General Provisions

(1) Scope, Purpose and Effective Date. 114.3 CMR 40.00 governs the payment rates effective April 1, 2009 for purchasers of health care services under M.G.L. c. 152, the Workers’ Compensation Act. Payment rates for services provided by hospitals are set forth in 114.1 CMR 41.00. Program policies relating to medical necessity and clinical appropriateness are determined pursuant to M.G.L. c. 152 and 452 CMR 6.00. (2) Coverage. The payment rates set forth in 114.3 CMR 40.06 are full payment for services provided under M.G.L. c. 152, § 13, including any related administrative or overhead costs. The insurer, employer and health care service provider may agree upon a different payment rate for any service set forth in the fee schedule in 114.3 CMR 40.00. No employee may be held liable for the payment for health care services determined compensable under M.G.L. c. 152, § 13. (3) Administrative Bulletins. The Division may issue administrative bulletins to clarify substantive provisions of 114.3 CMR 40.00, or to publish procedure code updates and corrections. For coding updates and correction, the bulletin will list: (a) new code numbers for existing codes, with the corresponding cross references between existing and new codes numbers; (b) deleted codes for which there are no corresponding new codes; and (c) codes for entirely new services that require pricing. The Division will designate these codes to be paid by individual consideration under 114.3 CMR 40.04(3) until appropriate rates are developed. (4) Rate Updates for Services Covered by Other Regulations. The Division will post rate amendments for services governed by other regulations on its website. (5) Disclaimer for Authorization of Services. 114.3 CMR 40.00 is not authorization for or approval of services for which rates are determined pursuant to 114.3 CMR 40.00. (6) Authority. 114.3 CMR 40.00 is adopted pursuant to M.G.L. c. 118G and M.G.L. c. 152, § 13.