§ 604 — Criteria for determining a reasonable fee

§ 604. Criteria for determining a reasonable fee. In determining the\nappropriate amount to pay for a health care service, an independent\ndispute resolution entity shall consider all relevant factors,\nincluding:\n (a) whether there is a gross disparity between the fee charged by the\nprovider for services rendered as compared to:\n (1) fees paid to the involved provider for the same services rendered\nby the provider to other patients in health care plans in which the\nprovider is not participating, and\n (2) in the case of a dispute involving a health care plan, fees paid\nby the health care plan to reimburse similarly qualified providers for\nthe same services in the same region who are not participating with the\nhealth care plan;\n (b) the level of training, education and experience of the health care\nprofessional, and in the case of a hospital, the teaching staff, scope\nof services and case mix;\n (c) the provider's usual charge for comparable services with regard to\npatients in health care plans in which the provider is not\nparticipating;\n (d) the circumstances and complexity of the particular case, including\ntime and place of the service;\n (e) individual patient characteristics;\n (f) the median of the rate recognized by the health care plan to\nreimburse similarly qualified providers for the same or similar services\nin the same region that are participating with the health care plan; and\n (g) with regard to physician services, the usual and customary cost of\nthe service.\n