101 CMR, § 318.03

Current through Register 1536, December 6, 2024

Section 318.03 - General Rate Provisions

(1)Rate Determination. Rates of payment for services for which 101 CMR 318.00 applies are the lowest of

(a) the eligible provider's usual fee to patients other than publicly aided individuals;

(b) the eligible provider's actual charge submitted; or

(c) the schedule of allowable fees set forth in 101 CMR 318.04(3), taking into account appropriate modifiers and any other applicable rate provision(s) in accordance with 101 CMR 318.03.

(2)Supplemental Payment.

(a)Eligibility. An eligible provider who is a physician, certified nurse practitioner, physician assistant, or CRNA is eligible for a supplemental payment for services to publicly aided individuals eligible under Titles XIX and XXI of the Social Security Act if the following conditions are met:

1. the eligible provider is employed by a nonprofit group practice that was established in accordance with St.1997, c.163 and is affiliated with a Commonwealth-owned medical school;

2. such nonprofit group practice must have been established on or before January 1, 2000, in order to support the purposes of a teaching hospital affiliated with and appurtenant to a Commonwealth-owned medical school; and

3. the services are provided at a teaching hospital affiliated with and appurtenant to a Commonwealth-owned medical school.

(b)Payment Method. This supplemental payment may not exceed the difference between

1. payments to the eligible provider made pursuant to the rates applicable under 101 CMR 316.03(1): Rate Determination, 101 CMR 317.03(1): Rate Determination and 318.03(1); and

2. the federal upper payment established by the Centers for Medicare & Medicaid Services.

(3) The sum of the professional and technical components of an individual procedure will not be greater than the allowable global fee set forth in 101 CMR 318.04(3).

(4)Allowable Fee for Certain Eligible Providers. Payment for services provided by eligible providers who are certified nurse practitioners, certified nurse midwives, psychiatric clinical nurse specialists, clinical nurse specialists, and physician assistants as specified in 101 CMR 318.02, is 85% of the fees contained in 101 CMR 318.04.

(5)CPT Category III Codes. All radiology-related CPT category III codes are included as a part of 101 CMR 318.00 and have an assigned fee of I.C.