Administrative Rules of Montana
Department 24 - LABOR AND INDUSTRY
Chapter 24.29 - WORKERS' COMPENSATION AND OCCUPATIONAL DISEASE
Subchapter 24.29.14 - General Medical Rules and Facility Service Rules
Rule 24.29.1402 - PAYMENT OF MEDICAL CLAIMS

Universal Citation: MT Admin Rules 24.29.1402

Current through Register Vol. 18, September 20, 2024

(1) Payment of medical claims must be made in accordance with the schedule of facility and professional medical fees adopted by the department.

(a) Payment of medical claims must also be made in accordance with the utilization and treatment guidelines adopted by the department in ARM Title 24, chapter 29, subchapter 16.

(b) The department may assess a penalty on insurers for neglect or failure to use the correct fee schedule. It is the insurer's responsibility to ensure that the correct fee schedule is used by a third-party agent.

(c) A provider of medical treatment or services shall only be paid for services under this chapter if the bill for medical treatment or services is timely received by the employer or appropriate payer. Absent a showing of good cause, a bill for treatment or services is timely received by the employer or appropriate payer when it is actually received within 365 days of the later of:
(i) the date of service; or

(ii) the date the provider of medical treatment or services knew the treatment or services was related to a claim for benefits under this chapter.

(2) The insurer shall make timely payments of all medical bills for which liability is accepted. For services provided on or after July 1, 2013, the department may assess a penalty on an insurer that without good cause neglects or fails to pay undisputed medical bills on an accepted liability claim within 60 days of receipt of the bill(s). The insurer must document receipt date of the bill(s) or the receipt date will be three days after the bill(s) was sent by the provider.

(3) For purposes of coding interest billing on unpaid charges, providers must bill the interest amount using the Montana unique code MT005 established by this rule.

(4) Payment of private room charges shall be made only if ordered by the treating physician.

(5) Special nurses shall be paid only if ordered by the treating physician.

(6) For claims arising on or after July 1, 1993, no fee or charge is payable by the injured worker for treatment of injuries sustained if liability is accepted by the insurer, other than:

(a) the co-payment provided by 39-71-704, MCA. The decision whether to require a co-payment rests with the insurer, not the medical provider. If the insurer does not require a co-payment by the worker, the provider may not charge or bill the worker any fee. The insurer must give enough advance notice to known medical providers that it will require co-payments from a worker so that the provider can make arrangements with the worker to collect the co-payment;

(b) the charges for a nonpreferred provider, after notice is given as provided in 39-71-1102, MCA;

(c) the charges for medical services obtained from other than a managed care organization, once an organization is designated by the insurer as provided in 39-71-1101, MCA; or

(d) the charges for medical services denied by the insurer on the basis that the services meet both of the following criteria:
(i) the medical services do not return the injured worker to employment; and

(ii) the medical services do not sustain medical stability.

(7) For compensable services provided on or after July 1, 2013, if the injured worker pays for the initial medical service prior to acceptance of the claim by the insurer, the injured worker must be reimbursed the entire amount they paid out-of-pocket within 30 days of acceptance.

(a) If the insurer pays the provider, the provider must reimburse the injured worker.

(b) Otherwise, the insurer must reimburse the injured worker.

AUTH: 39-71-203, MCA IMP: 39-71-107, 39-71-203, 39-71-510, 39-71-704, MCA

Disclaimer: These regulations may not be the most recent version. Montana may have more current or accurate information. We make no warranties or guarantees about the accuracy, completeness, or adequacy of the information contained on this site or the information linked to on the state site. Please check official sources.
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