Section 418.10109. Definitions; M to U.

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, 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.

(v)    "Subrogation" means substituting 1 creditor for another. An example of subrogation in workers' compensation is when a case is determined to be workers' compensation and the health  benefits  plan   has  already  paid     for     the  service  and   is  requesting  the   workers'

compensation carrier or  the  provider to refund the money that the plan paid on behalf of the worker.

(w)   "Technical surgical  assist"  means  that  additional   payment  for  an assistant   surgeon, referenced   in  R  418.10416,   is allowed  for  certain designated surgical procedures. The Health Care Services Manual, published annually by the workers' compensation agency, denotes a surgical procedure allowing payment for the technical surgical assist with the letter "T." (x)"Treatment   plan"  means  a  plan  of  care  for  restorative   physical treatment services that indicates the diagnosis and anticipated goals.

(y)    "Usual and customary charge" means a particular provider's average charge for a procedure to all payment sources, and includes itemized charges which were previously billed separately and which are included in the package for that procedure as defined by these rules. A usual and customary charge for a procedure shall be calculated based on data beginning January 1, 2000.

History: 1998-2000 AACS; 2004 AACS; 2005 AACS; 2009 AACS; 2010 AACS; . 2014 AACS.