Section 418.10108. Definitions; A to I.

Rule 108. As used in these rules:

(a)   "Act" means the worker’s disability compensation act of 1969, 1969 PA 317, MCL 418.101 to 418.941.

(b)   "Adjust" means that a carrier or a carrier's agent reduces a health care provider's request for payment to the maximum fee allowed by these rules, to a provider's usual and customary charge, or, when the maximum fee is by report, to a reasonable amount. "Adjust" also means when a carrier re-codes a procedure, or reduces payment as a result of professional review.

(c)    "Agency" means the workers' compensation agency in the department of licensing and regulatory affairs.

(d)   "Ambulatory surgical center" (ASC) means an entity that operates exclusively for providing surgical services to patients not requiring hospitalization and has an  agreement with the centers for Medicare and Medicaid services (CMS) to participate in Medicare.

(e)    "Appropriate care" means health care that is suitable for a particular person, condition, occasion, or place.

(f)    “Biologics” or “biologicals” include drugs or other products that are derived from life forms. Biologics are biology-based products used to prevent, diagnose, treat, or cure disease or other conditions in humans and animals. Biologics generally include products such as vaccines, blood, blood components, allergenics, somatic cells, genes, proteins, DNA, tissues, skin substitutes, recombinant therapeutic proteins, microorganisms, antibodies, immunoglobins, and others, including, but not limited to, those that are produced using biotechnology and are made from proteins, genes, antibodies, and nucleic acids.

(g)   "BR" or "by report" means that the procedure is not assigned a relative value unit, (RVU) or a maximum fee and requires a written description.

(h)   "Carrier" means an organization that transacts the business of workers' compensation insurance in Michigan and which  may be any of the following:

(i)   A private insurer.

(ii)   A self-insurer.

(iii)   One of the funds in chapter 5 of the act, MCL 418.501 to 408.561.

(i)   "Case" means a covered injury or illness that occurs on a specific date and is identified by the worker's name and date of injury or illness.

(j)    "Case record" means the complete health care record that is maintained by a carrier and pertains to a covered injury or illness that occurs on a specific date.

(k)   "Complete procedure" means a procedure that contains a series of steps that are not to be billed separately.

(l)   "Covered injury or illness" means an injury or illness for which treatment is mandated by section 315 of the act, MCL 418.315.

(m)      "Current procedural terminology (CPT®)" means a listing of descriptive terms and identifying codes and provides a uniform nationally accepted nomenclature for reporting medical services and procedures. The CPT codebook provides instructions for coding and claims processing.

(n)     “Custom compound” as used in these rules, means a customized topical medication prescribed or ordered by a duly licensed prescriber for the specific patient that is prepared in a pharmacy by a licensed pharmacist in response to a licensed practitioner’s prescription or order, by combining, mixing, or altering of ingredients, but not reconstituting, to meet the unique needs of an individual patient.

(o)   "Dispute" means a disagreement between a carrier or a carrier's agent and a health care provider on the application of these rules.

(p)   "Durable medical equipment" means specialized equipment that is designed to stand repeated use, is used to serve a medical purpose, and is appropriate for home use.

(q)   "Emergency condition" means that a delay in treating a patient would lead to a significant increase in the threat to the patient's life or to a body part.

(r)     "Established patient" means a patient whose medical and administrative records for a particular covered injury or  illness  are  available to  the provider.

(s)   "Expendable medical supply" means a disposable article that is needed in quantity on a daily or monthly basis.

(t)   "Facility" means an entity licensed by the state pursuant to the public health code, 1978 PA 368, MCL 333.1101 to 333.25211. The office of an individual practitioner is not considered a facility.

(u)    "Focused review" means the evaluation of a specific health care service or provider to establish patterns of use and dollar expenditures.

(v)   "Follow-up days" means the days of care following a surgical procedure that are included in the procedure's maximum allowable payment, but does not include care for complications. If the surgical procedure lists "xxx" for the follow-up days, then the global concept does not apply. If "yyy" is listed for follow-up days, then the carrier shall set the global period. If "zzz" is used, then the procedure code is part of another service and falls within the global period of the other service.

(w)    "Free standing outpatient facility" (FSOF) means a facility, other than the office of a physician, dentist, podiatrist, or other private practice, offering a surgical procedure and related care that in the opinion of the attending physician can be safely  performed   without requiring overnight inpatient hospital care.

(x)       "Health care organization" means a group of  practitioners  or individuals joined together to provide health care services and includes any of the following:

(i)   Health maintenance organization.

(ii)   Industrial or other clinic.

(iii)   Occupational health care center.

(iv)   Home health agency.

(v)   Visiting nurse association.

(vi)   Laboratory.

(vii)   Medical supply company.

(viii)   Community mental health board.

(y)   "Health care review" means the review of a health care case or bill, or both, by a carrier, and includes technical health care  review  and professional health care review.

(z)   "Incidental surgery" means a surgery that is performed through the same incision, on the same day, by the same doctor of dental surgery, doctor of medicine, doctor of osteopathy, or doctor of podiatry  and  that  is  not related to diagnosis.

(aa) "Independent medical examination" means an examination and evaluation that is requested by a carrier or an employee and that is conducted by a different practitioner than the practitioner who provides care.

(bb) "Industrial medicine clinic" also referred to as an "occupational health clinic" means an organization that primarily treats injured workers. The industrial medicine clinic or occupational clinic may be a health care organization as defined by these rules or may be a clinic owned and  operated by a hospital for the purposes of treating injured workers.

(cc) "Insured employer" means an employer  who  purchases  workers' compensation insurance from an insurance company that is licensed to write insurance in the state of Michigan.

History: 2000 AACS; 2001 AACS; 2003 AACS; 2005 AACS; 2010 AACS; 2012 AACS; 2014 AACS.