HAR §17-1739.1-3. Controlling factors for payment

(a) The department shall pay for the cost of medical care when the department's medical consultants determine medical care to be necessary to the eligible patient's well-being and medical care is provided, under standards generally acceptable to the medical community, by a practitioner approved by the department to participate in Medicaid. (b) The department shall not increase the payment made to any provider to offset uncollected amounts for deductibles, coinsurance, copayments, or similar charges. (c) No payment shall be made where program rules are violated, or when services furnished are inappropriate to the patient's health care management as determined by the department's medical consultant. (d) Rates of payment to providers of medical care who are individual practitioners shall be based upon the Hawaii Medicaid fee schedule. The amount paid shall not exceed the maximum permitted to be paid to individual practitioners or other individuals under federal Medicaid laws and regulations, the Medicare fee schedule applicable in the year the service was rendered, the state limits as provided in the appropriation act, the provider’s billed amount, or the rate set by the department. (e) Rates of payment to out-of-state providers of medical care who are individual practitioners shall be the Medicaid rate paid in the practitioner's state, subject to the conditions of section 17-1736-13. In the absence of a Medicaid payment rate, payment will be according to the Hawaii Medicaid fee schedule. UNOFFICIAL 1739.1-3 (f) Payments may be prepaid to health maintenance organizations which the department contracts to provide medical care to eligible public assistance recipients. (g) The department may withhold payment of claims to recoup overpayments, or may withhold payment pending completion of an audit or investigation. (1) Payment of pending or future claims may be withheld in an amount reasonably calculated to approximate the amounts of past overpayments. (2) Payment of pending claims may be withheld until completion of a pending audit or investigation, at which time the department may initiate actions to recoup the amounts of any overpayments discovered. (3) The department shall notify the provider in writing of its intent to withhold payments and shall include reasons for the proposed action, the effective date of the action, and a statement of the provider's right to request administrative review of the proposed action. (4) The effective date of withholding shall be sixteen calendar days following the issuance of the notice. (h) For a Medicaid recipient with Medicare coverage, payment on a Medicare covered service shall be the applicable Medicare deductible and coinsurance amounts. (i) For a Medicaid recipient with Medicare coverage, payment on a service that is not covered by Medicare, but is covered by Medicaid, shall be up to the Medicaid rate. (j) Payment on a QMB claim shall be the applicable Medicare deductible and coinsurance amounts. [Eff 10/26/01; am 05/10/03; am 02/07/05] (Auth: HRS §346-59) (Imp: 42 C.F.R. §§447.10, 447.15, 447.57, 447.200)