10A NCAC 45A .0404       REIMBURSEMENT rates FOR SERVICES NOT COVERED BY MEDICAID

(a)  The Department shall reimburse providers of authorized mobility systems (including components and accessories), environmental control units, and custom seating systems for which there are no Medicaid reimbursement rates at the manufacturer's catalog price less five percent.

(b)  The Department shall reimburse providers of authorized prosthetics and orthotics at the Medicare rate of reimbursement when there is no Medicaid rate of reimbursement for the item.  When there is neither a Medicaid rate nor a Medicare rate for the item, the Department shall reimburse at the provider's usual charge to the general public.

(c)  The Department shall reimburse providers of authorized equipment repair services for which there are no Medicaid reimbursement rates at forty five dollars ($45.00) per hour.

(d)  The Department shall reimburse physicians and dentists for authorized services for which there are no Medicaid rates at the Medicaid rate for a comparable procedure as determined by the program's medical director or at 80 percent of the amount billed, whichever is less.

(e)  The Department shall reimburse providers of authorized assistive listening devices and those types of hearing aids for which there are no Medicaid rates at invoice cost plus the Medicaid dispensing fee for a new hearing aid(s).

(f)  The Department shall reimburse providers of authorized amplification-related services for which there are no Medicaid rates at the rates paid for audiology services under Medicaid's Independent Practitioner Program.

(g)  The Department shall reimburse providers of authorized services not otherwise specified in this Section, for which there are no Medicaid reimbursement rates, at the provider's usual charge to the general public.

History Note:        Authority G.S. 130A-5(3); 130A-124; 130A-127; 130A-129; 130A-205;

Eff. October 1, 1982;

Transferred and Recodified from 10 NCAC 4C .0404 Eff. April 4, 1990;

Amended Eff. December 1, 1990;

RRC Objection Eff. November 17, 1994 due to lack of statutory authority;

Amended Eff. January 1, 2014; April 1, 1999; October 1, 1995; February 1, 1995;

Pursuant to G.S. 150B-21.3A, rule is necessary without substantive public interest Eff. January 13, 2015.