Personal injury protection (PIP) information for insurers and providers

ORS 742.525 (1) prohibits health care providers from billing persons who receive personal injury protection benefits more than they charge the general public or an amount that exceeds the fee schedules for medical and other services published under Oregon workers' compensation laws.

ORS 742.525 (2) made adjustments to PIP benefits and hospital reimbursements effective January 1, 2006. The law established a separate alternative measure for payment of hospital services, replacing the standard that applies to payment for medical services generally. The general standard, enacted in 2003, ties PIP reimbursements to the workers compensation fee schedule. This change allows a more complete reimbursement of hospital expenses.

Current workers' compensation fee schedules

Claims should be paid using the workers' compensation fee schedule in effect when the medical service was provided. The fee schedule usually changes April 1 each year.

The cost/charge ratios for hospitals are revised April 1 and October 1 of each year.

• Insurance Division Bulletin INS 2003-7

Use of NCCI edits on PIP claims not allowed

It has recently come to the Insurance Division's attention that some auto insurers are utilizing NCCI (National Correct Coding Initiative) edits in the processing of billings on PIP claims. These are edits developed by the Centers for Medicare and Medicaid Services that are used in the processing of Medicare claims.

However, in reviewing Oregon Administrative Rule 436-009-0004, the use of these NCCI edits is not permitted. Please note that the NCCI edits are not listed in the references that comprise the Oregon Workers' Compensation Fee Schedule. The Workers' Compensation Division's interpretation has been consistent that only the references specifically cited in OAR 436-009-0004 are allowed to be used as the basis for the fee schedule, and that NCCI edits are not to be used in the calculation of payment for services under the fee schedule.

Accordingly, it is the Insurance Division's decision that NCCI edits are not to be used in calculating PIP benefits. Any vendor being used to audit bills on an insurer's behalf should abide by this finding, and not use NCCI edits as part of their bill review process.

Conversion factors for specific CPT codes

Several questions have arisen on the appropriate fee schedule conversion factor for chiropractic services under CPT codes 98940 though 98943. These particular treatment codes are to be calculated under the conversion factors for the medicine service category, not physical medicine.

Questions?

Please contact Cliff Nolen, 503-947-7221.