General Rate Provisions and Maximum Allowable Fees

(1) Rate Determination. Rates of payment for authorized community health center services to which 101 CMR 304.00 applies are the lower of (a) the community health center’s usual charge to the general public (other than publicly aided individuals or industrial accident patients) for the same or similar services; or (b) the schedule of allowable fees set forth in 101 CMR 304.04. (2) Individual Consideration (I.C.). Non-listed procedures and services designated I.C. are individually considered items. The community health center’s bill for such an item must be accompanied by a brief report of the procedure or service provided, including a pertinent history and diagnosis, a description of the service rendered, and the length of time spent with the patient. In making the determination of whether the service is appropriately classified as an individually considered item, the purchasing agency uses the following criteria: (a) policies, procedures, and practices of other third-party purchasers of care, both governmental and private; (b) the severity and complexity of the patient's disorder or disability; (c) prevailing provider ethics and accepted practice; and (d) time, degree of skill, and cost including equipment cost required to perform the procedure(s).