2005 Minnesota Statutes - 256B.0626 — Estimation of 50th percentile of prevailing charges.

     256B.0626 Estimation of 50th percentile of prevailing 
  charges. 


    (a) The 50th percentile of the prevailing charge for the 
 base year identified in statute must be estimated by the 
 commissioner in the following situations: 


    (1) there were less than five billings in the calendar year 
 specified in legislation governing maximum payment rates; 


    (2) the service was not available in the calendar year 
 specified in legislation governing maximum payment rates; 


    (3) the payment amount is the result of a provider appeal; 


    (4) the procedure code description has changed since the 
 calendar year specified in legislation governing maximum payment 
 rates, and, therefore, the prevailing charge information 
 reflects the same code but a different procedure description; or 


    (5) the 50th percentile reflects a payment which is grossly 
 inequitable when compared with payment rates for procedures or 
 services which are substantially similar. 


    (b) When one of the situations identified in paragraph (a) 
 occurs, the commissioner shall use the following methodology to 
 reconstruct a rate comparable to the 50th percentile of the 
 prevailing rate: 


    (1) refer to information which exists for the first four 
 billings in the calendar year specified in legislation governing 
 maximum payment rates; or 


    (2) refer to surrounding or comparable procedure codes; or 


    (3) refer to the 50th percentile of years subsequent to the 
 calendar year specified in legislation governing maximum payment 
 rates, and reduce that amount by applying an appropriate 
 Consumer Price Index formula; or 


    (4) refer to relative value indexes; or 


    (5) refer to reimbursement information from other third 
 parties, such as Medicare. 


    HIST: 1Sp1993 c 1 art 5 s 50; 1997 c 203 art 4 s 27