Massachusetts Regulations 40.04

(2) Rate Determination. The rates of payment set forth in 114.3 CMR 40.06 shall constitute full payment for services provided under M.G.L. c. 152 &#167 13, as well as any related administrative or overhead costs. However, the insurer, the employer and the health care service provider may agree upon an alternative rate of payment for any service contained in this fee schedule. In no event shall an employee be liable for the compensation of health care services under M.G.L. c. 152 &#167 13.

(3) Out-of-State Providers. Rates of payment for out-of-state providers are determined in accordance with 114.3 CMR 40.04(2), except where otherwise specifically noted herein.

(4) Individual Consideration (I.C.). Services that are authorized but are unlisted or designated�I.C.� are individually considered items. The purchaser under M.G.L. c. 152 shall analyze the eligible provider's report of services rendered and charges submitted under the appropriate service or procedure category. Unless otherwise stated in sections under 114.3 CMR 40.05, Policies for Individual Service Types, determination of appropriate payment for procedures designated I.C. shall be in accordance with the following standards and criteria:

(a) The amount of time required to perform the procedure,

(b) The degree of skill required in care rendered,

(c) The severity or complexity of the patient's disease, disorder or disability,

(e) The policies, procedures and practices of other third party insurers,

(f) A copy of the current invoice from the supplier.

(5) Special Codes and Modifiers for Industrial Accident Treatment Providers. Certain direct care providers may utilize Modifier -32 Mandated Services to enhance payment rates as listed within provider sections 114.3 CMR40.05. Use of this modifier will indicate the additional work required under 452 CMR 1.13(1) performed for comprehensive initial visits and visits that determine changes in work capability. Codes 99371-99373 are also provided within 114.3 CMR 40.06 for required telephone consult as reimbursable expense for consultation between providers and employers, insurers, utilization reviewers or agents.

(6) Utilization Standard. Treatment guidelines pertaining to work place injury and illness are published and updated periodically by the Department of Industrial Accidents, Healthcare Services Board. These guidelines are used to define appropriate care deemed medically necessary.