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Rule Title: PAYMENT OF MEDICAL CLAIMS
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Department: LABOR AND INDUSTRY
Chapter: WORKERS' COMPENSATION AND OCCUPATIONAL DISEASE
Subchapter: General Medical Rules and Facility Service Rules
 
Latest version of the adopted rule presented in Administrative Rules of Montana (ARM):

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24.29.1402    PAYMENT OF MEDICAL CLAIMS

(1) As required by 39-71-704, MCA, charges submitted by providers must be the usual and customary charge billed for nonworkers' compensation patients. Payment of medical claims must be made in accordance with the schedule of facility and professional medical fees adopted by the department.

(a) For services provided on or after July 1, 2011, payment of medical claims must also be made in accordance with the utilization and treatment guidelines adopted by the department in ARM 24.29.1591.

(b) For services provided on or after July 1, 2013, 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.

(i) If the insurer does not properly process the entire medical bill using the correct fee schedule within 60 days of the receipt, the department may assess a $200.00 penalty for each occurrence. Each medical bill is an occurrence.

(ii) This fine may be increased $100.00 per subsequent occurrence up to a maximum of $1,000.00.

(iii) The department will not assess any penalty unless the provider submits adequate documentation that they attempted to resolve the bill with the insurer. If the insurer does not correct the error, the provider may forward the billing, explanation of benefits, if any, and documentation of contact and responses to the department.

(iv) The insurer has the burden of proof to notify the department either by e-mail, facsimile, or letter that the bill(s) in question have been processed using the correct Montana fee schedule.

(v) The amounts collected from the insurer must be deposited with the department to be used in the Workers' Compensation Administration Fund.

(vi) An insurer may contest a penalty assessed pursuant to 39-71-107(5)(b), MCA, in a hearing conducted according to department rules. A party may appeal the final agency order to the workers' compensation court. The court shall review the order pursuant to the requirements of 2-4-704, MCA.

(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.

(a) If the insurer does not pay the undisputed portions of a medical bill within 60 days of receipt, the department may assess a $200.00 penalty for each occurrence. Each medical bill is an occurrence.

(b) This fine may be increased $100.00 per subsequent occurrence up to a maximum of $1,000.00.

(c) The department will not assess any penalty unless the provider submits adequate documentation that they attempted to resolve the bill with the insurer. If the insurer does not pay the undisputed bill(s), the provider may forward the billing, explanation of benefits, if any, and documentation of contact and responses to the department.

(d) The insurer has the burden of proof to notify the department either by e-mail, facsimile, or letter that the bill(s) in question have been paid.

(e) The amounts collected from the insurer must be deposited with the department to be used in the Workers' Compensation Administration Fund.

(f) An insurer may contest a penalty assessed pursuant to 39-71-107(5)(c), MCA, in a hearing conducted according to department rules. A party may appeal the final agency order to the workers' compensation court.

(3) For services provided on or after July 1, 2013, the provider may charge 1 percent per month simple interest for unpaid balances on an undisputed medical bill on a claim pursuant to 39-71-704, MCA. The interest will start accruing on the 31st day after receipt of the bill by the insurer. The insurer must document receipt date of the bill or the receipt date will be three days after the bill was sent by the provider. If there is no payment within 30 days, the provider may bill the insurer 1 percent per month on the unpaid balance. For purposes of coding billed amounts, the Montana unique code MT005 is established by this rule and must be used by the provider to bill the interest amount.

(4) For services provided on or after July 1, 2013, the insurer may charge a 1 percent per month simple interest for overpayment made to a provider pursuant to 39-71-704, MCA. The interest will start accruing on the 31st day after receipt by the provider of the reimbursement request. The provider must document the receipt date of the reimbursement request or the receipt date will be three days after the request was sent by the insurer. If there is no payment within 30 days of the provider's receipt of a reimbursement request or if the provider has not made alternative arrangements for repaying the overpayment within 30 days, the insurer may charge the provider 1 percent per month simple interest on the balance.

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

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

(7) For claims arising before 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.

(8) 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.

(9) 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.

(10) For injured workers who are receiving benefits from the Uninsured Employers' Fund pursuant to 39-71-503, MCA, the provisions of this rule are subject to 39-71-510, MCA.

History: 39-71-203, MCA; IMP, 39-71-203, 39-71-510, 39-71-704, MCA; Eff. 12/31/72; AMD, 1991 MAR p. 2622, Eff. 12/27/91; AMD, 1993 MAR p. 2801, Eff. 12/1/93; AMD, 2007 MAR p. 260, Eff. 2/23/07; AMD, 2008 MAR p. 2490, Eff. 12/1/08; AMD, 2011 MAR p. 1137, Eff. 6/24/11; AMD, 2013 MAR p. 1185, Eff. 7/12/13.


 

 
MAR Notices Effective From Effective To History Notes
24-29-273 7/12/2013 Current History: 39-71-203, MCA; IMP, 39-71-203, 39-71-510, 39-71-704, MCA; Eff. 12/31/72; AMD, 1991 MAR p. 2622, Eff. 12/27/91; AMD, 1993 MAR p. 2801, Eff. 12/1/93; AMD, 2007 MAR p. 260, Eff. 2/23/07; AMD, 2008 MAR p. 2490, Eff. 12/1/08; AMD, 2011 MAR p. 1137, Eff. 6/24/11; AMD, 2013 MAR p. 1185, Eff. 7/12/13.
24-29-256 6/24/2011 7/12/2013 History: 39-71-203, MCA; IMP, 39-71-203, 39-71-510, 39-71-704, MCA; Eff. 12/31/72; AMD, 1991 MAR p. 2622, Eff. 12/27/91; AMD, 1993 MAR p. 2801, Eff. 12/1/93; AMD, 2007 MAR p. 260, Eff. 2/23/07; AMD, 2008 MAR p. 2490, Eff. 12/1/08; AMD, 2011 MAR. p. 1137, Eff. 6/24/11.
24-29-231 12/1/2008 6/24/2011 History: 39-71-203, MCA; IMP, 39-71-203, 39-71-510, 39-71-704, MCA; Eff. 12/31/72; AMD, 1991 MAR p. 2622, Eff. 12/27/91; AMD, 1993 MAR p. 2801, Eff. 12/1/93; AMD, 2007 MAR p. 260, Eff. 2/23/07; AMD, 2008 MAR p. 2490, Eff. 12/1/08.
2/23/2007 12/1/2008 History: 39-71-203, MCA; IMP, 39-71-203, 39-71-510, 39-71-704, MCA; Eff. 12/31/72; AMD, 1991 MAR p. 2622, Eff. 12/27/91; AMD, 1993 MAR p. 2801, Eff. 12/1/93; AMD, 2007 MAR p. 260, Eff. 2/23/07.
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