California Medical Bill Reviewer Certification

1. California Medical Bill Reviewer Certification Unit 2: Official Medical Fee Schedule Module 1: California Fee Schedule

2. Overview The California Fee Schedule is complex and provides a great deal of information on how to accurately price medical bills. In this module, you will learn about the different sections of the Fee Schedule, how to review out of state services, and the importance of timeliness of payment. Let’s start by looking at the different sections of the California Fee Schedule... • Understand the Different Sections of the California Fee Schedule • Understand How to Review Out of State Services • Understand the Importance of Timeliness of Payment • Understand the Different Sections of the California Fee Schedule • Understand How to Review Out of State Services • Understand the Importance of Timeliness of Payment

3. California Fee Schedule • The California Fee Schedule is comprised of several different fee schedules. Fee Schedules - Pursuant to LC 4603.5 and 5307.1 • Physician Services Title 8 CCR 9789.11 • Inpatient Title 8 CCR 9789.22 & 9789.23 • Outpatient Title 8 CCR 9789.33, 9789.34 & 789.35 • Pharmacy Title 8 CCR 9789.40 • Pathology & Laboratory Title 8 CCR 9789.50 • DME, P & O, Supplies Title 8 CCR 9789.60 • Ambulance Title 8 CCR 9789.70

4. Under no circumstances shall the employee be billed for the treatment of an accepted workers’ compensation claim. Billing Procedures & Medical Necessity Recall that California law requires the employer, or the employer’s insurer to provide reimbursement for all medical care necessary to cure or relieve the effects of the employee’s industrial or work-related illness or injury.

5. Billing Procedures & Medical Necessity • All services and supplies provided to injured workers must be medically necessary.   This includes any service or supply, which is: • Provided as remedial treatment for an on-the-job illness or injury. • Appropriate to the patient’s diagnosis and clinical conditions in relation to any industrial injury. • Performed in an appropriate setting. • Consistent with published medical literature and practice Ground Rules generally accepted by the practitioner’s peer group.

6. Refer to your client rules when processing bills that include out of state services. Out of State Services • California claims fall under California jurisdiction, however, the claims administrator may opt to reimburse according to where services are rendered.

7. Out of State Services • Occasionally a California worker may be injured out of state or move out of state after their injury. • In this case, California would still be obligated to pay for medical services, only to an out-of-state provider. Portland, OR Alturas, CA • Claims administrators have specific guidelines on how to handle these scenarios.

8. The claims administrator will have guidelines on: Out of State Services • How to pay these providers. • Whether reimbursements should be made per the: • California Fee Schedule • The Fee Schedule in the Provider’s state • U&C guidelines • Contracted rate • Consult with the insurer to see what their out of state policy is.

9. The State of California mandates that reimbursement for medical services must be paid within a specific timeframe. You should be aware that the client for which you process may have their own timelines for issuing payment that are different from those of the State. Timeliness of Payment Per LC 4603.2(b): “Payment for medical treatment shall be made within 45 working days (60 days if government entity is the employer) after receipt of each separate, itemized billing, together with any required reports. In the absence of proper objection, automatic penalty and interest is required.”

10. If a provider submits a bill to the claims administrator without proper documentation for his services, the claims administrator must notify the provider in writing of the necessary documentation before payment is made. This must take place within 30 business days. Once the information is received from the provider, the 45-day time period for payment begins again. Timeliness of Payment

11. If however, all required documentation has been submitted and payment is not made within the required timeframe, the provider is entitled to penalties and interest based on the reimbursement amount. This is a self-imposed fee issued by the administrator to the provider. Timeliness of Payment This is why turnaround time in bill review is so important and something you should be very aware of.

12. The different sections of the California Fee Schedule. The importance of timeliness of payment. How to review out of state services. Summary

13. Module 1 Quiz Click on the link to go directly to the quiz. Feel free to review any of the material before you move on. Good Luck! Quiz: U2M1: California Fee Schedule