HAR §16-23-114. Drugs, supplies and materials

(a) All charges for prescribed drugs, supplies, or materials for the use of the claimant shall be separately listed and certified by the health care provider, or a duly authorized representative that the charges for the drugs, supplies, or materials were required or prescribed for the injury covered by motor vehicle insurance benefits. (b) Dietary supplements such as minerals and vitamins shall not be reimbursable unless a specific compensable dietary deficiency has been clinically established in the claimant as a result of the injury covered by motor vehicle insurance benefits. (c) Payment for covered prescription drugs and supplies shall be made at the average wholesale price plus forty per cent of the average wholesale price when sold by a health care provider, hospital, pharmacy, or alternative health care provider of service. Billings for prescriptive drugs shall include the national drug code number listed in the current American Druggist Red Book followed by the average wholesale price listed at time of purchase by the health care provider of service. Approved generics shall be substituted for brand name pharmaceuticals unless the prescribing health care provider certifies no substitution is permitted because the claimant's condition will not tolerate a generic preparation. [Eff and comp 6/1/93; am and comp 1/1/98; comp 1/8/99; comp 11/11/12; comp 7/2/22; comp 4/17/26] (Auth: HRS §§431:2-201, 431:10C-214, 431:10C-308.5) (Imp: HRS §431:10C-308.5) §16-23-115 Workers' compensation medical fee schedule. (a) Charges for medical services shall not exceed one hundred ten per cent of participating fees prescribed in the Medicare Resource Based Relative Value Scale System applicable to Hawaii (Medicare Fee Schedule) or Exhibit A at the end of Title 12, Chapter 15, entitled "Workers' Compensation Supplemental Medical Fee Schedule" (Exhibit A). The Medicare Fee §16-23-115 23-59 Schedule and Exhibit A, together herein referred to as the "medical fee schedule", is made a part of this chapter and shall be used to determine the maximum allowable fees using the procedure codes and unit values established by the department of labor and industrial relations pursuant to section 386-21, HRS. Any subsequent amendment by the department of labor and industrial relations to the Medicare fee schedule and Exhibit A, shall be incorporated into this chapter by reference. (b) If the maximum allowable fees for medical services are listed in both the Medicare Fee Schedule and Exhibit A, charges shall not exceed the maximum allowable fees allowed under Exhibit A. (c) For the purposes of this section "private patient" means a patient not covered by insurance. If the charges are not listed in the medical fee schedule or in Exhibit A, the health care provider shall charge a fee not to exceed eighty per cent of the health care or alternative care provider's usual and customary fee for the same service rendered to a private patient. Upon request by the insurer, a health care or alternative care provider shall submit a statement itemizing the lowest fee charged for the same health care, services, and supplies furnished to any private patient during a one-year period preceding the date of the particular charge. Requests shall be submitted in writing within twenty calendar days of receipt of a charge allegedly in excess of the allowable amount. The health care or alternative care provider shall reply in writing within ten calendar days of receipt of the request. Failure to comply with the request of the insurer shall be reason for the insurer to deny payment. (d) Fees listed in the Medicare Fee Schedule shall be subject to the current Medicare Fee Schedule correct coding initiative ("CCI") and follow-up rules. The Health Care Financial Administration Common Procedure Coding System alphabet codes adopted by Medicare shall not be allowed unless specifically adopted by the director of labor. [Eff and comp 6/1/93; am and comp 1/1/98; am and comp 1/8/99; comp §16-23-115 23-60 11/11/12; comp 7/2/22; am and comp 4/17/26] (Auth: HRS §§431:2-201, 431:10C-214, 431:10C-308.5) (Imp: HRS §431:10C-308.5)