<?xml version='1.0' encoding='utf-8'?>
<regulation prefix="Regulation" num=".04" citation="COMAR 14.09.08.04" title_num="14" subtitle_num="09" chapter_num="08" heading="MRA or Fee Not Established.">
  <paragraph num="A.">
    <text>The Commission has not established a medical fee schedule for dental services, durable medical equipment, and pharmaceuticals.</text>
  </paragraph>
  <paragraph num="B.">
    <text>For products and services for which the Commission has not established an MRA or medical fee schedule, including dental services, durable medical equipment, and pharmaceuticals, the insurance carrier shall assign a relative value to the product or service.</text>
  </paragraph>
  <paragraph num="C.">
    <text>An insurance carrier may base the assigned value on nationally recognized and published relative value studies, or on the values assigned for services involving similar work and resources.</text>
  </paragraph>
  <paragraph num="D.">
    <text>Upon application of either party, the amount of reimbursement is subject to review by the Commission under the procedures set forth in Regulation .06 of this chapter.</text>
  </paragraph>
  <paragraph num="E.">
    <text>Reimbursement.</text>
    <paragraph num="(1)">
      <text>Except as provided in §E(2) of this regulation, reimbursement shall be the lesser of:</text>
      <paragraph num="(a)">
        <text>The MRA amount as established by this regulation; or</text>
      </paragraph>
      <paragraph num="(b)">
        <text>The authorized provider's usual and customary charge.</text>
      </paragraph>
    </paragraph>
    <paragraph num="(2)">
      <text>If, in the opinion of a health care provider it is medically necessary to exceed the MRA, the authorized provider shall submit substantiating documentation to the payor with the Form CMS-1500.</text>
    </paragraph>
  </paragraph>
  <paragraph num="F.">
    <text>For relevant CPT/HCPCS level I codes that are not valued by CMS, the Commission shall post MRAs for those codes on its website.</text>
  </paragraph>
</regulation>