R 418.101001 General rules for practitioner reimbursement.

Rule 1001. (1) A provider that is authorized to practice in the state of Michigan shall receive the maximum allowable payment in accordance with these rules. A provider shall follow the process specified in these rules for resolving differences with a carrier regarding payment for appropriate health care services rendered to an injured worker. Reimbursement shall be based upon the site of service. The agency shall publish the maximum allowable payment for a procedure performed in the non-facility setting and the maximum allowable payment for a procedure performed in the facility setting. (2) A carrier shall not make a payment for a service unless all required review activities pertaining to that service are completed. (3) A carrier's payment shall reflect any adjustments in the bill made through the carrier's utilization review program. (4) A carrier shall pay, adjust, or reject a properly submitted bill within 30 days of receipt. The carrier shall notify the provider on a form entitled "Carrier's Explanation of Benefits" in a format specified by the agency. A copy shall be sent to the injured worker. (5) A carrier shall not make a payment for any service that is determined inappropriate by the carrier's professional health care review program. (6) The carrier shall reimburse the provider a 3% late fee if more than 30 calendar days elapse between a carrier's receipt of a properly submitted bill and a carrier's mailing of the payment. (7) If a procedure code has a maximum fee of "by report," the provider shall be paid its usual and customary charge or the reasonable amount, whichever is less. The carrier shall provide an explanation of its determination that the fee is unreasonable or excessive in accordance with these rules.