Michigan Administrative Code › Department - Labor and Economic Opportunity › Workers Compensation Agency › Workers' Compensation Health Care Services Rules › Part 1 - GENERAL PROVISIONS › Section R. 418.10109 - Definitions; M to U

Current through Vol. 24-12, July 15, 2024
Rule 109. As used in these rules:
(a) "Maximum allowable payment" means the
				  maximum fee for a procedure that is established by these rules, a reasonable
				  amount for a "by report" procedure, or a provider's usual and customary charge,
				  whichever is less.
(b) "Medical
				  only case" means a case that does not involve wage loss compensation.
(c) "Medical rehabilitation" means, to the
				  extent possible, the interruption, control, correction, or amelioration of a
				  medical or a physical problem that causes incapacity through the use of
				  appropriate treatment disciplines and modalities that are designed to achieve
				  the highest possible level of post-injury function and a return to gainful
				  employment.
(d) "Medically accepted
				  standards" means a measure that is set by a competent authority as the rule for
				  evaluating quantity or quality of health care or health care services ensuring
				  that the health care is suitable for a particular person, condition, occasion,
				  or place.
(e) "Morbidity" means the
				  extent of illness, injury, or disability.
(f) "Mortality" means the likelihood of
				  death.
(g) "New patient" means a
				  patient who is new to the provider for a particular covered injury or illness
				  and who needs to have medical and administrative records established.
(h) "Nursing home" means a nursing care
				  facility, including a county medical care facility, created pursuant to section
				  20109 of the public health code, 1978 PA 368, MCL 333.20109.
(i) "Opioid drugs" as used in these rules,
				  refers to opiate analgesics, narcotic analgesics, or any other Schedule C
				  (II-III) controlled substance as identified in United States Code Controlled
				  Substances Act of 1970, 21. U.S.C. §812. Opioid analgesics are the class
				  of drugs, such as morphine, codeine, and methadone, that have the primary
				  indication for the relief of pain.
(j) "Orthotic equipment" means an orthopedic
				  apparatus that is designed to support, align, prevent, or correct deformities
				  of, or improve the function of, a movable body part.
(k) "Pharmacy" means the place where the
				  science, art, and practice of preparing, preserving, compounding, dispensing,
				  and giving appropriate instruction in the use of drugs is practiced.
(l) "Practitioner" means an individual who is
				  licensed, registered, or certified as used in the public health code, 1978 PA
				  368, MCL 333.1101 to 333.25211.
(m)
				  "Primary procedure" means the therapeutic procedure that is most closely
				  related to the principal diagnosis and has the highest assigned relative value
				  unit (RVU).
(n) "Properly submitted
				  bill" means a request by a provider for payment of health care services that is
				  submitted to a carrier on the appropriate completed claim form with attachments
				  as required by these rules.
(o)
				  "Prosthesis" means an artificial substitute for a missing body part. A
				  prosthesis is constructed by a "prosthetist", a person who is skilled in the
				  construction and application of a prosthesis.
(p) "Provider" means a facility, health care
				  organization, or a practitioner.
(q) "Reasonable amount" means a payment based
				  upon the amount generally paid in the state for a particular procedure code
				  using data available from the provider, the carrier, or the workers'
				  compensation agency, health care services division.
(r) "Restorative" means that the patient's
				  function will demonstrate measurable improvement in a reasonable and generally
				  predictable period of time and includes appropriate periodic care to maintain
				  the level of function.
(s)
				  "Secondary procedure" means a surgical procedure that is performed to
				  ameliorate conditions that are found to exist during the performance of a
				  primary surgery and is considered an independent procedure that may not be
				  performed as a part of the primary surgery or for the existing
				  condition.
(t) "Separate procedure"
				  means procedures or services listed in the CPT code set that are commonly
				  carried out as an integral component of a total service or procedure have been
				  identified by the inclusion of a term "separate procedure."
(u) "Specialist" means any of the following
				  entities that are board-certified, board-eligible, or otherwise considered an
				  expert in a particular field of health care by virtue of education, training,
				  and experience generally accepted in that particular field:
(i) A doctor of chiropractic.
(ii) A doctor of dental surgery.
(iii) A doctor of medicine.
(iv) A doctor of optometry.
(v) A doctor of osteopathic medicine and
				  surgery.
(vi) A doctor of podiatric
				  medicine and surgery.