Code of Massachusetts Regulations
114 CMR - DIVISION OF HEALTH CARE FINANCE AND POLICY
Title 114.3 CMR 40.00 - RATES FOR SERVICES UNDER M.G.L. c. 152, WORKERS' COMPENSATION ACT
Section 40.04 - Provisions Affecting Eligible Providers
Current through Register 1531, September 27, 2024
(1) Facility Rate. If a procedure other than those listed in 114.3 CMR 40.06 with a PC and TC fee is performed at a site other than the provider's office and is also properly billed by another health care provider, each provider will be reimbursed at 50% of the listed fee.
(2) Out-of-state Providers. An insurer may pay out-of-state provider for services at the payment rates set forth in 114.3 CMR 40.00.
(3) Individual Consideration (I.C.). Services that are authorized but for which there are no established rates are designated as I.C. items. The purchaser under M.G.L. c. 152 will determine an appropriate payment rate. Unless otherwise provided in 114.3 CMR 40.05, the payment will be determined in accordance with all of the applicable following standards and criteria:
(4) Utilization Standard. The DIA Healthcare Services Board publishes treatment guidelines pertaining to work place injury and illness that define appropriate care deemed medically necessary. All services provided under the Workers' Compensation Act must be delivered within the scope of these guidelines.