Section 69-10.21 - Rates of Payment

69-10.21 Rates of Payment.

(a) Physicians shall be paid at the eightieth percentile of the usual and customary charges for services provided in private physician practices, as reported by FAIR Health, Inc. in its Usual, Customary and Reasonable ("UCR") database at the time of billing. Payment of these charges shall constitute payment in full for any such services provided to an enrollee of the Fund.

(b) Emods, vehicle modifications and assistive technology will be paid at an amount established by the prior approval process pursuant to sections 69-10.7, 69-10.8, 69-10.9 and 69-10.10 of this Subpart.

(c) Services, supplies, and equipment for which there is a Medicaid fee or rate available will be paid at that fee or rate.

(d) Medications will be paid at the Medicaid rate, provided however, if the Department of Health determines that Medicaid rates are not available due to technological issues and related administrative costs, a pharmacy benefits manager designated by the Fund Administrator and approved by the Department of Health may be used to price medications.

(e) Any other service will be paid at a reasonable rate for that type of service in that geographic area as determined by the Fund Administrator. Rates shall be deemed reasonable if they are sufficient to provide the enrollee with access to services and are not in excess of the prevailing rates paid by other payers in the region. When Fair Health, Inc.'s UCR database specifies a rate for a particular service, the Fund Administrator shall pay at the 80
thpercentile of such rate.

Effective Date: 
Wednesday, June 18, 2014
Doc Status: 
Complete