604. Criteria for determining a reasonable fee. In determining the appropriate amount to pay for a health care service, an independent dispute resolution entity shall consider all relevant factors, including:
(a) whether there is a gross disparity between the fee charged by the physician for services rendered as compared to:
(1) fees paid to the involved physician for the same services rendered by the physician to other patients in health care plans in which the physician is not participating, and
(2) in the case of a dispute involving a health care plan, fees paid by the health care plan to reimburse similarly qualified physicians for the same services in the same region who are not participating with the health care plan;
(b) the level of training, education and experience of the physician;
(c) the physician's usual charge for comparable services with regard to patients in health care plans in which the physician is not participating;
(d) the circumstances and complexity of the particular case, including time and place of the service;
(e) individual patient characteristics; and
(f) the usual and customary cost of the service.
Last modified: February 3, 2019