47:03:05:05. Reimbursement criteria. To be reimbursed, the charge must be for reasonable and necessary services for the cure or relief of the effects of a compensable injury or disability. A health care provider is not entitled to payment from an insurer or employee for fees in excess of the maximum reimbursement allowed under this chapter.
Except as otherwise provided in this chapter, to determine the maximum reimbursement for services, the base unit value for a procedure code is multiplied by the following factors:
Procedure Code Factor
10000-69999 $100.80
70000-79999 $ 19.07
80000-89999 $ 15.28
90000-95906 $ 6.57
95907-95913 $ 8.39
95914-97150 $ 6.57
97161 $ 21.11
97162 $ 13.20
97163 $ 6.61
97164 $ 15.08
97165 $ 21.11
97166 $ 13.20
97167 $ 6.61
97168 $ 15.08
97169-99071 $ 6.57
99075 $ 14.37 1st hour, $1.78 each additional 15 min
99076-99199 $ 6.57
99201-99450 $ 8.00
99455-99456 $ 19.33 1st hour, $2.41 each additional 15 min
99460-99499 $ 8.00
99500-99607 $ 6.57
If a code is properly submitted for one of these services, but is not listed in Relative Values for Physicians, or the base unit value is RNE or BR, the reimbursement is 80% of the provider's charge.
Source: 21 SDR 67, effective October 13, 1994; 23 SDR 23, effective August 22, 1996; 38 SDR 105, effective December 12, 2011; 39 SDR 100, effective December 6, 2012; 39 SDR 219, effective June 26, 2013; 42 SDR 177, effective June 28, 2016; 43 SDR 181, effective July 7, 2017; 44 SDR 185, effective June 25, 2018; 47 SDR 42, effective October 14, 2020.
General Authority: SDCL 62-7-8.
Law Implemented: SDCL 62-7-8.
Cross-Reference: Properly submitted medical bill, § 47:03:09:01.
Reference: Relative Values for Physicians, Relative Value Studies, Inc., 2020, published by Optum360, LLC. Copies may be obtained from Optum360, LLC, PO Box 88050, Chicago, IL 60680-9920. Cost $329.95.
