Michigan Administrative Code
Department - Labor and Economic Opportunity
Workers Compensation Agency
Workers' Compensation Health Care Services Rules
Part 10 - REIMBURSEMENT
Subpart A - Eligibility for premium tax credit
Section R. 418.101015 - General rules for facility reimbursement

Universal Citation: MI Admin Code R. 418.101015

Current through Vol. 24-16, September 15, 2024

Rule 1015.

(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.

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