(a) The division
administrator shall be responsible for all funds under the jurisdiction of the
division, in all of its programs and organizational subdivisions, regardless of
their source or designation.
(b)
Any charge for services not covered by approved fee schedules shall be
authorized by authorized staff of the division in accordance with this section,
section 17-400.1-10 and applicable State fiscal policies and procedures
governing purchase of services.
(c)
Payment for services must be authorized in writing, by authorized staff of the
division either simultaneously with or before the services are rendered. In an
emergency situation, verbal authorization by authorized staff of the division
will be permitted if there is prompt documentation and the authorization is
confirmed in writing and forwarded to the provider of the services immediately
thereafter.
(d) Services shall be
provided by qualified vendors who meet the requirements of section
17-400.1-10(g) and are duly licensed to practice their profession in accordance
with State licensed laws.
(1) Physicians must
be licensed by the State board of medical examiners;
(2) Specialists must be licensed to practice
in the State and certified by the American board in the particular medical
specialty;
(3) Dentists must be
licensed by the State board of dental examiners;
(4) Psychologists must be licensed by the
State and certified by the appropriate certifying body; and
(5) Other duly authorized medically-oriented
resource persons, such as osteopaths, must be licensed and certified by the
appropriate governing bodies.
(e) When board certified or licensed service
providers are not available, the division's medical consultant shall assist in
making a selection of a service provider guided by available objective
standards of competence, such as the following:
(1) Completion of training and experience
requirements for admission to board examinations;
(2) Recognition as a competent specialist by
State or county medical societies;
(3) Acceptance as a specialist by the
workers' compensation board;
(4)
Membership on the clinical teaching staff of a medical school; or
(5) Similar objective standards of competence
as described in (1) through (4).
(f) New schedules or changes in existing fee
schedules shall be authorized only by the division administrator and are
subject to the public hearing process before purchase of services.
(1) The 1970 relative value studies (RVS) of
the Hawaii medical association and the conversion factors approved by the
division and distributed under internal communication memo entitled "VRSBD
Medical Fee Schedule -RVS Conversion Factors" shall be the division's fee
schedule for all medical diagnostic and treatment (restoration) services
purchased by the division. Where there is no procedure code or fee that
adequately covers a particular situation or is indicated "by report" in the
RVS, the physician must provide a brief description of the services plus the
charge, for review and approval by authorized staff of the division. A change
of physicians or vendors may be necessary in instances where agreement on
charges cannot be reached.
(2) The
dental fee schedule approved by the division and distributed under internal
communication memo entitled "VRSBD Dental Fee Schedule" shall be the schedule
used for all dental services purchased by the division.
(3) The division's list of allowed
psychological services distributed under internal communication memo entitled
"VRSBD Psychological Fee Schedule" shall be the division's fee schedule for
psychological services purchased by the division.
(4) The sign language interpreter services
fee schedule approved by the division and distributed under internal
communication memo entitled "VRSBD Interpreters for the Deaf and Deaf-Blind"
shall be the schedule for all sign language interpreter services purchased by
the division. The division's maximum rates for interpreter services shall be
determined by the division in consideration of:
(A) The current guidelines issued by the
Disability and Communication Access Board; and
(B) The Certification levels of the National
Registry of Interpreters for the Deaf, the National Association of the Deaf,
and the Hawaii Quality Assurance System.
(5) When health insurance is available for
applicants or eligible individuals, the division shall only pay the difference
between the amount indicated on the division's applicable fee schedule and the
amount covered by the health insurance. If the amount covered by the health
insurance equals or exceeds the amount indicated on the division's applicable
fee schedule, the division's share shall be zero.
(A) In arranging for the purchase of
services, the division shall inform the vendor of the above arrangements in
determining the division's share in the cost.
(B) Regardless of the amount of the
division's share in the cost, the division shall ensure that the vendor agrees
not to bill the applicant or eligible individual for any remaining difference
in charges resulting from the differences in the amounts covered by insurance,
the division's fee schedule, and the vendor's charges for the
service.
(C) A change of physician
or vendor may be necessary in instances where agreement on charges cannot be
reached.
(6) No payment
shall be made to vendors for services canceled by the division. Vendors shall
be notified in writing of the cancellation.
(7) The division may pay up to fifty per cent
of the amount authorized in instances when the applicant or eligible individual
fails to keep an appointment. Exact amount of payment shall be individually
adjusted. Factors such as prolonged procedures, e.g., psychiatry-psychological
evaluations, and repeated "no shows" should be considered in setting the final
payment amounts.
(8) When a request
is made to a vendor for special reports such as narrative reports, reviews of
medical records, or copies of medical files necessary to establish or clarify
an applicant's or eligible individual's status, a charge adequate to cover the
value of the additional service may be authorized within the limits set by the
division administrator. The cost allowed will vary with the complexity,
extensiveness, and time required by a vendor to prepare the report.
(9) Payments to hospitals shall be the usual
and customary rates as published by the hospital for procedures that are not
covered by the division's fee schedules. Payments shall not be authorized for
private rooms unless it is a medical necessity, authorized by the physician and
approved by the division's medical consultant.
