Maximum allowable rate setting

• The maximum allowable reimbursement rates described on this page are specific for services directly billed to DMAP.
• For information about the managed care rate setting process, go to the OHP Capitation Rate and Cost Reports page at this link.
• DMAP bases all reimbursement on client eligibility and DMAP covered services. For more information, refer to DMAP's General Rules and OHP administrative rulebooks.

Procedure codes used for billing

For billing purposes, DMAP uses Current Procedural Terminology (CPT), Level III National Codes (HCPCS) and Current Dental Terminology (CDT) procedure codes. DMAP does not cover all valid codes, and DMAP may not allow covered codes in all settings.

DMAP expects providers to bill their usual and customary charges unless otherwise specified in the rules for a specific provider program; for example, DMAP pays for some services at acquisition costs only.

Relative Value Unit assigned codes

Effective Jan. 1, 2010, most CPT/HCPCS codes assigned a Relative Value Unit (RVU) weight assignment use the 2009 Transitional Non-Facility Total RVU weights published in the Federal Register Vol. 73, dated Dec. 31, 2008. The Transitional Facility Total RVU weights are used for professional services typically performed in a facility.

• Labor and delivery services (59400-59622) have a base rate of $41.61.
• CPT codes 92340-92342 and 92352-92353 have a flat rate of $26.81.
• All remaining RVU weight based CPT/HCPCS codes have a base rate of $27.82.

To get the RVU-based rate, multiply the base rate by the RVU weight. You can download the Transitional Non-Facility RVU weights at www.cms.hhs.gov/PhysicianFeeSched as follows:

• Select "PFS Relative Value Files." Scroll down and go to "2009."
• Select the "RVU09AR folder. Unzip it and select "PPRRVU09."
• The Transitional Nonfacility Total is in Column P.

Medicare will delete some consult codes for 2010. However, DMAP adopts the 2009 Medicare RVU values and will accept these codes during 2010 for services provided to clients who do not have Medicare as their primary coverage. The consult codes removed from Medicare 2010 RVU tables should not be used to bill Medicare.

Surgical assist

DMAP reimburses surgical assists at 20% of the surgical rate.

Anesthesia services

Anesthesia services (00100-01996) have a base rate of $24.19, based on per unit of service.

Non-RVU weight-based lab

Clinical lab codes are priced based upon the Centers for Medicare and Medicaid Services (CMS) mandates. Rates for other non-RVU weight-based lab services vary by code and are generally between 62% to 97% of Medicare's rates.

Ambulatory Surgical Center

Effective Jan. 1, 2010, DMAP prices all approved Ambulatory Surgical Center (ASC) procedures at 80% of Medicare's 2009 fee schedule.

Drugs assigned a HCPCS code

For physician-administered drugs billed under a HCPCS code, DMAP bases maximum allowable reimbursement on Medicare's Average Sale Price (ASP), when available. When no ASP rate is available, DMAP bases reimbursement on Average Wholesale Price (AWP) information provided by First Data Bank. These rates may change periodically based on drug costs.

Vision materials and supplies

For all procedures used for vision materials and supplies, DMAP bases reimbursement on contracted rates, which include acquisition cost plus shipping and handling.

All other codes

For all other codes not defined in this list, DMAP prices manually. DMAP's manual pricing factors a variety of conditions into how a rate is determined, such as access issues, legislative direction, and provider input of actual costs and negotiated rates.