S.D. Admin. R. 47:03:05:05

Current through Register Vol. 51, page 71, January 6, 2025

Section 47:03:05:05 - Reimbursement criteria

To be reimbursed, the charge must be for reasonable and necessary services for the cure or relief of the effects of a compensable injury or disability. A health care provider is not entitled to payment from an insurer or employee for fees in excess of the maximum reimbursement allowed under this chapter.

Except as otherwise provided in this chapter, to determine the maximum reimbursement for services, the base unit value for a procedure code is multiplied by the following factors:

Procedure Code	Factor
10000-69999	$100.80
70000-79999	$ 19.07
80000-89999	$ 15.28
90000-95906	$ 6.57
95907-95913	$ 8.39
95914-97150	$ 6.57
97161	$21.11
97162	$ 13.20
97163	$ 6.61
97164	$ 15.08
97165	$21.11
97166	$ 13.20
97167	$ 6.61
97168	$ 15.08
97169-99071	$ 6.57
99075	$ 14.37 1^st hour, $1.78 each additional 15 min
99076-99199	$ 6.57
99201-99450	$ 8.00
99455-99456	$ 19.33 1^st hour, $2.41 each additional 15 min
99460-99499	$ 8.00
99500-99607	$ 6.57

If a code is properly submitted for one of these services, but is not listed in Relative Values for Physicians, or the base unit value is RNE or BR, the reimbursement is 80% of the provider's charge.

S.D. Admin. R. 47:03:05:05

21 SDR 67, effective 10/13/1994; 23 SDR 23, effective 8/22/1996; 38 SDR 105, effective 12/12/2011; 39 SDR 100, effective 12/6/2012; 39 SDR 219, effective 6/26/2013; 42 SDR 177, effective 6/28/2016; 43 SDR 181, effective 7/7/2017; 44 SDR 185, effective 6/25/2018; 47 SDR 042, effective 10/14/2020

General Authority: SDCL 62-7-8.

Law Implemented: SDCL 62-7-8.

Properly submitted medical bill, § 47:03:09:01. Relative Values for Physicians, Relative Value Studies, Inc., 2020. published by Optum 360, LLC. Copies may be obtained from Optum 360, LLC, PO Box 88050, Chicago, IL 60680-9920. Cost $329.95.