Rule 24.29.1534 - PROFESSIONAL FEE SCHEDULE(1) An insurer must pay the fee schedule or the billed charge, whichever is less, for a service provided within the state of Montana. The fee schedules are available online at the department's web site and are updated as soon as is reasonably feasible relative to the effective dates of the medical codes as described below. All current and prior instruction sets for services provided starting July 1, 2013, are available on the department's website. The fee schedules are comprised of the elements listed in 39-71-704, MCA, and the following: (a) the conversion factors established by the department in ARM 24.29.1538;(b) modifiers, listed on the department's web site;(c) the Montana unique code, MT001, described in (9);(d) the Montana unique code, MT003, adopted and described in ARM 24.29.1433; and(e) the Montana unique code, MT009, for referral to a vocational rehabilitation counselor for on-site job evaluation with the injured worker to assist in returning him/her to work either to his/her time of injury job or a new job/position.(2) The conversion factors, the Current Procedural Terminology (CPT) codes, and the relative value units (RVU) used depend on the date the medical service, procedure, or supply is provided. The reimbursement amount is generally determined by finding the proper CPT code in the Resource-Based Relative Value Scale (RBRVS) then multiplying the RVU for that code by the conversion factor.(3) The insurer shall pay 100 percent of the usual and customary charges for dental codes. The insurer shall pay a minimum of 75 percent of the usual and customary charges for dental codes D6010 through D6199.(4) Where a permitted procedure is not covered by these rules or uses a new code, the insurer must pay 75 percent of the usual and customary fee charged by the provider to nonworkers' compensation patients.(5) The maximum fee that an insurer is required to pay for a particular procedure is listed on the department web site and was computed using the RVU in the total facility or nonfacility column of the RBRVS times the conversion factor, except as otherwise provided for in these rules.(6) Professionals, including those who furnish services in a hospital, critical access hospital, ambulatory surgery center, or other facility setting must bill insurers using the CMS 1500, with the exception of physical therapy, occupational therapy, and speech therapy services provided on an outpatient basis and billed on a UB04. Dental providers may bill insurers using the American Dental Association (ADA) Dental Claim Form.(7) Each provider is to limit services to those which can be performed within the provider's scope of license. For nonlicensed providers, the insurer is not required to reimburse above the related CPT codes for appropriate services.(8) When billing the services listed below, the Montana unique code, MT001, must be used and a separate written report is required describing the services provided. The reimbursement rate for this code is 0.54 RVUs per 15 minutes with time documented by the provider. These requirements apply to the following services: (a) face-to-face conferences with payor representative(s) to update the status of a patient upon request of the payor; (b) a report associated with nonphysician conferences required by the payor;(c) completion of a job description or job analysis form requested by the payor; or(d) written questions that require a written response from the provider, excluding the Medical Status Form.(9) Where a service is listed as "by report", the fee charged may not exceed the usual and customary fee charged by the provider to nonworkers' compensation patients.(10) It is the responsibility of the provider to use the proper procedure, service, and supply codes on any bills submitted for payment. The failure of a provider to do so, however, does not relieve the insurer's obligation to pay the bill, but it may justify delays in payment until proper coding of the services provided is received by the insurer.(11) Copies of the RBRVS are available from the publisher. Ordering information may be obtained from the department.Mont. Admin. r. 24.29.1534
NEW, 2013 MAR p. 1185, Eff. 7/12/13; AMD, 2014 MAR p. 1513, Eff. 7/11/14; AMD, 2015 MAR p. 818, Eff. 6/26/2015; AMD, 2016 MAR p. 1055, Eff. 6/18/2016; AMD, 2017 MAR p. 784, Eff. 6/10/2017; AMD,2018 MAR p. 1036, Eff.5/26/2018; AMD,2019 MAR p. 848, Eff.6/22/2019; AMD, 2020 MAR p. 1021, Eff. 6/13/2020; AMD, 2021 MAR p. 716, Eff.6/12/2021; AMD, 2022 MAR p. 1075, Eff. 6/25/2022; AMD, 2024 MAR p. 1066, Eff. 5/11/2024; AMD, 2024 MAR p. 1457, Eff. 7/1/2024AUTH: 39-71-203, MCA IMP: 39-71-704, MCA