Payment

(1) Unless a waiver is obtained from the Administrator, reimbursement for all health care services and supplies shall be the lesser of (a) the provider’s usual billed charge, (b) the fees listed in the rate tables in the Fee Schedule, after applying any applicable modifiers, methodologies, or exceptions set forth in these Rules; or 100% of the Medicare rate if the code is not listed in the rate tables, or the methodology is not set forth in these Rules or (c) the agreed contracted or published rate between the provider and the MCO/PPO pursuant to T.C.A. § 50-6-215. A licensed provider or institution shall receive no more than the maximum allowable payment, in accordance with these Rules for appropriate health care services rendered to a person who is entitled to health care services under the Law. Any provider reimbursed or employer paying an amount which is in excess of these Rules shall have a period of one hundred eighty (180) calendar days from the time of receipt/payment of such excessive payment in which to refund/recover the overpayment amount. Overpayments refunded/recovered within this time period shall not constitute a violation under these Rules. (2) Whenever a guideline or procedure is not set forth in these Rules, the Medicare guidelines and procedures in effect on the date of service shall be followed. (3) When extraordinary services resulting from severe head injuries, major burns, severe neurological injuries or any injury requiring an extended period of intensive care are required, a greater fee may be allowed up to 150% of the professional service fees normally allowed under these Rules. Such cases shall be billed with modifier 22 (for CPT® coded procedures) and shall contain a detailed written description of the extraordinary service rendered and the need therefore. This provision does not apply to Inpatient Hospital Care facility fees which are specifically addressed in the Inpatient Hospital Fee Schedule Rules, Chapter 0800-02-19. (4) Billing for provider services shall be submitted on industry standard billing forms; UB-04, CMS-1450, CMS-1500, the ADA form for dental providers, and the NCPDP WC/PC UCF for pharmacies, their electronic equivalent, or their official replacement forms. Electronic billing submissions shall be in accord with the Bureau’s rules for electronic billing. RULES FOR MEDICAL PAYMENTS CHAPTER 0800-02-17 (5) An employer’s payment shall reflect any adjustments in the bill, subject to the following: (a) Whenever the employer’s reimbursement differs from the amount billed by the provider, the employer/adjuster/bill review organization shall provide an explanation of medical benefits with current and complete contact information to the health care provider. Industry standard remark codes and a clear reason for the adjustment shall be provided. (b) A provider shall not attempt to collect from the injured employee or from the employer any amounts properly reduced by the employer. (c) All such communications shall comply with all applicable Medicare and HIPAA requirements. (d) Remittances for electronically submitted bills shall be in accordance with the Bureau’s rules for electronic billing. (6) All providers and carriers shall use electronic billing and EDI, if they have the capability to do so. All such communications shall comply with all applicable Medicare and HIPPA requirements. (7) An employer shall date stamp medical bills and reports not submitted electronically upon receipt. Payment for a properly submitted and complete bill not disputed within fifteen (15) business days (or uncontested portions of the bill) shall be made to the provider within thirty (30) calendar days. (8) The employer shall notify the provider within fifteen (15) business days of receipt of the bill that it was not properly submitted and specify the reason(s). (9) When an employer disputes a bill submitted on paper or portion thereof, the employer shall pay the undisputed portion of the paper bill within thirty (30) calendar days of receipt of a properly submitted paper bill. For the time frames applicable to electronic billing see Rule 0800-02-26-.06. (10) A provider shall request the employer to reconsider a disputed bill (or portion of a bill) within thirty (30) days of receiving notification from the employer that the bill was not properly submitted. The employer shall complete the review of the reconsideration and notify the provider of the determination within thirty (30) days of receiving the request for reconsideration. (11) Any provider not receiving timely payment of the undisputed portion of the provider’s bill may institute a collection action against the employer in a state court having proper jurisdiction over such matters to obtain payment of the bill. (12) Billings not submitted on the proper form, as prescribed in these Rules, the Inpatient Hospital Fee Schedule Rules, and the Medical Fee Schedule Rules, may be returned to the provider for correction and resubmission. If an employer returns such billings, it shall do so within fifteen (15) business days of receipt of the bill. The number of days between the date the employer returns the billing to the provider and the date the employer receives the corrected billing, shall not apply toward the thirty (30) calendar days within which the employer is required to make payment. The rules for electronic billing shall apply to the types of forms where applicable. (13) Payments to providers for initial examinations and treatment authorized by the carrier or employer shall be paid by that employer and shall not later be subject to reimbursement by RULES FOR MEDICAL PAYMENTS CHAPTER 0800-02-17 the employee, even if the injury or condition for which the employee was sent to the provider is later determined non-compensable under the Law. (14) Orders by the Medical Director overturning a utilization review denial do not necessarily guarantee payment. Authorization for payment by the adjuster is still necessary.