BASIC (09-06)

A. Policy

DDSs will conduct periodic reviews of its CE fee schedules to ensure fees do not exceed the maximum payment rates. DDSs should fully document the methodology for establishing and updating its payment rates for medical services.

B. Procedure – maintaining fee schedules

• Submit to the RO a copy of the DDS fee schedule.

• Submit to the RO on a flow basis copies of changes to an existing fee schedule with any issuances and instructions pertinent to their application. If only portions or specific items were changed, submit only those changes. Allow sufficient time for RO review before implementing any changes.

• Review the DDS fee schedule with the RO on a regular basis to determine whether the fee schedule is adequate and cost effective.

• If the DDS uses a Federal fee schedule or a fee schedule used by another agency in that State, ensure that any changes to that fee schedule are reflected, when appropriate, in the rates paid by the DDS.

C. Procedure – monitoring fee schedules

• DDS case processing/fiscal system should be programmed to ensure that all payments authorized are consistent with the fee schedule or any approved exemptions to the fee schedule. In addition, DDSs will conduct periodic sample checks, when possible, to ensure payments to providers are consistent with the fee schedule.

• DDSs should have internal controls in place to ensure that it has received all medical evidence for which it has made payment. DDSs will check medical source reimbursements on a random basis, when possible, to determine if there is corresponding and appropriate evidence in the claims file and an indication of its receipt in the DDS, such as an annotation on a control sheet. DDSs will investigate any incidence of missing evidence and take action to review the basis for the disability determination.