10A NCAC 22G .0401. PHYSICIAN’S FEE SCHEDULE

(a)  Effective September 1, 2001, physicians' services whether furnished in the office, the patient's home, a hospital, a nursing facility or elsewhere shall be reimbursed based on the North Carolina Medicaid Fee Schedule which is based on 95 percent of the Medicare Fee Schedule Resource Based Relative Value System (RBRVS) in effect on the date of service, except for payments to the various Medical Faculty Practice Plans of the University of North Carolina - Chapel Hill and East Carolina University which shall be reimbursed at cost and cost settled at year end; but with the following clarifications and modifications:

(1)           A maximum fee is established for each service and is applicable to all specialties and settings in which the service is rendered.  Payment is equal to the lower of the maximum fee or the providers customary charge to the general public for the particular service rendered.

(2)           Fees for services deemed to be associated with adequacy of access to health care services may be increased based on administrative review.  The service must be essential to the health needs of the Medicaid recipients, no other comparable treatment available and a fee adjustment must be necessary to maintain physician participation at a level adequate to meet the needs of Medicaid recipients.

(3)           Fees for new services are established based on this Rule, utilizing the most recent RBRVS, if applicable.  If there is no relative value unit (RVU) available from Medicare, fees shall be established based on the fees for similar services.  If there is no RVU or similar service, the fee shall be set at 75 percent of the provider's customary charge to the general public.  For codes not covered by Medicare that Medicaid covers, annual changes in the Medicaid payments shall be applied each January 1 and fee increases shall be applied based on the forecasted Gross National Product (GNP) Implicit Price Deflator.  Said manual changes in the Medicaid payments shall not exceed the percentage increase granted by the North Carolina State Legislature.

(4)           For codes not covered by Medicare that Medicaid covers, a code may also be decreased, based on administrative review, if it is determined that the fee may exceed the Medicare allowable amount for similar services, or if the fee is higher than Medicaid fees for similar services, or if the fee is too high in relation to the skills, time, and other resources required to provide the particular service.

The Resource Based Relative Value System (RBRVS), published annually in the Federal Register, is hereby incorporated by reference including any subsequent amendments and editions.  A copy is available for inspection at the Division of Medical Assistance, 1985 Umstead Drive, Raleigh, NC.  Copies may be obtained from Superintendent of Documents, PO Box 371954, Pittsburgh, PA 15250-7954 at a cost of nine dollars ($9.00) for the issue containing the RBRVS values.  Purchasing instructions may be received by calling 202/512-1800.

(b)  This reimbursement limitation shall become effective in accordance with the provisions of G.S. 108A-55(c).  These changes to the Physician's Fee Schedule allowables shall become effective when the Centers for Medicare and Medicaid Services (CMS), U.S. Department of Health and Human Services, approves amendment submitted to CMS by the Director of the Division of Medical Assistance as 01-18, #TN.

 

History Note:        Authority G.S. 108A-25(b);

Eff. October 1, 1982;

Amended Eff. July 1, 1997; July 1, 1995; January 4, 1993; June 1, 1990; December 1, 1988;

Temporary Amendment Eff. July 22, 1998; January 22, 1998;

Amended Eff. April 1, 1999;

Temporary Amendment Eff. January 1, 2000 (This temporary amendment amends and replaces a permanent rulemaking originally proposed to be effective August 2000);

Amended Eff. March 19, 2001;

Temporary Amendment Eff. September 10, 2001;

Temporary Amendment Expired June 28, 2002;

Amended Eff. April 1, 2003.