and Procedure Name:
Johnson, Esq., Chief of Medical Services (Signature on file)
policies, procedures, directives and memos (specifically the memo issued
03/01/2012) regarding pricing overrides that predate the effective date of this
purpose of this policy is to ensure that BWC provides the necessary information
to MCOs for completion of documentation and provision of appropriate EOB codes
for a pricing override process.
policy applies to MCOs.
A. For pricing overrides,
it is the policy of BWC:
1. To have BWC
process MCO requests for payment above fee schedule from the following provider
2. To have BWC
verify requests via a retrospective audit and not require MCOs to obtain front-end
approval from BWC for:
out of state providers for payment over fee schedule;
b. Requests for
pricing codes designated as By Report/Not Routinely Covered.
is the policy of BWC to require MCOs to document/include, at a minimum, the following
in all claims for which a pricing override is being requested:
1. How Miller
criteria is met;
3. Research that
confirms the correct code was billed;
4. Cost analysis information;
rationale for authorization.
MCO is responsible for maintaining all supporting documentation for pricing
shall maintain supporting documentation for all pricing override requests.
pricing override requests requiring BWC front-end approval, the MCO shall
submit the completed Pricing Override template to the MedPol email box.
pricing override requests not requiring BWC front-end approval, the MCOs shall:
1. Create a note
entitled “MCO code and fee approval” with the following information, at a
a. Date of service;
b. Description of
service with code;
c. Description of
how Miller criteria is met;
d. MCO approved
amount per code;
e. Provider name;
f. Bill type (e.g.,
professional, ASC, outpatient, inpatient).
2. For the
a. Codes designated
as By Report/Not Routinely Covered that exceed $10,000 (ten thousand); or,
b. By Report
vocational rehabilitation codes:
c. Submit the
i. An explanation
detailing why the MCO is approving payment;
iii. Bill containing EOB
752 and all applicable EOBs from the following list, indicating the services
and circumstances related to the authorization:
a) 787 –
b) 788 – J3490 Unclassified
c) 789 – Unlisted
d) 790 – Unlisted
e) 791 – Other
coded services/procedure requiring EOB 752 override
f) 792 – Out-of-state
non-certified provider payment above fee schedule (used in addition to EOB 860
for BR/NC/NRC codes); and,
iv. Bill containing EOB
a) An email to
MB&A with EOB 717 listed in the subject line;
instructions, including manual pricing instructions, in a secured document
emailed to the MBASUPV email box.
c) Both MB&A and
the MCO, for auditing purposes, shall maintain supporting documentation for
bills processed using EOB 717.