Section 418.101015. General rules for facility reimbursement.

(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.

(5)   Additional records not listed in subrule (4) of this rule may be requested by the carrier and shall be reimbursed in accordance with R 418.10118.

History: 2000 AACS; 2005 AACS; 2008 AACS; 2015 MR 17, Eff. Sept. 15, 2015.