47:03:05:05Reimbursement criteria.

To be eligible for reimbursement, a charge must be for reasonable and necessary medical services. A health care provider is not entitled to payment from an insurer or employee for fees that exceed 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 minute 99076-99199 $ 6.57 99201-99450 $ 12.00 99455-99456 $ 19.33 1st hour, $2.41 each additional 15 minute 99460-99499 $ 12.00 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 considered Relativity Not Established (RNE) or By Report (BR) in Relative Values for Physicians, the reimbursement is eighty percent of the provider's charge. For purposes of this section, "health care provider" means a person or entity providing medical services, dental services, or treatment to an employee for a compensable injury or disability.

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; 52 SDR 48, effective November 17, 2025.