Ancillary Resource Guide May 2016 | Workers’ Compensation

Information contained in this Ancillary Resource Guide is provided “as is” for informational purposes only and is not intended to constitute legal advice. Due to the rapidly changing nature of regulatory information, Optum does not warrant or guarantee the accuracy of content of this Guide. Before taking any action on the reimbursement or delivery of care based upon our Guide, the reader should consult their legal representatives.

Workers' Compensation

Ancillary Resource Guide The more we know, the better positioned we are to make a positive difference for our clients, in our industry and in the lives of the injured workers we serve. We are pleased to share this Ancillary Resource Guide offering a state-by-state summary of the ancillary fee schedule for Medical Equipment and Supplies, Transportation, Home Health and Physical and Occupational therapy. While comprehensive, the regulatory landscape and our industry is ever-changing. Should you have questions regarding the information contained, please contact Brian Allen, vice president government affairs, at 801-230-8379 or via email at [email protected]. Questions about our program may be shared with your account manager.

4

Louisiana.................... 19

Oklahoma .................. 37

Alabama ...................... 2

Maine ........................ 20

Oregon ...................... 38

Alaska .......................... 3

Maryland.................... 21

Pennsylvania .............. 39

Arizona ........................ 4

Massachusetts............ 22

Rhode Island .............. 40

Arkansas ...................... 5

Michigan.................... 23

South Carolina ........... 41

California ..................... 6

Minnesota.................. 24

South Dakota ............. 42

Colorado...................... 7

Mississippi .................. 25

Tennessee................... 43

Connecticut ................. 8

Missouri ..................... 26

Texas .......................... 44

Delaware...................... 9

Montana .................... 27

Utah........................... 45

Florida........................ 10

Nebraska.................... 28

Vermont..................... 46

Georgia...................... 11

Nevada....................... 29

Virginia ...................... 47

Hawaii........................ 12

New Hampshire.......... 30

Washington................ 48

Idaho.......................... 13

New Jersey ................. 31

Washington D.C......... 49

Illinois......................... 14

New Mexico ............... 32

West Virginia.............. 50

Indiana....................... 15

New York ................... 33

Wisconsin................... 51

Iowa........................... 16

North Carolina ........... 34

Wyoming ................... 52

Kansas ....................... 17

North Dakota............. 35

Kentucky.................... 18

Ohio........................... 36

U.S. Department of Labor...................... 53

Table of Contents

Abbreviations............... 1

5

MAR = Maximum Allowable Reimbursement

ASP = Average Sales Price

MEI = Medicare Economic Index

AWP = Average Wholesale Price

MSRP = Manufacturer’s Suggested Retail Price

BR = By Report

NDC = National Drug Code

BWC = Bureau of Workers’ Compensation

O&P = Orthotics and Prosthetics

CMS = Centers for Medicare and Medicaid Services

ODG = Official Disability Guidelines

CPT = Current Procedural Terminology

OWCP = Office of Workers’ Compensation Programs

DME = Durable Medical Equipment

PT/OT/ST = Physical Therapy/Occupational Therapy/ Speech Therapy

DMEPOS = Durable Medical Equipment, Prosthetics/Orthotics and Supplies

RBRVS = Resource Based Relative Value Scale

DOS = Date of Service

RN(s) = Registered Nurse(s)

DWD = Department of Workforce Development

RR = Report Required

EEOIC = Energy Employees Occupational Illness Compensation

RVU = Relative Value Unit

FS = Fee Schedule HCPCS = Healthcare Common Procedure Coding System



Abbreviations

ALS/BLS = Advanced Life Support / Basic Life Support

TENS = Transcutaneous Electrical Nerve Stimulation(or) U&C = Usual and Customary WC = Workers’ Compensation

HHC = Home Health Care MAP = Maximum Allowable Payment

1

Alabama 2

Medical Equipment and Supplies DMEPOS rate(s)

Rental requirements

Miscellaneous

Reimbursed per FS, contract or if neither exists AWP plus 33.3%.

Must purchase the durable medical equipment (DME) if cost to rent exceeds purchase price.

Providers to bill at FS, U&C or contract rate.

Transportation rate(s)

Home Health rate(s)

Physical/Occupational therapy rate(s)

Ambulance reimbursed at the lesser of submitted charges or FS.

Rates and codes in FS. If not listed in FS, reimbursement determined by agreed rate or contract.

Specific rates and codes in FS. If not in FS, reimbursement determined BR and based on U&C.

DMEPOS rate(s)

Rental requirements

Miscellaneous

Medicare plus 84%.

None stated.

MAR for most services covered in FS. Where not covered in FS, reimbursement shall be the lesser of 85% of billed charge, charge to general public or the negotiated rates.

Transportation rate(s)

Home Health rate(s)

Physical/Occupational therapy rate(s)

Fees not covered by a relevant FS. Reimbursement shall be the lesser of 85% of billed charge, charge to general public or the negotiated rates.

Injections reimbursed at Average Sales Price, which is CMS times 3.375. Reimbursement covered by FS. Where not covered in FS, reimbursement shall be the lesser of 85% of billed charge, charge to general public or the negotiated rates.

Services provided by physicians conversion factors apply to total facility or non-facility RVU in CMS RBRVS.

Alaska

Medical Equipment and Supplies

3

Arizona

Medical Equipment and Supplies DMEPOS rate(s)

Rental requirements

Miscellaneous

None stated for DME suppliers.

None stated.

None stated.

Transportation rate(s)

Home Health rate(s)

Physical/Occupational therapy rate(s)

None stated.

None for services.

Reimbursement values in FS shown in dollar amounts.

Reimbursement for injectable medications requires provider to identify medication through the use of accepted industry identifier, such as an NDC, to enable payer to make appropriate payment.

4

DMEPOS rate(s)

Rental requirements

Miscellaneous

Reimbursed at “reasonable amount” as defined in FS.

TENS rental limited to 30-day trial period. Should purchase if rental exceeds purchase price. Only first month rent applies to purchase price.

FS based on Medicare RBRVS and state WC specific conversion factors. General reimbursement is the lesser of the provider’s U&C, FS or MCO/PPO contract price.

Transportation rate(s)

Home Health rate(s)

Physical/Occupational therapy rate(s)

Lesser of U&C or the contract rate.

Medicare RBRVS and state WC-specific levels found in FS. If not in Medicare RBRVS, reimbursed at U&C. Reimbursement for injections (J codes) includes allowance for CPT 96372 in addition to AWP of each medication (only one administration fee owed when multiple medications are given as one injection).

Medicare RBRVS and state WC-specific conversion factors found in FS. If not in Medicare RBRVS, reimbursed at U&C.

Arkansas

Medical Equipment and Supplies

5

California 6

Medical Equipment and Supplies DMEPOS rate(s)

Rental requirements

Miscellaneous

Medicare plus 20%. If considered a “dangerous device” and dispensed by a physician, reimbursement shall be lesser of Medicare plus 20%, 120% of documented paid cost plus applicable dispensing fee or 100% of documented paid cost plus $250. DMEPOS that is “integral” part of procedure (ASC, hospital, etc.) not separately reimbursed.

Applicable Medicare DMEPOS FS including some purchase/rental stipulations.

None stated.

Transportation rate(s)

Home Health rate(s)

Physical/Occupational therapy rate(s)

Ambulance reimbursed at 120% Medicare plus 2.4% inflation. If not in Medicare, then U&C.

In absence of FS, reimbursement negotiated. Rates should be negotiated at time authorization for services is sought.

Rates listed in FS (RBRVS based)

DMEPOS rate(s)

Rental requirements

Miscellaneous

DME/O&P reimbursed at Colorado Medicare HCPCS MARs (January 2015 version). If no code exists in Medicare, reimbursed 100% of Colorado Medicaid (January 2015) FS. If no code exists in Medicare or Medicaid, reimburse supplier’s published MSRP less 20%. If no FS value or MSRP, pay 120% of cost for item as indicated on the supplier’s invoice.

None stated.

Instruction/application of TENS billed under education code in medicine FS (conversion factor updated annually). Shipping and handling charges are not separately payable for DMEPOS.

Transportation rate(s)

Home Health rate(s)

Physical/Occupational therapy rate(s)

Certain HCPCS ambulance A code rates listed in FS as applicable.

Rates in FS for home infusion therapy and nursing with state-specific codes. Per-diem rates only payable when licensed professionals (RNs) providing “reasonable and necessary” skilled assessment and evaluation services in home. Skilled nursing fees separately payable when nurse travels to injured workers’ home to perform evaluations, education and coordination of care. Infusion therapy medication cost portion based on Medicare ASP (If no ASP, use AWP).

PT/OT reimbursed per FS (RBRVS-based; conversion factor update annually) Physical medicine supplies reimbursed according to DMEPOS rules.

Colorado

Medical Equipment and Supplies

7

Connecticut 8

Medical Equipment and Supplies DMEPOS rate(s)

Rental requirements

Miscellaneous

Reimbursed at acquisition price, including sales tax, plus 30%.

Only for short term usage < 60 days, monthly rental is 1/12 acquisition price plus 30% not to exceed 60 days.

Reimburse custom orthotics and prosthetics based on L codes listed in FS unless written agreement between insurer and provider for different reimbursement. All other O&P reimbursed at 130% of acquisition cost (invoice, including sales tax) plus 30%.

Transportation rate(s)

Home Health rate(s)

Physical/Occupational therapy rate(s)

None stated.

Not addressed. Agreed upon between provider and payer. HCPCS injection code reimbursement formula shall be acquisition price plus 30%, including sales tax.

Payment for services based on FS using CPT codes with corresponding values.

DMEPOS rate(s)

Rental requirements

Miscellaneous

Reimbursed at the lesser of FS or the provider’s actual charge.

None stated.

FS is relative value based, using Delawarespecific geographically adjusted factors (by geo-zips). If not found in FS then reimbursement is 68% of provider’s actual charge.

Transportation rate(s)

Home Health rate(s)

Physical/Occupational therapy rate(s)

If in FS, then FS rate. If not in FS, 68% of charges.

Reimbursed at lesser of FS or the provider’s actual charge.

Reimbursed at lesser of FS or the provider’s actual charge.

Delaware

Medical Equipment and Supplies

9

Florida 10

Medical Equipment and Supplies DMEPOS rate(s)

Rental requirements

Miscellaneous

None stated. Supplier should obtain written authorization and payment agreement from insurer prior to furnishing.

Prior authorization required on TENS rentals.

Not to exceed 20% above cost for TENS.

Transportation rate(s)

Home Health rate(s)

Physical/Occupational therapy rate(s)

None stated.

Home health delivered through home health agency reimbursed as agreed between provider and payer.

Reimbursement based on established reimbursement amounts listed in the FS per CPT code.

DMEPOS rate(s)

Rental requirements

Miscellaneous

Reimbursed at cost times 1.5 plus a $4 handling charge. Charges exceeding $50 must include a copy of the wholesale vendor invoice(s) showing actual cost. Custom O&P and rental equipment exempt from FS and reimbursed based on usual, customary and reasonable charges.

Rental equipment exempt from FS reimbursed based on usual, customary and reasonable charges or by agreement.

In general, reimbursement shall be the lesser of FS or billed charges.

Transportation rate(s)

Home Health rate(s)

Physical/Occupational therapy rate(s)

Ambulance and air reimbursed at FS. If not in FS, then U&C or negotiated rate applies.

FS or negotiated rate includes hourly and per-visit rates for nursing. PT/OT in home reimbursed according to listed FS plus $36.08/visit.

PT/OT services with CPT codes listed in FS, including some state specific codes.

Georgia

Medical Equipment and Supplies

11

Hawaii 12

Medical Equipment and Supplies DMEPOS rate(s)

Rental requirements

Miscellaneous

DME/O&P reimbursed at Medicare plus 10%. Supplies reimbursed at cost plus 40%, includes shipping charges.

None stated.

None stated.

Transportation rate(s)

Home Health rate(s)

Physical/Occupational therapy rate(s)

Medicare plus 10%.

Medicare RBRVS plus 10% or the state supplemental FS, where applicable.

Medicare RBRVS plus 10% or the state supplemental FS, where applicable.

DMEPOS rate(s)

Rental requirements

Miscellaneous

None stated.

None stated.

General reimbursement “acceptable charge” shall be lesser of FS or billed charge, or the charge agreed to pursuant to a written contract.

Transportation rate(s)

Home Health rate(s)

Physical/Occupational therapy rate(s)

“Acceptable charge.”

If service is included in the listed/ recognized CPT category, apply category’s conversion factor.

If service is included in the listed/recognized CPT category, apply category’s conversion factor.

Idaho

Medical Equipment and Supplies

13

Illinois 14

Medical Equipment and Supplies DMEPOS rate(s)

Rental requirements

Miscellaneous

Reimbursed based on MAR in FS for specific HCPCS code per region or geo-zip, depending on DOS.

None stated.

FS contains MAR per specific CPT/HCPCS codes. General reimbursement shall be lesser of FS or the provider’s actual charge. If not in the FS, paid at the providers U&C.

Transportation rate(s)

Home Health rate(s)

Physical/Occupational therapy rate(s)

Reimbursed based on MAR in FS. If no FS, then U&C.

Reimbursed based on MAR in the FS for specific CPT code per region or geo-zip, depending on DOS.

Reimbursed based on MAR in the FS for specific CPT code per region or geo-zip, depending on DOS.

DMEPOS rate(s)

Rental requirements

Miscellaneous

None stated.

None stated.

May be reduced to 80% of U&C for state specific geo-zips. Reimbursement may not exceed the actual charge invoiced by provider.

Transportation rate(s)

Home Health rate(s)

Physical/Occupational therapy rate(s)

80th percentile of IN U&C.

None stated.

None stated.

Indiana

Medical Equipment and Supplies

15

Iowa 16

Medical Equipment and Supplies DMEPOS rate(s)

Rental requirements

Miscellaneous

None stated.

None stated.

Providers U&C; no controlling FS.

Transportation rate(s)

Home Health rate(s)

Physical/Occupational therapy rate(s)

None stated.

None stated.

None stated.

DMEPOS rate(s)

Rental requirements

Miscellaneous

Reimbursed at the lesser of contract or FS MAR of Medicare plus 40%. If no Medicare, then cost plus 40%.

None stated.

Lesser of contract or MAR, with conversion factor in FS or BR. Tax, freight and handling are not reimbursable costs for DME.

Transportation rate(s)

Home Health rate(s)

Physical/Occupational therapy rate(s)

ALS/BLS: Billed Charges less 10%. Special Services (specialized life support, extra attendants, administration of medication) if warranted, Billed Charges less 15%.

Home Care increases Unit Value by 50%. Bills for J codes required to include metric quantity of medication used and the NDC of the medication being dispensed (if no NDC, medication/biological shall be identified on CMS-1500 or equivalent form as being a supply).

PT/OT limited to lesser of contract or FS MAR.

Kansas

Medical Equipment and Supplies

17

Kentucky 18

Medical Equipment and Supplies DMEPOS rate(s)

Rental requirements

Miscellaneous

DME reimbursed as listed in FS. HCPCS with no listed value and listed as BR reimbursed at the lesser of invoice plus 20% or the manufacturer’s invoice plus 20%. Prosthetic devices and items custom-made for individuals and billed by custom-maker not included in DME definition and reimbursed at U&C.

Total rental cost of DME cannot exceed purchase cost.

Reimbursement at lesser amount permitted if agreed upon. Generally BR services reimbursed on individual basis. Sales tax, shipping and handling may be added to FS value but documentation of these additional costs must be provided.

Transportation rate(s)

Home Health rate(s)

Physical/Occupational therapy rate(s)

Medicare plus 30%. Several HCPCS ambulance A codes listed in FS tables with rates based on zip code.

Reimbursed per FS for the CPT code or an agreed upon rate.

FS includes MAR for some CPT codes. Reimbursement for physical medicine modality and/or procedure codes limited to 60 minutes collectively (with some exceptions). Procedures designated as 30- or 15-minute intervals shall not collectively exceed 60 minutes. CPT 97010 not reimbursable.

DMEPOS rate(s)

Rental requirements

Miscellaneous

All DME and Services (not supplies) based upon Lesser of Reimbursement Formula.

Rental cost cannot exceed purchase price.

General Reimbursement shall be the lesser of FS MAR, contract or providers U&C.

Transportation rate(s)

Home Health rate(s)

Physical/Occupational therapy rate(s)

FS Rates

Based on FS MAR or FS Reimbursement Formula.

Lesser of FS, contract or provider U&C.

Louisiana

Medical Equipment and Supplies

19

Maine 20

Medical Equipment and Supplies DMEPOS rate(s)

Rental requirements

Miscellaneous

Reimbursed at FS MAP.

None stated.

FS creates MAP for medical services by CPT or HCPCS code. The employer/insurer must pay the lesser of the provider’s U&C charge or MAP.

Transportation rate(s)

Home Health rate(s)

Physical/Occupational therapy rate(s)

Some travel expenses incurred by injured worker addressed in rules and certain HCPCS ambulance A codes listed in FS.

If included in FS, then reimbursed per FS MAP.

Per FS MAP.

DMEPOS rate(s)

Rental requirements

Miscellaneous

None stated.

None stated.

General reimbursement shall be the lesser of FS or the provider’s U&C charge. For products or services lacking a FS, carriers may assign a relative value for reimbursement.

Transportation rate(s)

Home Health rate(s)

Physical/Occupational therapy rate(s)

None stated.

Services reimbursed at lesser of the FS MAR (per conversion factor) or the authorized provider’s U&C charge.

Services reimbursed at the lesser of FS MAR (per conversion factor) or the authorized provider’s U&C charge.

Maryland

Medical Equipment and Supplies

21

Massachusetts 22

Medical Equipment and Supplies DMEPOS rate(s)

Rental requirements

Miscellaneous

Reimbursed at FS MAR listed by HCPCS. Unlisted items are reimbursed at the lesser of U&C or Adjusted Acquisition Cost plus markup.

“Capped Rental Items” shall be a maximum of 15-month rental or until rental fees equal purchase price.

General reimbursement lesser of FS MAR or U&C shipping and handling may be included in “adjusted acquisition cost” for unlisted items and certain hearing aids.

• Less than 1 month shall be prorated • 1 to 3 months shall be 10% new purchase fee • 4-15 months shall be 75% monthly fee for months 1-3

Transportation rate(s)

Home Health rate(s)

Physical/Occupational therapy rate(s)

Rates listed in FS.

Rates listed in 114.3 CMR 50.00 and includes PT/OT in home.

State-specific FS for rehabilitation, restorative, speech/language pathology and audiological services governs PT/OT and is listed by CPT code with specific reimbursement rates.

DMEPOS rate(s)

Rental requirements

Miscellaneous

Reimbursed at FS MAR state or Medicare plus 5%. DME/supplies lacking HCPCS or a FS MAR (over $35) shall be reimbursed on a sliding scale of invoice cost plus a percentage markup.

Requires copy of the prescription with the initial billing. With exception of oxygen equipment, rented DME is considered purchased once monthly rental allowance exceeds purchase price or payment of 12 months rental, whichever comes first.

General reimbursement shall be the lesser of state specific FS MAR or provider’s U&C. If a procedure code does not have a listed relative value, or is noted BR, reimbursement shall be lesser of provider’s U&C charge or reasonable payment.

Transportation rate(s)

Home Health rate(s)

Physical/Occupational therapy rate(s)

None stated.

Billed and paid as BR. Reimbursed at lesser of provider’s U&C charge or reasonable payment.

State FS MAR based on RBRVS.

Michigan

Medical Equipment and Supplies

23

Minnesota 24

Medical Equipment and Supplies DMEPOS rate(s)

Rental requirements

Miscellaneous

Use RVU calculation in the FS. If not listed in the FS, reimbursement shall be 85% of U&C.

None stated.

None stated.

Transportation rate(s)

Home Health rate(s)

Physical/Occupational therapy rate(s)

“Non-emergency” transportation is not addressed in the FS.

Use HCPCS codes and RVUs found in the FS for home care and aide.

Use RVU calculation in FS. There are varied reimbursement rates for multiple procedures.

DMEPOS rate(s)

Rental requirements

Miscellaneous

Reimbursed at the lesser of FS or billed charge Supplies/Materials provided by physician over/above those usually included reimbursed at “reasonable rate”.

If rental cost more than purchase, then payer shall purchase. Prior authorization required before purchase or rental agreements for TENS.

General reimbursement shall be lesser of FS or the total billed charge. The FS has specific MAR values for CPT/HCPCS codes. FS allowable includes shipping and handling.

Transportation rate(s)

Home Health rate(s)

Physical/Occupational therapy rate(s)

Reimbursed at FS rates. If no FS, then Optum U&C. If no U&C, then Medicare plus 30%. If no Medicare, then billed charges.

Home health and therapy reimbursed at lesser of FS or the provider’s total billed charge. Nurse practitioner reimbursed at 85% of FS rate.

Reimbursed a FS MAR for specific CPT codes. PT/OT assistant reimbursed at 85% of FS value.

Mississippi

Medical Equipment and Supplies

25

Missouri 26

Medical Equipment and Supplies DMEPOS rate(s)

Rental requirements

Miscellaneous

Fair and reasonable reimbursement.

None stated.

None stated.

Transportation rate(s)

Home Health rate(s)

Physical/Occupational therapy rate(s)

None stated.

None stated.

None stated.

DMEPOS rate(s)

Rental requirements

Miscellaneous

Reimbursement as set in FS. If item not found in FS, reimbursement at lesser of cost plus freight plus $30/30%.

None stated.

Healthcare provider (related to professional FS) who is referred by “designated treating physician” compensated at 90% of FS. For professional services where a procedure is not covered by FS, reimbursed at 75% of U&C.

Transportation rate(s)

Home Health rate(s)

Physical/Occupational therapy rate(s)

As listed in FS.

As listed in FS.

As listed in FS.

Montana

Medical Equipment and Supplies

27

Nebraska 28

Medical Equipment and Supplies DMEPOS rate(s)

Rental requirements

Miscellaneous

Reimburse at actual billed charge unless payer has evidence actual charge exceeds regular charge for service by Nebraska providers.

None stated.

General reimbursement shall be lower of FS or provider’s billed charge.

Transportation rate(s)

Home Health rate(s)

Physical/Occupational therapy rate(s)

Reimburse at actual charge.

Home services add 50% to listed FS amount.

Reimburse at FS MAR using physical medicine conversion factor.

DMEPOS rate(s)

Rental requirements

Miscellaneous

Reimburse at the provider’s documented cost (excluding tax and freight) plus 20% or written agreement. Custom O&P reimbursed at Medicare plus 40% or written agreement if lower.

None stated.

Tax and freight are not reimbursable costs for DME.

Transportation rate(s)

Home Health rate(s)

Physical/Occupational therapy rate(s)

None stated.

State-specific codes for home health care, nursing assistant care and skilled home healthcare, which includes home PT/OT. No established reimbursement for home infusion therapy.

Some services listed in FS are based upon Relative Value conversion factor.

Nevada

Medical Equipment and Supplies

29

New Hampshire 30

Medical Equipment and Supplies DMEPOS rate(s)

Rental requirements

Miscellaneous

None stated.

None stated.

No established FS. Shall pay full amount of provider’s bill unless payer can show just cause as to why total amount should not be paid.

Transportation rate(s)

Home Health rate(s)

Physical/Occupational therapy rate(s)

None stated.

None stated.

None stated.

DMEPOS rate(s)

Rental requirements

Miscellaneous

None stated.

None stated.

None stated.

Transportation rate(s)

Home Health rate(s)

Physical/Occupational therapy rate(s)

None stated.

None stated.

None stated.

New Jersey

Medical Equipment and Supplies

31

New Mexico 32

Medical Equipment and Supplies DMEPOS rate(s)

Rental requirements

Miscellaneous

Reimburse at invoice cost plus 25% plus shipping, handling and taxes or lesser of U&C or contract. Reasonable charges for O&P fitting can be included and invoice may be requested.

Rental shall be less than 90 days and first 30 days rental price applies to purchase price.

None stated.

Transportation rate(s)

Home Health rate(s)

Physical/Occupational therapy rate(s)

None stated.

Reimburse at FS amounts listed for home health codes 99500-99602 and applicable CPT codes.

Reimburse at FS amounts listed for physical medicine codes 97001-97799.

DMEPOS rate(s)

Rental requirements

Miscellaneous

Reimburse at rate based upon state Medicaid rate. For footwear or items not recognized in Medicaid, reimbursement at lesser of acquisition cost to provider plus 50% or U&C. Reimbursement lower than FS is allowed for DME with a written agreement.

Maximum monthly rental charge for DMEPOS shall not exceed lower of monthly rental charge to general public or price determined by NY Dept. of Health. The total accumulated monthly rental charges are not to exceed fee amount allowed under Medicaid.

FS is maximum rate for DMEPOS. There are no separate/additional payments for shipping, handling and delivery.

Transportation rate(s)

Home Health rate(s)

Physical/Occupational therapy rate(s)

None stated.

For PT/OT in home, add 50% to the listed FS value and requires documentation explaining necessity of home care versus office/outpatient treatment. Home services not listed in FS not specified.

Reimbursement per FS (RVU times conversion factor). Reimbursement lower or greater than FS allowed for PT/OT with written agreement.

New York

Medical Equipment and Supplies

33

North Carolina 34

Medical Equipment and Supplies DMEPOS rate(s)

Rental requirements

Miscellaneous

Reimburse at FS MAR for DME and supplies provided in context of professional services which equals 100% of the rates established for North Carolina in the CMS DMEPOS FS.

Rentals must be prior authorized.

State establishes FS MAR for some items listed specifically by HCPCS codes.

Transportation rate(s)

Home Health rate(s)

Physical/Occupational therapy rate(s)

Refer to HCPCS ambulance A codes if listed in FS.

Reimburse at FS if listed by specific CPT codes. If not listed, reimburse at U&C or an agreed upon rate.

Physical medicine services reimbursed at Medicare plus 40% base amount. Some specific codes/rates are provided in the FS.

DMEPOS rate(s)

Rental requirements

Miscellaneous

Medicare plus 20%. If not recognized by Medicare, reimburse at 85% of the cost-to-charge ratio, not to exceed 50th percentile of U&C database for ND. Certain electromedical equipment and related supplies are only reimbursed under the preferred provider agreement.

Limits monthly rental payments for Capped Rental items to 13 months.

None stated.

Transportation rate(s)

Home Health rate(s)

Physical/Occupational therapy rate(s)

Reimburse at FS MAR.

Reimburse at FS MAR Home Health/ Nursing usually reimbursed on per visit basis unless approved otherwise.

Reimburse at FS MAR is divided into “facility” and “non-facility”.

North Dakota

Medical Equipment and Supplies

35

Ohio

Medical Equipment and Supplies DMEPOS rate(s)

Rental requirements

Miscellaneous

Reimburse at Medicare plus 20% when recognized by CMS. Items not recognized by CMS, reimburse at BWC FS. BR codes priced at manufacturer’s invoice price plus a negotiated percentage not to exceed certain maximums.

DME considered to be purchased when rental has reached the purchase fee. TENS rental generally limited to 30 days after surgery. Reimbursement of rental costs considered only for trial period that the TENS unit was actually used before treatment discontinued.

General reimbursement for HCPCS codes at Medicare plus 20% or rate established in FS for items not recognized by Medicare.

Transportation rate(s)

Home Health rate(s)

Physical/Occupational therapy rate(s)

Not Reimbursable

• Current general medicine codes (CPT codes 90281-96999, 9900099600) reimbursed at 142% of Medicare

Reimburse per CPT codes and rates listed in the FS. Current physical medicine codes (CPT codes 97001-98943) are reimbursed at 142% of Medicare.

• Home health agency nursing service fees determined by the BWC • Home infusion therapy rates negotiated per diem 36

DMEPOS rate(s)

Rental requirements

Miscellaneous

Reimburse at lesser of the provider’s U&C or 90% of allowable in FS (Medicare). If no FS amount or Medicare allowable, reimburse at the lesser of provider’s U&C or 10% above manufacturer’s invoice price, plus the reasonable and customary acquisition cost of item(s) to the provider.

Prior authorization required on rental to compare cost to purchase.

None stated.

Transportation rate(s)

Home Health rate(s)

Physical/Occupational therapy rate(s)

Non-emergency ambulance reimbursed at Medicare plus 25%.

FS MAR listed by CPT code.

Reimbursed at FS MAR listed by CPT code. PT/OT at home reimburse at FS plus 50%.

Oklahoma

Medical Equipment and Supplies

37

Oregon 38

Medical Equipment and Supplies DMEPOS rate(s)

Rental requirements

Miscellaneous

Reimburse new items at the lesser of FS or the provider’s usual fee. Reimburse used items at the lesser of 75% of FS or the provider’s usual fee. Rented (monthly) items reimbursed at the lesser of 10% of FS or the provider’s usual fee with specific rental codes.

Unless otherwise provided in the contract, after a rental period of 13 months the item is considered purchased. Insurer may purchase rental item anytime within the 13 month rental period with a credit of 75% of rental paid toward the purchase.

General reimbursement shall be 80% of the provider’s usual fee when no MAR or fixed FS amount is established.

Transportation rate(s)

Home Health rate(s)

Physical/Occupational therapy rate(s)

Ambulance services reimbursed at the provider’s usual fee for certain HCPCS codes.

Home health care reimbursed using most current CPT codes in accordance with medical provider fee formula at lesser of the FS MAR or provider’s usual fee.

Reimbursed using the most current CPT codes in accordance with medical service provider fee formula at lesser of the FS MAR or the provider’s usual fee.

DMEPOS rate(s)

Rental requirements

Miscellaneous

Reimburse DME/Supplies at FS MAR listed by HCPCS codes. If no FS MAR, reimburse at the lesser of the actual charge or 80% of U&C.

None stated.

Reimbursement for DME, supplies, and services listed in FS based upon Medicare plus 13%.

Transportation rate(s)

Home Health rate(s)

Physical/Occupational therapy rate(s)

Reimburse at MAR as listed in the FS or, if no FS MAR, reimburse at the lesser of the actual charge or 80% of U&C.

Reimburse at MAR as listed in the FS or, if no FS MAR, reimburse at the lesser of the actual charge or 80% of U&C.

Reimburse at MAR as listed in the FS, or if no FS MAR, reimburse at the lesser of the actual charge or 80% of U&C.

Pennsylvania

Medical Equipment and Supplies

39

Rhode Island 40

Medical Equipment and Supplies DMEPOS rate(s)

Rental requirements

Miscellaneous

Reimburse as listed in the FS.

The sum of payments for rental items should not exceed the purchase price over life of claim. No additional payments should be allowed upon reaching the purchase price.

Reimbursement of interpreters should not exceed U&C.

Transportation rate(s)

Home Health rate(s)

Physical/Occupational therapy rate(s)

None stated.

If not recognized in the FS, reimbursement should not exceed U&C.

State-specific codes (X7001 - X7005) shall be used to code physical and occupational therapist services.

DMEPOS rate(s)

Rental requirements

Miscellaneous

Lesser of FS MAP as or U&C DME/supplies not listed in the FS are reimbursed at the actual cost plus 20%.

None stated.

General reimbursement is the lesser of the FS MAP, by listed CPT/HCPCS code, or the provider’s U&C. Payment for other services not included in FS based on providers U&C or negotiated rate.

Transportation rate(s)

Home Health rate(s)

Physical/Occupational therapy rate(s)

None stated.

Home health rates are not addressed. Nurse practitioners reimbursed at 85% of the FS. Cost of injectable pharmaceuticals must be billed using appropriate HCPCPS code with the medication charge based on AWP.

Lesser of the FS MAP, listed by CPT/HCPCS code or the providers U&C.

South Carolina

Medical Equipment and Supplies

41

South Dakota 42

Medical Equipment and Supplies DMEPOS rate(s)

Rental requirements

Miscellaneous

DME/Supplies are reimbursed at 80% of the billed rate. Certain O&P fittingmanufacturer listed in the physician FS are reimbursed at the lesser of FS or U&C.

None stated.

None stated.

Transportation rate(s)

Home Health rate(s)

Physical/Occupational therapy rate(s)

None stated.

Services not listed in the FS are reimbursed at 80% of the billed rate.

Services and re-evaluations reimbursed as listed in the FS, by CPT Code.

DMEPOS rate(s)

Rental requirements

Miscellaneous

DME/supplies (other than implants) recognized by Medicare shall be reimbursed at the lesser of Medicare or the billed charge.

DME rental fees applicable in instances of short-term use. The maximum allowable rental fee shall be Medicare. First month fees apply to the purchase. Provider shall use RR modifier when billing rental.

General reimbursement shall be lesser of provider’s usual charge, FS or the negotiated/contract rate.

• Items not recognized by Medicare with a billed charge of less than $100 shall be reimbursed at 80% of the billed charge

“Usual and customary” when used in rules means 80% of a specific provider’s billed charges.

Tennessee

Medical Equipment and Supplies

• Items with a billed charge greater than $100 shall be reimbursed at cost plus 15% but not to exceed $1,000 • O&P reimbursed at Medicare plus 15%

Transportation rate(s)

Home Health rate(s)

Physical/Occupational therapy rate(s)

Ambulance services reimbursed at the lesser of the submitted charge or Medicare plus 50%.

Reimbursed at a maximum of U&C (80% of billed charges). Certain care by licensed professionals is not considered home health care. Injection reimbursement allowed for both administration of the medication and the medication itself at AWP.

Reimbursed at Medicare plus 30%.

43

Texas

Medical Equipment and Supplies DMEPOS rate(s)

Rental requirements

Miscellaneous

Reimbursement shall be at Medicare plus 25%.

None stated.

None stated.

• Where not recognized by Medicare, or no contract amount, reimbursement shall be at Medicaid plus 25% • Where no Medicaid amount, reimbursement shall be provider’s U&C or a Fair and Reasonable amount • Contract reimbursement rates permitted under compliant and negotiated contract rates

44

Transportation rate(s)

Home Health rate(s)

Physical/Occupational therapy rate(s)

Reimbursement shall be at Medicare plus 25%.

Reimbursement shall be at Medicare plus 25%.

• Where not recognized by Medicare, or no contract amount, reimbursement shall be at Medicaid plus 25%

• Where not recognized by Medicare, or no contract amount, reimbursement shall be at Medicaid plus 25%

Physical Medicine reimbursed per Medicare, with a state-specific conversion factor (updated annually based on MEI).

• Where no Medicaid amount, reimbursement shall be provider’s U&C or a Fair and Reasonable amount

• Where no Medicaid amount, reimbursement shall be provider’s U&C or a Fair and Reasonable amount

• Contract reimbursement rates permitted under compliant and negotiated contract rates

• Contract reimbursement rates permitted under compliant and negotiated contract rates

DMEPOS rate(s)

Rental requirements

Miscellaneous

No reimbursement specifically stated for suppliers. Providers (special or unusual supplies, materials) may be billed at cost plus a 15% restocking fee. No fee allowed for TENS unless prescribed by physician and supported by prior diagnostic testing showing efficacy.

None stated.

General reimbursement determined by multiplying the RVU for the CPT code by the relevant conversion factor. Care not addressed in FS payer and the provider may agree to a reasonable fee.

Transportation rate(s)

Home Health rate(s)

Physical/Occupational therapy rate(s)

None stated.

Reimburse at hourly rates or visit listed for Home Healthcare codes.

Reimburse per the FS adopted RBRVS system. All providers billing under CPT 97001-97610 are limited to payment of a maximum of three procedures/units per visit or six procedures if treating different sites, even if billing for additional procedures.

Home Infusion to be done with direct provider contract. If contract not established, reimburse at HHC rates and pay U&C/cost plus 15% for medications and supplies.

Utah

Medical Equipment and Supplies

Physicians and physical therapists may bill for up to two modalities/procedures per day. With prior-authorization, may make additional billing when justified. 45

Vermont

Medical Equipment and Supplies DMEPOS rate(s)

Rental requirements

Miscellaneous

Supplies and DME reimbursed at the listed FS rates. Items not listed in the FS reimbursed at lesser of 83% of the charge or 150% of the cost.

None stated.

None stated.

Transportation rate(s)

Home Health rate(s)

Physical/Occupational therapy rate(s)

Reimbursement at listed FS MAR. Items not in the FS are reimbursed at 83% of the billed charge.

Reimbursement at listed FS MAR. Items not in the FS are reimbursed at 83% of the billed charge.

Reimbursement at listed FS. Items not in the FS are reimbursed at 83% of the billed charge. Various charge calculations for multiple modalities on the same visit.

46

DMEPOS rate(s)

Rental requirements

Miscellaneous

None stated.

None stated.

Bill disputes arising will use the prevailing community rate.

Transportation rate(s)

Home Health rate(s)

Physical/Occupational therapy rate(s)

None stated.

None stated.

None stated.

Virginia

Medical Equipment and Supplies

47

Washington 48

Medical Equipment and Supplies DMEPOS rate(s)

Rental requirements

Miscellaneous

• Reimbursement for State Fund claims shall be listed at FS MAR

Rental for more than 60 days requires prior authorization.

Delivery charges, shipping and handling, tax and fitting fees are not payable separately, and shall be included in total charge.

• Reimbursement for Self Insured claims shall be listed at FS MAR or the contract rate • Specific coverage requirements and codes for TENS. Some TENS no longer reimbursed • Reimbursement for BR prosthetic items and medical or surgical supplies shall be at 80% of billed charge

Transportation rate(s)

Home Health rate(s)

Physical/Occupational therapy rate(s)

Reimbursement shall be at the listed FS rates.

Reimbursement at listed (state specific) HHC codes FS MAR.

Reimbursement at listed FS MAR. The daily max for PT/OT is $124.44. The conversion factor for most RBRVS services is $59.98. When multiple treatments or different billing codes are performed in one day, reimbursement shall be lesser of the sum of individual fee maximums, provider’s U&C charge or FS maximum.

DMEPOS rate(s)

Rental requirements

Miscellaneous

DME, supplies and O&P reimbursed at Medicare plus 13%.

None stated.

None stated.

Transportation rate(s)

Home Health rate(s)

Physical/Occupational therapy rate(s)

Medicare plus 13%. If no Medicare rate, reimbursement is at the prevailing community rate.

None stated.

Medicare plus 13%.

Washington D.C.

Medical Equipment and Supplies

49

West Virginia 50

Medical Equipment and Supplies DMEPOS rate(s)

Rental requirements

Miscellaneous

Reimbursement shall be at Medicare plus 35%. If not recognized by Medicare, reimbursement shall be at U&C.

None stated.

None stated.

Transportation rate(s)

Home Health rate(s)

Physical/Occupational therapy rate(s)

Reimbursement shall be at Medicare plus 35%. If not recognized by Medicare, reimbursement shall be at U&C.

Reimbursement shall be at Medicare plus 35%. If not recognized by Medicare, reimbursement shall be at U&C.

Reimbursement shall be at Medicare plus 35%. If not recognized by Medicare, reimbursement shall be at U&C.

DMEPOS rate(s)

Rental requirements

Miscellaneous

None stated.

None stated.

Reimbursement determinations tied to DWD definition of “Reasonable and Customary or Agreed.”

Transportation rate(s)

Home Health rate(s)

Physical/Occupational therapy rate(s)

None stated.

None stated.

None stated.

Wisconsin

Medical Equipment and Supplies

51

Wyoming

Medical Equipment and Supplies DMEPOS rate(s)

Rental requirements

Miscellaneous

Reimbursement shall be at FS listed MAR, which is currently Medicare allowable for Wyoming.

None stated.

“Usual and customary” is provider’s charge to the general public for the same or similar service.

• For items not recognized by Medicare and billed at less than $1,000, reimbursement shall be 80% of the billed charge • Items billed at greater than $1000 with the invoice provided, reimbursement shall be invoice plus 30 • Items billed at greater than $1000 without an invoice, shall be reimbursed at 40% of the billed charge

52

Transportation rate(s)

Home Health rate(s)

Physical/Occupational therapy rate(s)

Reimbursement shall be the lesser of FS or billed charges.

Reimbursement shall be at rates established by FS. Home nursing services paid for a maximum of 12 hours per day, per provider.

Specific conversion factor/MAR for PT and OT.

DMEPOS rate(s)

Rental requirements

Miscellaneous

Reimbursement shall be lesser of FS or billed charge. If not in FS, reimbursement shall be at the billed charge.

OWCP may offset cost of prior rental payments against a future purchase price.

General reimbursement shall be lesser of billed charge or FS.

Transportation rate(s)

Home Health rate(s)

Physical/Occupational therapy rate(s)

FS rates, if no FS rates, then other State or Federal FS rates or prevailing community rates.

Reimbursement shall be lesser of FS or billed charge. If not in FS, reimbursement shall be billed charge.

Reimbursement shall be lesser of FS or billed charge. If not in FS, reimbursement shall be billed charge.

EEOIC programs may have programspecific policies for Home Health.

U.S. Department of Labor

Medical Equipment and Supplies

53

About Optum for Workers’ Compensation Helios, Healthcare Solutions and their subsidiaries, as Optum companies, collaborate with our clients to deliver value beyond transactional savings while helping ensure injured workers receive safe and effective clinical care. Our innovative and comprehensive medical cost management programs include pharmacy benefit management, ancillary benefit management, managed care services and settlement solutions. Optum and its respective marks are trademarks of Optum, Inc. All other brand or product names are trademarks or registered marks of their respective owners. Because we are continuously improving our products and services, Optum reserves the right to change specifications without prior notice. Optum is an equal opportunity employer. © 2016 Optum, Inc. All Rights Reserved. PHM14-16205