C.M.R. 90, 351, ch. 5, § 351-5-4, subsec. 351-5-4-06
Current through 2025-02, January 8, 2025
The threshold for outlier payments is $2,500.00 per procedure code plus the fee listed in Appendix IV. If the outlier threshold is met, the outlier payment is the charges above the threshold multiplied by 75%. If a bill has more than one surgical procedure with a status indicator of J, S or T and one or more of those procedures has less than a $1.01 charge, charges for all status J, S and T lines are summed and the charges are then divided across the J, S and T lines in proportion to their APC payment rate. The new charge amount is used in place of the submitted charge amount in the outlier calculation.
C.M.R. 90, 351, ch. 5, § 351-5-4, subsec. 351-5-4-06