Medical and hospital fees - Reimbursement methods

Maximum medical and hospital fees paid by the organization, including reimbursement for pharmaceuticals and durable medical equipment, are determined in accordance with the most current edition of the organization's fee schedule guidelines or the organization's formulary and medication restrictions list. Reimbursement for services and procedures not addressed within the fee schedules or lists will be determined on a "by report" basis, in which case a description of the nature, extent and need for the procedure or service, including the time, skills, equipment, and any other pertinent facts necessary to furnish the procedure or service, must be provided to the organization.