452 CMR 6.05 - Utilization Reporting
(1) Providers must
use, and insurers must accept, standard forms prescribed by the DIA, based on
the most recent Center for Medicare and Medicaid Services forms.
(2) The Department may require utilization
review agents to provide a sample of up to 100% of all billing records, both
inpatient and outpatient, which sample shall be transmitted to the Department
of Industrial Accidents so that the Department can implement appropriate
utilization oversight. In addition to the standard billing file, for every
outpatient service the Department may request information about the insurer,
any procedures, and the employer's and provider's identification numbers. For
inpatient services, the Department must receive all relevant diagnostic and
procedure International Classification of Disease (ICD) codes, Current
Procedural Terminology (CPT) and other codes, the length of stay and the cost
of any ancillary services. The Department may require both counts of services
as well as the amount reimbursed.
Notes
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No prior version found.