Mich. Admin. Code R. 418.10108

Current through Vol. 24-19, November 1, 2024

Section R. 418.10108 - Definitions; A to I

Rule 108. As used in these rules:

(a) "Acquisition cost" means the provider's purchase cost established by an invoice detailing the line-item cost to the provider from a manufacturer or wholesaler net of any rebates or discounts.

(b) "Act" means the worker"s disability compensation act of 1969, 1969 PA 317, MCL 418.101 to 418.941.

(c) "Adjust" means that a carrier or a carrier's agent reduces a healthcare provider's request for payment to the maximum fee allowed by these rules, to a provider's usual and customary charge, or, when the maximum fee is by report, to a reasonable amount. "Adjust" also means when a carrier re-codes a procedure or reduces payment as a result of professional review.

(d) "Agency" means the workers' disability compensation agency.

(e) "Ambulatory surgical center" (ASC) means an entity that operates exclusively for providing surgical services to patients not requiring hospitalization and has an agreement with the centers for Medicare and Medicaid services (CMS) to participate in Medicare.

(f) "Appropriate care" means healthcare that is suitable for a particular individual, condition, occasion, or place.

(g) "Biologics" or "biologicals" include drugs or other products that are derived from life forms. Biologics are biology-based products used to prevent, diagnose, treat, or cure disease or other conditions in humans and animals. Biologics generally include products such as vaccines, blood, blood components, allergenics, somatic cells, genes, proteins, DNA, tissues, skin substitutes, recombinant therapeutic proteins, microorganisms, antibodies, immunoglobins, and others, including, but not limited to, those that are produced using biotechnology and are made from proteins, genes, antibodies, and nucleic acids.

(h) "BR" or "by report" means that the procedure is not assigned a relative value unit or a maximum fee and requires a written description.

(i) "Carrier" means an organization that transacts the business of workers' compensation insurance in this state and that may be any of the following:

(i) A private insurer.

(ii) A self-insurer.

(iii) One of the funds in chapter 5 of the act, MCL 418.501 to 418.561.

(iv) The Christopher R. Slezak first responder presumed coverage fund.

(j) "Case" means a covered injury or illness that occurs on a specific date and is identified by the worker's name and date of injury or illness.

(k) "Case record" means the complete healthcare record that is maintained by a carrier and pertains to a covered injury or illness that occurs on a specific date.

(l) "Complete procedure" means a procedure that contains a series of steps that are not billed separately.

(m) "Covered injury or illness" means an injury or illness for which treatment is mandated by section 315 of the act, MCL 418.315.

(n) "Current Procedural Terminology (CPT)" means a listing of descriptive terms and identifying codes and provides a uniform nationally accepted nomenclature for reporting medical services and procedures. The CPT codebook provides instructions for coding and claims processing.

(o) "Custom compound" means a customized topical medication prescribed or ordered by a duly licensed prescriber for the specific patient that is prepared in a pharmacy by a licensed pharmacist in response to a licensed practitioner"s prescription or order, by combining, mixing, or altering of ingredients, but not reconstituting, to meet the unique needs of an individual patient.

(p) "Dispute" means a disagreement between a carrier or a carrier's agent and a healthcare provider on the application of these rules.

(q) "Durable medical equipment" means specialized equipment that is designed to stand repeated use, is used to serve a medical purpose, and is appropriate for home use.

(r) "Emergency condition" means that a delay in treating a patient would lead to a significant increase in the threat to the patient's life or to a body part.

(s) "Established patient" means a patient whose medical and administrative records for a particular covered injury or illness are available to the provider.

(t) "Expendable medical supply" means a disposable article that is needed in quantity on a daily or monthly basis.

(u) "Facility" means an entity licensed by this state pursuant to the public health code, 1978 PA 368, MCL 333.1101 to 333.25211. The office of an individual practitioner is not considered a facility.

(v) "Focused review" means the evaluation of a specific healthcare service or provider to establish patterns of use and dollar expenditures.

(w) "Follow-up days" means the days of care following a surgical procedure that are included in the procedure's maximum allowable payment, but does not include care for complications. The health care services division shall provide the follow-up days for surgical procedures separate from these rules on the agency's website, www.michigan.gov/leo/bureaus-agencies/wdca.

(x) "Free standing outpatient facility" (FSOF) means a facility, other than the office of a physician, dentist, podiatrist, or other private practice, offering a surgical procedure and related care that in the opinion of the attending physician can be safely performed without requiring overnight inpatient hospital care.

(y) "Healthcare organization" means a group of practitioners or individuals joined together to provide healthcare services and includes any of the following:

(i) Health maintenance organization.

(ii) Industrial or other clinic.

(iii) Occupational healthcare center.

(iv) Home health agency.

(v) Visiting nurse association.

(vi) Laboratory.

(vii) Medical supply company.

(viii) Community mental health board.

(z)"Healthcare review" means the review of a healthcare case or bill, or both, by a carrier, and includes technical healthcare review and professional healthcare review.

(aa) "Incidental surgery" means a surgery that is performed through the same incision, on the same day, by the same doctor of dental surgery, doctor of medicine, doctor of osteopathy, or doctor of podiatry, that is not related to diagnosis.

(bb) "Independent medical examination" means an examination and evaluation that is requested by a carrier or an employee, that is conducted by a different practitioner than the practitioner who provides care.

(cc) "Industrial medicine clinic," also referred to as an "occupational health clinic," means an organization that primarily treats injured workers. The industrial medicine clinic or occupational health clinic may be a healthcare organization or may be a clinic owned and operated by a hospital for the purposes of treating injured workers.

(dd) "Insured employer" means an employer who purchases workers' compensation insurance from an insurance company that is licensed to write insurance in this state.

Mich. Admin. Code R. 418.10108

2000 AACS; 2001 AACS; 2003 AACS; 2005 AACS; 2010 AACS; 2012 AACS; 2014 AACS; 2017 AACS; 2021 AACS; 2023 MR 20, Eff. 10/12/2023