Hospital-based physicians will be reimbursed under the same general system as is used in Medicare. Bills for services rendered will be submitted as follows:

1. (1) All hospital-based physicians, including emergency room physicians, radiologists, and pathologists, shall bill the Medicaid program on a CMS-1500, Health Insurance Claim form or assign their billing rights to the hospital, which shall bill the Medicaid program on a CMS-1500 (Health Insurance Claim) form.

   1. (a) Physician services personally rendered for individual patients will be paid only on a reasonable charge basis (i.e., claims submitted under an individual provider number on a physician claim form). This includes services provided by a radiologist and/or pathologist.
   2. (b) Reasonable charge services are: a.) personally furnished for a patient by a physician; b.) ordinarily require performance by a physician; and c.) contribute to the diagnosis or treatment of an individual patient.
2. (2) Services of hospital-based physicians that do not meet the criteria of reasonable charge as defined above, but benefit a hospital or its patient are reimbursable only on a reasonable cost basis through the hospital cost report. Please refer to laboratory, Radiology, and Hospital Chapters of this Code for further details.

Author: Desiree Nelson; Program Manager; Medical Support

Statutory Authority: Title XIX, Social Security Act; 42 C.F.R. §§405.401, et seq.; State Plan.

History: Rule effective October 1, 1982. Emergency rule effective October 1, 1984; January 8, 1985. Amended effective March 12, 1987. Amended: Filed December 7, 1994; effective January 12, 1995. Amended: Filed May 11, 2012; effective June 15, 2012.