| Montana WORKERS COMPENSATION COLLECTION PUBLICATIONS AND INFORMATION FOR MEDICAL PROVIDERS |
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November 22, 2011: Montana: News:
Montana’s Workplace Injuries and Illnesses
are Declining
November 08, 2011:Montana: Issues:
In Montana “usual and customary” means the
provider’s normal charges for a service, and
does not include state or regional database
information purporting to be usual and
customary
Montana’s Workplace Injuries and Illnesses
are Declining
November 08, 2011:Montana: Issues:
In Montana “usual and customary” means the
provider’s normal charges for a service, and
does not include state or regional database
information purporting to be usual and
customary
| General Information |
| Publications |
| Work Comp News and Issues |
- Medical Control
The injured employee may select a medical provider of their choice. Any change of provider
requires pre-approval of the insurance carrier. The employee may select his/her own pharmacy or
select a pharmacy from the Express Scripts pharmacy network. Emergency medical care does not
require preapproval and should be secured at the nearest location.
- State Fee Schedule
Inpatient rehabilitation services are paid at 75%of the usual and customary charges
In Montana “usual and customary” means the provider’s normal charges for a service, and does
not include state or regional
database information purporting to be usual and customary
Insurer payment is due within 30 days of receipt of the bill from the provider facility, or a 1%
interest payment penalty per month is charged
MS-DRG Calculations
• Each MS-DRG is given a Relative Weight
based on its relative complexity and use
of resources
• Montana’s Conversion Factor (CF) is
$7,735 for the period beginning 12/01/08
• The payment formula is the Relative
Weight multiplied by the CF ($7,735)
Inpatient Implant Reimbursement System
• Implants costing less than $10,000 are considered to be bundled into the MS-DRG
reimbursement
• Implants costing more than $10,000 can be separately reimbursed at cost plus 15%
• Copies of Implant invoices are required for this separate reimbursement process
• Implant costs include shipping and handling
• Implant costs are excluded from outlier calculations
Outpatient Implant Reimbursement System
• Implants costing less than $500 are considered to be bundled into the APC reimbursement
• Implants costing more than $500* can, separately from the APC system, be reimbursed at cost
plus 15 percent;
use Code L8699
• Copies of Implant invoices are required for this separate reimbursement process
• Implant costs include shipping and handling
* It is important to note that “implant cost” as used in the Montana WC system refers to the
total implant costs for all implants combined for a patient
- The Mediation Unit provides an alternative method of resolving workers' compensation
benefit disputes before the dispute goes to the Workers' Compensation Court. This is a
mandatory, non-binding process.
concerning benefits under the Workers' Compensation Act. The mediator is a neutral third person
who listens to the concerns of both parties and assists them in resolving the dispute. The
conferences are informal and confidential, and there is no verbatim record kept.
Mediation conferences are held by telephone.
The purpose of mediation is to prevent, when possible, the filing in the workers' compensation
court of disputes by injured workers or insurers if a fair and reasonable resolution can be reached
at an earlier stage.
In general, any dispute between a claimant and the insurance company concerning benefits under
either the Workers' Compensation Act qualify for mediation. However, there are some exceptions
to this. If you are in doubt as to whether your dispute falls under the jurisdiction of the mediation
unit please call the examiner handling your claim or the mediation unit at (406) 444-6534.
Prior to the mediation conference you should submit copies of any documentation you feel may
support your position or assist the mediator in making a recommendation.
During the conference, you and the insurer will be asked to present your positions. Prior to the
conference, it may be helpful to write down your concerns and note any information you wish to
present during the conference. This will ensure nothing is forgotten.
The conference will be held at the date and time indicated in the NOTICE OF MEDIATION
CONFERENCE. You are expected to be available at the phone number listed on the REQUEST
FOR MEDIATION CONFERENCE you completed. If your phone number changes or you are
unavailable at the time scheduled, it is your responsibility to call as soon as possible so other
arrangements can be made.
Every effort will be made by the Mediator to help the parties resolve the issue during the
conference. If this does not happen, the mediator will issue a written recommendation to all
parties within ten working days. Once you receive the recommendation, you have 25 days to
advise the Mediator as to whether you agree with the recommendation or not. If the parties
cannot resolve the dispute once the recommendation is issued, either party may proceed to the
Workers' Compensation Court.
Workers Compensation Claims Assistance Bureau
Mediation Unit
P.O. Box 1728
Helena, MT 59624-1728
Kay Henry
(406) 444-6534
khenry@mt.gov