Sec. 14.09.08.04. MRA or Fee Not Established

A. The Commission has not established a medical fee schedule for dental services, durable medical equipment, and pharmaceuticals.

B. For products and services for which the Commission has not established an MRA or medical fee schedule, including dental services, durable medical equipment, and pharmaceuticals, the insurance carrier shall assign a relative value to the product or service.

C. An insurance carrier may base the assigned value on nationally recognized and published relative value studies, or on the values assigned for services involving similar work and resources.

D. Upon application of either party, the amount of reimbursement is subject to review by the Commission under the procedures set forth in Regulation .06 of this chapter.

E. Reimbursement.

(1) Except as provided in §E(2) of this regulation, reimbursement shall be the lesser of:

(a) The MRA amount as established by this regulation; or

(b) The authorized provider's usual and customary charge.

(2) If, in the opinion of a health care provider it is medically necessary to exceed the MRA, the authorized provider shall submit substantiating documentation to the payor with the Form CMS-1500.

F. For relevant CPT/HCPCS level I codes that are not valued by CMS, the Commission shall post MRAs for those codes on its website.