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Workers' compensation -- HIPAA 835 Health care claim payment/remittance advice



5221.0600 Payer responsibilities

Subpart 1. Compensability. This chapter does not require a payer to pay a charge for a service that is not for the treatment of a compensable injury or a charge that is the primary obligation of another payer.

Subp. 2. Determination of excessiveness. Subject to a determination of the commissioner or compensation judge, the payer shall determine whether a charge or service is compensable by evaluating the charge and service according to the conditions of excessiveness and payer liability specified in part 5221.0500, subparts 1 and 2, and Minnesota Statutes, section 176.136, subdivision 2. If the payer determines that the provider has assigned an incorrect code for a service, the payer may determine the correct code for the service and evaluate liability for payment on the basis of the correct code.

Subp. 3. Determination of charges. As soon as reasonably possible, and no later than 30 calendar days after receiving the bill, the payer shall:

A. pay the charge or any portion of the charge that is not denied;

B. deny all or a portion of a charge on the basis that the injury is noncompensable; the charge is excessive or noncompensable under Minnesota Statutes, section 176.136, subdivision 2; or part 5221.0500, subparts 1 and 2; or the charges are not submitted on the appropriate billing form prescribed in part 5221.0700; or

C. request specific additional information to determine whether the charge or the condition is compensable. The payer shall make a determination as set forth in items A and B no later than 30 calendar days following receipt of the provider's response to the initial request for specific additional information.

Subp. 4. Notification. Within 30 calendar days of receipt of the bill, the payer shall provide written notification to the employee and provider of denial of part or all of a charge, or of any request for additional information. Written notification shall include:

A. the basis for denial of all or part of a charge that the payer has determined is not for a compensable injury under part 5221.0100, subpart 6;

B. the basis for denial or reduction of each charge and the specific amounts being denied or reduced for each charge meeting the conditions of an excessive or noncompensable charge under part 5221.0500, subparts 1 and 2, or Minnesota Statutes, section 176.136, subdivision 2;

C. denial of a charge for failure to submit it on the billing form prescribed in part 5221.0700, subpart 2; and

D. a request for an appropriate record or the specific information requested to allow for proper determination of the bill under this part.

The payer shall specify the applicable rule, part, and subpart in this chapter supporting its denial or reduction of a charge. A general statement that a service or charge "exceeds the fee schedule or treatment parameters" is not adequate notification.

If payment is denied under item B, C, or D, the payer shall reconsider the charges in accordance with this rule as soon as reasonably possible, and no later than 30 calendar days after receipt of additional relevant information or documents. Notice of denial of part or all of a charge shall be given by the payer consistent with the guidelines in this subpart.

Subp. 5. Penalties. Failure to comply with the requirements of this part may subject the payer to the penalties provided in Minnesota Statutes, sections 176.221, 176.225, and 176.194.

Subp. 6. Collection of excessive payment. Any payment made to a provider which is determined to be wholly or partially excessive, according to the conditions prevailing at the time of payment, may be collected from the provider by the payer in the amount that the reimbursement was excessive. The payer must demand reimbursement of the excessive payment from the provider within one year of the payment.

Statutory authority:  MS s 175.171; 176.101; 176.135; 176.1351; 176.136; 176.231; 176.83

History:  9 SR 601; 13 SR 2609; 18 SR 1472; 25 SR 1142

Posted:  June 11, 2008

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