4
subrule (3) of this rule or after the expiration of the time period within which the carrier was
required to respond, including any extensions provided under subrule (3) of this rule.
R 500.244 Median amount; access to database.
Rule 4. (1) Subject to subrule (3) of this rule, a carrier may satisfy the requirement under R
500.243 by providing the department with access to a database that contains all of the carrier’s
median amounts. The database must meet all of the following requirements:
(a) Be updated no less frequently than quarterly.
(b) Be searchable by region, provider specialty, and health care service.
(c) Include negotiated rates for all health care services covered by the carrier,
GEOGRAPHICALLY ADJUSTED AND IF APPLICABLE, ISOLATED BY PLAN
PRODUCT TYPE SO NOT TO BLEND OR MERGE VARYING CONTRACT RATE
STRUCTURES FOR THE PURPOSES OF ARTIFICIALLY ADJUSTING THE MEDAIN.
THIS SHALL BE FURTHER LIMITED TO PROVIDERS REPORTED IN THE
CARRIER’S CURRENTLY PUBLISHED PROVIDER DIRECTORY, SORTED FOR
EACH GIVEN SPECIALTY;
(d) REPRESENT CONTRACTED PAYMENT RATES FOR COMMERCIAL HEALTH
BENEFIT PLANS ONLY, THAT ARE REGULATED BY THE DEPARTMENT, AND
WHICH. SHALL NOT INCLUDE PROVIDER CONTRACT RATES ASSOCIATED
WITH BENEFIT PLANS THE CARRIER ADMINISTERS ON BEHALF OF MEDICARE,
MEDICAID OR OTHER GOVERNMENT HEALTH BENEFIT PROGRAMS.
(e) Be continuously accessible to the department.
(2) For the purposes of conducting a calculation review under section 24510 of the
act, MCL 333.24510, the department may, at its discretion, consult any external database
described under section 24510(2) of the act, MCL 333.24510, without regard to whether a
carrier made the database accessible to the department or whether the database otherwise
meets the requirements under subrule (1) of this rule.
SUCH
DATABASE
SHALL
BE
NATIONALLY
RECOGNIZED,
GEOGRAPHICALLY ADJUSTED AND SPECIALTY SPECIFIC, SORTED BY
GEOGRAPHIC ALLOWABLE PAYMENT PERCENTILES, PROCURED BY A NOT-
FOR-PROFIT ENTITY, WHICH IS NOT AFFILIATED, EITHER DIRECTLY OR
INDIRECTLY, WITH AN INSURANCE CARRIER OR HEALTH. BENEFIT PLAN.
(3) A carrier’s provision of access to a database under this rule does not preclude
the department from requesting additional documents, materials, or other information that the
department determines is necessary for conducting a review under section 24510 of the act,
MCL 333.24510.
R 500.245 Approval of arbitrators.
Rule 5. (1) The department shall create and maintain a list of arbitrators trained by the
American Arbitration Association or American Health Lawyers Association WHO POSSESS
KNOWLEDGE OF MEDICAL REIMBURSEMENT AND EXPERIENCE IN THE USE OF
MEDICAL TERMINOLOGY AND MEDICAL CODING, INCLUDING BUT NOT
LIMITED TO THE INTERNATIONAL CLASSIFICATION OF DISEASE, TENTH
EDITION (ICD-10), AND THE AMERICAN MEDICAL ASSOCIATION’S COMMON
PROCEDURE TERMINOLOGY (CPT) AND WHO SHALL BE approved by the director.
TH/AF/JK 2-2-21