10A NCAC 22G .0402. OTHER SERVICES PERFORMED BY PHYSICIANS AND OTHER PRACTITIONERS

A maximum fee is established for other services performed by physicians and other practitioners 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 provider's customary charge to the general public for the particular service rendered.

(1)           Fees for all services are established by applying the following method to the fees in effect on May 1, 1989:

(a)           The higher of the inpatient or outpatient fee is selected for each service within each specialty and the weighted average of this amount is computed among all specialties.  The average is weighted by the number of services billed by each specialty in 1988.

(b)           The weighted average fee is then increased by 10 percent.

(2)           Annual fee increases are applied each January 1 based on the forecast of the gross national product (GNP) implicit price deflator, but not to exceed the percentage increase approved by the North Carolina General Assembly.

(3)           Fees for new services are established based on the fees for similar existing services.  If there are no similar services the fee is established at 75 percent of the billed amount.

(4)           Fees for particular services may be increased based on administrative review if it is determined that the service is essential to the health needs of Medicaid recipients, that no alternative treatment is available, and that a fee adjustment is necessary to maintain physician participation at a level adequate to meet the needs of Medicaid recipients.  A fee may also be decreased based on administrative review if it is determined that the fee may exceed the Medicare allowable amount for the same or similar services, or if the fee is higher than Medicaid fees for similar services, or if the fee is deemed unreasonable in relation to the skills, time, and other resources required to provide the particular service.

 

History Note:        Authority G.S. 108A‑25(b); S.L. 1985, c. 479, s. 86;

Eff. January 4, 1993;

Temporary Amendment Eff. March 7, 2002;

Temporary Amendment Expired December 27, 2002.

Amended Eff. August 1, 2004.