114-1-41 (1).doc - Adopted Regulation 114 CMR DIVISION OF...

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Adopted Regulation 1 14 CMR DIVISION OF HEALTH CARE FINANCE AND POLICY 114.1 CMR 41.00: RATES OF PAYMENT FOR SERVICES PROVIDED TO INDUSTRIAL ACCIDENT PATIENTS BY HOSPITALS Section 41.01: General Provisions 41.02: Definitions 41.03: Payment for Inpatient Services 41.04: Hospital Outpatient Rates 41.05: Other Provisions 41.06: Severability 41.01: General Provisions (1) Scope, Purpose and Effective Date . 114.1 CMR 41.00 establishes payment rates effective April 1, 2009, for services provided to Industrial Accident Patients by Acute and Non-acute Hospitals under M.G.L. c. 152, the Worker’s Compensation Act. Payment rates for services provided to industrial accident patients by other providers are set forth in 114.3 CMR 40.00. Program policies relating to medical necessity and clinical appropriateness are determined pursuant to M.G.L. c. 152 and 452 CMR 6.00. Hospitals must comply with the Department of Industrial Accidents billing requirements under 452 CMR 7.02. (2) Coverage . The payment rates set forth in 114.3 CMR 41.00 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 than that established by 114.1 CMR 41.00. No Industrial Accident Patient may be held liable for the payment for health care services determined compensable under M.G.L. c. 152, § 13. (3) Authority . 114.1 CMR 41.00 is adopted pursuant to M.G.L. c. 118G and M.G.L. c. 152. 41.02: Definitions Meaning of Terms . As used in 114.1 CMR 41.00, unless the context requires otherwise, terms shall have the meanings set forth in 114.1 CMR 41.02: Acute Hospital . A Hospital licensed under M.G.L. c. 111, § 51, which contains a majority of medical- surgical, pediatric, obstetric, and maternity beds, as defined by the Department of Public Health. Acute Median Payment on Account Factor . The median of all Payment on Account Factors determined for each Acute Hospital. Base Year . The Hospital fiscal year for which DHCFP-403 data is used to compute the Payment on Account Factor. Only data from a complete or non-partial fiscal year is used in the computation of the Payment on Account Factor. If the Division determines that the data source is inadequate or not representative of the Hospital’s ongoing costs, the Division may consider alternative data sources to determine Base Year costs. Criteria for such review will include but shall not be limited to peer group analysis. Charge . A Hospital's uniform price for each specific service within a revenue center as filed with the Division. DHCFP-403 . The Hospital Statement of Costs, Revenues and Statistics. 1
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Adopted Regulation 1 14 CMR DIVISION OF HEALTH CARE FINANCE AND POLICY 114.1 CMR 41.00: RATES OF PAYMENT FOR SERVICES PROVIDED TO INDUSTRIAL ACCIDENT PATIENTS BY HOSPITALS Division. The Division of Health Care Finance and Policy as established under M.G.L. c. 118G.
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