurers that are parties to the proceeding
				shall, unless they agree otherwise, split the cost equally.
2. If additional diagnostic tests are
				required, payment for such tests whether performed by the independent medical
				examiner or by another health care provider at the request of the examiner,
				shall be in accordance with the Board's Medical Fee Schedule and paid for by
				the employer.
3. If the employee
				fails to attend the independent medical examination or if an examination is
				cancelled by the employee or employer within 48 hours of the scheduled time,
				the independent medical examiner may charge and receive up to $200. The
				independent medical examiner may also charge $200 per hour for up to three (3)
				hours of preparation time unless the examination is conducted at a later date.
				These charges shall be paid initially by the employer/insurer that requested
				the exam unless otherwise agreed to by the requesting employer/insurer and any
				other employer/insurer that is a party to the proceeding. If the employee
				requested the exam, all employers/insurers that are parties to the proceeding
				shall, unless they agree otherwise, split the cost equally. Payment of these
				charges is subject to the right of the employer(s)/insurer(s) to be reimbursed
				by the employee if the failure to appear or the cancellation by the employee
				was without good cause. This determination shall be made by the Administrative
				Law Judge.
4. The reasonable costs
				of depositions of examiners, including the examiner's fees, court reporter's
				fees, and transcript costs, shall be borne by the requesting party.
Code of Maine Rules › 90 - INDEPENDENT AGENCIES › 351 - WORKERS' COMPENSATION BOARD › Chapter 4 - INDEPENDENT MEDICAL EXAMINER › Section 351-4-5 - Application

Current through 2024-29, July 17, 2024
These rules apply to all dates of injury. If any section,
				  term, provision, or application of this Rule is adjudged invalid for any
				  reason, such judgment shall not impair or invalidate any other section, term,
				  provision, or application and the remainder of this Rule shall continue in full
				  force and effect.
Code of Maine Rules › 90 - INDEPENDENT AGENCIES › 351 - WORKERS' COMPENSATION BOARD › Chapter 5 - MEDICAL FEES; REIMBURSEMENT LEVELS; REPORTING REQUIREMENTS › Sec2 351-5-1 - GENERAL PROVISIONS › Subsection 351-5-1-01 - APPLICATION

Current through 2024-29, July 17, 2024
1. This chapter is promulgated pursuant to
				  39­A M.R.S.A. §§208 and 209-A . It applies to all medical,
				  surgical and hospital services, nursing, medicines, and mechanical, surgical
				  aids provided for treatment of a claimed work-related injury or disease on or
				  after the effective date of this chapter, regardless of the employee's date of
				  injury or illness. Treatment does not include expenses related to managed care
				  services such as utilization review, case management, and bill review or to
				  examinations performed pursuant to 39­A M.R.S.A. §§207 and
				  312.
Code of Maine Rules › 90 - INDEPENDENT AGENCIES › 351 - WORKERS' COMPENSATION BOARD › Chapter 5 - MEDICAL FEES; REIMBURSEMENT LEVELS; REPORTING REQUIREMENTS › Sec2 351-5-1 - GENERAL PROVISIONS › Subsection 351-5-1-02 - PAYMENT CALCULATION

Current through 2024-29, July 17, 2024
1. Pursuant to
				  Title
				  39-A M.R.S.A.
				  §209-A, the Board has adopted this
				  medical fee schedule which reflects the payment methodology developed by the
				  federal Centers for Medicare and Medicaid Services. The Board has not adopted
				  all components used by the federal Centers for Medicare and Medicaid Services.
				  Therefore, the application of any fee schedule, payment system, claims
				  processing rule, edit or other method of determining the reimbursement level
				  for a service(s) not expressly adopted in this chapter is prohibited.
2. Payment is based on the fees in effect on
				  the date of service.
Code of Maine Rules › 90 - INDEPENDENT AGENCIES › 351 - WORKERS' COMPENSATION BOARD › Chapter 5 - MEDICAL FEES; REIMBURSEMENT LEVELS; REPORTING REQUIREMENTS › Sec2 351-5-1 - GENERAL PROVISIONS › Subsection 351-5-1-04 - LEGAL DISCLAIMERS

Current through 2024-29, July 17, 2024
1. This chapter
				  includes data that is proprietary to the AMA, therefore, certain restrictions
				  apply. These restrictions are established by the AMA and are set out below:
A. The five character codes included in this
				  chapter are obtained from the Current Procedural Terminology (CPT®),
				  Copyright by the AMA. CPT® is developed by the AMA as a listing of
				  descriptive terms and five character identifying codes and modifiers for
				  reporting medical services and procedures.
B. The responsibility for the content of this
				  chapter is with the Board and no endorsement by the AMA is intended or should
				  be implied. The AMA disclaims responsibility for any consequences or liability
				  attributable or related to any use, nonuse or interpretation of information
				  contained in this chapter.
C. No
				  fee schedules, basic unit values, relative value guides, conversion factors or
				  scales are included in any part of CPT®. Any use of CPT® outside of
				  this chapter should refer to the most current CPT® which contains the
				  complete and most current listing of codes and descriptive terms.
Code of Maine Rules › 90 - INDEPENDENT AGENCIES › 351 - WORKERS' COMPENSATION BOARD › Chapter 5 - MEDICAL FEES; REIMBURSEMENT LEVELS; REPORTING REQUIREMENTS › Sec2 351-5-1 - GENERAL PROVISIONS › Subsection 351-5-1-05 - AUTHORIZATION

Current through 2024-29, July 17, 2024
1. Nothing in the Act or these rules requires
				  the authorization of medical, surgical and hospital services, nursing,
				  medicines, and mechanical, surgical aids provided pursuant to 39 A M.R.S.A.
				  §206.
2. An employer/insurer
				  is not permitted to require pre-authorization of medical, surgical and hospital
				  services, nursing, medicines, and mechanical, surgical aids provided pursuant
				  to 39A M.R.S.A. §206 as a condition of payment.
Code of Maine Rules › 90 - INDEPENDENT AGENCIES › 351 - WORKERS' COMPENSATION BOARD › Chapter 5 - MEDICAL FEES; REIMBURSEMENT LEVELS; REPORTING REQUIREMENTS › Sec2 351-5-1 - GENERAL PROVISIONS › Subsection 351-5-1-06 - BILLING PROCEDURES

Current through 2024-29, July 17, 2024
1. Bills must
				  specify the billing entity's tax identification number; the license number,
				  registration number, certificate number, or National Provider Identifier of the
				  health care provider; the employer; the employee; the date of
				  injury/occurrence; the date of service; the work-related injury or disease
				  treated; the appropriate procedure code(s) for the work-related injury or
				  disease treated; and the charges for each procedure code. Bills properly
				  submitted on standardized claim forms prescribed by the Centers for Medicare
				  & Medicaid are sufficient to comply with this requirement. Uncoded bills
				  may be returned for coding.
2.
				  Bills for insured employers must be submitted directly to the insurer of record
				  on the date of injury/illness. Health care providers shall attempt to verify
				  the name of the insurer that wrote the workers' compensation policy for the
				  specific employer on the date of injury/illness prior to the submission of a
				  bill to an insurer.
3. In the event
				  a patient fails to keep a scheduled appointment, health care providers are not
				  to bill for any services that would have been provided nor will there be any
				  reimbursement for such scheduled services.
4. A bill must be accompanied by health care
				  records to substantiate the services rendered. Fees for copies of health care
				  records are outlined below.
Code of Maine Rules › 90 - INDEPENDENT AGENCIES › 351 - WORKERS' COMPENSATION BOARD › Chapter 5 - MEDICAL FEES; REIMBURSEMENT LEVELS; REPORTING REQUIREMENTS › Sec2 351-5-1 - GENERAL PROVISIONS › Subsection 351-5-1-07 - REIMBURSEMENT

Current through 2024-29, July 17, 2024
1. The injured employee is not liable for
				  payment of any medical, surgical and hospital services, nursing, medicines, and
				  mechanical, surgical aids provided pursuant to 39­A M.R.S.A. §206.
				  Except as provided by 39­A M.R.S.A. §206(2)(B), health care
				  providers may charge the patient directly only for the treatment of conditions
				  that are unrelated to the compensable injury or disease. See 39­A
				  M.R.S.A. §206(13).
2. Changes
				  to bills by employers/insurers are not allowed. The employer/insurer must pay
				  the health care provider's usual and customary charge or the maximum allowable
				  payment under this chapter, whichever is less, within 30 days of receipt of a
				  properly coded bill unless the bill or previous bills from the same health care
				  provider or the underlying injury has been controverted or denied.
A. When there is a dispute whether the
				  provision of medical, surgical and hospital services, nursing, medicines, and
				  mechanical, surgical aids is reasonable and proper under §206 of the Act,
				  the employer/insurer shall pay the undisputed amounts, if any, and file a
				  notice of controversy within 30 days of receipt. A copy of the notice of
				  controversy must be sent to the health care provider from whom the bill
				  originated in accordance with Chapter 3.
B. In cases where the underlying injury has
				  been controverted or denied, a copy of the notice of controversy must be sent
				  to each health care provider that submits or has submitted a request for
				  payment within 30 days of receipt.
C. A health care provider, employee or other
				  interested party is entitled to file a petition for payment of medical and
				  related services for determination of any dispute regarding the provision of
				  medical services.
Code of Maine Rules › 90 - INDEPENDENT AGENCIES › 351 - WORKERS' COMPENSATION BOARD › Chapter 5 - MEDICAL FEES; REIMBURSEMENT LEVELS; REPORTING REQUIREMENTS › Sec2 351-5-1 - GENERAL PROVISIONS › Subsection 351-5-1-08 - FEES FOR REPORTS/COPIES

Current through 2024-29, July 17, 2024
1. Health care
				  providers may charge for completing an initial diagnostic medical report (Form
				  M­1) or other supplemental report. The charge is to be identified by
				  billing CPT® Code 99080.
2. The maximum fee for completing an initial
				  M-1 form or other supplemental report is: Each 10 minutes: $30.00
3. Health care providers may charge for
				  copies of the health care records required to accompany the bill. The charge is
				  to be identified on the bill using CPT® Code
				  S9981 (units equal total number of pages). The maximum fee for copies is $5 for
				  the first page and 45¢ for each additional page, up to a maximum of
				  $250.00.
4. For copies of health
				  care records or other written information, including, but not limited to,
				  billing records furnished in paper form, the maximum fee is $5 for the first
				  page and 45¢ for each additional page, up to a maximum of $250.00. The
				  copying charge must be paid by the requesting party. Health care providers
				  shall not require payment prior to responding to the request unless the
				  requesting party has an unpaid balance for previously requested information
				  from the health care provider. In this event, a health care provider may
				  require payment of the past due balance in addition to pre-payment of the
				  current request prior to responding to the request. Health care providers shall
				  not charge a fee for postage/shipping, sales tax, or a fee for researching a
				  request that results in no records.
5. If the requested information exists in a
				  digital or electronic format, the health care provider shall provide an
				  electronic copy of the requested information, if an electronic copy is
				  requested and it is reasonably possible to provide it. The health care provider
				  may charge reasonable actual costs of staff time to create the electronic
				  information and the costs of necessary supplies, up to a maximum of $150.00.
				  The copying charge must be paid by the requesting party. Health care providers
				  shall not require payment prior to responding to the request unless the
				  requesting party has an unpaid balance for previously requested information
				  from the health care provider. In this event, a health care provider may
				  require payment of the past due balance in addition to pre-payment of the
				  current request prior to responding to the request. Health care providers shall
				  not charge a fee for postage/shipping, sales tax, or a fee for researching a
				  request that results in no records.
Code of Maine Rules › 90 - INDEPENDENT AGENCIES › 351 - WORKERS' COMPENSATION BOARD › Chapter 5 - MEDICAL FEES; REIMBURSEMENT LEVELS; REPORTING REQUIREMENTS › Sec2 351-5-1 - GENERAL PROVISIONS › Subsection 351-5-1-09 - FEES FOR MEDICAL TESTIMONY

Current through 2024-29, July 17, 2024
1. Health care
				  providers may charge for preparing to testify at depositions and hearings and
				  for attendance at depositions and hearings for the purpose of giving
				  testimony.
2. The maximum fee for
				  preparing to testify at depositions and hearings is:
First 30 minutes: $250.00
Each additional 15 minutes: $125.00
3. The maximum fee for attendance at
				  depositions and hearings for the purpose of giving testimony is:
First hour or any fraction thereof: $500.00
Each subsequent 15 minutes: $125.00
4. Travel time for attendance at depositions
				  and hearings for the purpose of giving testimony is paid on a portal to portal
				  basis when a deposition or hearing is more than ten miles from the health care
				  provider's home base. The maximum fee for portal-to-portal travel for the
				  purpose of giving testimony is:
Each 60 minutes: $400.00
5. Health care providers may request advance
				  payment of not more than $400.00 in order to schedule attendance at depositions
				  and hearings. The advance payment will be applied against the total fees for
				  medical testimony (preparation, travel, and attendance).
6. Health care providers will receive a
				  maximum of $350.00 per canceled deposition when the cancellation occurs less
				  than 24 hours prior to the scheduled start of the deposition. Health care
				  providers will receive a maximum of $300.00 per canceled deposition when the
				  cancellation takes place less than 48 but more than 24 hours prior to the
				  scheduled start of the deposition. The party canceling the deposition is
				  responsible for the fee.
Code of Maine Rules › 90 - INDEPENDENT AGENCIES › 351 - WORKERS' COMPENSATION BOARD › Chapter 5 - MEDICAL FEES; REIMBURSEMENT LEVELS; REPORTING REQUIREMENTS › Sec2 351-5-1 - GENERAL PROVISIONS › Subsection 351-5-1-010 - EXPENSES

Current through 2024-29, July 17, 2024
1. The employer/insurer must pay the
				  employee's travel-related expenses incurred for treatment (includes travel to
				  the pharmacy) related to the claimed injury in accordance with Board Rules and
				  Regulations Chapter 17.
2. The
				  employer/insurer must pay the employee's travel-related expenses within 30 days
				  of receipt of a request for reimbursement.
3. The employer/insurer must reimburse the
				  employee's out-of-pocket costs for medicines and other non-travel-related
				  expenses within 30 days of a request for reimbursement accompanied by
				  receipts.
Code of Maine Rules › 90 - INDEPENDENT AGENCIES › 351 - WORKERS' COMPENSATION BOARD › Chapter 5 - MEDICAL FEES; REIMBURSEMENT LEVELS; REPORTING REQUIREMENTS › Sec2 351-5-1 - GENERAL PROVISIONS › Subsection 351-5-1-011 - MEDICAL INFORMATION

Current through 2024-29, July 17, 2024
1.
A. Pursuant to 39­A M.R.S.A.
				  §208(1), authorization from the employee for release of medical
				  information by health care providers to the employee or the employee's
				  representative, employer or the employer's representative, or insurer or
				  insurer's representative is not required if the information pertains to
				  treatment of an injury or disease that is claimed to be compensable under this
				  Act regardless of whether the claimed injury or disease is denied by the
				  employer/insurer.
B. Pursuant to
				  39­A M.R.S.A. §208(1), health care providers must, at the written
				  request of the employer/insurer representative, furnish copies of health care
				  records or other written information, including, but not limited to, billing
				  records to the employer/insurer representative and to the employee
				  representative (if none, to the employee) pertaining to a claimed workers'
				  compensation injury or disease, regardless of whether the claimed injury or
				  disease is denied by the employer/insurer. Copies must be furnished within 10
				  business days from receipt of the written request. An itemized invoice must
				  accompany the copies sent to the requestor.
C. Pursuant to 39­A M.R.S.A.
				  §208(1), health care providers must, at the written request of the
				  employee or the employee's representative, furnish copies of health care
				  records or other written information, including, but not limited to, billing
				  records to the employee or the employee's representative pertaining to a
				  claimed workers' compensation injury or disease, regardless of whether the
				  claimed injury or disease is denied by the employer/insurer. Copies must be
				  furnished within 10 business days from receipt of the written request. An
				  itemized invoice must accompany the copies sent to the requestor.
Code of Maine Rules › 90 - INDEPENDENT AGENCIES › 351 - WORKERS' COMPENSATION BOARD › Chapter 5 - MEDICAL FEES; REIMBURSEMENT LEVELS; REPORTING REQUIREMENTS › Sec2 351-5-1 - GENERAL PROVISIONS › Subsection 351-5-1-012 - PERMANENT IMPAIRMENT RATINGS

Current through 2024-29, July 17, 2024
1. Permanent
				  impairment will be determined by the use of the American Medical Association's
				  Guides to the Evaluation of Permanent Impairment, 4th edition, copyright
				  1993.
2. Permanent impairment
				  examinations performed by the employee's treating health care provider will
				  have a maximum charge of $450.00.
Code of Maine Rules › 90 - INDEPENDENT AGENCIES › 351 - WORKERS' COMPENSATION BOARD › Chapter 5 - MEDICAL FEES; REIMBURSEMENT LEVELS; REPORTING REQUIREMENTS › Sec2 351-5-2 - PROFESSIONAL SERVICES › Subsection 351-5-2-01 - PAYMENT CALCULATION

Current through 2024-29, July 17, 2024
1. Pursuant to
				  39-A M.R.S.A.
				  §209-A, the medical fee schedule for
				  services rendered by individual health care providers must reflect the
				  methodology underlying the federal Centers for Medicare and Medicaid Services
				  resource-based relative value scale.
2. Fees for anesthesia services are
				  calculated for procedure codes by multiplying the applicable conversion factor
				  times the sum of the base unit (relative value unit (RVU) of the procedure code
				  plus any modifying units) and time unit. The definition of the unit components
				  are as outlined below. The conversion factor for anesthesia services is
				  $60.00.
3. Fees for all other
				  professional services are calculated for procedure codes by multiplying the
				  applicable conversion factor times the non-facility total RVU. The conversion
				  factor for all other professional services is $60.00.
4. Fees for professional services (excluding
				  anesthesia) are as outlined in Appendix II. In the event of a dispute regarding
				  the fee listed in Appendix II, the listed relative weight times the base rate
				  controls.
Code of Maine Rules › 90 - INDEPENDENT AGENCIES › 351 - WORKERS' COMPENSATION BOARD › Chapter 5 - MEDICAL FEES; REIMBURSEMENT LEVELS; REPORTING REQUIREMENTS › Sec2 351-5-2 - PROFESSIONAL SERVICES › Subsection 351-5-2-02 - EVALUATION AND MANAGEMENT GUIDELINES

Current through 2024-29, July 17, 2024
1.
Definition of New Patient
A. A
				  new patient is one who has not received any professional services from the
				  health care provider (or another health care provider of the exact same
				  specialty and subspecialty who belongs to the same group practice) within the
				  past three years, or
B. A new
				  patient is one who is being evaluated for a new injury/illness to determine
				  work relatedness/causality, or
C. A
				  new patient is one who is being seen for a new episode of care for an existing
				  injury/illness.
Code of Maine Rules › 90 - INDEPENDENT AGENCIES › 351 - WORKERS' COMPENSATION BOARD › Chapter 5 - MEDICAL FEES; REIMBURSEMENT LEVELS; REPORTING REQUIREMENTS › Sec2 351-5-2 - PROFESSIONAL SERVICES › Subsection 351-5-2-03 - ANESTHESIA GUIDELINES

Current through 2024-29, July 17, 2024
1.
Definition of the Unit Components
A.
Base Unit
: RVU of the five digit anesthesia procedure code
				  (00100-01999) listed in Appendix II plus the unit value of the physical status
				  modifier plus the unit values for any qualifying circumstances.
Physical Status Modifiers
. Physical Status
					 modifiers are represented by the initial letter 'P' followed by a single digit
					 from 1 to 6 as defined in the following list:
UNIT VALUE
P1: A normal healthy patient 0
P2: A patient with mild systemic disease 0
P3: A patient with severe systemic disease 1
P4: A patient with severe systemic disease that is a
					 constant threat to life 2
P5: A moribund patient who is not expected to survive
					 without the operation 3
P6: A declared brain-dead patient whose organs are being
					 Removed for donor purposes 0
Qualifying Circumstances
. More than one
					 qualifying circumstance may be selected. Many anesthesia services are provided
					 under particularly difficult circumstances, depending on factors such as the
					 extraordinary condition of patient, notable operative conditions, and/or
					 unusual risk factors. This section includes a list of important qualifying
					 circumstances that significantly affect the character of the anesthesia service
					 provided. These procedures would not be reported alone, but would be reported
					 as additional procedure numbers qualifying as an anesthesia procedure or
					 service.
UNIT VALUE
99100: Anesthesia for patient of extreme age, under one
					 year and over seventy 1
99116: Anesthesia complicated by utilization of total body
					 hypothermia 5
99135: Anesthesia complicated by utilization of controlled
					 hypotension
5 99140: Anesthesia complicated by emergency conditions
					 (an emergency is defined as existing when delay in treatment of the patient
					 would lead to a significant increase in the threat to life or body part)
					 2
B.
Time Unit
:
				  Health care providers must bill the number of minutes of anesthesia time. One
				  time unit is allowed for each 15 minute time interval, or significant fraction
				  thereof (7.5 minutes or more) of anesthesia time. If anesthesia time extends
				  beyond three hours, one time unit for each 10 minute time interval, or
				  significant fraction thereof (5 minutes or more) is allowed after the first
				  three hours. Documentation of actual anesthesia time is required, such as a
				  copy of the anesthesia record.
Code of Maine Rules › 90 - INDEPENDENT AGENCIES › 351 - WORKERS' COMPENSATION BOARD › Chapter 5 - MEDICAL FEES; REIMBURSEMENT LEVELS; REPORTING REQUIREMENTS › Sec2 351-5-2 - PROFESSIONAL SERVICES › Subsection 351-5-2-04 - SURGICAL GUIDELINES

Current through 2024-29, July 17, 2024
1. For surgical
				  procedures that usually mandate a variety of attendant services, the
				  reimbursement allowances are based on a global reimbursement concept. Global
				  reimbursement covers the performance of the basic service and the normal range
				  of care required before and after surgery. The normal range of
				  post­surgical care is indicated under "Global Days" in Appendix II. The
				  maximum allowable payment for a surgical procedure includes all of the
				  following:
A. Any visit that has as its
				  principal function the determination that the surgical procedure is
				  needed.
B. All visits which occur
				  after the need for surgery is determined and are related to or preparatory to
				  the surgery.
C. Surgery.
D. All post-surgical care services, which are
				  routinely performed by the surgeon or by members of the same group within the
				  same specialty as the surgeon, including removal of sutures.
Code of Maine Rules › 90 - INDEPENDENT AGENCIES › 351 - WORKERS' COMPENSATION BOARD › Chapter 5 - MEDICAL FEES; REIMBURSEMENT LEVELS; REPORTING REQUIREMENTS › Sec2 351-5-2 - PROFESSIONAL SERVICES › Subsection 351-5-2-05 - DURABLE MEDICAL EQUIPMENT, PROSTHETICS, ORTHOTICS, AND SUPPLIES

Current through 2024-29, July 17, 2024
1. The employer/insurer must pay for all
				  durable medical equipment, prosthetics, orthotics, and supplies that are
				  ordered and approved by the treating health care provider.
2. Fees for durable medical equipment,
				  prosthetics, orthotics, and supplies are as outlined in Appendix II. Invoices
				  need not be requested by the employer/insurer.
Code of Maine Rules › 90 - INDEPENDENT AGENCIES › 351 - WORKERS' COMPENSATION BOARD › Chapter 5 - MEDICAL FEES; REIMBURSEMENT LEVELS; REPORTING REQUIREMENTS › Sec2 351-5-3 - INPATIENT FACILITY FEES › Subsection 351-5-3-01 - BILLING

Current through 2024-29, July 17, 2024
Bills for inpatient services must be submitted on a CMS
					 Uniform Billing (UB-04) form. Health care providers are not required to provide
					 the MS-DRG. Inpatient bills without the MS-DRG do not constitute uncoded
					 bills.
Code of Maine Rules › 90 - INDEPENDENT AGENCIES › 351 - WORKERS' COMPENSATION BOARD › Chapter 5 - MEDICAL FEES; REIMBURSEMENT LEVELS; REPORTING REQUIREMENTS › Sec2 351-5-3 - INPATIENT FACILITY FEES › Subsection 351-5-3-02 - ACUTE CARE HOSPITALS

Current through 2024-29, July 17, 2024
The base rate for inpatient services at acute care
					 hospitals is $11,121.68.
Code of Maine Rules › 90 - INDEPENDENT AGENCIES › 351 - WORKERS' COMPENSATION BOARD › Chapter 5 - MEDICAL FEES; REIMBURSEMENT LEVELS; REPORTING REQUIREMENTS › Sec2 351-5-3 - INPATIENT FACILITY FEES › Subsection 351-5-3-03 - CRITICAL ACCESS HOSPITALS

Current through 2024-29, July 17, 2024
The base rate for inpatient services at critical access
					 hospitals is $11,788.98.
Code of Maine Rules › 90 - INDEPENDENT AGENCIES › 351 - WORKERS' COMPENSATION BOARD › Chapter 5 - MEDICAL FEES; REIMBURSEMENT LEVELS; REPORTING REQUIREMENTS › Sec2 351-5-3 - INPATIENT FACILITY FEES › Subsection 351-5-3-05 - PAYMENT CALCULATION

Current through 2024-29, July 17, 2024
Pursuant to
					 39-A M.R.S.A.
					 §209-A, the medical fee schedule for
					 services rendered by health care facilities must reflect the methodology and
					 categories set forth in the federal Centers for Medicare and Medicaid Services
					 severity-diagnosis related group system for inpatient services. Inpatient fees
					 are calculated by multiplying the base rate times the MS-DRG weight. In the
					 event of a dispute regarding the fee listed in Appendix III, the listed
					 relative weight times the base rate controls. For inpatient services that take
					 place during two different calendar years, payment is calculated based on the
					 fees in effect on the discharge date.
Code of Maine Rules › 90 - INDEPENDENT AGENCIES › 351 - WORKERS' COMPENSATION BOARD › Chapter 5 - MEDICAL FEES; REIMBURSEMENT LEVELS; REPORTING REQUIREMENTS › Sec2 351-5-3 - INPATIENT FACILITY FEES › Subsection 351-5-3-06 - OUTLIER PAYMENTS

Current through 2024-29, July 17, 2024
The threshold for outlier payments is $75,000.00 plus the
					 fee established in Appendix III. If the outlier threshold is met, the outlier
					 payment is the charges above the threshold multiplied by 75%.
Code of Maine Rules › 90 - INDEPENDENT AGENCIES › 351 - WORKERS' COMPENSATION BOARD › Chapter 5 - MEDICAL FEES; REIMBURSEMENT LEVELS; REPORTING REQUIREMENTS › Sec2 351-5-3 - INPATIENT FACILITY FEES › Subsection 351-5-3-07 - IMPLANTABLES

Current through 2024-29, July 17, 2024
Where an implantable exceeds $10,000.00 in cost, an acute
					 care or critical access hospital may seek additional reimbursement by
					 submitting a copy of the invoice(s) along with the bill. Invoices need not be
					 requested by the employer/insurer. Reimbursement is set at the actual amount
					 paid plus $500.00. Handling and freight charges must be included in the
					 hospital's invoiced cost and are not to be reimbursed separately. When a
					 hospital seeks additional reimbursement pursuant to this chapter, the
					 implantable charge is excluded from any calculation for an outlier payment.
Code of Maine Rules › 90 - INDEPENDENT AGENCIES › 351 - WORKERS' COMPENSATION BOARD › Chapter 5 - MEDICAL FEES; REIMBURSEMENT LEVELS; REPORTING REQUIREMENTS › Sec2 351-5-3 - INPATIENT FACILITY FEES › Subsection 351-5-3-08 - SERVICES INCLUDED

Current through 2024-29, July 17, 2024
All services provided during an uninterrupted patient
					 encounter leading to an inpatient admission must be included in the inpatient
					 stay. Services do not include costs related to transportation of a patient to
					 obtain medical care. Costs related to transportation are payable
					 separately.
Code of Maine Rules › 90 - INDEPENDENT AGENCIES › 351 - WORKERS' COMPENSATION BOARD › Chapter 5 - MEDICAL FEES; REIMBURSEMENT LEVELS; REPORTING REQUIREMENTS › Sec2 351-5-3 - INPATIENT FACILITY FEES › Subsection 351-5-3-09 - FACILITY TRANSFERS

Current through 2024-29, July 17, 2024
The following applies to facility transfers when a patient
					 is transferred for continuation of medical treatment between two
					 hospitals:
1. A hospital transferring
				  a patient is paid as follows: The MS-DRG reimbursement amount is divided by the
				  number of days duration listed for the DRG; the resultant per diem amount is
				  then multiplied by two for the first day of stay at the transferring hospital;
				  the per diem amount is multiplied by one for each subsequent day of stay at the
				  transferring hospital; and the amounts for each day of stay at the transferring
				  hospital are totaled. If the result is greater than the MS-DRG reimbursement
				  amount, the transferring hospital is paid the MS-DRG reimbursement amount.
				  Associated outliers and add-ons are then added to the payment.
2. A hospital discharging a patient is paid
				  the full MS-DRG payment plus any appropriate outliers and add-ons.
3. Facility transfers do not include costs
				  related to transportation of a patient to obtain medical care. Costs related to
				  transportation are payable separately.
Code of Maine Rules › 90 - INDEPENDENT AGENCIES › 351 - WORKERS' COMPENSATION BOARD › Chapter 5 - MEDICAL FEES; REIMBURSEMENT LEVELS; REPORTING REQUIREMENTS › Sec2 351-5-3 - INPATIENT FACILITY FEES › Subsection 351-5-3-010 - OTHER INPATIENT FACILITY FEES

Current through 2024-29, July 17, 2024
Inpatient services provided by institutional health care
					 providers other than acute care or critical access hospitals must be paid at
					 75% of the provider's usual and customary charge.
Code of Maine Rules › 90 - INDEPENDENT AGENCIES › 351 - WORKERS' COMPENSATION BOARD › Chapter 5 - MEDICAL FEES; REIMBURSEMENT LEVELS; REPORTING REQUIREMENTS › Sec2 351-5-3 - INPATIENT FACILITY FEES › Subsection 351-5-3-011 - PROFESSIONAL SERVICES

Current through 2024-29, July 17, 2024
Individual health care providers who furnish professional
					 services in an inpatient setting must be reimbursed using the fees set forth in
					 Appendix II. The individual health care provider's charges are excluded from
					 any calculation of outlier payments.
Code of Maine Rules › 90 - INDEPENDENT AGENCIES › 351 - WORKERS' COMPENSATION BOARD › Chapter 5 - MEDICAL FEES; REIMBURSEMENT LEVELS; REPORTING REQUIREMENTS › Sec2 351-5-4 - OUTPATIENT FACILITY FEES › Subsection 351-5-4-01 - BILLING

Current through 2024-29, July 17, 2024
Bills for hospital outpatient and ambulatory surgical
					 services must be submitted on a UB-04 form. Outpatient hospital facility
					 services performed on the same day for the same patient must be reported on a
					 single UB-04 form.
Code of Maine Rules › 90 - INDEPENDENT AGENCIES › 351 - WORKERS' COMPENSATION BOARD › Chapter 5 - MEDICAL FEES; REIMBURSEMENT LEVELS; REPORTING REQUIREMENTS › Sec2 351-5-4 - OUTPATIENT FACILITY FEES › Subsection 351-5-4-02 - ACUTE CARE HOSPITALS

Current through 2024-29, July 17, 2024
The base rate for outpatient services at acute care
					 hospitals is $150.05.
Code of Maine Rules › 90 - INDEPENDENT AGENCIES › 351 - WORKERS' COMPENSATION BOARD › Chapter 5 - MEDICAL FEES; REIMBURSEMENT LEVELS; REPORTING REQUIREMENTS › Sec2 351-5-4 - OUTPATIENT FACILITY FEES › Subsection 351-5-4-03 - CRITICAL ACCESS HOSPITALS

Current through 2024-29, July 17, 2024
The base rate for outpatient services at critical access
					 hospitals is $174.00.
Code of Maine Rules › 90 - INDEPENDENT AGENCIES › 351 - WORKERS' COMPENSATION BOARD › Chapter 5 - MEDICAL FEES; REIMBURSEMENT LEVELS; REPORTING REQUIREMENTS › Sec2 351-5-4 - OUTPATIENT FACILITY FEES › Subsection 351-5-4-04 - AMBULATORY SURGICAL CENTERS

Current through 2024-29, July 17, 2024
The base rate for surgical services at ambulatory surgical
					 centers is $113.39.
Code of Maine Rules › 90 - INDEPENDENT AGENCIES › 351 - WORKERS' COMPENSATION BOARD › Chapter 5 - MEDICAL FEES; REIMBURSEMENT LEVELS; REPORTING REQUIREMENTS › Sec2 351-5-4 - OUTPATIENT FACILITY FEES › Subsection 351-5-4-05 - PAYMENT CALCULATION

Current through 2024-29, July 17, 2024
Pursuant to
					 39-A M.R.S.A.
					 §209-A, the medical fee schedule for
					 services rendered by health care facilities must reflect the methodology and
					 categories set forth in the federal Centers for Medicare and Medicaid Services
					 ambulatory payment classification system for outpatient services. Fees for
					 procedure codes are calculated by multiplying the base rate times the APC
					 weight. In the event of a dispute regarding the fee listed in Appendix IV, the
					 listed relative weight times the base rate controls.
1. For procedure codes with no
				  CPT®/HCPCS code or for procedure codes with a
				  status indicator of N, there is no separate payment.
2. If the ACH Fee, CAH Fee or ASC Fee listed
				  in Appendix IV is $0.00 for a procedure code with a status indicator other than
				  N, then payment must be calculated at 75% of the health care provider's usual
				  and customary charge.
3. When two
				  or more procedure codes with a status indicator of T are billed on the same
				  date of service, the highest weighted code is paid at 100% of the fee listed in
				  Appendix IV and additional T status code procedures are paid at 50% of the fee
				  listed in Appendix IV. Add-on codes are not subject to discounting.
4. When one or more procedure codes with a
				  status indicator of N are billed without any other outpatient services (i.e.
				  non-patient referred specimens or the facility collects the specimen and
				  furnishes only the outpatient labs on a given date of service, etc.), payment
				  must be calculated at 75% of the provider's usual and customary
				  charge.
Code of Maine Rules › 90 - INDEPENDENT AGENCIES › 351 - WORKERS' COMPENSATION BOARD › Chapter 5 - MEDICAL FEES; REIMBURSEMENT LEVELS; REPORTING REQUIREMENTS › Sec2 351-5-4 - OUTPATIENT FACILITY FEES › Subsection 351-5-4-06 - OUTLIER PAYMENTS

Current through 2024-29, July 17, 2024
The threshold for outlier payments is $2,500.00 per
					 procedure code plus the fee listed in Appendix IV. If the outlier threshold is
					 met, the outlier payment is the charges above the threshold multiplied by 75%.
					 If a bill has more than one surgical procedure with a status indicator of J, S
					 or T and one or more of those procedures has less than a $1.01 charge, charges
					 for all status J, S and T lines are summed and the charges are then divided
					 across the J, S and T lines in proportion to their APC payment rate. The new
					 charge amount is used in place of the submitted charge amount in the outlier
					 calculation.
Code of Maine Rules › 90 - INDEPENDENT AGENCIES › 351 - WORKERS' COMPENSATION BOARD › Chapter 5 - MEDICAL FEES; REIMBURSEMENT LEVELS; REPORTING REQUIREMENTS › Sec2 351-5-4 - OUTPATIENT FACILITY FEES › Subsection 351-5-4-07 - IMPLANTABLES

Current through 2024-29, July 17, 2024
Where an implantable exceeds $250.00 in cost, hospitals or
					 ambulatory surgical centers may seek additional reimbursement (regardless of
					 the status indicator) by submitting a copy of the invoice(s) along with the
					 bill. Invoices need not be requested by the employer/insurer. Reimbursement is
					 set at the actual amount paid plus 20% or the actual amount paid plus $500.00,
					 whichever is less. Handling and freight charges must be included in the
					 facility's invoiced cost and are not to be reimbursed separately.
Code of Maine Rules › 90 - INDEPENDENT AGENCIES › 351 - WORKERS' COMPENSATION BOARD › Chapter 5 - MEDICAL FEES; REIMBURSEMENT LEVELS; REPORTING REQUIREMENTS › Sec2 351-5-4 - OUTPATIENT FACILITY FEES › Subsection 351-5-4-08 - SERVICES INCLUDED

Current through 2024-29, July 17, 2024
Outpatient services include observation in an outpatient
					 status.
Code of Maine Rules › 90 - INDEPENDENT AGENCIES › 351 - WORKERS' COMPENSATION BOARD › Chapter 5 - MEDICAL FEES; REIMBURSEMENT LEVELS; REPORTING REQUIREMENTS › Sec2 351-5-4 - OUTPATIENT FACILITY FEES › Subsection 351-5-4-09 - TRANSFERS

Current through 2024-29, July 17, 2024
The following applies to facility transfers when a patient
					 is transferred for continuation of medical treatment between two
					 facilities:
1. A hospital or
				  ambulatory surgical center transferring a patient is paid the maximum allowable
				  payment established in this section.
2. A hospital discharging a patient is paid
				  the full MS-DRG payment plus any appropriate outliers and add-ons per section
				  3.
3. Facility transfers do not
				  include costs related to transportation of a patient to obtain medical care.
				  Costs related to transportation are payable separately.
Code of Maine Rules › 90 - INDEPENDENT AGENCIES › 351 - WORKERS' COMPENSATION BOARD › Chapter 5 - MEDICAL FEES; REIMBURSEMENT LEVELS; REPORTING REQUIREMENTS › Sec2 351-5-4 - OUTPATIENT FACILITY FEES › Subsection 351-5-4-10 - OTHER OUTPATIENT FACILITY FEES

Current through 2024-29, July 17, 2024
Outpatient services provided by institutional health care
					 providers other than acute care or critical access hospitals and ambulatory
					 surgical centers (e.g. clinical medical laboratories, free standing outpatient
					 facilities, etc.) must be paid at 75% of the provider's usual and customary
					 charge.
Code of Maine Rules › 90 - INDEPENDENT AGENCIES › 351 - WORKERS' COMPENSATION BOARD › Chapter 5 - MEDICAL FEES; REIMBURSEMENT LEVELS; REPORTING REQUIREMENTS › Sec2 351-5-4 - OUTPATIENT FACILITY FEES › Subsection 351-5-4-11 - PROFESSIONAL SERVICES

Current through 2024-29, July 17, 2024
Individual health care providers who furnish professional
					 services in an outpatient setting must be reimbursed using the maximum fees set
					 forth in Appendix II. The individual health care provider's charges are
					 excluded from any calculation of outlier payments.
Code of Maine Rules › 90 - INDEPENDENT AGENCIES › 351 - WORKERS' COMPENSATION BOARD › Chapter 5 - MEDICAL FEES; REIMBURSEMENT LEVELS; REPORTING REQUIREMENTS › Appendix 351-5-II - IV - MEDICAL FEE SCHEDULE

Current through 2024-29, July 17, 2024
NOTE
: For a complete copy of the Medical Fee
				  Schedule, including the Appendices, please see the separate Publication
				  entitled:
"Medical Fee Schedule" located on the Board's website here:
				  http://www.maine.gov/wcb/Departments/omrs/medfeesched.html.
Code of Maine Rules › 90 - INDEPENDENT AGENCIES › 351 - WORKERS' COMPENSATION BOARD › Chapter 5 - MEDICAL FEES; REIMBURSEMENT LEVELS; REPORTING REQUIREMENTS › Appendix 351-5-V - MEDICAL RELEASE FORMS

Current through 2024-29, July 17, 2024
FORMS WCB-220, WCB-220A, WCB-220B, WCB-220C, AND
				  WCB-220R
Click here to view
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Click here to view
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Code of Maine Rules › 90 - INDEPENDENT AGENCIES › 351 - WORKERS' COMPENSATION BOARD › Chapter 6 - REHABILITATION › Subchapter I - PROVIDER PROVISIONS › Section 351-6-1 - Board-Approved Employment Rehabilitation Providers/Facilities

Current through 2024-29, July 17, 2024
1.
Minimum Qualifications
An employment rehabilitation provider/facility ("provider")
					 must have at least five years of experience in employment rehabilitation
					 services, and:
A. Certification as a
				  Certified Rehabilitation Counselor (CRC);
B. A Bachelor's degree in rehabilitation
				  counseling or a closely related field; and/or
C. A Master's degree in rehabilitation
				  counseling or a closely related field.
Code of Maine Rules › 90 - INDEPENDENT AGENCIES › 351 - WORKERS' COMPENSATION BOARD › Chapter 6 - REHABILITATION › Subchapter I - PROVIDER PROVISIONS › Section 351-6-2 - Provider Requirements

Current through 2024-29, July 17, 2024
1.
Evaluation
				  and Plan
A. A provider must consider
				  medical evidence and information received with a referral for
				  evaluation.
B. If a provider finds
				  the employee is not suitable for employment rehabilitation services, the
				  provider must clearly articulate the reason(s) in the evaluation.
C. If a provider finds an employee is
				  suitable for employment rehabilitation services, the provider must include in
				  the evaluation, at a minimum, the following:
i. Clearly articulated reasons the provider
				  believes employment rehabilitation services are warranted;
ii. A concise summary of medical records
				  reviewed;
iii. The source, date,
				  and description of the employee's current work capacity, including
				  restrictions;
iv. Clearly defined
				  vocational goals for the employee; and
v. A detailed employment rehabilitation plan,
				  including a clear plan for workforce re-entry, an outline of expected costs,
				  and the estimated length of the plan.
D. A provider must submit the evaluation of
				  the employee to the Executive Director or the Executive Director's designee no
				  later than sixty days after the referral from the Board, unless the provider
				  has received an extension of time from the Executive Director or the Executive
				  Director's designee.