In rare instances, reimbursements may differ from those in the Official Medical Fee Schedule.
Frequently Asked Question
Q: Does Labor Code Section 5307.11 allow reimbursements different from those in fee schedules?
A: Yes. Labor Code § 5307.11 allows healthcare providers and health facilities to “contract for reimbursement rates different from those in the fee schedule adopted.”
A health care provider or health facility licensed pursuant to Section 1250 of the Health and Safety Code, and a contracting agent, employer, or carrier may contract for reimbursement rates different from those in the fee schedule adopted and revised pursuant to Section 5307.1.
To contract for a fee that is different from the maximum reimbursement amount allowed by the Official Medical Fee Schedule (OMFS), a provider of services must memorialize in writing the reimbursement amount as agreed to by an authorized agent of the claims administrator, prior to providing services.
Signed Authorization, with fees and individually initialed by the Claims Administrator, is considered contractual in nature.
To memorialize the different rates for the authorized treatment, use DaisyBill’s sample “Contract Pursuant to LC Section 5307.11 Pre-Authorization and Pre-Negotiated Fee Arrangement,” and substitute billing codes and fees as necessary.
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