02-031-330 Me. Code R. § 4

Current through 2025-03, January 15, 2025

Section 031-330-4 - Definitions

For purposes of this Rule, the following terms shall have the following meanings:

A. "Usual Charge" means the most consistent charge by a provider for a given service.

B. "Customary Charge" means a charge within the range of usual charges for a given service billed by most providers with similar training and experience taking into consideration the geographic area in which the services are provided and significant regional variations in the cost of services.

C. "Reasonable Charge" means a charge that is not more than the usual and customary charge.

D. "Allowable Charge" means the amount which would be payable for services of a preferred provider under a preferred provider arrangement prior to the application of any deductible or coinsurance.

E. "Inpatient Services" means those services defined by 24 § 2325-A, 24-A M.R.S.A. §2843, subsection 3, paragraph B, or 24-A M.R.S.A. §4234-A, subsection 5, paragraph A, whether billed by the facility or by a physician or other professional.

F. "Large Employer" means an employer who employed an average of at least 51 employees, including part-time employees, on business days during the preceding calendar year and who employs at least two employees on the first day of the plan year.

G. "Home Health Care Services" means those services rendered by a licensed provider of mental health services to provide medically necessary health care to a person suffering from a mental illness in the person's place of residence if:

1. Hospitalization or confinement in a residential treatment facility would otherwise have been required if home health care services were not provided;

2. Hospitalization or confinement in a residential treatment facility is not required as an antecedent to the provision of home health care services; and

3. The services are prescribed in writing by a licensed allopathic or osteopathic physician or a licensed psychologist who is trained and has received a doctorate in psychology specializing in the evaluation and treatment of mental illness.

02-031 C.M.R. ch. 330, § 4