Maximum allowable rate setting

• The maximum allowable reimbursement rates described on this page are specific for services directly billed to DMAP.
• The rates and rate setting processes described on this page do not apply to managed care reimbursements. For information about the managed care rate setting process, go to the DHS Actuarial Services Web 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, 2008, all CPT/HCPCS codes assigned a Relative Value Unit (RVU) weight assignment use the 2007 Fully Implemented Non-Facility Total RVU weights published in the Federal Register Vol. 71, dated Dec.1, 2006. If this weight was a significant change from the previous year’s RVU total, then the transitional year RVU Total was adopted.

• Labor and delivery services (59400-59622) have a base rate of $40.20.
• CPT codes 92340-92342 and 92352-92353 have a flat rate of $25.90.
• All remaining RVU weight based CPT/HCPCS codes have a base rate of $26.88.

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

DMAP pays non-RVU weight based lab procedures at 97% of 62% of Medicare’s rates or as minimally required by Medicare. DMAP prices other non-RVU lab services based on the Centers for Medicare and Medicaid Services mandates.

Ambulatory Surgical Center

DMAP prices all approved Ambulatory Surgical Center (ASC) procedures using Medicare’s Group assignment for each surgical procedure.

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 not ASP 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.