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(1) These requirements are in addition to those rule provisions generally applicable to Medicaid providers.

(2) The department or its designated review organization may conduct utilization and peer review of physician services.

(3) Physician services for conditions or ailments that are generally considered cosmetic in nature are not a benefit of the Medicaid program except in such cases where it can be demonstrated that the physical and psycho-social well being of the recipient is severely affected in a detrimental manner by the condition or ailment. Such services must be prior authorized by the Medicaid services bureau, based on recommendations of the designated peer review organization.

(a) A request for prior authorization must include all relevant information to justify the need for the service. This information includes statements from a physician qualified in the area of concern and a potential provider.

(b) The information must clearly document the necessity for the service and include assurances that the plan will be followed to completion.

(4) Coverage of physician services for sterilization is limited as follows:

(a) The recipient to be sterilized must not be declared mentally incompetent by a federal, state, or local court of law.

(b) The recipient to be sterilized must be 21 years of age or older at the time informed consent to sterilization is obtained from the recipient.

(c) The recipient to be sterilized must not be institutionalized in a corrective, penal, mental, or rehabilitative facility.

(5) Physician services for sterilization must meet the following requirements in order to receive Medicaid reimbursement:

(a) The recipient to be sterilized must give informed consent, in accordance with the Medicaid approved informed consent to sterilization form, not less than 30 days nor more than 180 days prior to sterilization except in the case of premature delivery or emergency abdominal surgery. For these exceptions, at least 72 hours must pass between informed consent and the sterilization procedure. In cases of premature delivery, informed consent must be given at least 30 days before the expected delivery date.

(b) The recipient to be sterilized, the person who obtained the consent, and the interpreter (if required) must sign the informed consent form at least 30 days but not more than 180 days prior to the sterilization. The physician performing the sterilization must sign and date the informed consent form after the sterilization has been performed.

(c) A copy of the informed consent to sterilization form must be attached to the Medicaid claim when billing for sterilization procedures.

(6) Coverage of physician services for hysterectomies is limited as follows:

(a) The surgery must not be solely for the purpose of rendering the recipient incapable of reproducing; and

(b) The surgery must be medically necessary to treat injury or pathology.

(7) Physician services for hysterectomies must meet the following requirements in order to receive Medicaid reimbursement:

(a) The physician must inform the recipient that the hysterectomy will render her permanently incapable of reproducing;

(b) A completed copy of the approved acknowledgment of receipt of hysterectomy information form must be attached to the Medicaid claim when billing for hysterectomy services;

(c) In a case where the recipient is sterile before the hysterectomy or there is a life-threatening emergency that precludes the recipient from giving prior acknowledgment of receipt of hysterectomy information, the requirements in (7)(a) and (7)(b) do not apply. Instead, the physician who performed the hysterectomy either:

(i) must certify in writing that the recipient was sterile before the hysterectomy and state the cause of sterility; or

(ii) must certify in writing that the hysterectomy was performed during a life-threatening emergency situation that precluded the recipient from giving prior acknowledgment of receipt of hysterectomy information and gives a description of the nature of the emergency.

(8) Coverage of physician services for abortions is limited as follows:

(a) the life of the mother will be endangered if the fetus is carried to term;

(b) the pregnancy is the result of an act of rape or incest; or

(c) to the extent required by statute, when an abortion is a medically necessary service, even if the abortion does not meet the standard in (8)(a) and (9).

(9) Physician services for abortions, in a case of endangerment of the mother's life, must meet the following requirements in order to receive Medicaid reimbursement:

(a) The physician must find, and certify in writing, that in the physician's professional judgement, the life of the mother will be endangered if the fetus is carried to term. The certification must contain the name and address of the patient and must be on or attached to the Medicaid claim.

(10) Physician services for abortions in cases of pregnancy resulting from an act of rape or incest must meet the following requirements in order to receive Medicaid reimbursement:

(a) the recipient certifies in writing that the pregnancy resulted from an act of rape or incest; and

(b) the physician certifies in writing either that:

(i) the recipient has stated to the physician that she reported the rape or incest to a law enforcement or protective services agency having jurisdiction over the matter, or if the recipient is a child enrolled in a school, to a school counselor; or

(ii) in the physician's professional opinion, the recipient was and is unable for physical or psychological reasons to report the act of rape or incest.

(11) Abortion is a medically necessary service and eligible for coverage under the Montana Medicaid program when:

(a) a woman suffers from a physical disorder, physical injury, or physical illness, including a life-endangering physical condition caused by or arising from the pregnancy itself, that would, as certified by a physician, place the woman in danger of death unless an abortion is performed; or

(b) although it does not place the woman in danger of death unless an abortion is performed, a woman suffers from:

(i) a physical condition that would, as certified by a physician, be significantly aggravated by the pregnancy; or

(ii) a psychological condition that would, as certified by a physician, be significantly aggravated by the pregnancy.

(12) Physician services for abortions require prior authorization. If prior authorization is not obtained, due to an emergency situation or otherwise, a claim for payment for such physician services will undergo post-service, prepayment review. The request for prior authorization or the claim for payment must be accompanied by a completed and signed Physician Certification for Abortion Services Form (MA-037 form).

(13) Supporting documentation must be submitted for abortions covered under (8)(a) or (c). The following documentation must be submitted with the prior authorization request or with any claim for payment for which prior authorization was not received to support the determination of medical necessity:

(a) History and Physical, which should include (at a minimum) as it relates to the pregnancy:

(i) medical history, including age, current medications and allergies, number of times the patient has been pregnant and number of times she has had a live birth, last menstrual period, status and results of any pregnancy test, allergies, chronic illnesses, surgeries, behavioral health issues, smoking, substance abuse, and obstetric history;

(ii) brief review of systems to identify symptoms a patient may be experiencing;

(iii) the results of a physical examination, including vital signs, heart, lungs, abdomen, extremities, and estimate of gestational age (if imaging is not available);

(iv) results of laboratory tests (if available), including Rh factor, Hemoglobin, and Human Chorionic Gonadotropin;

(v) imaging (if available), to estimate gestational age;

(vi) documentation that the diagnosis of the physical or psychological condition leading to the medical necessity determination has been made by a medical professional qualified by education, training, and/or experience to make such diagnosis and that the woman is receiving care for such condition;

(vii) reason for the abortion procedure;

(viii) for medication/chemical abortions, documentation confirming review of contraindications, adequate patient education, and compliance with the requirements of the Physician-Related Services Manual;

(ix) treatment plan; and

(x) signed informed consent for the proposed abortion procedure.

(14) Physician services for abortions must be performed by a physician as defined in 37-3-102, MCA.

(15) Prior authorization is not required for treatments for incomplete abortions, miscarriages, or septic abortions.

(16) Physician services for routine podiatric care and orthotics must be in accord with the definitions of ARM 37.86.501 and meet the requirements of ARM 37.86.505.

(17) The department adopts and incorporates by reference the Physician-Related Services Manual governing the administration of the Physician program dated December 1, 2017. The Physician-Related Services Manual is available for public viewing at the Department of Public Health and Human Services, Health Resources Division, 1400 Broadway, P.O. Box 202951, Helena, MT 59620-2951 and at the department's web site at http://medicaidprovider.mt.gov.

(1) Providers must bill for services using the procedure codes and modifiers set forth, and according to the definitions contained, in the Centers for Medicare and Medicaid Services' (CMS) Healthcare Common Procedure Coding System (HCPCS). Information regarding billing codes, modifiers, and HCPCS is available upon request from the Health Resources Division at the address stated in ARM 37.86.101(3).

(2) Reimbursement for physician services, except as otherwise provided in this rule, is the lower of:

(a) the provider's usual and customary charges (billed charges); or

(b) the department's fee schedule maintained in accordance with the methodologies described in ARM 37.85.212.

(3) Reimbursement for services of a psychiatrist, except as otherwise provided in this rule, is the lower of:

(a) the provider's usual and customary charges (billed charges); or

(b) to address problems of access to mental health services, subject to funding, mental health services performed by a psychiatrist are reimbursed using a provider rate of reimbursement which is a percentage of the reimbursement for physicians provided in accordance with the methodologies described in ARM 37.85.212. The effective date and percentage are as provided in ARM 37.85.105(2).

(4) Reimbursement to physicians for physician-administered drugs billed under HCPCS "A", "J", "Q", or "S" codes will be paid according to the department's fee schedule or the provider's usual and customary charge, whichever is lower. The department's fee schedule is updated at least annually based upon:

(a) the effective date and citation for the Medicare Average Sale Price (ASP) as provided in ARM 37.85.105(2);

(b) the RBRVS fee as defined in ARM 37.85.212 if there is an RBRVS fee;

(d) the Medicaid fee as determined in (9).

(5) Physician administered compound drugs must be billed with the associated HCPCS; an invoice is required to be attached. The invoice must list each ingredient in the compound with the associated NDCs, and the quantity of each ingredient. Physician administered compound drugs are paid by invoice.

(6) The maximum allowable cost limitation does not apply in those cases where the physician certifies in their own handwriting that in their medical judgment a specific brand name drug is medically necessary for a particular patient. Acceptable certification statements are "brand necessary" or "brand required." A check-off box on a form or a rubber stamp is not acceptable.

(7) Reimbursement rates for adult and children vaccines are extracted from the Private/Sector Cost/Dose fee schedule maintained by the Center for Disease Control (CDC). Private sector vaccine pricing are reported by vaccine manufacturers annually to the CDC.

(8) A Medicaid fee for services without fees is determined for physician services and anesthesia services as defined at ARM 37.85.212 and licensed direct-entry midwife services as defined at ARM 37.86.1201.

(a) The Medicaid fee is determined for procedure codes:

(i) that are new, less than one year in existence;

(ii) that have no or low utilization;

(iii) that have inconsistent charges by reviewing cost information for the service if available; or

(iv) by reviewing the reimbursement of similar services if cost information is not available.

(b) Otherwise, the Medicaid fee in this section is determined by multiplying the average charge for the service by the payment-to-charge ratio.

(9) Claims for child delivery must have one of the following line procedure code modifiers or the line will be denied:

(a) CG-cesarean section/induction prior to 39 weeks;

(b) GK-spontaneous vaginal delivery prior to 39 weeks (noninduced);

(d) SC - cesarean section at or after 39 weeks.

(10) The maternity policy adjustor is not applied to early elective delivery.

(11) Gestational age must be determined and documented in medical records. The department accepts the following American Congress of Obstetricians and Gynecologists guidelines for determining gestational age:

(a) fetal heart tones documented for 20 weeks by nonelectronic fetoscope or 30 weeks by Doppler;

(b) a positive serum or urine pregnancy test by a reliable laboratory at least 36 weeks prior to delivery;

(d) when pregnancy care is not initiated within 20 weeks of gestation, the gestational age may be documented from the first day of the last menstrual period (LMP).

(1) Application forms and information regarding eligibility for the plan are available at all local county human services departments.

(2) The applicant must submit with the application form a completed and signed income statement and the necessary documentation to verify the income reported.

(3) For purposes of (2), necessary income verification may include one or more of the following or other appropriate and persuasive documentation:

(a) pay stubs or other pay statements;

(b) employee's W-2 forms;

(d) union records;

(e) check copies;

(f) self-employment bookkeeping records;

(g) sales and expenditure records;

(h) employer's wage or payroll records;

(i) award notices or award letters;

(j) correspondence specifying a benefit;

(k) records of any government payer;

(l) court records or correspondence from attorneys;

(m) financial institution records;

(n) insurance company correspondence or records; or

(o) college or university financial aid correspondence or records.

(1) Eligibility determinations under ARM 37.89.106 are effective until the earlier of:

(a) one year; or

(b) the effective date of any redetermination.

(2) The department may redetermine eligibility at any time.

(a) Eligibility must be redetermined within one year after the most recent determination or sooner based upon changes in income, family composition or the federal poverty level. Members may be required to submit completed forms and verification by a specified date for purposes of eligibility redetermination.

(b) Members must give notice of any change in total family income or family composition within 30 days of the change. Failure to give notice will be grounds for termination of eligibility until such time as complete and accurate income and family composition information is provided.

(c) Termination of eligibility, based upon a change in the federal poverty level, income or family composition, may not be effective earlier than ten days after mailing of written notice of termination to the member.

(d) An individual is liable to the department and the department may collect from the individual the amount of actual payments by the department or its agents to providers for any services furnished to the individual because of misrepresentation of income or a failure to give the required notice of changes in income or family composition.

(1) A nonmember receiving covered emergency mental health services, which do not include hospital emergency room or other hospital services, is eligible on an emergency basis for the plan and may receive covered medically necessary services for a covered diagnosis unless the provider determines that the individual has the means, financially or otherwise, by which to make payment. If the individual is subsequently determined ineligible for the plan or fails to complete an application for plan eligibility within 60 days following completion of emergency treatment, the individual is liable for and may be billed by the provider at its usual and customary (billed charges) private pay charges or by the department for the amount of payments actually made by the department or its agents to the provider for the services provided.

(1) ARM 37.86.202 and 37.86.205 provide the requirements for Medicaid coverage of mid-level practitioner services. The requirements in these rules are in addition to those contained in ARM 37.85.401 through 37.85.414.

For the purpose of these rules, the following definitions will apply:

(1) "Advanced practice registered nurse" means a registered professional nurse licensed as provided in Title 37, chapter 8, MCA and ARM Title 24, chapter 159, subchapter 14 and includes nurse practitioner, nurse anesthetist, and nurse midwife and clinical nurse specialist.

(2) "Clinical nurse specialist" means a person who is licensed in accord with 37-8-405 through 37-8-407, MCA and ARM 24.159.1412, 24.159.1413, 24.159.1414, and 24.159.1485.

(3) "Delivery services" means services necessary to protect the health and safety of the woman and fetus from the onset of labor through delivery.

(4) "Early elective delivery" means either a nonmedically necessary labor induction or cesarean section that is performed prior to 39 weeks and 0/7 days gestation.

(5) "Independent employment status" means that a separate federal tax identification number is obtained for the mid-level practitioner and the billed services are not provided in the course of the mid-level practitioner's employment by or contract with a physician, hospital, or ambulatory surgical center.

(6) "Mid-level practitioner" means the following professionals:

(a) advanced practice registered nurse; and

(b) physician assistant.

(7) "Mid-level practitioner services" means those services provided by mid-level practitioners in accord with the laws and rules defining and governing through licensing and certification the practices of advanced practice registered nurses and physician assistants.

(8) "Nurse anesthetist" means a person who is licensed in accord with 37-8-405 through 37-8-407, MCA and ARM 24.159.1412, 24.159.1413, 24.159.1414, and 24.159.1480.

(9) "Nurse midwife" means a person who is licensed in accord with 37-8-405 through 37-8-407, 37-8-409, MCA and ARM 24.159.1412, 24.159.1413, 24.159.1414, and 24.159.1475.

(10) "Nurse practitioner" means a person who is licensed in accord with 37-8-405 through 37-8-407, MCA and ARM 24.159.1412, 24.159.1413, 24.159.1414, and 24.159.1470.

(11) "Physician assistant" means a person who is licensed as provided in Title 37, chapter 20, MCA and ARM Title 24, chapter 159, subchapter 14.

(12) "Postpartum services" means services rendered to a woman during the 60-day period following the delivery for any health conditions or complications that are pregnancy-related.

(13) "Pregnancy-related services" means services for the treatment of conditions or complications that exist or are exacerbated because of pregnancy.

(14) "Prenatal services" means services directed at protecting and insuring the health of the woman and the fetus during pregnancy.

(15) The definitions found in the introduction to Physicians Current Procedural Terminology, fourth edition (CPT4), published by the American Medical Association of Chicago, Illinois and adopted at ARM 37.86.101 set forth meanings of terms commonly used by the Montana Medicaid program in implementation of the program's mid-level practitioner fee schedule.

(16) The "Physician-Related Services Manual" means the physician-related services manual adopted at ARM 37.86.101. It governs the administration of the mid-level practitioner program.

(1) These requirements are in addition to those rule provisions generally applicable to Medicaid providers.

(2) Medicaid coverage of mid-level practitioner services is available according to the requirements and procedures specified for physicians under ARM 37.86.101, 37.86.104, and 37.86.105.

(3) Mid-level practitioner services must be medically necessary as defined in ARM 37.82.102 and 37.85.410.

(4) Coverage of mid-level practitioner services is limited to the provision of services by the following providers:

(a) mid-level practitioners who are considered to have an independent employment status;

(b) hospitals employing or contracting with certified registered nurse anesthetists if:

(i) the Secretary of Health and Human Services has not granted the hospital authorization for continuation of cost pass-through under section 9320 of the Omnibus Budget Reconciliation Act of 1986, as amended by section 608(c) of the Family Support Act of 1988 (Public Law 100-485);

(ii) the hospital obtains from the department or its fiscal agent a provider number for certified registered nurse anesthetist services; and

(iii) the hospital bills for services on form CMS 1500 or CMS 837P electronic transaction.

(c) physicians, ambulatory surgical centers, diagnostic centers or public health departments, employing or contracting with mid-level practitioners if:

(i) the physician or the provider entity obtains from the department or its fiscal agent a provider number for the mid-level practitioner; and

(ii) the physician or the provider entity bills for services on form CMS 1500 or CMS 837P electronic transaction.

(5) Reimbursement for services, except as otherwise provided in this rule, is the lower of:

(a) usual and customary charges; or

(b) a provider rate of reimbursement which is a percentage of the reimbursement for physicians provided in accordance with the methodologies described in ARM 37.85.212 and 37.86.105. The effective date and percentage is as provided in ARM 37.85.105(2).

(6) Reimbursement for immunizations, drugs which are billed under associated HCPCS codes, family planning services, administration of injectables, radiology, laboratory and pathology, cardiography and echocardiography services, and for clients under 21 years of age is the lower of:

(a) usual and customary charges; or

(b) 100% of the reimbursement for physicians provided in accordance with the methodologies described in ARM 37.85.212 and 37.86.105.

(7) The following services are not covered by Medicaid as mid-level practitioner services:

(a) educational visits and educational materials (including group settings);

(b) mileage and travel expenses;

(d) preparation of special medical or insurance reports;

(e) consultations with other mid-level practitioners;

(f) delivery services not provided in a licensed health care facility unless provided in an emergency situation; and

(g) drug dispensing fees.

(8) Claims for child delivery must have one of the following line procedure code modifiers or the line will be denied:

(a) CG-cesarean section/induction prior to 39 weeks;

(b) GK–spontaneous vaginal delivery prior to 39 weeks (noninduced);

(d) SC–cesarean section at or after 39 weeks.

(9) The maternity policy adjustor is not applied to early elective delivery.

(10) Gestational age must be determined and documented in medical records. The department accepts the following American Congress of Obstetricians and Gynecologists guidelines for determining gestational age:

(a) fetal heart tones documented for 20 weeks by nonelectronic fetoscope or 30 weeks by Doppler;

(b) a positive serum or urine pregnancy test by a reliable laboratory at least 36 weeks prior to delivery;

(d) when pregnancy care was not initiated within 20 weeks gestation, the gestational age may be documented from the first day of the last menstrual period (LMP).

(1) "Orthotic" means a mechanical device to assist in restoring normal function of the foot, applied to the foot or used with the shoe either as an insert for the shoe or as an attachment to the exterior of the shoe.

(2) "Podiatry services" means those services provided by individuals licensed under state law to practice podiatry which are within the scope of their practice.

(3) "Routine podiatric care" means the cutting or removing of corns and calluses, the trimming of nails or the application of skin creams and other hygienic, preventive maintenance care and debridement of nails.

(4) The definitions found in the introduction to Physicians Current Procedural Terminology, fourth edition (CPT4), published by the American Medical Association of Chicago, Illinois and adopted at ARM 37.86.101 defines the terms commonly used by the Montana Medicaid program in implementation of the program's podiatry fee schedule.

(5) The "Physician-Related Services Manual" means the physician-related services manual adopted at ARM 37.86.101. It governs the administration of the Podiatry program.

(1) These requirements are in addition to those rule provisions generally applicable to Medicaid providers.

(2) The department or its designated review organization may conduct utilization and peer review of podiatry services.

(1) Reimbursement for podiatry services is in accordance with the methodologies described in ARM 37.85.212 and 37.86.105.

In ARM 37.86.601, 37.86.605, 37.86.606, and 37.86.610, the following definitions apply:

(1) "Assistant/aide" means an assistant, aide or other person authorized under and practicing in accordance with the applicable provisions of Title 37, MCA, who subject to supervision required by law, assists in the provision of a therapy service.

(2) "Condition" means an illness, injury, disorder, or disability.

(3) "Habilitative care" means services provided when a member requires help to maintain, learn, or improve skills and functioning for daily living, or to prevent deterioration. These services include: physical therapy, occupational therapy, speech-language pathology, and behavioral health professional treatment. Applied behavior analysis (ABA) for adults is excluded. Habilitative services are reimbursable if a licensed therapist is needed and the service must be provided by a licensed therapist. Services may be provided in a variety of inpatient and outpatient settings as prescribed by a physician or mid-level practitioner.

(4) "Licensed therapist" means a physical therapist, speech-language pathologist, or occupational therapist licensed under the applicable provisions of Title 37, MCA to practice the particular category of therapy services provided, but does not include an assistant, aide, or other person whose authority to perform services is restricted to working under the supervision of another.

(5) "Maintenance therapy" means repetitive therapy services that are required to maintain functions, that are performed without reasonable expectation of significant progress and that do not involve complex and sophisticated therapy services requiring the judgment or skill of a licensed therapist.

(6) "Mid-level practitioner" means an advanced practice registered nurse or a physician assistant as defined in ARM 37.86.202.

(7) "Occupational therapy services" means occupational therapy services as defined in 37-24-103, MCA. For purposes of ARM 37.86.601, 37.86.605, 37.86.606, 37.86.610, 46.12.526, and 46.12.529, occupational therapy services do not include services provided by a hospital or home health agency.

(8) "Physical therapy services" means physical therapy services as defined in 37-11-101, MCA. For purposes of ARM 37.86.601, 37.86.605, 37.86.606, 37.86.610, 46.12.526, and through 46.12.529, physical therapy services do not include services provided by a hospital or home health agency.

(9) "Rehabilitative care" means services provided when a member needs help to keep, get back, or improve skills and functioning for daily living that have been lost or impaired because a member was sick, hurt, or disabled. Rehabilitative services include: physical therapy, occupational therapy, speech-language pathology, and behavioral health professional treatment. Applied behavioral analysis (ABA) for adults is excluded. Rehabilitative services are reimbursable if a licensed therapist is needed and the service must be provided by a licensed therapist. Services may be provided in a variety of inpatient and outpatient settings as prescribed by a physician or mid-level practitioner.

(10) "Restorative therapy" means therapy services that are performed with a reasonable expectation that the recipient's function will improve significantly in a reasonable and predictable period of time, based upon an assessment of the recipient's restoration potential made by a physician or mid-level practitioner in consultation, with the licensed therapist. Therapy services are not restorative therapy if the recipient's expected restoration potential would be insignificant in relation to the extent and duration of services required. Therapy services are no longer restorative therapy if at any time after commencement of treatment it is determined that the reasonable expectation of significant improvement in function will not materialize.

(11) "Speech therapy services" means the practice of speech-language pathology as defined in 37-15-102, MCA. For purposes of ARM 37.86.601, 37.86.605, 37.86.606, 37.86.610, and 46.12.529, speech therapy services do not include services provided by a hospital or home health agency.

(12) "Therapy services" or "therapies" means speech therapy services, occupational therapy services and physical therapy services.

(1) These requirements are in addition to those contained in rule provisions generally applicable to Medicaid providers.

(2) As a condition of participation in the Montana Medicaid program, a therapist must:

(a) maintain a current license issued by the applicable Montana licensing board for the category of therapy being provided, or, if the provider is serving recipients outside the state of Montana, maintain a current license in the equivalent category under the laws of the state in which the services are provided;

(b) enter into and maintain a current provider enrollment form under the provisions of ARM 37.85.402 with the department's fiscal agent to provide the category of therapy services being provided.

(3) An assistant/aide may not enroll as a provider.

(1) The requirements and restrictions in this rule apply for purposes of coverage and reimbursement of therapy services under the Montana Medicaid program.

(2) Except as otherwise provided by these rules, therapy services must be provided by a therapist or assistant/aide within the scope of practice permitted by state law. The provider's records maintained under ARM 37.85.414 must demonstrate compliance with applicable supervision and protocol requirements.

(a) Services provided by an assistant/aide may only be billed by a supervising therapist.

(3) Therapy services may be provided to a member only upon a current written or verbal order or referral by a physician or mid-level practitioner. All verbal orders or referrals must be followed up by a written order received by the provider within 30 days of the verbal order or referral.

(a) The provider is not entitled to Medicaid reimbursement if services are provided prior to actual receipt of the written or verbal order or referral. Referral and orders are valid for Medicaid purposes for no more than 180 days.

(b) The provider must maintain the referral or order of the physician or mid-level practitioner and appropriate records that demonstrate compliance with Medicaid requirements. The provider must provide copies of these documents at no charge to the department or its agents upon request.

(4) Services that do not require the performance or supervision of a licensed therapist are not reasonable and necessary even if the services are performed by or under the supervision of a licensed therapist.

(5) Medicaid reimbursement for therapy service procedures includes all related supplies and items used in the performance of the service, except that the design, fabrication, fitting, and instruction by a licensed therapist in the use of splints, braces, and slings are reimbursable as provided in ARM 37.86.1801 through 37.86.1807.

(1) Providers must bill for services using the procedure codes and modifiers set forth, and according to the definitions contained, in the Health Care Financing Administration's Common Procedure Coding System (HCPCS). Information regarding billing codes, modifiers and HCPCS is available upon request from the Department of Public Health and Human Services, Health Resources Division, 1400 Broadway, P.O. Box 202951, Helena, MT 59620-2951.

(2) Subject to the requirements of this rule, the Montana Medicaid program pays the following for therapy services:

(a) For patients who are eligible for Medicaid, the lower of:

(i) the provider's usual and customary charge for the service;

(ii) the reimbursement provided in accordance with the methodologies described in ARM 37.85.212; or

(iii) for items or services where no RBRVS or Medicare fee is available, the fee schedule amount will be calculated using the following methodology:

(A) Establishing a fee for a service that has been billed at least 50 times by all providers in the aggregate during the previous 12-month period. The department will set each fee at the payment-to-charge ratio in accordance with ARM 37.85.105(2)(d).

(B) For services where utilization cannot meet the methodology outlined in (A), the fee will be set at the same rate as a service similar in scope.

(1) These requirements are in addition to those contained in rule provisions generally applicable to Medicaid providers.

(2) Audiology service providers, as a condition of participation in the Montana Medicaid program, must:

(a) maintain a current audiology license issued by the Montana Board of Speech-Language Pathologists and Audiologists, or, if the provider is serving recipients outside the state of Montana, maintain a current license in the equivalent category under the laws of the state in which the services are provided;

(b) enter into and maintain a current provider enrollment form under the provisions of ARM 37.85.402 with the department's fiscal agent to provide audiology services.

(1) The following requirements and restrictions apply for purposes of coverage and reimbursement of audiology services under the Montana Medicaid program.

(2) Audiology services are hearing aid evaluations and basic audio assessments provided within the scope of practice permitted by state law to recipients with hearing disorders. Audiology services must be provided by a licensed practitioner within the scope of the practice permitted by state law. The provider's records maintained under ARM 37.85.414 must demonstrate the medical necessity for the service, and compliance with applicable supervision and protocol requirements.

(a) Medicaid coverage and reimbursement for dispensing of hearing aids is available to licensed hearing aid dispensers and audiologists, subject to the requirements of ARM 37.86.801 through 37.86.805 and the requirements generally applicable to Medicaid providers.

(3) Audiology services may be provided to a recipient only upon a current written or verbal order or referral by a physician or mid-level practitioner. All verbal orders or referrals must be followed up by a written order received by the provider within 30 days of the verbal order or referral.

(a) The provider is not entitled to Medicaid reimbursement if services are provided prior to actual receipt of the written or verbal order or referral. Referrals and orders are valid for Medicaid purposes for no more than 90 days.

(4) In addition to the requirements of ARM 37.85.414, a provider must maintain the written orders of the physician or mid-level practitioner and all diagnostic and evaluative reports. The provider must provide copies of these documents at no charge to the department or its agents upon request.

(5) The audiology services must be required as preliminary steps to obtaining a medically necessary hearing aid or device for the recipient.

(6) Basic audio assessments must include for each ear under earphones:

(a) Pure tone air conduction thresholds at the frequencies of .5, 1, 2, 3, and 4 KHZ;

(b) Speech reception threshold; and

(c) Speech discrimination (word recognition) test under phonetically-balanced (PB) max conditions, and either pure tone bone conduction thresholds at the frequencies specified in (6)(a), or tympanometry, including tympanogram, acoustic reflexes, and static compliance.

(7) Medicaid reimbursement for a basic audio assessment or a hearing aid evaluation includes all related supplies and items used in the performance of the assessment or evaluation.

(1) Providers must bill for services using the procedure codes and modifiers set forth, and according to the definitions contained in the Health Care Financing Administration's Common Procedure Coding System (HCPCS). Information regarding billing codes, modifiers, and HCPCS is available upon request from the Department of Public Health and Human Services, Health Resources Division, 1401 East Lockey, P.O. Box 202951, Helena, MT 59620-2951.

(2) Subject to the requirements of this rule, the Montana Medicaid program pays the following for audiology services:

(a) For patients who are eligible for Medicaid, the lowest of:

(i) the provider's usual and customary charge for the service;

(ii) the reimbursement provided in accordance with the methodologies described in ARM 37.85.212;

(iii) 100% of the Medicare Region D allowable fee; or

(iv) for items or services where no RBRVS fee is available, the fee schedule amount will be calculated using the following methodology:

(A) Establishing a fee for a service or item that has been billed at least 50 times by all providers in the aggregate during the previous 12-month period. The department will set each fee at the payment-to-charge ratio under ARM 37.85.105(2)(d).

(B) For services where utilization cannot meet the methodology outlined in (A), the fee shall be set at the same rate as a service similar in scope.

(1) "Hearing aid" means an instrument or device designed for or represented as aiding or improving defective human hearing and includes the parts, attachments, or accessories of the instrument or device.

(2) "Hearing aid dispenser" or "dispenser" means a person holding a current license issued by the Montana Board of Hearing Aid Dispensers under Title 37, chapter 16, MCA to engage in selling, dispensing, or fitting hearing aids. The term does not include any person to the extent that the person acts beyond the scope of the person's hearing aid dispenser license.

(3) "Dispenser" also means a person holding a current audiology license issued by the Montana Board of Speech-Language Pathologists and Audiologists under Title 37, chapter 15, MCA to engage in selling, dispensing, or fitting hearing aids.

(1) These requirements are in addition to those contained in rule provisions generally applicable to Medicaid providers.

(2) Medicaid payment for purchase of hearing aids will be made only to a licensed hearing aid dispenser or audiologist for Medicaid covered services provided in accordance with all applicable Medicaid requirements and within the scope of practice permitted under the dispenser's license.

(3) A hearing aid may be covered under the Medicaid program if:

(a) the recipient has been referred by a physician or mid-level practitioner for an audiological examination and the physician or mid-level practitioner has determined that there is no medical reason for which a hearing aid would not be effective in correcting the recipient's hearing loss;

(b) the examination by a licensed audiologist results in a determination that a hearing aid or aids are needed; and

(i) for persons over 21 years of age, the audiological examination results show that there is an average pure tone loss of at least 40 decibels for each of the frequencies of 500, 1000, 2000, and 3000 Hertz in the better ear and word recognition or speech discrimination scores obtained at a level to ensure pb max. The following criteria shall apply to adults aged 21 years or older for binaural hearing aids:

(A) the two frequency average at 1khz and 2khz must be greater than 40db in both ears;

(B) the two frequency average at 1khz and 2khz must be less than 90db in both ears;

(D) the interaural word recognition or speech discrimination score must have a difference of not greater than 20%;

(E) demonstrated success in using a monaural hearing aid for at least six months; and

(F) documented need to understand speech with a high level comprehension based on an educational or vocational need.

(ii) for persons under 21 years of age, the department or its designee determines after review of the audiology report that the hearing aid would be appropriate for the person. Persons under 21 years of age will be evaluated under the early periodic screening and testing program.

(d) the original hearing aid no longer meets the needs of the individual, and a new hearing aid is determined to be medically necessary by a licensed audiologist.

(4) The audiologist shall indicate in a written report whether in his or her professional opinion a hearing aid is required for the recipient. The report shall also indicate the type of hearing aid required by the recipient and whether monaural or binaural hearing aids are required. The audiologist's report will be prepared in accordance with the format described in the audiologists' provider manual.

(5) A claim for coverage of a hearing aid must be approved in writing by the department or its designee prior to the provision of the service. Copies of the physician's referral and audiologist's report must be submitted with the claim.

(6) The date of service is defined as the date the hearing aid(s) is ordered by the dispenser.

(7) For individuals age 21 or over, a hearing aid purchased by Medicaid will be replaced no more than once in a five year period and only if:

(a) the original hearing aid has been irreparably broken after the one year warranty period or has been lost;

(b) the provider's records document the loss or broken condition of the original hearing aid; and

(1) The department will pay the lowest of the following for covered hearing aid services and items:

(a) the provider's reasonable usual and customary charge for the service or item;

(b) the amount specified for the particular service or item in the department's fee schedule. The department adopts and incorporates by reference the department's Hearing Aid Fee Schedule dated July 2009. A copy of the department's fee schedule is posted at http://medicaidprovider.hhs.mt.gov and may be obtained from the Department of Public Health and Human Services, Health Resources Division, 1401 East Lockey, P.O. Box 202951, Helena, MT 59620-2951; or

(2) The provider may bill Medicaid for a dispensing fee, as specified in the fee schedule adopted in (1)(b). The dispensing fee covers and includes the initial ordering, fitting, orientation, counseling, two return visits for the services listed, and the insurance for loss or damages covered under a one-year warranty.

(1) The department will pay the lowest of the following for covered hearing aid services and items:

(a) the provider's reasonable usual and customary charge for the service or item;

(2) For items or services where no Medicare allowable fee is available, the fee schedule amount in (1)(b) will be calculated using the following methodology:

(a) Establishing a fee for a service that has been billed at least 50 times by all providers in the aggregate during the previous 12-month period. The department will set each fee at the payment-to-charge ratio under ARM 37.85.105(2)(d).

(b) For supplies or equipment, reimbursement will be set at 75% of the manufacturer's suggested retail price. For items without a manufacturer's suggested retail price, the charge will be considered reasonable if the provider's acquisition cost from the manufacturer is at least 50% of the charge amount. For items that are custom-fabricated at the place of service, the amount charged will be considered reasonable if it does not exceed the average charge of all Medicaid providers by more than 20%.

(c) For services where utilization cannot meet the methodology outlined in (a), the fee will be set at the same rate as a service similar in scope.

(3) The provider may bill Medicaid for a dispensing fee, as specified in the fee schedule adopted in (1)(b). The dispensing fee covers and includes the initial ordering, fitting, orientation, counseling, two return visits for the services listed, and the insurance for loss or damages covered under a one-year warranty.

(1) "Clinical pharmacist practitioner" means a pharmacist who meets the requirements outlined in ARM 24.174.526 and is licensed in the State of Montana.

(2) "Collaborative practice drug therapy management" means face-to-face direct member care, provided by a clinical pharmacist practitioner as outlined in ARM 24.174.524. The care provided must be within the scope of practice for clinical pharmacist practitioners.

(3) "Medical practitioner" means a medical practitioner as defined in 37-2-101, MCA.

(1) These requirements are in addition to those requirements contained in administrative rule and statutory provisions generally applicable to Medicaid providers.

(2) A clinical pharmacist practitioner who provides collaborative practice drug therapy management must:

(a) have a collaborative practice agreement with a medical practitioner, as provided in ARM 24.174.524;

(b) manage a member's drug therapy by providing face-to-face, direct care; and

(3) Members who have at least one chronic condition needing at least one maintenance medication are eligible for collaborative practice drug therapy management.

(1) Reimbursement for collaborative practice drug therapy management is reimbursed only to the medical practitioner or facility, at the lower of the following:

(a) the provider's usual and customary charge to the general public for the service; or

(b) the department's current fee schedule in ARM 37.85.105 for the appropriate provider type.

(2) Collaborative practice drug therapy management services performed at a federally qualified health center or rural health clinic will be reimbursed in accordance with ARM 37.86.4401 through 37.86.4420.

For purposes of this subchapter, the following definitions apply:

(1) "By-report method" means the department reimburses a percent of the provider's usual and customary charges for a procedure code for which no fee has been assigned.

(2) "Conversion factor" means the multiplier used to convert the relative value unit or units of a procedure to a reimbursement rate a provider may receive in payment from Montana Medicaid. The dental conversion factor approximates the amount the Legislature has appropriated for one unit of value of dental services.

(3) "Dental service" means medically necessary treatment of the teeth and associated structures of the oral cavity. Dental service includes the provision of orthodontia and prostheses.

(4) "Dental hygiene" means services performed by a licensed preventive oral health practitioner known as a dental hygienist, that are therapeutic, prophylactic, or preventive procedures in nature.

(5) "Dental hygienist" means a licensed preventive oral health practitioner practicing in compliance with the provisions of Title 37, chapter 4, MCA.

(6) "Policy adjustor" means a factor by which the product of the relative value units of a procedure or the conversion factor is multiplied to increase or decrease the fees paid by Montana Medicaid for certain categories of services.

(7) "Procedure code" means the number identifying a particular procedure. Montana Medicaid has adopted national uniform procedure codes.

(8) "Public health supervision" means the provision of limited dental hygiene preventative services without the prior authorization or presence of a licensed dentist in a public health facility.

(9) "Relative Values for Dentists (RVD) Scale" means the scale published biennially by Relative Value Studies Inc., 1675 Larimer, Suite 410, Denver, CO 80202, listing the relative value of dental services provided by dentists and denturists.

(10) "Relative value unit (RVU)" means a numerical value assigned in the resource based relative value scale to each procedure code for which a relative value is available. The RVD is a comprehensive relative value system that lists dental procedures used by dentists, denturists, and hygienists as an expression of the relative effort and expense expended by a provider in providing one service as compared to another service.

(1) These requirements are in addition to those rule provisions generally applicable to Medicaid providers and the provision of services under Medicaid coverage.

(2) Medicaid reimbursement for dental care is limited to those services specified in ARM 37.86.1006.

(1) For procedures listed in the relative values for dentists scale, reimbursement rates shall be determined using the following methodology:

(a) The fee for a covered service shall be the amount determined by multiplying the relative value unit specified in the relative values for dentists scale by the conversion factor specified in (1)(c). The department adopts and incorporates by reference the Relative Values for Dentists (RVDs) as provided in ARM 37.85.105(3).

(b) The conversion factor and provider fees for dentists, dental hygienists, and denturists procedures are calculated as follows:

(i) The total units of each procedure code paid in a prior period is multiplied by the RVU as published in (1)(a) to equal the RVD for each procedure code. Typically, the prior period used is the prior state fiscal year.

(ii) The sum of all RVDs calculated in (1)(b)(i) equals the total units of dental service.

(iii) The Montana Legislature's appropriation for dental service during the appropriation period is divided by the total units of dental service calculated in (1)(b)(ii). The resulting dollar value is equal to one unit of dental value and is the dental conversion factor.

(iv) The RVU as published in (1)(a) for each dental procedure is multiplied by the dental conversion factor calculated in (1)(b)(iii) to calculate the Medicaid reimbursement for the procedure. When this calculation is made for all covered procedures the Montana Medicaid Dental, Dental Hygienist, and Denturist Fee Schedules are generated.

(v) A policy adjuster may be applied to some fees calculated in (1)(b)(iv) for certain categories of services or to the conversion factor to increase or decrease the fees paid by Medicaid.

(c) The conversion factor used to determine the Medicaid payment amount for services provided to eligible individuals is provided in ARM 37.85.105(3).

(1) For dental services listed in the department's fee schedule, the department will pay the lowest of the following for dental services covered by the Medicaid program:

(a) the provider's usual and customary charge for the service;

(b) the amount determined using the methodology described in ARM 37.86.1004; or

(c) for items or services when there is no RVD, the department will set the fee at the same rate as a service similar in scope.

(2) No extra fee for pulp capping or bases is reimbursable.

(3) Payment for all dentures includes:

(a) payment for any tissue conditioners provided;

(b) the first three adjustments after the dentures are placed; and

(c) adjustments during the first year after delivery of the dentures is available only to a dentist or denturist who did not make the dentures.

(4) Medical procedures, within the scope of practice for licensed dentists, that are not listed in the dental services provider manual are reimbursed in accordance with the methodologies provided in ARM 37.85.212 and 37.86.105.

(5) A dentist examining more than one Medicaid recipient in a long term care facility on the same day is allowed payment for one nursing home call in addition to the examination fees. Examination is considered a recorded evaluation.

(1) For purposes of specifying coverage of dental services through the Medicaid program, the department adopts and incorporates by reference the Dental and Denturist Program Provider Manual as provided in ARM 37.85.105(3). The Dental and Denturist Program Provider Manual informs the providers of the requirements applicable to the delivery of services. Copies of the manual are available on the Montana Medicaid provider web site at http://medicaidprovider.mt.gov and from the Department of Public Health and Human Services, Health Resources Division, 1400 Broadway, P.O. Box 202951, Helena, MT 59620-2951.

(2) Dentists who are Medicaid provider participants under ARM 37.85.401 may bill medical CPT procedure codes as provided in ARM 37.85.212 and 37.86.101 for any Medicaid covered medical procedure that they are allowed to provide under the Dental Practice Act that is not otherwise listed in the Dental and Denturist Program Provider Manual.

(3) All services which require prior authorization from the designated review organization are identified in the department's fee schedule. Reimbursement is not provided for such services unless prior authorization has been given by the designated review organization.

(4) A licensed dental hygienist practicing under public health supervision may provide dental hygiene preventative services as defined by the Board of Dentistry.

(5) Covered services for adults age 21 and over include:

(a) diagnostic;

(b) preventative;

(d) extractions; and

(e) porcelain fused to base metal crowns, and porcelain/ceramic crowns are limited to two per person per year, total. For second molars, base metal crowns only.

(6) Medically necessary dental services outlined in (5)(c) through (e), excluding anesthesia services, are subject to an annual limit of $1,125 per benefit year. A benefit year begins on July 1st and ends the following June 30th. Members determined categorically eligible for Aged, Blind, and Disabled (ABD) Medicaid, in accordance with ARM 37.82.204, are not subject to the annual limit.

(7) Full maxillary and full mandibular dentures are a Medicaid-covered service. Coverage is limited to one set of dentures every ten years. Only one lifetime exception to the ten-year time period is allowed per person if one of the following exceptions is authorized by the department:

(a) The dentures are no longer serviceable and cannot be relined or rebased; or

(b) The dentures are lost, stolen, or damaged beyond repair.

(8) Maxillary partial dentures and mandibular partial dentures are a Medicaid-covered service. Coverage is limited to one set of partial dentures every five years. Only one lifetime exception to the five-year limit is allowed per person if one of the following exceptions is authorized by the department:

(a) The partial dentures are no longer serviceable and can no longer be relined or rebased; or

(b) The partial dentures are lost, stolen, or damaged beyond repair.

(9) The limits on coverage of denture replacement may be exceeded when the department determines that the existing dentures are causing the person serious physical health problems. The dentist or denturist should indicate "replacement dentures" on the request for prior authorization of replacement dentures and document the medical necessity for the replacement.

(10) Coverage of all denture services is subject to the following requirements and limitations:

(a) A denturist may provide initial immediate full prosthesis and initial immediate partial prosthesis only when prescribed in writing by a dentist. The prescription must be signed and dated within 90 days of the order and must be maintained in the patient file.

(b) Requests for full prosthesis must show the approximate date of the most recent extractions, and/or the age and type of the present prosthesis.

(11) Orthodontia for persons age 21 and older who have maxillofacial anomalies that must be corrected surgically and for which the orthodontia is a necessary adjunct to the surgery is a covered service.

(12) Full band comprehensive orthodontic or interceptive orthodontic treatment for persons 20 and younger who have one of the following handicapping conditions, indicated with an 'X' on the HLD score sheet:

(a) cleft palate;

(b) deep impinging overbite;

(d) who score a 30 or higher without a handicapping condition (as listed above) on the Handicapping Labio-Lingual Form (HLD Index).

(13) Unless otherwise provided by these rules, interceptive orthodontia is limited to children 12 years of age or younger with one or more of the following conditions:

(a) posterior unilateral crossbite;

(b) bilateral crossbite; or

(14) All orthodontia treatment plans must receive prior authorization from the department's designated peer reviewer to determine individual eligibility for such orthodontia services.

(15) Orthodontic treatment not progressing to the extent of the treatment plan because of noncompliance by the person and which jeopardizes the health of the person may result in termination of orthodontic treatment. If termination of orthodontic treatment occurs because of noncompliance by the person, Medicaid will not authorize any future orthodontic requests for that person.

(16) Cosmetic dentistry is not a covered service of the Medicaid program.

(17) Dental implants are not a covered benefit of the Medicaid program.

(18) Nobel metal crowns, and bridges are not covered benefits of the Medicaid program for individuals age 21 and over.

(1) "Acquisition cost" means the actual price paid by a provider for a drug.

(2) "Active pharmaceutical ingredient (API)" means a nonrebatable bulk drug substance, defined in 21 CFR 207.3(a)(4) (2011) as any substance that is represented for use in a drug and that, when used in manufacturing, processing, or packaging of a drug, becomes an active ingredient of the drug product.

(3) "Allowed ingredient cost" means the "Average Acquisition Cost (AAC)" or "submitted ingredient cost," whichever is lower. If AAC is not available, drug reimbursement is determined at the lesser of "Wholesale Acquisition Cost (WAC)", "Federal Maximum Allowable Cost (FMAC)," or the "submitted ingredient cost."

(4) "Average acquisition cost (AAC)" means the calculated average drug ingredient cost per drug determined by direct pharmacy survey, wholesale survey, and other relevant cost information.

(5) "Average manufacturer price" means the price as defined at 42 CFR Part 447.504(a).

(6) "Best price" means with respect to a single source drug or innovator multiple source drug of a manufacturer the lowest price available from the manufacturer during the rebate period to any wholesaler, retailer, provider, health maintenance organization, nonprofit entity, or governmental entity within the United States. Best price includes the lowest price available to any entity for any such drug of a manufacturer that is sold under an approved new drug application.

(7) "Federal maximum allowable cost" (FMAC) means the per unit amount the department reimburses a provider for a prescription drug included in the federal upper-limit program. FMAC is the federal upper limit the department will pay for multi-source drugs as published by the Centers for Medicare and Medicaid Services (CMS) at: https://www.medicaid.gov/medicaid-chip-program-information/by-topics/benefits/prescription-drugs/pharmacy-pricing.html.

(8) "Legend drugs" means drugs that federal law prohibits dispensing without a prescription.

(9) "Maintenance medications" means oral tablet or capsule drugs that:

(a) have a low probability for dosage or therapy changes due to side effects;

(b) are subject to serum drug concentration monitoring or therapeutic response of a course of prolonged therapy;

(d) therapeutically are not considered curative or promoting of recovery; and

(e) are administered continuously rather than intermittently.

(10) "Multi-source" means a drug product sold under its generic name for which the active ingredients are identical in chemical composition to one or more other drugs sold under trademark that can be purchased from different manufacturers or distributors.

(11) "Outpatient drugs" means drugs that are obtained outside of a hospital.

(12) "Preferred drug list (PDL)" means selected drugs that have a significant clinical benefit over other agents in the same therapeutic class and also represent good value to the department based on total cost.

(13) "Submitted ingredient cost" means a pharmacy's actual ingredient cost. For drugs purchased under the 340B Drug Pricing Program, "submitted ingredient cost" means the actual 340B purchase price. For drugs purchased under the Federal Supply Schedule (FSS), "submitted ingredient cost" means the actual FSS purchase price.

(14) "Usual and customary charge" means the price the provider charges a typical customer in the provider's typical course of business.

(15) "Wholesale acquisition cost (WAC)" is the cost as defined in 42 USC 1395w-3a(c)(6)(B).

(1) These requirements are in addition to those contained in ARM 37.85.401 through 37.85.415.

(2) For purposes of Medicaid reimbursement, outpatient drugs may not be filled or refilled without the authorization of the physician or other licensed practitioner who is authorized by law to prescribe drugs and is recognized by the Medicaid program.

(3) The department will only participate in the payment of legend and over-the-counter drugs listed on the department drug formulary, as determined by the Medicaid Drug Formulary Committee established by the department. The formulary committee is the Drug Use Review Board, established and operating in accordance with 42 USC 1396r-8 (2016), which governs Medicaid drug programs. The drug formulary includes a preferred drug list. Prescribers must prescribe from the preferred drug list if medically appropriate.

(a) The PDL includes drugs subject to a Centers for Medicare and Medicaid Services (CMS) approved supplemental rebate agreement between the manufacturer and the department. Drugs in the same therapeutic class as those identified on the preferred drug list but not identified as a preferred drug are subject to prior authorization as outlined in (6)(c).

(4) The inappropriate use of drugs, as determined by professional review, may result in the imposition of a limitation upon the quantities of medications which are payable by the medical assistance program. Retroactive limitation is not applied, unless the involved pharmacy has knowledge or can reasonably be expected to have had knowledge of the inappropriate use of drugs by the member.

(5) Each prescription must be dispensed in the quantity ordered except that:

(a) Prescriptions for which a specific quantity has not been ordered must be dispensed in sufficient quantities to cover the period of time for which the condition is being treated except for injectable antibiotics, which may be dispensed in sufficient quantities to cover a three-day period.

(b) Notwithstanding the above, maintenance medications may be dispensed in quantities sufficient for a 90-day supply or 100 units, whichever is greater. Other medications may not be dispensed in quantities greater than a 34-day supply. The department maintains a list of current drug classes which are considered maintenance medications and are posted on the department's web site at http://medicaidprovider.mt.gov.

(6) The department does not participate in the payment of a prescription drug:

(a) which the Secretary of Health and Human Services (HHS) has determined is less than effective for all conditions of use prescribed, recommended or suggested in the drug's labeling;

(b) that is not subject to a rebate agreement between the manufacturer and the secretary of HHS as required by 42 USC 1396r-8 (2016); and

(c) that does not meet prior authorization criteria as determined by the Medicaid Drug Formulary Committee, established and operating in accordance with 42 USC 1396r-8 (2016), without the existence of a prior authorization request approved by the department or its designated representative. A list of drugs subject to prior authorization, known as the prior authorization drug list, will be provided to interested Medicaid providers.

(7) The department may pay for nonrebatable API bulk powders and excipients compounded in accordance with ARM 37.86.1105(5).

(8) The drug formulary, PDL, and the prior authorization drug list is updated by the department on a monthly basis, on the last day of each month. A copy of the most current listings may be obtained from the department web site at www.dphhs.mt.gov, or by writing to the Department of Public Health and Human Services, Health Resources Division, Allied Health Services Bureau, 1400 Broadway, P.O. Box 202951, Helena, MT 59620-2951.

(9) The department has a drug rebate program administered in accordance with 42 USC 1396r-8 (2016) and CMS drug program state releases, CMS drug manufacturer releases, and the National Drug Rebate Agreement in effect in 2008. The department adopts and incorporates by reference the National Drug Rebate Agreement (2008). A copy of all documents incorporated by reference in this rule may be obtained from the department web site at www.dphhs.mt.gov, or by writing to the Department of Public Health and Human Services, Health Resources Division, Allied Health Services Bureau, 1400 Broadway, P.O. Box 202951, Helena, MT 59620-2951.

(a) Pharmaceutical manufacturers, hereafter referred to as the manufacturer, must make rebate payments to the department for each calendar quarter within 30 days after receiving from the department the Medicaid utilization information defined in their federal rebate agreement. The manufacturer is responsible for timely payment of the rebate within 30 days of receiving, at a minimum, information on the number of units paid, by NDC number.

(b) 42 USC 1396r-8 (2016) establishes the requirements that must be met by the department, drug manufacturers, and providers in order for providers to receive reimbursement for outpatient drugs that have been dispensed. This statute describes rebate agreements, covered drugs, prior authorization, reimbursement limits, and drug use review programs.

(10) A provider must maintain a signature log to act as proof that the dispensed medication has been received by the member or an individual acting on behalf of the member. The member, or an individual acting on behalf of the member, must sign the log each time that they receive a prescription drug from a pharmacy provider. For prescription drugs delivered to a nursing facility, the individual charged with ensuring the security of pharmaceutical supplies may sign the log after verifying delivery of all prescription drugs.

(11) The department uses the following procedures to develop the preferred drug list (PDL):

(a) The department performs a pharmacoeconomic analysis of the Medicaid Pharmacy Program and identifies therapeutic classes of drugs for possible PDL inclusion.

(b) The department and the Drug Use Review (DUR) Board/Formulary Committee members consider recommendations and determine which therapeutic drug classes will be reviewed at a meeting of the committee. Notice of the meeting and the therapeutic drug class to be considered is posted on the department's web site in advance of the meeting date.

(c) The department performs drug class reviews using peer-reviewed literature, established evidence-based practice methods, and local clinicians to interpret and apply practical experience to the structured evidence reviews. The department also conducts supplemental rebate negotiations.

(d) The committee combines its members' evaluations and the evaluations from the department to consider equivalent products within the drug class. Information used by the department and its contractors is available to the public prior to the meeting. During the meeting, the committee also hears comments from interested parties.

(e) The committee recommends to the department which preferred agents should be selected for the specific therapeutic class.

(f) The department makes a final decision and posts its decision on the department's web site.

(1) Medicaid, Healthy Montana Kids, and Mental Health Services Plan members may be subject to investigation for prescription fraud and abuse in accordance with 42 CFR 455.

(2) "Fraud" means the intentional deception or misrepresentation with knowledge that the deception could result in some unauthorized benefit to the individual or some other person. Examples include:

(a) doctor shopping;

(b) reported cash payment for drugs of abuse where it is suspected that the member has circumvented the Medicaid benefit system to avoid detection; and

(3) "Abuse" means the misuse of the prescription drug program resulting in undue expenditures or substance abuse. Examples include:

(a) high utilization;

(b) multiple provider usages that result in the receipt of unnecessary services;

(d) repeated use of emergency rooms or urgent care clinics; and

(e) unwarranted multiple pharmacy usage.

(4) "Drug not covered" means that a member is unable to receive a selected medication or class of medication unless a prior authorization is granted.

(5) "Opioid naïve member" means a member has not received a prescription for an opioid within the last 90 days.

(6) Pharmacy providers may notify the department when Medicaid members pay cash for controlled substances (CII-CV), ultram (tramadol), ultracet (tramadol and acetaminophen), carisoprodol, and gabapentin.

(7) Prescriptions for noncontrolled substances may be refilled after 75% of the estimated therapy days have elapsed. Prescriptions for controlled substances (CII-CV), ultram (tramadol), ultracet (tramadol and acetaminophen), carisoprodol, and gabapentin may be refilled after 90% of the estimated therapy days have elapsed. Members who have a "drug not covered" in place may be required to have 100% of the estimated therapy days elapse prior to a refill being authorized.

(8) As stated in ARM 37.86.1102, the department does not authorize payment for medications dispensed in quantities greater than a 34-day supply excluding maintenance medications and where manufacturer packaging precludes the 34-day supply limit. Authorization for early refills, lost or stolen medication, or vacation supplies will not be granted.

(9) Except as provided in (10), for an opioid-naïve member, the department does not authorize payment for opioid medications in quantities greater than a 7-day supply.

(10) The restriction imposed under (9) does not apply if the opioid is prescribed to treat:

(a) chronic pain, pain associated with cancer, or pain experienced while the patient is in palliative care; or

(b) opioid abuse or dependence, including but not limited to opioid agonists and opioid antagonists.

(11) The use of tamper-resistant pads for written prescriptions is required. The department follows ARM 24.174.831 established by the Montana Board of Pharmacy to define tamper-resistant prescriptions.

(12) As stated in ARM 37.86.1102, the department may impose prescription limitations and requirements due to inappropriate use of drugs, as determined by professional review. These limitations or requirements may include:

(a) random drug screening;

(b) random pill counts;

(d) restrictions through "Drug Not Covered";

(e) member requirement to have utilized 100 percent of the estimated therapy days prior to granting a prescription authorization; or

(f) member referral to the team care program, as outlined in ARM 37.86.5303.

(1) Outpatient drugs are reimbursed at the lower of:

(a) the provider's "usual and customary charge"; or

(b) the "allowed ingredient cost" plus a dispensing fee.

(2) The FMAC limitation will not apply in a case where a physician certifies in their own handwriting the specific brand is medically necessary for a particular member. An example of an acceptable certification is the handwritten notation "Brand Necessary" or "Brand Required." A check-off box on a form or rubber stamp is not acceptable.

(3) The dispensing fee for filling prescriptions is determined for each pharmacy provider annually.

(a) The dispensing fee is based on the pharmacy's average cost of filling prescriptions and prescription volume. The average cost of filling a prescription is based on the direct and indirect costs that can be allocated to the cost of the prescription department and that of filling a prescription, as determined from the Montana Dispensing Fee Questionnaire. The prescription volume of a provider is determined using the information provided on the annual Montana Dispensing Fee Questionnaire. If a provider fails to submit a properly completed dispensing fee questionnaire, the provider will receive a dispensing fee in an amount equal to the lowest calculated cost to dispense assigned that year. A copy of the Montana Dispensing Fee Questionnaire is available upon request from the department.

(b) The dispensing fees assigned are as provided in ARM 37.85.105(3).

(c) If the individual provider's usual and customary average dispensing fee for filling prescription is less than the foregoing method of determining the dispensing fee, then the lesser dispensing fee is applied in the computation of the payment to the pharmacy provider.

(4) All pharmacy providers that are new to the Montana Medicaid program are assigned the maximum dispensing fee in ARM 37.85.105(3)(f)(i) until a dispensing fee questionnaire, as provided in (3), can be completed for six months of operation. At that time, a new dispensing fee is assigned which is the lower of the dispensing fee calculated in accordance with (3) for the pharmacy or the maximum allowed dispensing fee provided in (3)(b). If the provider fails to submit the

six-month dispensing fee questionnaire, the provider will receive a dispensing fee in an amount equal to the lowest calculated cost to dispense assigned that year.

(5) The department reimburses pharmacies for compounding drugs only if the member's drug therapy needs cannot be met by commercially available dosage strengths, forms of the therapy, or both.

(a) Prescription claims for compound drugs are billed and reimbursed using the National Drug Code (NDC) number and quantity for each compensable ingredient in the compound.

(b) No more than 25 ingredients may be reimbursed in any compound.

(d) Prior authorization requirements for individual components of a compound must be met for reimbursement purposes.

(e) The department reimburses pharmacies a compound-drug dispensing fee as provided in ARM 37.85.105(3) in lieu of the dispensing fee stated in (3). Prior authorization is required for reimbursement above the lowest compound dispensing fee.

(f) The department does not consider reconstitution to be compounding.

(g) The department publishes guidelines for billing the different level of effort fees.

(h) The department may reimburse for compounded nonrebatable API bulk powders and excipients on the department's drug formulary maintained in accordance with ARM 37.86.1102.

(6) The department reimburses pharmacies a vaccine administration fee as provided in ARM 37.85.105(3) in lieu of the dispensing fee stated in (3) for any covered vaccine as allowed by the Montana Pharmacy Practice Act, 37-7-101, MCA.

(7) Reimbursement for outpatient drugs provided to Medicaid persons in state institutions is as follows:

(a) for institutions participating in the state contract for pharmacy services, the rates agreed to in that contract. Such reimbursement must not exceed, in the aggregate, reimbursement under (1); or

(b) for institutions not participating in the state contract for pharmacy services, the actual cost of the drug and dispensing fee. Such reimbursement must not exceed, in the aggregate, reimbursement under (1).

(8) Full-benefit dual eligible persons qualify for pharmaceutical drug coverage under Medicare Part D prescription drug plans (PDPs) under 42 USC 1302, 1395w-101 through 1395w-152 (2011), the Medicare Prescription Drug Improvement and Modernization Act of 2003 (MMA). For purposes of the MMA and this rule, the term full-benefit dual eligible has the same meaning as stated in 42 CFR 423.772.

(9) The MMA allows PDPs to exclude from coverage the drug classes listed in 42 USC 1396r-8(d)(2) (2011). Montana Medicaid may also exclude these drugs and has chosen to do so except for the prescription and nonprescription drugs identified on the department's drug formulary. Montana Medicaid's reimbursement for outpatient drugs provided to full-benefit dual eligible persons, for whom third party payment is not available, is limited to the excluded drugs identified on the department's drug formulary.

(10) The department reimburses pharmacies a unit dose prescription fee as provided in ARM 37.85.105(3). The unit dose prescription fee offsets the additional cost of packaging supplies and materials which are directly related to filling unit dose prescriptions by the individual pharmacy. This fee is in addition to the regular dispensing fee allowed. The unit dose prescription fee is not paid for a unit dose prescription packaged by drug manufacturers. Unit dose prescriptions may not exceed the 34-day supply limit. Only one unit dose prescription fee is allowed each month for each prescribed medication.

(11) Providers must bill Montana Medicaid the following:

(a) their actual acquisition cost including providers who purchase drugs through the Federal Supply Schedule or providers who are participating in the 340B Drug Pricing Program; and

(b) their "usual and customary charge" as defined in ARM 37.86.1101.

(12) In accordance with the NCPDP 340B Information Exchange Reference Guide Version 1.0 (July 2011), a claim for Section 340B drugs must be identified through the use of a valid value 20 in the NCPDP Submission Clarification Code (420-DK) field. If a claim is identified as a 340B claim and the submitted ingredient cost is greater than the AAC, or the lower of WAC or FMAC, if no AAC is present, the claim will deny.

(13) Specialty pharmacies, hemophilia treatment centers, or centers of excellence that dispense clotting factors:

(a) not purchased through the 340B program will be reimbursed at the lesser of the usual and customary charge, submitted ingredient cost, or wholesale acquisition cost, plus the professional dispensing fee; or

(b) when purchased through the 340B program, will be reimbursed the lesser of the usual and customary charge or wholesale acquisition cost, plus the professional dispensing fee.

(1) The Average Acquisition Cost (AAC) is the cost per drug determined by direct pharmacy survey, wholesale survey, and other relevant cost information.

(a) The department reviews AAC rates on an ongoing basis and adjusts the rates as necessary to reflect prevailing market conditions and ensure reasonable access by providers to drugs at or below the applicable AAC rate.

(b) Pharmacies and providers that are enrolled in Montana Medicaid are required, as a condition of participation, to submit, upon request, to the department, or its designee, acquisition cost information, product availability information, and other information deemed relevant by the department for the efficient operation of the pharmacy benefit. Information is provided in the format requested by the department or its designee. Providers are not reimbursed for this information and must submit information to the department or its designee within 30 days following a request for such information unless the department or its designee grants an extension upon written request of the pharmacy or provider.

(1) In any quarter in which a discrepancy in Medicaid utilization information is discovered by the manufacturer, which the manufacturer and the department are unable to resolve, the manufacturer will provide written notice of the discrepancy, by NDC number, to the department prior to the due date specified in ARM 37.86.1102.

(2) If the manufacturer asserts the department's Medicaid utilization information is erroneous, the manufacturer shall pay the department that portion of the rebate amount that is not disputed by the required due date in ARM 37.86.1102. The balance due, if any, plus a reasonable rate of interest as set forth in 42 USC 1396b(d)(5)(2008), will be paid or credited by the manufacturer or the department by the due date of the next quarterly payment in ARM 37.86.1102(8) after resolution of the dispute.

(3) Adjustments to rebate payments shall be made if information indicates that either Medicaid utilization information, Average Manufacturer Price (AMP), or Best Price were greater or less than the amount previously specified.

(4) The department and the manufacturer will use their best efforts to resolve the discrepancy within 60 days of receipt of disputes noted by the manufacturer in ARM 37.86.1102. In the event that the department and the manufacturer are not able to resolve a discrepancy within 60 days, the department shall make available to the manufacturer the department's hearing mechanism as set forth in Title 37, chapter 5, subchapter 3.

(1) "Direct-entry midwife" means a person that is licensed as defined in Title 37, chapter 27, MCA and ARM Title 24, chapter 111, subchapter 6.

(2) Direct-entry midwives may only provide prenatal labor and delivery or postpartum care in a birthing center as defined at ARM 37.86.3001.

(3) Reimbursement for direct-entry midwives will be determined in accordance with ARM 37.85.212 and 37.86.105.

(4) The definitions found in the introduction to Physicians Current Procedural Terminology, fourth edition (CPT4), published by the American Medical Association of Chicago, Illinois and adopted at ARM 37.86.101 describe the terms commonly used by the Montana Medicaid Program in implementation of the program's direct-entry midwife fee schedule.

(5) The "Physician-Related Services Manual" adopted at ARM 37.86.101 governs the administration of the Direct-Entry Midwife Program.

(1) "Clinic services" means preventive diagnostic, therapeutic, rehabilitative, or palliative items or services provided under the direction of a physician by an outpatient facility that is not part of a hospital, but is organized and operated to provide medical care to outpatients independent of a hospital. Clinic services may be provided in surgical centers and public health departments. Clinic services do not include mental health center services as defined in ARM 37.88.901.

(2) "Ambulatory surgical center services" means clinic services which are provided in a licensed, freestanding ambulatory surgical center, but do not include physicians services, anesthesiologists services, ambulance services, or major prosthetic appliances such as intraocular lenses.

(1) These requirements are in addition to those requirements contained in ARM 37.85.401 through 37.85.414.

(2) Clinic services must be provided by a clinic which is licensed as an outpatient facility by the appropriate licensing entity of the state where the facility is located and meet the requirement for participation in Medicare.

(3) Clinic services must be provided by, or under the direction of a licensed physician or, where appropriate a licensed dentist.

(4) Conditions for coverage of listed ambulatory surgical center procedures:

(a) Subject to the exclusions in (b), covered surgical procedures are surgical procedures that would not be expected to pose a significant safety risk to a member when performed in an ambulatory surgical center and for which standard medical practice dictates that the member would not typically be expected to require active medical monitoring more than 24 hours following an admission. Active medical monitoring includes the monitoring or assessment of respiratory function, cardiovascular function, mental status, pain, temperature, or post-operative hydration at least every 30 minutes.

(b) Covered surgical procedures do not include those that:

(i) generally result in extensive blood loss;

(ii) requires a major or prolonged invasion of body cavities;

(iii) directly involves major blood vessels;

(iv) are generally emergency or life threatening in nature; or

(v) can safely be performed in a physician's or dentist's office.

(5) Telephone contacts are not a clinic service.

(1) Ambulatory surgical center (ASC) services:

(a) are services that will be covered by Medicaid if provided in an outpatient ASC setting incident to provision of physician or dental services to the patient where the services and supplies are furnished in the ASC on a physician's or dentist's order by ASC personnel under the supervision of ASC medical staff;

(b) are limited as provided by ARM 37.86.1402(1) through (4) with the term clinic taken to mean ASC.

(2) Clinic services, covered by the Medicaid program, include physician services covered in ARM 37.86.101, 37.86.104 and 37.86.105.

(3) Clinic services, covered by the Medicaid program, include mid-level practitioner services covered in ARM 37.86.201, 37.86.202 and 37.86.205.

(1) Ambulatory surgical center (ASC) services as defined in ARM 37.86.1401(2) provided by an ASC will be reimbursed on a fee basis as follows:

(a) 100% of the Medicare allowable amount. For purposes of determining the Medicare allowable amount for ASC services to Medicaid members under this rule, the department adopts and incorporates by reference the methodology at 42 CFR part 416, subpart F, and the schedule listing the allowable amounts for ASC services in the Medicare Claims Processing Manual. The cited authorities are federal regulations and manuals specifying the methods and rules used to determine reasonable cost for purposes of the Medicare program. The Medicare Claims Processing Manual can be found on the Centers for Medicare and Medicaid website at www.cms.gov. The Code of Federal Regulations can be found at www.gpo.gov.

(i) For purposes of applying the provisions of 42 CFR part 416, subpart F, and the Medicare Claims Processing Manual, any reference in such authorities to Medicare, Medicare beneficiary, beneficiary, intermediary or secretary shall be deemed to refer also to Medicaid, Medicaid member, member, or the department.

(b) For ASC services where no Medicare fee has been assigned, the fees will be set at the average Medicaid payment-to-charge ratio for all ASC services that have a Medicaid fee.

(c) Except as provided in (1)(d), the payment specified in (1)(a) or (1)(b) is an all inclusive bundled payment per procedure or service which shall be deemed to cover all outpatient services provided to the patient, including but not limited to nursing, pharmacy, laboratory, imaging services, other diagnostic services, supplies and equipment and other ASC services. For purposes of ASC surgery services, a visit shall be deemed to include all ASC services related or incident to the ambulatory surgery visit that are provided the day before or the day of the ambulatory surgery event.

(d) Physician services are separately billable according to the applicable Medicaid rules governing billing for physician services.

(e) When multiple procedures are performed at the same time on the same patient, the first procedure listed shall be paid as provided at (1)(a) or (1)(b) as appropriate. Subsequent procedures shall be paid at 50% of the amount provided at (1)(a) or (1)(b) as appropriate.

(2) Reimbursement for major prosthetic appliance shall be made in accordance with ARM 37.86.1806 and 37.86.1807.

In ARM 37.86.1501, 37.86.1502, 37.86.1505, and 37.86.1506, the following definitions apply:

(1) "Agency staff services" means all services provided by the home infusion therapy agency's staff, as provided in ARM 37.106.2405, including all professional and nonprofessional employed and contracted individuals. Agency staff services include:

(a) preparation and revision of the plan of care;

(b) coordination of treatment with other health care providers;

(d) clinical monitoring of laboratory values and therapy progression;

(e) reporting clinical information to the recipient's physician and other health care providers;

(f) delivery, pick up, and disposal of equipment, supplies, or drugs;

(g) 24-hour on call status; and

(h) any other services provided by the agency staff related to the recipient's home infusion therapy services.

(2) "Home infusion therapy services" means a comprehensive treatment program for the preparation and administration of parenteral medications or parenteral nutritional services to a recipient who is not receiving infusion therapy as a hospital inpatient or outpatient. Home infusion therapy services include all pharmacist professional services, all agency staff services and all associated medical equipment and supplies for care required at home or an ambulatory infusion suite (AIS). Home infusion therapy services do not include professional physician services or drugs. Drugs are covered under the pharmacy outpatient program.

(3) "Home Nursing Services for Infusion/Specialty Drug Administration" means high-tech registered nurse (RN) services provided by an RN with special education, training and expertise in home administration of drugs via infusion, home/AIS administration of specialty drugs, or home nursing management of disease state and care management programs. Typical services include:

(a) evaluation and assessment;

(b) education and training for the patient or caregiver;

(d) catheter insertion/maintenance; and

(e) patient assessment.

(4) "Pharmacist professional services" include:

(a) preparation and revision of the plan of care;

(b) preparation and compounding of drugs;

(d) reporting clinical information to the recipient's physician and other health care providers;

(e) delivery, pick up, and disposal of equipment, supplies and/or, drugs; and

(f) 24-hour on call status.

(5) Other home infusion therapy services include services as provided in ARM 37.106.2411 and the procedure codes included in the department's Home Infusion Therapy Fee Schedule.

(1) These requirements are in addition to those contained in rule provisions generally applicable to Medicaid providers.

(2) Home infusion therapy service providers, as a condition of participation in the Montana Medicaid program, must:

(a) maintain a current home infusion therapy agency license issued by the department's quality assurance division, and meet the standards set forth in ARM 37.106.2422, or if the provider is serving recipients outside the state of Montana, maintain a current license in the equivalent category under the laws of the state in which the services are provided; and

(b) enter into and maintain a current provider enrollment form under the provisions of ARM 37.85.402 with the department's fiscal agent to provide home infusion therapy services.

(1) The requirements and restrictions in these rules apply for purposes of coverage and reimbursement of home infusion therapy services under the Montana Medicaid program.

(2) Medicaid coverage and reimbursement of home infusion therapy services is available, subject to applicable requirements, for services provided to recipients that are residing in their own home, a nursing facility or any setting other than a hospital. Medicaid coverage and reimbursement of home infusion therapy services is not available to recipients who are receiving infusion therapy as a hospital inpatient or outpatient service.

(3) Except as otherwise provided by these rules, home infusion therapy services must be provided within the scope of practice permitted by applicable state law.

(4) For those services subject to prior authorization, the Montana Medicaid program will not cover or reimburse home infusion therapy services unless the department or its designated agent has approved a prior authorization request. The department will determine the specific home infusion therapy services that require prior authorization in consultation with the department's Drug Use Review Board established pursuant to 42 USCA 1396r-8(g). A list of the specific services subject to prior authorization will be provided upon request made to the Department of Public Health and Human Services, Health Resources Division, 1400 Broadway, P.O. Box 202951, Helena, MT 59620-2951.

(5) The Montana Medicaid program will not cover or reimburse home infusion therapy services for the following:

(a) medications which can be appropriately administered orally, through intramuscular or subcutaneous injection, or through inhalation; and

(b) drug products that are not FDA approved or whose use in the nonhospital setting presents an unreasonable health risk to the patient.

(6) The department will determine the specific therapies that are not allowable as home infusion therapy services under (5)(a) or (b) in consultation with the department's Drug Use Review Board established pursuant to 42 USCA 1396r-8(g). A list of the specific therapies determined not allowable under this rule will be provided upon request made to the Department of Public Health and Human Services, Health Resources Division, 1400 Broadway, P.O. Box 202951, Helena, MT 59620-2951.

(1) Subject to the requirements of these rules, the Montana Medicaid program will pay for home infusion therapy services on a fee basis, as specified in the department's home infusion therapy services fee schedule. The department adopts and incorporates by reference the Home Infusion Therapy Services Fee Schedule as provided in ARM 37.85.105(3). A copy of the department's fee schedule is posted at the Montana Medicaid provider web site at http://medicaidprovider.mt.gov. A copy of the Home Infusion Therapy Services Fee Schedule may also be obtained from the Department of Public Health and Human Services, Health Resources Division, 1400 Broadway, P.O. Box 202951, Helena, MT 59620-2951. The specified fees are on a per day or a per dose basis as specified in the fee schedule. The fees are bundled fees which cover all home infusion therapy services as defined in ARM 37.86.1501.

(2) For home infusion therapy services also reimbursed for the person by the Medicare program, Medicare payments will be considered to be third party payments and, if the Medicare payment is less than the Medicaid fee schedule amount, Medicaid will pay the difference between the Medicare payment and the Medicaid fee specified in the home infusion therapy fee schedule described in (1).

(3) Covered drugs prepared and administered as part of a person's home infusion therapy program are separately billable under the Montana Medicaid Outpatient Drug program as specified in ARM 37.86.1102 and 37.86.1105.

(4) Nursing services provided by licensed nurses employed by the home infusion therapy agency will be reimbursed to the agency as specified in the Home Infusion Therapy Fee Schedule. Home nursing services for infusion/specialty drug administration are not billable when the home infusion therapy program is provided in a nursing facility.

(1) Family planning services may be provided by a physician in accordance with ARM 37.86.101 through 37.86.105, mid-level practitioner in accordance with ARM 37.86.201 through 37.86.205, or a local family planning program defined at ARM 37.19.101. Family planning services include:

(a) comprehensive history;

(b) contraceptive supplies and procedures;

(d) laboratory services;

(e) medical counseling; and

(f) testing and treatment for sexually transmitted infections and testing for human immunodeficiency virus (HIV).

(2) A copy of the family planning procedures and service code table for Plan First may be obtained from the Department of Public Health and Human Services, Health Resources Division, 1400 Broadway, P.O. Box 202951, Helena, MT 59620-2951.

(3) The definitions found in the introduction to Physicians Current Procedural Terminology, fourth edition (CPT4), published by the American Medical Association of Chicago, Illinois and adopted at ARM 37.86.101 defines the terms commonly used by the Montana Medicaid program in implementation of the program's family planning clinic fee schedule.

(4) The "Physician-Related Services Manual" means the physician-related services manual. It governs the administration of the Family Planning Clinic program.

(1) These requirements are in addition to those contained in ARM 37.85.401, 37.85.406, 37.85.407, 37.85.410, and 37.85.414.

(a) Contraceptive clinic services are the services of a physician, a mid-level practitioner, or a local family planning program defined at ARM 37.19.101.

(b) Laboratory services must be ordered by a physician or a mid-level practitioner.

(d) Eligible clients requesting family planning services must be free from coercion or mental pressure and free to choose the method of family planning to be used.

(1) Reimbursement for family planning services is as follows:

(a) for physicians reimbursement is provided in accordance with the methodologies described in ARM 37.85.212 and 37.86.105;

(b) for mid-level practitioners reimbursement is provided in accordance with the methodologies described in ARM 37.85.212 and 37.86.205;

(c) for local family planning programs as defined at ARM 37.19.101 reimbursement is provided in accordance with the methodologies described in ARM 37.85.212, 37.86.105, and 37.86.205.

(2) The procedure billing codes and department fee schedules are available at the department's web site located at

https://medicaidprovider.mt.gov/16#186992922-fee-schedules--family-planning.

(1) "Durable medical equipment and supplies" means the most economical equipment or supplies that are medically necessary to treat a health problem or a physical condition. The equipment or supplies must be appropriate for use in a patient's home, residence, school, or workplace. Equipment or supplies that are useful or convenient, but are not medically necessary to treat an illness or injury do not qualify for Medicaid coverage.

(2) "Prescription" means a prescription or order as provided in ARM 37.86.1802.

(3) "Prior authorization" means the Medicaid program's review and approval of an item's medical necessity and coverage by Medicaid prior to the delivery of the item.

(4) "Prosthetic devices" means replacement, corrective, or supportive devices or appliances which artificially replace a missing portion of the body to:

(a) prevent or correct physical deformity or malfunction; or

(b) support a weak or deformed portion of the body.

(1) These requirements are in addition to those contained in rule provisions generally applicable to Medicaid providers. Requirements for prosthetic devices, durable medical equipment, and medical supplies utilized by nursing facility residents are contained in the department's rules governing nursing facility reimbursement when the nursing facility bills for separately billable items as a skilled nursing durable medical equipment provider as outlined in ARM 37.40.330.

(2) Reimbursement for prosthetic devices, durable medical equipment, and medical supplies will be limited to items included on the department's fee schedule delivered in the most appropriate and cost effective manner. Montana Medicaid adopts Medicare coverage criteria for Medicare covered durable medical equipment as outlined in the Region D Supplier Manual, local coverage determinations (LCDs) and national coverage determinations (NCDs) and as provided in ARM 37.85.105(3). For prosthetic devices, durable medical equipment, and medical supplies not covered by Medicare coverage will be determined by the department and published on the department's fee schedule in accordance with ARM 37.86.1807. The items must be medically necessary and prescribed in accordance with (2)(a) by a physician or other licensed practitioner of the healing arts within the scope of his practice as defined by state law.

(a) A prescription or order must include the member's name or Medicaid identification number; order date; general description of the item or HCPCS code or HCPCS code narrative, or a brand name and model number; quantity to be dispensed, if applicable; treating practitioner's name or national provider identifier; and treating practitioner's signature. The original prescription must be retained in accordance with the requirements of ARM 37.85.414. Prescriptions may be transmitted by an authorized provider to the durable medical equipment provider by electronic means or pursuant to an oral prescription made by an individual practitioner and promptly reduced to hard copy by the durable medical equipment provider containing all information required. Prescriptions for durable medical equipment, prosthetics, and orthotics (DMEPOS) must follow the Medicare criteria outlined in chapters 3 and 4 of the Region D Medicare Supplier Manual as provided in ARM 37.85.105(3). A copy of the Region D Medicare Supplier Manual may be obtained from the Department of Public Health and Human Services, Health Resources Division, 1401 East Lockey, P.O. Box 202951, Helena, MT 59620-2951. For items requiring prior authorization the provider must include a copy of the prescription when submitting the prior authorization request.

(i) Prescriptions for oxygen must include the liter flow per minute, the hours of use per day, and the person's PO2 or oxygen saturation blood test(s) results.

(ii) If applicable, an order for durable medical equipment must list separately all concurrently ordered options, accessories, or additional features that are separately billed or require an upgrade code.

(iii) If applicable, an order for medical supplies must include all concurrently ordered supplies that are separately billed, listing each separately.

(b) Subject to the provisions of (3), medical necessity for oxygen is determined in accordance with the Medicare criteria outlined in the Medicare Durable Medical Equipment Regional Carrier (DMERC) Region D Supplier Manual, Local Coverage Determination (LCD) and policy articles, and National Coverage Determination (NCD) as provided in ARM 37.85.105(3). The Medicare criteria specify the health conditions and levels of hypoxemia in terms of blood gas values for which oxygen will be considered medically necessary. The Medicare criteria also specify the medical documentation and laboratory evidence required to support medical necessity.

(c) Reimbursement for oxygen is made on a monthly basis. Only one unit may be billed per month regardless of the actual amount used by the patient.

(d) A statement of medical necessity for the rental of durable medical equipment, excluding oxygen equipment must indicate the length of time the equipment will be needed. All prescriptions must be signed and dated.

(e) No more than one month's medical supplies may be provided to a Medicaid person based on the physician's orders.

(f) A determination of the medical necessity of an item made by the Medicare program is applicable to the Medicaid program.

(g) Persons will be limited to a new wheelchair no more than once every five years, unless the department determines that a new chair is required sooner because the person's current chair is causing the person serious health problems or because of a significant change in the person's medical condition.

(3) Providers of oxygen to persons for whom oxygen was determined to be medically necessary prior to the adoption of the Medicare criteria, effective March 1, 1998, set forth in (2) may be reimbursed for oxygen services to those persons, even though the oxygen would not be medically necessary for them under the Medicare criteria, until the person's next recertification of medical necessity.

(4) Reimbursement for out-of-home use includes:

(a) medically necessary wheelchair tie downs and head rests for transportation to work or school and laterals and flat free inserts required for activities in the workplace or at school used by children age 20 and under; and

(b) medically necessary wheelchair tie downs and head rests for transportation outside the home to go to work or school and laterals and flat free inserts used by adults in the workplace or at school.

(5) Reimbursement for nursing home residents includes:

(a) medically necessary custom molded wheelchair positioning equipment used by nursing home residents not covered under nursing home per diem (see department nursing home rules). A copy of the Medicaid criteria may be obtained from the Department of Public Health and Human Services, Health Resources Division, 1401 East Lockey, P.O. Box 202951, Helena, MT 59620-2951.

(6) The following items are not reimbursable by the program:

(a) items determined not to be medically necessary by the Medicare program, except as provided in (3);

(b) orthopedic shoes, corrections, and shoe repairs unless the criteria in (6)(b)(i) or (ii) are met and the physician's prescription indicates that:

(i) the shoes are attached to a brace or orthotic device which cannot be accommodated in a regular shoe; or

(ii) the shoes are covered under Medicare criteria for therapeutic shoes for diabetics under the same conditions the Medicare program will cover therapeutic shoes for diabetics. A copy of the Medicare criteria is available upon request from the Department of Public Health and Human Services, Health Resources Division, 1401 East Lockey, P.O. Box 202951, Helena, MT 59620-2951;

(d) payment for provider's travel;

(e) nutrient solutions except when they are for parenteral and enteral nutrition therapy, are the primary source of nutrition for patients, and are medically appropriate;

(f) purchase of air fluidized beds;

(g) any delivery, mailing or shipping fees, or other costs of transporting the item to the person's location;

(h) disposable incontinence wipes;

(i) adaptive equipment;

(j) building modifications;

(k) automobile modifications;

(l) environmental control devices;

(m) exercise equipment;

(n) personal care items;

(o) alarms;

(p) educational equipment;

(q) personal computers;

(r) sexual aids or devices;

(s) items included in the nursing home per diem rate;

(t) backup equipment;

(u) safety equipment unless explicitly covered by Medicare; and

(v) any item that does not appear on the DME fee schedule unless delivered in accordance with ARM 37.86.2201.

(7) The date of service for custom molded or fitted items is the date upon which the provider completes the mold or fitting and either orders the equipment from another party or makes an irrevocable commitment to the production of the item.

(1) Requirements for the purchase or rental of prosthetic devices, durable medical equipment, medical supplies and related maintenance, repair, and services are as follows:

(a) Subject to the requirements of this rule, the department will pay the lowest of the following for prosthetic devices, durable medical equipment, medical supplies and related maintenance, repair, and services:

(i) the provider's usual and customary charge for the item; or

(ii) the department's fee schedule maintained in accordance with the methodology described in ARM 37.86.1807.

(b) For all purposes under this rule and ARM 37.86.1807, the amount of the provider's usual and customary charge may not exceed the reasonable charge usually and customarily charged by the provider to all payers. The charge will be considered reasonable if less than or equal to the manufacturer's suggested list price. For items without a manufacturer's suggested list price, the charge will be considered reasonable if the provider's acquisition cost from the manufacturer is at least 50% of the charge amount. For items that are custom fabricated at the place of service, the amount charged will be considered reasonable if it does not exceed the average charge of all Medicaid providers by more than 20%. For rental items, the reasonable monthly charge may not exceed a percentage of the reasonable purchase charge, as specified in (3).

(i) for any line item of prosthetic device, durable medical equipment, medical supplies and related maintenance, repair, and services on which the department's fee is equal to or greater than $1,000; and

(ii) all items identified as requiring prior authorization in the department's fee schedule referenced in ARM 37.86.1807(2).

(d) Prior authorization of a claim does not guarantee payment for the requested item or service.

(e) Reimbursement for prosthetic devices, durable medical equipment, medical supplies and related maintenance, repair and services utilized by nursing facility residents and billed by a nursing facility is subject to the limits in the department's rules governing nursing facility reimbursement.

(2) For items that require prior authorization, the authorization number must be included on the submitted claim.

(3) Medicaid reimbursement for items provided on a rental basis is limited as follows:

(a) Total Medicaid rental reimbursement for items listed in Medicare's capped rental program or classified by Medicare as routine and inexpensive rental will be limited to 105% of the purchase price for that item. Monthly rental fees will be limited to 10% of the purchase price for the first three months and 7.5% of the remaining months and payments will be limited up to 13 months or less as outlined in chapter 5 of the Region D Medicare Supplier Manual.

(i) For purposes of this limit, the purchase price is the purchase fee specified in the department's fee schedule established under ARM 37.86.1807.

(ii) Interruptions in the rental period of less than 60 days will not result in the start of a new 13-month period or new purchase price limit, but periods in which service is interrupted will not count toward the 13-month limit.

(iii) A change in supplier during the 13-month period will not result in the start of a new 13-month period or new purchase price limit. Providers are responsible to investigate whether another supplier has been providing the item to the recipient and Medicaid will not notify suppliers of this information. The provider may rely upon a separate written statement of the recipient that another supplier has not been providing the item, unless the provider has knowledge of other facts or information indicating that another supplier has been providing the item. The supplier providing the item in the thirteenth month of the rental period is responsible to transfer ownership to the recipient.

(iv) If rental equipment is changed to different but similar equipment, the change will not result in the start of a new 13-month period or new 120% of purchase price limit, unless:

(A) the change in equipment is medically necessary as a result of a substantial change in the recipient's medical condition;

(B) a new certification of medical necessity for the new equipment is completed and signed by a physician; and

(b) During the 13-month rental period, Medicaid rental reimbursement includes all supplies, maintenance, repair, components, adjustments, and services related to the item during the rental month. Separately billable supplies allowed by Medicare will be reimbursed by Medicaid as outlined in the most current Region D Medicare Supplier Manual. No additional amounts related to the item may be billed or reimbursed for the item during the 13-month rental period. The supplier providing the rental equipment during the rental period is responsible for all maintenance and servicing of the equipment.

(c) After 13 months rental, the recipient will be deemed to own the item and the provider must transfer ownership of the item to the recipient. After the 13-month rental period, the provider may bill separately for supplies, maintenance, repair, components, adjustments, and services related to the item, subject to the requirements of these rules, except that repair charges are not reimbursable during the manufacturer's warranty period.

(d) All rentals will be paid on a monthly basis, except phototherapy (bilirubin) lights which will be reimbursed at a daily rental rate.

(i) Medicaid will pay an entire monthly rental fee for the initial month of rental even if less than a full month. When a rental extends into a second or subsequent month, Medicaid will pay a rental fee for a partial month only if the partial month period is at least 15 days.

(e) Items classified by Medicare as needing frequent and substantial servicing will be reimbursed by Medicaid on a monthly rental basis only. The cap specified in (3)(a) does not apply and rental reimbursement may continue as long as the item is medically necessary.

(f) If the purchase of a rental item is cost effective, the department may negotiate with the provider to purchase the item.

(4) If no purchase fee has been set for a purchase item but a monthly rental fee has been set, Medicaid reimbursement for purchased items shall be limited to ten times the monthly rental fee established in accordance with ARM 37.86.1807.

(5) The department may contract with providers of prosthetic devices, durable medical equipment and medical supplies to be sole providers of a specific item in a geographic area.

(6) Medical coverage of diapers is limited to 180 diapers per recipient per month.

(7) Purchased breast pumps are paid by the department through a single-volume purchase contract.

(1) Providers must bill for prosthetic devices, durable medical equipment, medical supplies and related maintenance, repair and services using the procedure codes and modifiers set forth and according to the definitions contained in the Centers for Medicare and Medicaid Services' (CMS) Healthcare Common Procedure Coding System (HCPCS). Information regarding billing codes, modifiers and HCPCS is available upon request from the Department of Public Health and Human Services, Health Resources Division, 1401 East Lockey, P.O. Box 202951, Helena, MT 59620-2951.

(2) Prosthetic devices, durable medical equipment, and medical supplies will be reimbursed in accordance with the department's Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) Fee Schedule, as provided in ARM 37.85.105(3), which is adopted and incorporated by reference.

(3) The department's DMEPOS Fee Schedule for items other than those billed under generic or miscellaneous codes as described in (1) will include fees set and maintained according to the following methodology:

(a) 100% of the Medicare region D allowable fee;

(b) 100% of the Medicaid allowable fee established by the department if there is no Medicare region D allowable fee established; or

(c) Except as provided in (4), for all items for which no Medicare or Medicaid allowable fee is available, the department's fee schedule amount will be 75% of the provider's usual and customary charge.

(i) For purposes of (3)(c) and (4), the amount of the provider's usual and customary charge may not exceed the reasonable charge usually and customarily charged by the provider to all payers.

(A) The charge will be considered reasonable if less than or equal to the manufacturer's suggested list price.

(B) For items without a manufacturer's suggested list price, the charge will be considered reasonable if the provider's acquisition cost from the manufacturer is at least 50% of the charge amount.

(C) For items that are custom fabricated at the place of service, the amount charged will be considered reasonable if it does not exceed the average charge of all Medicaid providers by more than 20%.

(D) For rental items, the reasonable monthly charge may not exceed a percentage of the reasonable purchase charge, as specified in ARM 37.86.1806(3).

(ii) Items having no product retail list price, such as items customized by the provider, will be reimbursed at 75% of the provider's usual and customary charge as defined in (3)(b)(i).

(4) The department's DMEPOS Fee Schedule, referred to in ARM 37.86.1807(2), for items billed under generic or miscellaneous codes as described in (1) will be 75% of the provider's usual and customary charge as defined in (3)(b)(i).

(1) Providers must bill for prosthetic devices, durable medical equipment, medical supplies and related maintenance, repair and services using the procedure codes and modifiers set forth and according to the definitions contained in the centers for Medicare and Medicaid Services' (CMS) Healthcare Common Procedure Coding System (HCPCS). Information regarding billing codes, modifiers and HCPCS is available upon request from the Department of Public Health and Human Services, Health Resources Division, 1400 Broadway, P.O. Box 202951, Helena, MT 59620-2951.

(2) Prosthetic devices, durable medical equipment, and medical supplies shall be reimbursed in accordance with the department's Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) Fee Schedule, effective January 2008, which is adopted and incorporated by reference. A copy of the department's fee schedule is posted at the Montana Medicaid provider web site at http://medicaidprovider.hhs.mt.gov. A copy of the department's Prosthetic Devices, Durable Medical Equipment, and Medical Supplies Fee Schedule may also be obtained from the Department of Public Health and Human Services, Health Resources Division, 1400 Broadway, P.O. Box 202951, Helena, MT 59620-2951.

(3) The department's DMEPOS Fee Schedule for items other than those billed under generic or miscellaneous codes as described in (1) shall include fees set and maintained according to the following methodology:

(a) 100% of the Medicare region D allowable fee;

(b) Except as provided in (4), for all items for which no Medicare allowable fee is available, the department's fee schedule amount shall be 75% of the provider's usual and customary charge.

(i) For purposes of (3)(b) and (4), the amount of the provider's usual and customary charge may not exceed the reasonable charge usually and customarily charged by the provider to all payers.

(A) The charge will be considered reasonable if less than or equal to the manufacturer's suggested list price.

(B) For items without a manufacturer's suggested list price, the charge will be considered reasonable if the provider's acquisition cost from the manufacturer is at least 50% of the charge amount.

(C) For items that are custom fabricated at the place of service, the amount charged will be considered reasonable if it does not exceed the average charge of all Medicaid providers by more than 20%.

(D) For rental items, the reasonable monthly charge may not exceed a percentage of the reasonable purchase charge, as specified in ARM 37.86.1806(3).

(ii) Items having no product retail list price, such as items customized by the provider, will be reimbursed at 75% of the provider's usual and customary charge as defined in (3)(b)(i).

(4) The department's DMEPOS Fee Schedule, referred to in ARM 37.86.1807(2), for items billed under generic or miscellaneous codes as described in (1) shall be 75% of the provider's usual and customary charge as defined in (3)(b)(i).

(1) "Optometric services" means services provided by a licensed optometrist that are within the scope of practice. Optometric services include visual training.

(1) These requirements are in addition to the rule provisions generally applicable to Medicaid providers.

(2) The department hereby adopts and incorporates by reference the definitions found in the introduction of Physicians Current Procedural Terminology, fourth edition (CPT 4), published by the American Medical Association of Chicago, Illinois. These materials set forth meanings of terms commonly used by the Montana Medicaid program in implementation of the program's optometric schedule. A copy of the definitions herein incorporated may be obtained through the Department of Public Health and Human Services, Health Resources Division, P.O. Box 202951, 1400 Broadway, Helena, MT 59620-2951. Providers must bill for services using the procedure codes, and modifiers set forth, and according to the definitions contained in the Health Care Financing Administration's Common Procedure Coding System (HCPCS). Information regarding billing codes, modifiers and HCPCS is available upon request from the Health Resources Division at the address stated above.

(3) A Medicaid member under 21 years of age is limited to one eye examination for determination of refractive state per 365-day period. A Medicaid member 21 years of age or older is limited to one eye examination for determination of refractive state per 730-day period unless one of the following circumstances exist:

(a) following cataract surgery more than one examination during the 365-day period is necessary; or

(b) the provider determines by screening that a loss of one line acuity has occurred with present glasses.

(1) Subject to the requirements of this rule, the department will pay the lowest of the following for optometric services:

(a) the provider's usual and customary charge for the service or item;

(b) the reimbursement provided in accordance with the methodologies described in ARM 37.85.212; or

(2) For items or services where no RBRVS or Medicare is available, the fee schedule amount in (1)(c) will be calculated using the following methodology:

(b) For supplies or equipment, reimbursement will be set at 75% of the manufacturer's suggested retail price. For items without a manufacturer's suggested retail price, the charge will be considered reasonable if the provider's acquisition charge from the manufacturer is at least 50% of the charge amount. For items that are custom-fabricated at the place of service, the amount charged will be considered reasonable if it does not exceed the average charge of all Medicaid providers by more than 20%.

(c) For services where utilization cannot meet the methodology outlined in (a), the fee shall be set at the same rate as a service similar in scope.

(3) To address problems of access to optometric services, a provider rate of reimbursement adjustment is provided in ARM 37.85.105(2)(h).

(1) Eyeglasses mean corrective lens and/or frames prescribed by an ophthalmologist or by an optometrist, to aid and improve vision.

(a) Corrective lenses also include contact lenses.

(1) These requirements are in addition to the rule provisions generally applicable to Medicaid providers.

(2) The dispensing service may be provided by an ophthalmologist, an optometrist, an optician, or their employees within the scope of their professional practice allowed by law.

(3) Ophthalmologists, optometrists, opticians, or their employees dispensing eyeglasses and ophthalmologists or optometrists, or their employees dispensing contact lenses must bill for services using the procedure codes and modifiers set forth, and according to the definitions contained, in the Health Care Financing Administration's Common Procedure Coding System (HCPCS). Information regarding billing codes, modifiers and HCPCS is available upon request from the Department of Public Health and Human Services, Health Services Division, 1400 Broadway, P.O. Box 202951, Helena, MT 59620-2951.

(4) A member under 21 years of age is limited to one pair of eyeglasses per 365-day period and a member 21 years of age or older is limited to one pair of eyeglasses every 730-day period.

(5) A member may receive additional lenses in the following circumstances:

(a) cataract surgery;

(b) .50 diopter change in correction in sphere;

(d) .5 prism diopter change in vertical prism;

(e) .50 diopter change in the near reading power;

(f) a minimum of a 5 degree change in axis of any cylinder less than or equal to 3.00 diopters;

(g) a minimum of a 3 degree change in axis of any cylinder greater than 3.00 diopters; or

(h) any 1 prism diopter or more change in lateral prism.

(6) A member may obtain replacement lenses only 365 days after the existing eyeglasses were dispensed if the lenses are unusable.

(7) The following lens features are not covered:

(a) photochromatic or transition lenses;

(b) progressive lenses;

(d) scratch resistant coating;

(e) anti-reflective coating;

(f) polycarbonate lenses except for monocular members; and

(g) tinted lenses except for rose 1 or rose 2.

(8) If a member is unable to wear bifocals because of a diagnosed medical condition and a provider requests an exception:

(a) a member under 21 years of age may be allowed two pairs of single vision eyeglasses every 365-day period; and

(b) a member 21 years of age and older may be allowed two pairs of single vision eyeglasses every 730-day period.

(9) Contact lenses may be provided only if medically necessary.

(a) The limits stated in (5) and (6) apply to contacts.

(b) The dispensing provider must receive prior authorization from the department for contact lenses and dispensing fee.

(1) Eyeglasses are paid by the department through a single volume purchase contract.

(2) Reimbursement for contact lenses or dispensing fees is as follows:

(a) The department pays the lower of the following:

(i) the provider's usual and customary charge for the service; or

(ii) the amount specified for the particular service or item in the department's Eyeglasses Fee Schedule.

(3) The department adopts and incorporates by reference the department's Eyeglasses Fee Schedule effective December 2016. A copy of the department's fee schedule is posted at the Montana Medicaid provider web site at http://medicaidprovider.mt.gov. A copy of the department's fee schedule may also be obtained from Department of Public Health and Human Services, Health Resources Division, 1400 Broadway, P.O. Box 202951, Helena, MT 59620-2951.

(1) The early and periodic screening, diagnostic and treatment services (EPSDT) are preventive health screenings, diagnostic services, and medically necessary treatment services as specified in these rules.

(2) Services provided for EPSDT purposes are only available to Medicaid eligible persons up to and including 20 years of age.

(3) Limitations on the amount, scope or duration for particular services, funded with Medicaid monies, do not apply to such services when provided to EPSDT recipients unless otherwise provided in these rules.

(4) Criteria, requirements, and limitations applicable to eligibility for and the receipt of home and community services provided under a Medicaid waiver, govern the provision of waiver and EPSDT services to persons who are eligible for both EPSDT and waiver services.

(5) Criteria, requirements and limitations generally applicable to Medicaid services, recipients, or providers, including but not limited to medical necessity requirements, experimental or cosmetic service exclusions, prior authorization, prescreening, certification or utilization review requirements, provider participation, billing or reimbursement requirements, recipient eligibility or copayment requirements, or other similar requirements or restrictions apply to EPSDT recipients, EPSDT services, and providers of services to EPSDT recipients.

(6) An EPSDT service may only be provided by a provider that is appropriate and qualified to deliver the service in accordance with the relevant and applicable educational, professional and licensing standards and requirements.

(7) An EPSDT service must be delivered in accordance with those standards and requirements applicable to the provision of the service.

(8) School based health related services may only be provided in public school districts, full-service education cooperatives and joint boards described in ARM 37.86.2231.

(9) A service, item or provider category is not available as an EPSDT service unless made available in accordance with these rules.

(1) EPSDT screening and preventive services are available in accordance with this rule.

(2) The number and timing of comprehensive health, vision, hearing and dental screenings should follow the American Academy of Pediatrics (AAP) Bright Futures schedule.

(a) Screening and preventive services must include assessments, exams, immunizations, tests, and appropriate health education.

(b) Caregiver depression screenings are covered for caregivers of children under one year of age. Appropriate evidence-based screening tools should be administered to caregivers as needed. Positive screenings must be appropriately referred for follow-up care.

(3) More frequent screening services than those specified in the AAP Bright Futures schedule are covered when considered medically necessary to determine the existence of suspected physical or mental illnesses or conditions.

(1) EPSDT eligible persons may receive any services otherwise available to persons eligible for Medicaid funded services.

(2) In addition to the services generally available to Medicaid persons, the following services are available to EPSDT eligible persons:

(a) nutrition services as provided in ARM 37.86.2209;

(b) chiropractic services as provided in ARM 37.86.2211;

(d) private duty nursing as provided in ARM 37.86.2217;

(e) mental health services for youth as provided in ARM Title 37, chapter 87;

(f) school-based health related services as provided in ARM 37.86.2230; and

(g) orientation and mobility specialist services as provided in ARM 37.86.2235.

(1) Reimbursement for an EPSDT service, except as otherwise provided in this rule, is the lowest of the following:

(a) the provider's usual and customary charge for the service;

(b) the reimbursement determined in accordance with the methodologies provided in ARM 37.85.212 and 37.86.105;

(d) for public agencies, cost based reimbursement as determined in accordance with OMB Circular A-87, Cost Principles for State, Local and Indian Tribal Governments as established and approved by the department. The department adopts and incorporates by reference the OMB Circular A-87, Cost Principles for State, Local and Indian Tribal Governments, as further amended May 14, 2004. A copy of OMB Circular A-87 may be obtained from the Department of Public Health and Human Services, Health Resources Division, 1400 Broadway, P.O. Box 202951, Helena, MT 59620-2951.

(2) Reimbursement for nutrition, private duty nursing services, and orientation and mobility specialist services are specified in the department's fee schedule. The department adopts and incorporates by reference the department's Private Duty Nursing Services EPSDT Fee Schedule, the Nutrition EPSDT Fee Schedule, and the Orientation and Mobility Specialist EPSDT Fee Schedule as provided in ARM 37.85.105(3). Reimbursement for outpatient chemical dependency treatment is outlined in ARM 37.27.912.

(3) A service for which a fee is not set in or determinable through the EPSDT provider manual, ARM 37.85.212 or 37.86.105 is reimbursed at a fee negotiated in advance of the provision of the service. A service provided before there is a negotiated fee is reimbursed at an amount determined by the department.

(4) Reimbursements for school-based health related services are specified in the School-Based Health Service Fee Schedule. Rates are adjusted to reimburse these services at the federal medical assistance percentage (FMAP) rate.

(1) Reimbursement for an EPSDT service, except as otherwise provided in this rule, is the lowest of the following:

(a) the provider's usual and customary charge for the service;

(b) the reimbursement determined in accordance with the methodologies provided in ARM 37.85.212 and 37.86.105;

(2) Reimbursement for nutrition and private duty nursing services is specified in the department's fee schedule. The department adopts and incorporates by reference the department's private duty nursing services EPSDT Fee Schedule dated July 2010 and the nutrition EPSDT Fee Schedule dated July 2010. The fee schedules are posted at http://medicaidprovider.hhs.mt.gov. Reimbursement for outpatient chemical dependency treatment is outlined in ARM 37.27.912. A copy of the Nutrition and Private Duty Nursing Services Fee Schedules may be obtained from the Department of Public Health and Human Services, Health Resources Division, 1400 Broadway, P.O. Box 202951, Helena, MT 59620-2951.

(3) Reimbursement for the therapeutic portion of therapeutic youth group home treatment services is the lesser of:

(a) the amount specified in the department's Medicaid Mental Health and Mental Health Services Plan, Individuals Under 18 Years of Age Fee Schedule adopted in ARM 37.87.901 and a direct care wage add-on, if applicable; or

(b) the provider's usual and customary charges (billed charges).

(4) Reimbursement for the therapeutic portion of therapeutic family care treatment services is the lesser of:

(b) the provider's usual and customary charges (billed charges).

(5) For purposes of (3) and (4), "patient day" means a whole 24-hour period that a person is present and receiving therapeutic youth group home or therapeutic family care services. Even though a person may not be present for a whole 24-hour period, the day of admission is a patient day. The day of discharge is not a patient day.

(6) Reimbursement will be made to a provider for reserving a therapeutic youth group home or therapeutic youth family care (other than permanency therapeutic family care) bed while the recipient is temporarily absent for a therapeutic home visit if:

(a) the recipient's plan of care documents the medical need for therapeutic home visits as part of a therapeutic plan to transition the recipient to a less restrictive level of care;

(b) the recipient is temporarily absent on a therapeutic home visit;

(c) the provider clearly documents staff contact and recipient achievements or regressions during and following the therapeutic home visit; and

(d) the recipient is absent from the provider's facility for no more than three patient days per therapeutic home visit, unless additional days are authorized by the department.

(7) No more than 14 patient days per recipient in each state fiscal year will be allowed for therapeutic home visits.

(8) A service for which a fee is not set in or determinable through the EPSDT provider manual, ARM 37.85.212 or 37.86.105 is reimbursed at a fee negotiated in advance of the provision of the service. A service provided before there is a negotiated fee is reimbursed at an amount determined by the department.

(9) Reimbursements for school-based health related services are specified in the School-Based Health Service Fee Schedule dated October 2010, which is adopted and incorporated by reference. A copy of the School-Based Health Service Fee Schedule is posted at http://medicaidprovider.hhs.mt.gov. Rates are adjusted to reimburse these services at the federal matching assistance percentage (FMAP) rate.

(10) The department will not reimburse providers for two services that duplicate one another on the same day according to the Medicaid Mental Health Plan and Mental Health Services Plan for Youth Services Excluded from Simultaneous Reimbursement (Service Matrix) adopted in ARM 37.87.901.

(11) Information regarding current reimbursement or copies of fee schedules for EPSDT services may be obtained from the Department of Public Health and Human Services, Health Resources Division, 1400 Broadway, P.O. Box 202951, Helena, MT 59620-2951.

(1) Nutrition services may include:

(a) nutrition counseling for counseling directly with a child, or with a responsible care giver, to explain the nutrition assessment and to implement a plan of nutrition care;

(b) nutrition assessment for evaluation of a child's nutritional problems, and design of a plan to prevent, improve or resolve identified nutritional problems, based upon the health objectives, resources and capacity of the child;

(c) nutrition consultation for consultation with or for health professionals, researching or resolving special nutrition problems or referring a child to other services, pertaining to the nutritional needs of a child; or

(d) nutrition education for routine education for normal nutritional needs.

(1) Chiropractic services are limited to evaluation and management office visits, manual manipulation of the spine, and x-rays to support the diagnosis of subluxation of the spine.

(2) There must be documented medical necessity for chiropractic services by the child's primary care provider and the treatment must be directly related to a neuromuscular diagnosis of the spine.

This rule has been repealed.

(1) Private duty nursing services are limited to:

(a) skilled nursing services provided directly to a child; and

(b) patient-specific training provided to a registered nurse or licensed practical nurse when a child is new to the nursing agency, when a change in the condition of a child requires additional training for the current nurse, or when a change in nursing personnel requires a new nurse to be trained to care for a child.

(2) Private duty nursing services do not include:

(a) psychological or mental health counseling;

(b) nurse supervision services including chart review, case discussion, or scheduling by a registered nurse;

(d) services provided to allow the client's family or caregiver to work or to go to school; or

(e) services provided to allow respite for caregivers or the client's family.

(3) Private duty nursing services must be authorized prior to the initial provision of services and any time the condition of the client changes resulting in a change to the amount of skilled nursing services being provided. Authorization must be renewed with the department, or the department's designated review agent, every 90 days during the first six months of services, and every six months thereafter.

(a) Authorization for private duty nursing services provided through school districts may be authorized for the duration of the regular school year. Services provided during the summer months are additional services that require separate prior authorization.

(4) Authorization is based on approval of a plan of care by the department or department's designated review agent.

(5) A provider of private duty nursing services must be an incorporated entity meeting the legal criteria for independent contractor status that either employs or contracts with nurses for the provision of nursing services. The department does not contract with or reimburse individual nurses as providers of private duty nursing services.

(6) Private duty nursing services provided to an eligible client by a person who is the client's legally responsible person as that term is used in this rule must be prior authorized by the department or its designee.

(a) For purposes of this rule, "legally responsible person" means a person who has a legal obligation under the provisions of Montana law to care for another person. Legally responsible person includes the parents (natural, adoptive, or foster) of minor children, legally assigned caretaker relatives of minor children, and spouses.

(b) For private duty nursing services provided to a Medicaid client by a person who is legally responsible for the Medicaid client, the department will approve no more than 40 hours of services under the EPSDT program in a seven day period. The legally responsible person must meet the department's criteria for providing PDN services. The individual must be a licensed RN or LPN and be employed by an agency enrolled to provide private duty nursing services.

This rule has been repealed.

(1) School-based services for the purposes of Medicaid are defined as medically necessary services provided through a public school district, joint board, or cooperative. The public school district or cooperative must receive funds from the state general fund for the purpose of providing special education.

(2) School-based health related services may include:

(a) physical therapy;

(b) speech-language pathology and audiology;

(d) private duty nursing;

(e) personal care paraprofessional services;

(f) licensed psychologist services;

(g) school psychologist services;

(h) licensed clinical social worker services;

(i) licensed professional counselor services;

(j) comprehensive school and community treatment;

(k) specialized transportation; and

(l) orientation and mobility specialist services.

(3) School-based health related services provided in the school to a child with disabilities, as that term is defined in Title 20, chapter 7, part 4, MCA, are eligible for Medicaid reimbursement when those services are required by the child's Individualized Education Program (IEP). The IEP is considered the order for health related services.

(4) School-based health related services include services that are not required by an IEP but are provided by schools to students for a fee and billed under the student's name. Schools cannot bill Medicaid for services not required by an IEP that are provided free to other children.

(5) All health related services billed to Medicaid must have PASSPORT approval with the exception of mental health related services and school-based health services.

(1) Only public school districts, full-service education cooperatives (established under 20-3-351 , MCA) and joint boards are eligible for enrollment and participation in the school based Montana Medicaid program.

(2) To qualify, the district, cooperative or joint board must receive special education funding from the state's general fund for the purpose of providing public education.

(3) School districts include only elementary, high school, and K-12 districts organized to provide public educational services under the jurisdiction of a board of trustees as provided in Title 20, MCA.

(4) Full-service education cooperatives and joint boards include only those cooperatives and joint boards eligible to receive direct state aid payments from the superintendent of public instruction for the purpose of providing special education services consistent with the provisions of Title 20, MCA.

(5) Cooperatives, joint boards and nonpublic schools that do not receive state general funds for special education do not meet the criteria for Medicaid enrollment and cannot participate in the Medicaid program as a school-based provider.

(1) Personal care paraprofessional services are medically necessary in-school services provided to Medicaid clients whose health conditions cause them to be functionally limited in performing activities of daily living.

(2) Personal care includes assistance with activities of daily living which include:

(a) grooming;

(b) transferring;

(d) eating;

(e) dressing;

(f) toileting; and

(g) bus escort for children with functional limitations.

(3) Personal care services do not include:

(a) any skilled services that require professional medical personnel; and

(b) instruction, tutoring or guidance in academics.

(4) Personal care service provided by an immediate family member will not be reimbursed. The term immediate family member includes:

(a) parent or stepparent;

(b) foster parent; or

(1) School psychologist services are those services provided by an individual with a class 6 specialist license with a school psychologist endorsement, as required by ARM 10.57.434.

(2) School psychologists may perform medically necessary evaluation and counseling services. Counseling services may be provided to individuals or groups.

(3) Group counseling and therapy services provided by a school psychologist must have no more than eight individuals participating in the group.

(4) When an eligible child receives school psychologist services and the psychologist consults with the parent as part of the child's treatment, time spent with the parent may be billed to Medicaid under the child's name. The provider shall indicate on the claim that the child is the patient and state the child's diagnosis.

(5) Services considered educational are not a covered benefit under Medicaid.

(1) Coverage of specialized transportation is limited to school-based transportation of clients with disabilities for the purpose of obtaining nonemergency medical services covered by the Medicaid program.

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(a) The client must be in need of specialized transportation due to the client either being wheelchair-bound or subject to transport by stretcher.

(2) Coverage of specialized transportation is not available if another mode of transportation is appropriate for the transport of the client and is less costly.

(3) Specialized transportation services must be listed in the Medicaid client's Individualized Education Plan (IEP) .

(4) Specialized transportation services may only be reimbursed by Medicaid if the Medicaid client receives a Medicaid covered service listed in his or her IEP on the day transportation is provided.

(1) Orientation and Mobility Specialist Services are those services provided by an individual with:

(a) a certification from the Academy for Certification of Vision Rehabilitation and Education Professionals (ACVREP); or

(b) a National Orientation and Mobility Certification (NOMC) offered by the National Blindness Professional Certification Board (NBPCB) to Medicaid clients with a diagnosis of a visual impairment.

(2) Orientation and Mobility Specialist Services are medically necessary services provided to Medicaid clients whose blindness and visual impairment cause them to need vision-assisted services.

(1) "Per diem" means financial assistance with expenses for a Medicaid recipient's meals and lodging enroute to and from, and while receiving medically necessary medical care.

(2) "Prior authorization" means the department or its designee's review and approval of the medical necessity and coverage of a service prior to delivery of the service.

(3) "Transportation service" means travel furnished by common carrier or private vehicle.

(a) Transportation service does not include ambulance services or specialized nonemergency medical transportation services for persons with disabilities.

(b) A motor carrier operated by the Indian Health Service or by a federally recognized Indian Tribe which meets all applicable standards for a class B public service commission license need not obtain such a license to be enrolled as a Medicaid provider under (3).

(1) These requirements are in addition to those rule provisions generally applicable to Medicaid providers.

(2) Coverage of transportation and per diem is limited to transportation and per diem necessary to obtain necessary medical services covered by the Medicaid program.

(3) Coverage for transportation and per diem is only available for transportation and per diem to the site of medical services at the provider closest to the locality of the recipient.

(a) The closest provider is determined based on equivalent licensure or certification from the appropriate national or state licensing board without consideration of continuing education credits or units.

(b) The closest provider is determined using providers who are currently accepting Medicaid recipients regardless of any individual client's:

(i) noncompliance with medical treatment plans;

(ii) financial or legal actions pending or filed against the provider; or

(iii) behavior (including but not limited to aggressive, inappropriate communication, failure to keep appointments or to arrive for appointments on time) that may have caused an individual not to be accepted as a patient in a particular practice.

(c) Transportation and per diem to a site, other than the one nearest to the locality of the recipient, is available if the combined total cost to the Medicaid program of medical services and transportation and per diem at the more distant site is less than the total cost to the Medicaid program for the provision of the services in the closest location, or to a Center of Excellence, as defined in ARM 37.86.2901, if prior authorization requirements have been met.

(4) Private vehicle transportation is limited to mileage reimbursement. Reimbursement is not available for any other private vehicle costs or fees.

(5) Coverage of per diem is not available when a round trip can reasonably be made in one day.

(6) Coverage of nonemergent transportation and per diem must be prior authorized by the department or its designee.

(a) If a medical appointment has been rescheduled, any prior authorization of the original appointment does not apply to the rescheduled appointment. Prior authorization must be obtained for the rescheduled appointment.

(7) Coverage of emergent transportation and per diem must be authorized by the department or its designee.

(a) Notification of emergent transportation must be received by the department or its designee within 30 days of the initial emergency treatment.

(8) Reimbursement for transportation is made to the common carrier unless otherwise authorized by the department or its designee.

(9) Coverage of transportation is limited to the least expensive available mode of transportation suitable to the recipient's medical needs plus any applicable per diem.

(10) Coverage of transportation and per diem are not available for transportation and per diem costs incurred during a retroactive eligibility period.

(11) Coverage of transportation and per diem for an attendant is only available for an attendant that is determined to be medically necessary.

(a) Use of an attendant must be prior authorized by the department or its designee.

(b) Coverage of transportation and per diem for an attendant is limited to the same standards and fees as for a recipient.

(c) An attendant must return home after accompanying the recipient to the destination for provision of medical services unless the department or its designee determine that the cost of the attendant's stay for the recipient's course of treatment will be less than the cost of additional transportation costs resulting from the return to home.

(d) Coverage of per diem and transportation is available for a responsible adult to accompany a minor.

(12) If a recipient dies enroute to or during treatment outside of the recipient's community, the cost of the recipient's transportation to the medical service is reimbursable. The cost of returning the body of a deceased recipient is not reimbursable.

(13) Mileage reimbursement is rounded to the nearest whole mile.

(14) Prior authorization is not a guarantee of payment as the department may subsequently deny payment based on factors other than medical necessity, including but not limited to ineligibility of the individual to whom services were provided or failure to comply with billing requirements set forth in ARM 37.85.406 or with any other Medicaid rule or requirement.

(15) Commercial providers are required to maintain and retain original dispatch records for services provided to a Montana Medicaid recipient that include:

(a) name of recipient;

(b) originating address;

(d) date;

(e) time;

(f) authorized units;

(g) charges; and

(h) the authorization number.

(1) The department pays the lower of the following reimbursement rates for transportation services:

(a) the provider's actual submitted charge; or

(b) the department's Personal and Commercial Transportation Fee Schedule adopted in this rule.

(2) The department adopts and incorporates by reference the department's Montana Medicaid Fee Schedule, Personal and Commercial Transportation as provided in ARM 37.85.105(3) that sets forth the reimbursement rates for transportation, per diem, and other Medicaid services.

(3) No payment is available for personal vehicle mileage or per diem costs that total less than $5 in a calendar month.

(4) Reimbursement for transportation and per diem may not exceed the reimbursement as calculated and specified by the department in the prior authorization.

(5) Mileage for transportation in a personally owned vehicle is reimbursed at the rate provided in the department's personal and commercial transportation fee schedule.

(1) Specialized nonemergency transportation means transportation service by a provider with a class B public service commission license allowing the provider to transport physically disabled individuals.

(a) A motor carrier operated by the Indian Health Service or by a federally recognized Indian Tribe which meets all applicable standards for a class B public service commission license need not obtain such a license to be enrolled as a Medicaid provider under (1).

(2) "Wheelchair bound" means individuals cannot mobilize without a wheelchair and are not able to get into or out of the wheelchair without assistance.

(3) "Prior authorization" means the department or its designee's review and approval of the medical necessity and coverage of a service prior to delivery of the service.

(1) These requirements are in addition to those rule provisions generally applicable to Medicaid providers.

(2) Coverage of specialized nonemergency medical transportation is limited to transportation of persons with disabilities for the purpose of obtaining nonemergency medical services covered by the Medicaid program.

(a) The person must be in need of specialized transportation due to the person either being wheelchair-bound or subject to transport by stretcher.

(3) Coverage of specialized nonemergency medical transportation is not available if another mode of transportation is appropriate for the transport of the recipient and is less costly.

(4) Coverage of specialized nonemergency medical transportation is not available for costs for the service incurred during a retroactive eligibility period.

(5) Mileage reimbursement is rounded to the nearest whole mile.

(6) Coverage of specialized nonemergency medical transportation is limited to mileage fees and does not include any other fees. Reimbursement is not available for other fees.

(7) Specialized nonemergency medical transportation services must be prior authorized by the department or its designee.

(8) Commercial providers are required to maintain and retain original dispatch records for services provided to a Montana Medicaid recipient that include:

(a) name of recipient;

(b) originating address;

(d) date;

(e) time;

(f) authorized units;

(g) charges; and

(h) the authorization number.

(1) The department pays the lower of the following for specialized nonemergency medical transportation services:

(a) the provider's usual and customary charge; or

(b) the department's fee schedule.

(2) The department adopts and incorporates by reference the department's fee schedule as provided in ARM 37.85.105(3) that sets forth the reimbursement rates for specialized nonemergency medical transportation services and other Medicaid services.

(1) "Air ambulance services" means ambulance services provided by aircraft. There are two categories of air ambulance services, namely, fixed wing (airplane) and rotary wing (helicopter) aircraft.

(a) Fixed wing air ambulance services are furnished when the recipient's medical condition is such that transport by ground ambulance, in whole or in part, is not appropriate. Generally, transport by fixed wing air ambulance may be necessary because the recipient's condition requires rapid transport to a treatment facility, and either great distances or other obstacles, for example, heavy traffic, preclude such rapid delivery. Transport by fixed wing air ambulance may also be necessary because the recipient is inaccessible by land or water ambulance vehicle.

(b) Rotary wing air ambulance services are furnished when the recipient's medical condition is such that transport by ground ambulance, in whole or in part, is not appropriate. Generally, transport by rotary wing air ambulance may be necessary because the recipient's condition requires rapid transport to a treatment facility, and either great distances or other obstacles, for example, heavy traffic, preclude such rapid delivery. Transport by rotary wing air ambulance may also be necessary because the recipient is inaccessible by land or water ambulance vehicle.

(2) "Ambulance" means a vehicle that:

(a) is specifically designed for transporting the sick or injured;

(b) contains a stretcher, linens, first aid supplies, oxygen equipment, and other lifesaving equipment required by state or local laws; and

(3) "Ambulance services" means services provided by a licensed ambulance provider in the ground or air transportation of a sick or injured person in a specially designed and equipped vehicle as defined above, which includes a trained ambulance attendant who is licensed or certified as required by state law.

(4) "Appropriate facility" means an institution equipped to provide the required hospital or nursing care for the illness or injury involved. In the case of a hospital, it also means that a physician or a physician specialist is available to provide the necessary care required to treat the patient's condition. However, the fact that the patient's personal physician does not have staff privileges in a hospital is not a consideration in determining whether the hospital is an appropriate facility.

(5) "Emergency services" means services provided after the sudden onset of a medical condition manifesting itself by acute symptoms of such severity (including severe pain) that the absence of immediate medical attention could reasonably be expected to result in placing the patient's health in serious jeopardy, serious impairment to bodily functions, or serious dysfunction of any bodily organ or part.

(6) "Ground ambulance services" means ambulance services provided by a vehicle designed to operate on the ground, including both water and land. Ground ambulance services include:

(a) Basic life support (BLS), which includes, when medically necessary, the provision of BLS services as defined in the national EMS education and practice blueprint for the EMT-basic, including other basic life support services, or the ambulance must be staffed by an individual who is qualified in accordance with state and local laws as an emergency medical technician-basic (EMT-basic);

(b) Basic life support emergency, which is furnished, when medically necessary, as specified above in (6)(a), in response to an emergency as defined in this rule;

(c) Advanced life support, level 1 (ALS1), which includes, when medically necessary, provision of an assessment by an ALS provider trained to the level of the emergency medical technician-intermediate or paramedic as defined in the national EMS education and practice blueprint or in accordance with state and local laws or the provision of one or more ALS interventions, that is, a procedure beyond the scope of an EMT-basic as defined in (6)(a). An ALS assessment does not necessarily result in a determination that the patient requires an ALS level of service.

(d) Advanced life support, level 1 (ALS1) emergency, which includes, when medically necessary, the provision of ALS1 services specified in (6)(c) above, in response to an emergency as defined in this rule;

(e) Advanced life support, level 2 (ALS2), which includes, when medically necessary, supplies and services including the administration of at least three separate administrations of one or more different medications or the provision of at least one of the following ALS procedures:

(i) manual defibrillation/cardioversion;

(ii) endotracheal intubation;

(iii) central venous line;

(iv) cardiac pacing;

(v) chest decompression;

(vi) surgical airway;

(vii) intraosseous line;

(f) Specialty care transport (SCT), which includes, when medically necessary, for a critically-injured or ill recipient, a level of interfacility service provided beyond the scope of the paramedic. SCT is necessary when a recipient's condition requires ongoing care that must be provided by one of more health professionals in an appropriate specialty area such as nursing, medicine, respiratory care, cardiovascular care or paramedic with additional training.

(7) "Nonemergency" means all scheduled transportation, regardless of origin and destination, that does not meet the above criteria for emergency. By definition, hospital discharge trips, trips to and from end stage renal disease (ESRD) facilities for maintenance dialysis, trips to and from other outpatient facilities for chemotherapy or radiation therapy, and other diagnostic and therapeutic services are scheduled runs and, therefore, are considered to be "nonemergency" services.

(1) These requirements are in addition to those rule provisions generally applicable to Medicaid providers.

(2) Ambulance services must be provided by a licensed ambulance provider.

(3) Coverage of ambulance services is limited to transportation necessary to obtain medically necessary services from the nearest appropriate facility.

(4) Coverage for ambulance services is not available where transportation by a mode other than the ambulance could be utilized without endangering the patient's health, whether or not such other transportation is actually available.

(5) Ground ambulance service is covered when the patient's medical condition requires transportation by ambulance. The following are examples of circumstances which may be considered in determining the medical need for ground ambulance service. However, the presence or absence of any one or more of the following does not necessarily establish the medical need for the service:

(a) the patient is transported in an emergency situation, e.g., as a result of an accident or injury;

(b) the patient is unconscious or in shock;

(c) the patient requires oxygen as an emergency rather than a maintenance measure or requires other emergency treatment on the way to the destination;

(d) the patient has to remain immobile because of a fracture that has not been set or the possibility of a fracture;

(e) the patient sustains an acute stroke or myocardial infarction; or

(f) the patient is hemorrhaging.

(6) Air ambulance services are covered if:

(a) All coverage requirements for ground ambulance services as specified in this rule are met; and

(b) One of the following conditions is met:

(i) the point of pickup is inaccessible by land vehicle; or

(ii) great distances or other obstacles are involved, and getting the patient to the nearest hospital with appropriate facilities and emergency admission is essential, for example, a situation where land transportation is available, but the time required to transport the recipient by land rather than air would endanger the recipient's life or health.

(c) Air ambulance services may be covered for the transfer of a patient from one hospital to another if the transferring hospital does not have adequate facilities to provide the specialized medical services needed by the recipient and if the requirements of (6)(a) through (b)(ii) are met.

(i) Air ambulance services are not covered to transport a recipient from a hospital capable of treating the recipient to another hospital simply because the recipient or his family prefers a specific hospital or physician.

(ii) Mileage is paid only to the nearest appropriate facility.

(7) Nonemergency scheduled ambulance services must be prior authorized by the department or its designee.

(8) Medicaid benefits cease at the time of death. When a recipient is pronounced dead after an ambulance is called but before pickup, the ambulance service provided to the point of pickup is covered at the base rate. If a recipient is pronounced dead by a legally authorized individual before the ambulance is called, no payment will be made.

(9) Emergency ambulance services must be reported to the department's designee within 180 days of the emergency transport or within 180 days of the retroactive eligibility determination date, by submitting an ambulance trip report and the associated professional claim form.

(10) Prior to processing payment, the department's designated review organization will evaluate ambulance claims for emergency services for medical necessity and appropriateness by reviewing the ambulance trip report and the associated professional claim form.

(11) Mileage submitted for travel reimbursement purposes must be rounded to the nearest whole mile.

(12) Ambulance services are reimbursable only to the extent that such services are medically necessary based on the recipient's condition. Where ambulance services are reimbursable, payment will be based on the level of services provided rather than being based on the type of vehicle used, regardless of any state or local ordinances or any policies which contain requirements for ambulance staffing or furnishing of ambulance services.

(1) Except as provided in (2), the base charge specified in the department's fee schedule referred to in ARM 37.86.2605 for both basic life support (BLS) and advanced life support (ALS) ambulance services includes charges for all personnel, reusable supplies and capital equipment. This includes:

(a) The driver and attendants, including extra attendants;

(b) Nurse, physician, or nonambulance personnel in ambulance;

(i) CPR and defibrillation;

(ii) monitoring of pulse oximeter;

(iii) monitoring of vital signs;

(iv) EKG monitoring;

(v) IV and drug therapy;

(vi) intubation; and

(vii) glucometer check.

(d) ALS director;

(e) Reusable supplies, including but not limited to:

(i) ambu bag (bag valve mask);

(ii) anti-shock trousers (mast pants/suits);

(iii) cervical collar (neck immobilization item), nondisposable;

(iv) CPR board;

(v) CPR pocket mask, nondisposable; and

(vi) splints, nondisposable.

(f) Capital equipment, including but not limited to:

(i) heart monitor;

(ii) defibrillator;

(iii) aspirator (see suction);

(iv) back board;

(v) pulse oximeter;

(vi) IV pumps;

(vii) special stretchers such as:

(A) scoop stretcher;

(B) plastic stretcher;

(D) flat cot;

(viii) suction and suction equipment;

(ix) glucometer;

(x) compressor; and

(xi) nebulizer.

(g) Billing charges;

(h) Decontamination of ambulance;

(i) Emergency charge;

(j) Night charge;

(k) Transporting of portable EKG to facility or location; and

(l) Waiting time.

(2) The following are not included in base rates for BLS and ALS and are separately billable:

(a) Mileage is allowed in addition to the base rate when the patient is transported to the nearest appropriate facility.

(i) charges for mileage must be based on loaded mileage only, i.e., from the pickup of a patient to their arrival destination; and

(ii) air ambulance mileage rate is calculated per actual loaded, patient onboard, miles flown and is expressed in statute miles, not nautical miles.

(b) EKG services (the technical component for obtaining tracing only, no interpretation and report) are reimbursable as a separate service for BLS, ALS and air ambulance. The reimbursement includes all EKG supplies.

(i) this service is allowed one time per transport;

(ii) reimbursement under this code includes the following:

(A) EKG paper;

(B) electrodes; and

(c) Defibrillation disposable supplies are for supplies used when a patient is actually defibrillated. Reimbursement includes the following:

(i) lubricant/conduction gel;

(ii) wet saline gauze;

(iii) disposable electrodes;

(iv) all disposable supplies used with defibrillation; and

(v) quick patch, fast patch, etc.

(d) Routine disposable, nonreusable supplies may be covered and reimbursed separately from the ambulance base rate. A service is allowed as a one time charge per transport and includes the following supplies:

(i) bandages/dressings;

(ii) gauze/4x4s, etc.;

(iii) CPR pocket mask;

(iv) restraints;

(v) gloves;

(vi) linens (disposable);

(vii) tape;

(viii) emesis basin;

(ix) urinal;

(x) needles and syringes;

(xi) alcohol wipes;

(xii) hot/cold packs;

(xiii) elastic bandages;

(xiv) splints (disposables);

(xv) sterile water or saline for irrigation;

(xvi) chemstrips;

(xvii) disposable cervical collar;

(xviii) disposable ambu bag; and

(xix) disposable suction supplies (NC tube, tubing, canister, etc.).

(e) IV drug therapy disposable supplies may be reimbursed separately only if they are medically necessary as documented in the trip report. No payment will be made for IV supplies when they are provided merely on the basis of ambulance protocol.

(i) This service is allowed one time per transport.

(ii) Reimbursement for this service includes the following:

(A) all needles/catheters (angiocath, etc.);

(B) all IV tubing (micro, macro and specialized);

(D) alcohol wipes;

(E) betadine or other antiseptic agents;

(F) filters;

(G) IV start kits;

(H) needles and syringes; and

(I) all dressings.

(f) Drugs may be reimbursed separately only if they are medically necessary as documented in the trip report.

(i) Injectable drugs and IV solutions administered in an emergency situation during the course of a covered ambulance trip are covered as nonreusable supplies. The medical necessity of such drugs and IV solutions and the need to administer them during transport must be clearly documented.

(g) Oxygen and oxygen supplies may be reimbursed separately only if they are medically necessary as documented in the trip report. No payment will be made for oxygen or oxygen supplies when they are provided merely on the basis of ambulance protocol.

(i) This service is allowed per 1/2 hour of oxygen usage per transport.

(ii) Reimbursement includes:

(A) oxygen;

(B) disposable oxygen supplies such as:

(I) cannulas;

(II) masks;

(III) tubing (extension, etc.);

(IV) humidifier;

(V) flow meter; and

(VI) nebulizers.

(iii) The administration of oxygen itself does not satisfy the requirement that a patient needs oxygen. If the patient travels for any other reason (e.g., church, grocery store, shopping, etc.) with portable oxygen, then they are not a candidate for ambulance transportation solely because of their oxygen requirement.

(h) Esophageal intubation may be reimbursed when establishing or maintaining an open airway but is not reimbursable for administering oxygen only.

(i) reimbursement for esophageal intubation includes the following:

(A) ET tube/NT tube;

(B) tape;

(D) bite mouthpiece;

(E) all airways (oral, esophageal, nasal, etc.);

(F) disposable ambu bag; and

(G) disposable airway suction equipment (suction catheters, tips, tubing, and canister).

(1) Except as provided in (4), the department pays the lowest of the following for ambulance services:

(a) the provider's usual and customary charge for the service; or

(b) the amount listed in the department's Ambulance Fee Schedule.

(2) The department adopts and incorporates by reference the Montana Medicaid Fee Schedule, Ambulance as provided in ARM 37.85.105(3) and ARM 37.85.105(2) for drugs.

(3) For items and services for which no fee has been set in the department's fee schedule referred to in (2), reimbursement will be set by the following method:

(a) if Medicare sets a fee, the Medicare fees are applicable as the Medicaid fee; or

(b) if Medicare does not set a fee, the Medicaid fees are set by evaluating the fees of services similar in scope to the new code.

(4) For supplies or equipment, where there is no Medicare or Medicaid set fee, the provider's usual and customary charge in (1)(a) will be considered reasonable if set at 75% of the manufacturer's suggested retail price. For items without a manufacturer's suggested retail price, the charge will be considered reasonable if the provider's acquisition cost from the manufacturer is at least 50% of the charge amount.

(5) The department may reimburse providers for ambulance services to transport patients to and from out-of-state facilities at negotiated fees where the department or its designee in its discretion determines that the in-state reimbursement rates are inadequate to assure that the person will receive medically necessary services.

(1) Eligible Montana ambulance providers may receive a qualified rate adjustment (QRA) from the department for ambulance services. Eligible providers are ambulance service providers that are either owned or operated by a local government unit.

(2) For an eligible provider to receive a QRA payment, the following conditions must be met:

(a) local government funds must be transferred in accordance with the contract required by (2)(d);

(b) the funds must be certified by the city or county treasurer, or an authorized local government official, as an intergovernmental transfer of public funds that qualifies as a payment of services eligible for federal financial participation (FFP, the federal government's share of a state's expenditures under the Medicaid program) in accordance with 42 CFR 433.51 (2004);

(d) the written contract covering the requirements for the QRA payment must be executed prior to the issuance of the QRA payment. A retroactive effective date on the written agreement will not be allowed.

(3) To be eligible for FFP, the local government funds cannot be federal funds unless the federal funds are authorized by federal law to be used to match other federal funds.

(4) The QRA payment will be computed separately for all eligible ambulance providers on or before December 31, annually, using the following formula:

QRA payment = C x D x FMAP

(a) For the purposes of calculating the QRA payment amount, the following definitions apply:

(i) "C" represents the number of the provider's complete set of Medicaid paid claims for dates of service for the most recent state fiscal year filed in accordance with ARM 37.85.406;

(ii) "D" represents the difference between the Medicare and Medicaid allowed amount per the Healthcare Common Procedure Coding System (HCPCS); and

(iii) "FMAP" represents the Federal Medical Assistance Percentage (FMAP) in effect at the time of department payment. This percentage is the amount of federal participating matching funds for payment of Montana Medicaid program services. The methodology for determining this percentage is set forth in 42 USC 1396b(a) (2004). The department adopts and incorporates by reference the methodology set out in 42 USC 1396b(a) (2004). A copy of that statute may be obtained from the Department of Public Health and Human Services, Health Resources Division, P.O. Box 202951, Helena, MT 59620-2951.

(5) The QRA is subject to the following conditions:

(a) the eligible ambulance provider's local government funds must be received by the department before it will disburse the QRA payment to the provider;

(b) information submitted from the eligible ambulance provider, the local Medicare fiscal intermediary, and the Montana Medicaid Paid Claims Database will be used for calculations, utilizing data from the most recent state fiscal year with completed Medicaid paid claims data filed in accordance with ARM 37.85.406;

(c) the limited situations where there is no Medicare HCPCS code or fee schedule for the ambulance service, the billed charges from the provider will be used in the computation; and

(d) the ambulance provider is not allowed to bill Medicaid more than it bills private payers and other insurers.

(6) The QRA payment is subject to the restrictions imposed by federal law and to the availability of sufficient local government, state and federal funding.

(1) Reimbursement for inpatient hospital services is set forth in ARM 37.86.2806, 37.86.2905, 37.86.2907, 37.86.2912, 37.86.2916, 37.86.2918, 37.86.2920, 37.86.2924, 37.86.2925, 37.86.2928, 37.86.2943, and 37.86.2947. Reimbursement for outpatient hospital services is set forth in ARM 37.86.3005, 37.86.3006, 37.86.3007, 37.86.3009, 37.86.3014, 37.86.3016, 37.86.3018, 37.86.3020, 37.86.3022, 37.86.3025, 37.86.3037, and 37.86.3109. Cost of hospital services will be determined for inpatient and outpatient care separately. Administratively necessary days are not a benefit of the Montana Medicaid program.

(2) The department may require providers of inpatient or outpatient hospital services to obtain authorization from the department or its designated review organization either prior to provision of services, prior to admission, or prior to payment.

(3) Medicaid reimbursement shall not be made or shall be reduced unless the provider has obtained authorization from the department or its designated review organization prior to providing any of the following services:

(a) inpatient psychiatric services provided in an acute care psychiatric hospital, acute care general hospital or a distinct part psychiatric unit of an acute care general hospital, and outpatient partial hospitalization as required by ARM 37.88.101:

(i) if prior authorization is not obtained, the claim will be denied;

(ii) Medicare crossover claims do not need prior authorization; and

(iii) third party liability claims must be prior authorized.

(b) services related to transplantations covered under ARM 37.86.4701 and 37.86.4705:

(i) if prior authorization is not obtained, the claim will be denied;

(ii) Medicare crossover claims must be prior authorized; and

(iii) third party liability claims must be prior authorized.

(c) any other services for specific diagnosis or procedures that require all Medicaid providers to obtain prior authorization:

(i) if prior authorization is not obtained, the claim will be denied;

(ii) Medicare crossover claims must be prior authorized; and

(iii) third party liability claims must be prior authorized.

(d) inpatient services in facilities designated as a Center of Excellence and all out-of-state facilities:

(i) if prior authorization is not obtained, reimbursement of the inpatient claim will be 50% of the amount calculated in (1); except in claims subject to (3)(a), (b), and (c) will be denied;

(ii) Medicare inpatient crossover claims do not need prior authorization except claims subject to (3)(b) and (c); and

(iii) inpatient third party liability claims must be prior authorized:

(A) if prior authorization is not obtained, reimbursement of the inpatient third party liability claim will be 50% of the amount calculated in (1); except claims subject to (3)(a), (b), and (c) will be denied.

(4) Upon request, the department may grant retroactive authorization for the provision of the hospital's services when:

(a) the person to whom services were provided was determined by the department to be retroactively eligible for Montana Medicaid benefits including hospital benefits;

(b) the hospital can document that at the time of admission it did not know, or have any basis to assume, that the client was Montana Medicaid eligible;

(c) the hospital can document that the admission was medically necessary for purposes of emergency stabilization or stabilization for transfer;

(d) interim claims in a PPS hospital equal to or greater than 30 days of continuous inpatient services at the same facility; or

(e) the hospital is retroactively enrolled as a Montana Medicaid provider, and the enrollment includes the dates of service for which authorization is requested provided the hospital's retroactive enrollment is completed allowing time for the hospital to obtain prior authorization and to submit a clean claim within timely filing deadlines in accordance with ARM 37.85.406.

(5) For purposes of (4)(a), (b), and (c) the hospital must call for authorization within three working days (Monday through Friday) of the admission or the date it gained knowledge of the client's Medicaid eligibility and must meet the requirements for timely filing as specified in ARM 37.85.406:

(a) the basis for the request must be documented in the client's hospital record; and

(b) providers seeking retroactive authorization for adult mental health claims must submit their requests in writing.

(6) The department or its designated review organization may approve a request for prior authorization when the service is medically necessary under any of the following conditions:

(a) the client travels to another state because the department finds the required inpatient services are not available in Montana, or it is determined by the department that it is general practice for clients in a particular locality to use inpatient resources in a border hospital, or an in-state qualified provider who could normally render the inpatient service but does not think they can adequately treat the client;

(b) there is a medical emergency and the recipient's health would be endangered if the client were required to travel to Montana to obtain the medical services;

(c) the client, or the client's representative, can demonstrate to the satisfaction of the department that medical services represent the least costly service and all other viable alternatives have been exhausted per medical standards of care; or

(d) the client is a child residing in another state for whom Montana makes adoption assistance or foster care maintenance payments.

(7) Medicaid reimbursement for early elective delivery and nonmedically necessary cesarean sections will not be made unless the hospital submitting the claim meets the following requirements:

(a) Effective July 1, 2014, a hospital submitting claims for deliveries must have a hard stop policy regarding early elective deliveries and nonmedically necessary cesarean sections that complies with the requirements in ARM 37.86.2902(9).

(b) Effective October 1, 2014, hospital claims for inductions and cesarean sections must meet the following coding requirements:

(i) current ICD inpatient procedure codes must be used on all inpatient hospital claims; and

(ii) claims for inductions or cesarean sections must have one of the following condition codes:

(A) Condition Code 81�cesarean section or induction performed at less than 39 weeks for medical necessity;

(B) Condition Code 82�cesarean section or induction performed at less than 39 weeks gestation elective; or

(iii) The department will begin accepting these coding changes as of July 1, 2014.

(c) Beginning October 1, 2014, the department will reduce reimbursement to hospitals that perform early elective inductions or cesarean sections prior to 39 weeks and 0/7 days gestation, or nonmedically necessary cesarean sections at any gestation:

(i) a 33% reduction in PPS reimbursement; or

(ii) cost-based hospital interim reimbursement will be reduced 33% and the total claim payment will not be eligible for final reimbursement through cost settlement as provided in ARM 37.86.2806.

(8) All hospitals must use current ICD procedure codes for inpatient claims and current CPT codes for outpatient claims, including Medicare crossover claims.

(1) Allowable costs will be determined in accordance with generally accepted accounting principles as defined by the American Institute of Certified Public Accountants.

(a) The department adopts and incorporates by reference CMS Publication 15, which is a manual published by the United States Department of Health and Human Services, Centers for Medicare and Medicaid Services (CMS), which provides guidelines and policies to implement Medicare regulations which set forth principles for determining the reasonable cost of provider services furnished under the Health Insurance for Aged Act of 1965, as amended. A copy of CMS Publication 15 may be obtained through the Department of Public Health and Human Services, Health Resources Division, 1400 Broadway, P.O. Box 202951, Helena, MT 59620-2951.

(b) For cost report periods occurring on or after May 1, 2010, such definition of allowable costs is further defined in accordance with the Medicare Provider Reimbursement Manual, CMS Publication 15, Form 2552-10, subject to the exceptions and limitations provided in the department's administrative rules.

(c) For cost report periods occurring prior to May 1, 2010, such definition of allowable costs is further defined in accordance with the Medicare Provider Reimbursement Manual, CMS Publication 15, Form 2552-96, subject to the exceptions and limitations provided in the department's administrative rules.

(d) For cost report periods ending January 1, 2006 through December 31, 2017, for each hospital which is a critical access hospital, as defined in ARM 37.86.2901, reimbursement for reasonable costs of inpatient and outpatient hospital services shall be limited to 101% of allowable costs, as determined in accordance with (1).

(e) For cost report periods ending January 1, 2018 through June 30, 2018, for each hospital which is a critical access hospital, as defined in ARM 37.86.2901, reimbursement for reasonable costs of inpatient and outpatient hospital services will be limited to 97.98% of allowable costs, as determined in accordance with (1).

(f) For cost report periods ending on or after July 1, 2018, for each hospital which is a critical access hospital, as defined in ARM 37.86.2901, reimbursement for reasonable costs of inpatient and outpatient hospital services will be limited to 101% of allowable costs, as determined in accordance with (1).

(2) All hospitals reimbursed under ARM 37.86.2806, 37.86.2905, 37.86.2907, 37.86.2912, 37.86.2916, 37.86.2918, 37.86.2920, 37.86.2924, 37.86.2925, 37.86.2928, 37.86.2943, 37.86.2947, 37.86.3005, 37.86.3006, 37.86.3007, 37.86.3009, 37.86.3014, 37.86.3016, 37.86.3018, 37.86.3020, 37.86.3022, 37.86.3025, or 37.86.3109 must submit, as provided in (3), an annual Medicare cost report in which costs have been allocated to the Medicaid program as they relate to charges. The facility shall maintain appropriate accounting records which will enable the facility to fully complete the cost report.

(3) All hospitals reimbursed under ARM 37.86.2806, 37.86.2905, 37.86.2907, 37.86.2912, 37.86.2916, 37.86.2918, 37.86.2920, 37.86.2924, 37.86.2925, 37.86.2928, 37.86.2943, 37.86.2947, 37.86.3005, 37.86.3006, 37.86.3007, 37.86.3009, 37.86.3014, 37.86.3016, 37.86.3018, 37.86.3020, 37.86.3022, 37.86.3025, or 37.86.3109 must file the cost report with the Montana Medicare intermediary and the department on or before the last day of the fifth calendar month following the close of the period covered by the report. For fiscal periods ending on a day other than the last day of the month, cost reports are due 150 days after the last day of the cost reporting period.

(a) Extensions of the due date for filing a cost report may be granted by the intermediary only when a provider's operations are significantly adversely affected due to extraordinary circumstances over which the provider has no control.

(1) Cost-based reimbursement shall be applied as follows:

(a) Critical access hospital (CAH) interim reimbursement is based on a hospital specific Medicaid inpatient cost-to-charge ratio (CCR), not to exceed 100%. For dates of service January 1, 2018 through June 30, 2018, CAH interim reimbursement is based on a hospital-specific Medicaid inpatient cost-to-charge ratio (CCR), less 2.99%, not to exceed 100%.

(b) For cost report periods ending on or prior to December 31, 2017, CAH final reimbursement is for reasonable costs of hospital services limited to 101% of allowable costs, as determined in accordance with ARM 37.86.2803(1). For cost report periods ending January 1, 2018 through June 30, 2018, CAH final reimbursement is for reasonable costs of hospital services limited to 97.98% of allowable costs as determined in accordance with ARM 37.86.2803(1). For cost report periods ending on or after July 1, 2018, CAH final reimbursement is for reasonable costs of hospital services limited to 101% of allowable costs as determined in accordance with ARM 37.86.2803(1).

(2) Where applicable, the statewide CCR for cost-based hospitals is determined in accordance with ARM 37.86.2905(6).

(3) Cost-based hospital reimbursement for capital expenses is as determined in accordance with ARM 37.86.2912(3).

(4) Certified registered nurse anesthetist (CRNA) reimbursement for CAHs is as determined in accordance with ARM 37.86.2924.

(5) Cost-based hospitals may be eligible to receive a disproportionate share hospital (DSH) payment in accordance with ARM 37.86.2925.

(6) All diagnostic services are included in the cost-based payment. Diagnostic services that are performed at a second hospital because the services are not available at the first hospital (e.g., a CT scan) are included in the first hospital's payment. This includes transportation to the second hospital and back to the first hospital. Arrangement for payment to the transportation provider and the second hospital where the services were actually performed must be between the first and second hospital and the transportation provider.

(7) Cost-based hospital claims for clients with partial eligibility shall be billed from the first date of Medicaid eligibility.

(8) The following are cost-based hospital claims that are not eligible for final reimbursement through cost settlement:

(a) elective deliveries as set forth in ARM 37.86.2801; and

(b) services that are reimbursed at a set rate outside of the CCR.

This rule has been repealed.

(1) Upon receipt of the cost report, the department will instruct the Medicare intermediary to consider Medicaid data when they perform a desk review or audit of the cost report and determine whether a Medicaid overpayment or underpayment has resulted.

(2) For cost reporting purposes where the department finds that an overpayment has occurred, the department will notify the provider of the overpayment.

(a) The provider will have 60 days from the date of the initial notification to repay the amount of the overpayment or to have an agreed upon repayment schedule. If the provider does not repay the whole overpayment within 60 days or defaults on a payment schedule, the department will withhold any future payments the state of Montana makes to the provider. Recovery will be undertaken even though the provider disputes in whole or part the department's determination of the overpayment and requests a fair hearing.

(b) The amount of the overpayment constitutes a debt due the department as of the date of the initial notification to the provider and may be recovered from any person, party, transferee, or fiduciary who has benefited from either the payment or from the transfer of assets.

(3) For cost reporting purposes in the event an underpayment has occurred, the department will reimburse the provider within 60 days from the date of the initial notification to the provider.

(4) When the upper payment limit has been exceeded based on filed cost reports the department will recover the overpayment amount. The department will collect overpayments using the following methodology:

(a) the costs of all facilities that are over the upper payment limit will be divided by the total amount to be collected; and

(b) the percentage in (a) will be multiplied by each facility's total costs to determine the recoverable amount.

(5) Providers aggrieved by adverse determinations by the department may request an administrative review and fair hearing as provided in ARM 37.5.304, 37.5.305, 37.5.307, 37.5.310, 37.5.311, 37.5.313, 37.5.316, 37.5.322, 37.5.325, 37.5.328, 37.5.331, 37.5.334, and 37.5.337.

(1) "Acute care psychiatric hospital" means a psychiatric facility accredited by the Joint Commission on Accreditation of Health Care Organizations that is devoted to the provision of inpatient psychiatric care for persons under the age of 21 and licensed as a hospital by:

(a) the department; or

(b) an equivalent agency in the state in which the facility is located.

(2) "Administratively necessary days" or "inappropriate level of care services" means those services for which alternative placement of a client is planned and/or effected and for which there is no medical necessity for acute level inpatient hospital care.

(3) "All patient refined diagnosis related groups (APR-DRGs)" means DRGs that classify each inpatient case based on claim information such as diagnosis, procedures performed, client age, client sex, and discharge status.

(4) "Bad debt" means inpatient and outpatient hospital services provided in which full payment is not received from the client or from a third party payor, for which the provider expected payment and the persons are unable or unwilling to pay their bill. Bad debts may be for services provided to clients who have no health insurance or clients who are underinsured and are net of payments (the amount that remains after payment) made toward these services. For the purpose of uncompensated care, bad debt is measured on the basis of revenue forgone, at full established rates, and bad debt does not include either provider discounts or Medicare bad debt.

(5) "Base price" means a dollar amount, including capital expenses, that is reviewed by the department each year to allow for appropriation neutrality.

(6) "Border hospital" means a hospital located outside Montana, but no more than 100 miles from the border.

(7) "Capital related cost" means a cost incurred in the purchase of land, buildings, construction, and equipment as provided in 42 CFR 413.130.

(8) "Center of Excellence" means a hospital specifically designated by the department as being able to provide a higher level multi-specialty of comprehensive care and meets the criteria in ARM 37.86.2947(3).

(9) "Charity care" means inpatient and outpatient hospital services in which hospital policies determine the client is unable to pay and the hospital did not expect to receive full reimbursement. Charity care results from a provider's policy to provide health care services free of charge (or where only partial payment is expected) to individuals who meet certain financial criteria. For the purpose of uncompensated care, charity care is measured on the basis of revenue forgone, at full established rates. Charity care does not include contractual write-offs.

(10) "Clinical trials" means trials that are directly funded or supported by centers or cooperating groups funded by the National Institutes of Health (NIH), Center for Disease Control (CDC), Agency for Healthcare Research and Quality (AHRQ), Center for Medicare and Medicaid Services (CMS), Department of Defense (DOD), or the Veterans Administration (VA).

(11) "Cost-based hospital" means a licensed acute care hospital that is reimbursed on the basis of allowable costs.

(12) "Cost outlier" means an additional payment for unusually high cost cases that exceeds the cost outlier thresholds as set forth in ARM 37.86.2916.

(13) "Critical access hospital" means a limited-service rural hospital licensed by the Montana Department of Public Health and Human Services.

(14) "Direct nursing care" means the care given directly to the client which requires the skills and expertise of an RN or LPN.

(15) "Discharging hospital" means a hospital, other than a transferring hospital, that formally discharges an inpatient. Release of a client to another hospital, as described in (39) or a leave of absence from the hospital will not be recognized as a discharge. A client who dies in the hospital is considered a discharge.

(16) "Disproportionate share hospital" means a hospital serving a disproportionate share of low income clients as defined in section 1923 of the Social Security Act.

(17) "Disproportionate share hospital specific uncompensated care" means the costs of inpatient and outpatient hospital services provided to clients who have no health insurance or source of third party coverage.

(18) "Distinct part psychiatric unit" means a psychiatric unit of an acute care general hospital that meets the requirements of 42 CFR part 412 (2008).

(19) "Distinct part rehabilitation unit" means a rehabilitation unit of an acute care general hospital that meets the requirements in 42 CFR 412.25 and 412.29.

(20) "Early elective delivery" means either a nonmedically necessary labor induction or cesarean section that is performed prior to 39 weeks and 0/7 days gestation.

(21) "Experimental/investigational service" means a noncovered item or procedure considered experimental and/or investigational by the U.S. Department of Health and Human Services or any other appropriate federal agency.

(22) "Graduate medical education" (GME) means a postgraduate primary care residency program approved by the Accreditation Council for Graduate Medical Education (ACGME) offered by an eligible in-state hospital for the purpose of providing formal hospital-based training and education under the supervision of a licensed medical physician.

(23) "Hospital Acquired Condition (HAC)" means a condition that occurs during an inpatient hospital stay and results in a high cost or high volume of care or both; results in a claim being assigned to a diagnosis related group (DRG) that has a higher payment when present as a secondary diagnosis; and could have reasonably been prevented through the application of evidence-based guidelines as defined in Section 5001(c) of the Deficit Reduction Act of 2005.

(24) "Hospital reimbursement adjustor (HRA)" means a payment to a Montana hospital as specified in ARM 37.86.2928 and 37.86.2940.

(25) "Hospital resident" means a client who is unable to be cared for in a setting other than the acute care hospital as provided in ARM 37.86.2921.

(26) "Inpatient" means a person who has been admitted to a hospital for bed occupancy for purposes of receiving inpatient hospital services. A person generally is considered an inpatient if formally admitted as an inpatient with an expectation that the client will remain more than 24 hours. The physician or other practitioner is responsible for deciding whether the client should be admitted as an inpatient. Inpatient hospital admissions are subject to retrospective review by the department or the department's designated review organization to determine whether the inpatient admission was medically necessary for Medicaid payment purposes.

(27) "Inpatient hospital services" means services that are ordinarily furnished in an acute care hospital for the care and treatment of an inpatient under the direction of a physician, dentist, or other practitioner as permitted by federal law, and that are furnished in an institution that:

(a) is licensed or formally approved as an acute care hospital by the officially designated authority in the state where the institution is located;

(b) except as otherwise permitted by federal law, meets the requirements for participation in Medicare as a hospital and has in effect a utilization review plan that meets the requirements of 42 CFR 482.30; or

(28) "Inpatient hospital utilization fee" means the utilization fee collected by the Department of Revenue as provided in 15-66-102, MCA.

(29) "Interim claim" in a prospective payment system (PPS) hospital means a claim being billed for an inpatient hospital stay equal to or exceeding 30 days at the same facility as referenced in ARM 37.86.2905.

(30) "Long-acting reversible contraceptives (LARCs)" means intrauterine devices and contraceptive implants that provide long-acting reversible contraception.

(31) "Long term care hospital (LTCH)" means an acute care hospital as defined in 42 CFR 412.

(32) "Low income utilization rate" means a hospital's percentage rate as specified in ARM 37.86.2935.

(33) "Medicaid inpatient utilization rate" means a hospital's percentage rate as specified in ARM 37.86.2932.

(34) "Out-of-state hospital" means a hospital located more than 100 miles beyond the Montana state border.

(35) "Partial eligibility" means a client that is only eligible for Medicaid benefits during a portion of the inpatient hospital stay as specified in ARM 37.86.2918.

(36) "Present on Admission (POA)" means conditions that are present at the time a medical order for an inpatient admission occurs.

(37) "Prior authorization (PA)" means the approval process required before certain services are paid by Medicaid. Prior authorization must be obtained before providing the service.

(38) "Prospective payment system (PPS) hospital" means a hospital reimbursed pursuant to the diagnosis related group (DRG) system. DRG hospitals are classified as such by the Centers for Medicare and Medicaid Services (CMS) in accordance with 42 CFR part 412.

(39) "Relative weight" means a weight assigned from a national database from 3M that reflects the typical resources consumed per APR-DRG.

(40) "Routine disproportionate share hospital" means a hospital in Montana which meets the criteria of ARM 37.86.2931.

(41) "Rural hospital" means for purposes of determining disproportionate share hospital payments, an acute care hospital that is located within a "rural area" as defined in 42 CFR 412.62(f)(iii).

(42) "Sole community hospital" means a DRG reimbursed hospital classified as such by the Centers for Medicare and Medicaid Services (CMS) in accordance with 42 CFR 412.92(a) through (d).

(43) "Third party liability (TPL)" means any entity that is, or may be, liable to pay all or part of the medical cost of care for a Medicaid eligible client.

(44) "Transferring hospital" means a hospital that formally releases an inpatient client to another inpatient hospital or inpatient unit of a hospital.

(45) "Transplant" means to transfer either tissue or an organ from one body or body part to another as referenced in ARM 37.86.4701. A transplant may be either:

(a) "organ transplantation", the implantation of a living, viable, and functioning human organ for the purpose of maintaining all or a major part of that organ function in the client; or

(b) "tissue transplantation", the implantation of living, human tissue.

(46) "Uncompensated care" means hospital services provided in which no payment is received from the client or from a third party payor. Uncompensated care includes charity care and bad debts.

(47) "Upper payment limit" means a federal limit placed on fee-for-service reimbursement of Medicaid providers.

(48) "Urban hospital" means an acute care hospital that is located within a metropolitan statistical area, as defined in 42 CFR 412.62(f)(2).

(1) These requirements are in addition to those contained in rule provisions generally applicable to Medicaid providers.

(2) Except as otherwise permitted by federal law, inpatient hospital services must be ordered by a physician or dentist licensed under state law.

(3) Inpatient hospital services include:

(a) bed and board;

(b) nursing services and other related services;

(d) medical social services;

(e) drugs, biologicals, supplies, appliances, and equipment;

(f) other diagnostic or therapeutic items, or services provided in the hospital and not specifically excluded in ARM 37.85.207; and

(g) medical or surgical services provided by interns or residents-in-training in hospitals with teaching programs approved by the Council on Medical Education of the American Medical Association, the Bureau of Professional Education of the American Osteopathic Association, the Council on Dental Education of the American Dental Association or the Council on Podiatry Education of the American Podiatry Association.

(4) Clinical trials are limited to:

(a) Medicaid coverage of routine costs plus reasonable and necessary items and services used to diagnose and treat complications arising from participation in all qualifying clinical trials;

(b) trials that are directly funded or supported by centers or cooperating groups funded by the National Institutes of Health (NIH), Center for Disease Control (CDC), Agency for Healthcare Research and Quality (AHRQ), Department of Defense (DOD), or the Veterans Administration (VA); and

(5) Inpatient hospital services provided outside the borders of the United States will not be reimbursed by the Montana Medicaid program.

(6) Inpatient hospital providers must comply with the applicable conditions of participation for hospitals as authorized in 42 CFR 482.

(7) Acute care psychiatric hospitals must comply with 42 CFR 440.160, 42 CFR 441 subpart D, and the applicable conditions of participation for hospitals as authorized in 42 CFR 482.

(8) Effective July 1, 2014, all hospitals that perform deliveries must have a hard stop policy regarding early elective deliveries and nonmedically necessary cesarean sections. The policy must have the following parts:

(a) no nonmedically necessary inductions or cesarean sections prior to 39 weeks and 0/7 days gestation, and no nonmedically necessary cesarean sections at any gestation;

(b) confirmation of weeks gestation must be determined by the American Congress of Obstetricians and Gynecologists guidelines. At least one of the following guidelines must be met:

(i) fetal heart tones must have been documented for 20 weeks by nonelectronic fetoscope or 30 weeks by doppler;

(ii) 36 weeks since a positive serum or urine pregnancy test that was performed by a reliable laboratory; or

(iii) an ultrasound prior to 20 weeks gestation that confirms the gestational age of at least 39 weeks.

(c) if pregnancy care was not initiated prior to 20 weeks gestation, the gestational age may be documented from first day of the last menstrual period (LMP); and

(d) a multistep review process prior to all inductions and cesarean sections, including a requirement that the final decision be made by the perinatology chair/obstetrical chair, OB director, or medical director.

(1) Inpatient hospital services do not include:

(a) services excluded from coverage by the Medicaid program under ARM 37.85.207;

(b) experimental or investigational services such as, the use of off-label drugs where this usage is not a national standard of practice, or non-FDA approved use of drugs, biologicals, and devices;

(d) inpatient hospital services provided outside the borders of the United States will not be covered or reimbursed by the Montana Medicaid program.

(1) Inpatient hospital service providers shall be subject to the billing requirements set forth in ARM 37.85.406. At the time a claim is submitted, the hospital must have on file a signed and dated acknowledgment from the attending physician that the physician has received the following notice: "Notice to physicians: Medicaid payment to hospitals is based on all of each patient's diagnoses and the procedures performed on the patient, as attested to by the patient's attending physician by virtue of his or her signature in the medical record. Anyone who misrepresents, falsifies or conceals essential information required for payment of federal funds, may be subject to fine, imprisonment or civil penalty under applicable federal laws."

(2) The acknowledgment must be completed by the physician at the time that the physician is granted admitting privileges at the hospital, or before or at the time the physician admits his or her first patient to the hospital.

(3) Existing acknowledgments signed by physicians already on staff remain in effect as long as the physician has admitting privileges at the hospital.

(4) The provider may, at its discretion, add to the language of this statement the word "Medicare" so that two separate forms will not be required by the provider to comply with both state and federal requirements.

(5) Except for hospital resident cases, a provider may not submit a claim until the recipient has been either:

(a) discharged from the hospital;

(b) a patient at least 30 days, in which case the hospital may bill on the 31st day and every 30 days thereafter;

(d) designated by the department as a hospital resident as set forth in ARM 37.86.2921.

(6) Cost based hospitals may split bill at their fiscal year end.

(7) Medical records must be received within 30 days of request by the department or the department's designated review organization.

(a) Claims may be denied if the receipt of the medical records exceeds the designated time period.

(1) Prospective payment system (PPS) hospitals including in-state PPS facilities, distinct part units, border facilities, all out-of-state facilities, acute care psychiatric hospitals, and Center of Excellence facilities will be reimbursed under the All Patient Refined Diagnosis Related Groups (APR-DRG) prospective payment system described in ARM 37.86.2907, 37.86.2912, 37.86.2916, 37.86.2918, and 37.86.2920.

(2) Interim reimbursement for cost-based facilities is based on a hospital-specific Medicaid inpatient cost-to-charge ratio, not to exceed 100%. For dates of service January 1, 2018 through June 30, 2018, the interim reimbursement is based on a hospital-specific Medicaid inpatient cost-to-charge ratio, less 2.99%, not to exceed 100%. Cost-based facilities will be reimbursed their allowable costs as determined according to ARM 37.86.2803. For cost report periods ending on or prior to December 31, 2017 final cost settlements for CAH facilities will be reimbursed at 101% of allowable costs. For cost report periods ending January 1, 2018 through June 30, 2018, final cost settlements for CAH facilities will be reimbursed at 97.98% of allowable costs. For cost report periods ending on or after July 1, 2018 final cost settlements for CAH facilities will be reimbursed at 101% of allowable costs.

(3) Except as otherwise specified in these rules, facilities reimbursed under the APR-DRG prospective payment system may be reimbursed for the following:

(a) cost outliers as set forth in ARM 37.86.2916;

(b) readmissions, partial eligibility, and transfers, as set forth in ARM 37.86.2918;

(d) disproportionate share hospital payments as provided in ARM 37.86.2925; and

(e) hospital reimbursement adjustor payments as provided in ARM 37.86.2928.

(4) PPS facilities may interim bill for stays equal to or exceeding 30 days at the same hospital.

(a) The interim rate will be a flat per diem rate times the number of covered days for the claim.

(b) Upon discharge the interim claims will be voided or credited by the hospital and the hospital must bill a single admit through discharge claim which will be paid by APR-DRG.

(c) The hospital must obtain authorization to interim bill prior to submission of the first claim and must provide medical records upon request of the department or the department's designated review organization for continued stay reviews.

(5) All PPS inpatient and outpatient hospital services that occur during an inpatient stay are included in the APR-DRG grouper except:

(a) dialysis services; and

(b) long-acting reversible contraceptives (LARCs) inserted at the time of delivery.

(1) The department's APR-DRG prospective payment rate for inpatient hospital services is based on the classification of inpatient hospital discharges to APR-DRGs. The provider reimbursement rates for inpatient hospital services, except as otherwise provided in ARM 37.85.206, is stated in the department's APR-DRG fee schedule adopted and effective at ARM 37.85.105. The procedure for determining the APR-DRG prospective payment rate is as follows:

(a) The department will assign an APR-DRG to each Medicaid client discharge in accordance with the current APR-grouper program version, as developed by 3M Health Information Systems. The assignment and reimbursement of each APR-DRG is based on:

(i) the ICD-9-CM principal diagnoses for dates of discharge prior to and including September 30, 2015, and the ICD-10-CM principal diagnoses for dates of discharge October 1, 2015 and thereafter;

(ii) all ICD-9-CM secondary diagnoses for dates of discharge prior to and including September 30, 2015, and the ICD-10-CM secondary diagnoses for dates of discharge October 1, 2015 and thereafter;

(iii) all ICD-9-CM medical procedures performed during the client's hospital stay for dates of discharge prior to and including September 30, 2015, and the ICD-10-PCS medical procedures performed during the client's hospital stay for dates of discharge October 1, 2015 and thereafter;

(iv) the client's age;

(v) the client's gender;

(vi) the client's discharge status; and

(vii) diagnosis codes related to hospital-acquired conditions that are not present or undetermined to be present on admission.

(b) For each APR-DRG, the department determines a relative weight using a national database from 3M that reflects the cost of hospital resources used to treat cases. The relative weights have been recentered so that the average Montana Medicaid stay has a base weight of 1.00. Adjustments are applied to specific APR-DRG weights to reflect department policy. The relative weight for each APR-DRG is available upon request from Department of Public Health and Human Services, Health Resources Division, 1400 Broadway, P.O. Box 202951, Helena, MT 59620-2951.

(c) The department computes a Montana average base price per case. This base price includes in-state and out-of-state distinct part rehabilitation units. The effective date and base rate amount is adopted and effective as provided at ARM 37.85.105. Disproportionate share payments are not included in this price.

(d) The department computes a base price for long term acute care (LTAC) hospitals. The effective date and base rate amount is adopted and effective as provided at ARM 37.85.105. Disproportionate share payments are not included in this price.

(e) The department computes a base price for Center of Excellence hospitals. The effective date and base rate amount is adopted and effective as provided at ARM 37.85.105. Disproportionate share payments are not included in this price.

(f) The relative weight for the assigned APR-DRG is multiplied by the average base price per case to compute the APR-DRG prospective payment rate for that Medicaid client discharge.

(g) For claims with dates of payment on or after August 1, 2011, when a hospital-acquired condition occurs during hospitalization and the condition was not present or undetermined to be present on admission, claims will be paid as though the diagnosis is not present or undetermined to be present. Hospital-acquired conditions refers to the Centers for Medicare and Medicaid Services (CMS) definition as provided in Section 1886(d)(4) of the Social Security Act.

(h) Inpatient reimbursement will be calculated at the lesser of the assigned APR-DRG rate or the claim billed charges.

(2) The department adopts and incorporates by reference the APR-DRG Table of Weights and Thresholds adopted and effective at ARM 37.85.105. The Montana Medicaid APR-DRG relative weight values, average national length of stay (ALOS), outlier thresholds, and APR-DRG grouper are contained in the APR-DRG Fee Schedule which is adopted and effective as provided at ARM 37.85.105 and published by the department. Copies may be obtained from the Department of Public Health and Human Services, Health Resources Division, 1400 Broadway, P.O. Box 202951, Helena, MT 59620-2951.

This rule has been repealed.

(1) Capital expenses are included within the APR-DRG base payment and will not be paid separately to PPS facilities and will not be cost settled.

(2) The interim payment made to CAHs is based on the hospital-specific cost-to-charge ratio and includes capital costs. For dates of service January 1, 2018 through June 30, 2018, the interim payment made is based on the hospital-specific cost-to-charge ratio, less 2.99%, and includes capital costs. For dates of service on or after July 1, 2018, the interim payment made is based on the hospital-specific cost-to-charge ratio, and includes capital costs.

(3) The department adopts and incorporates by reference 42 CFR 412.113(a) and (b), and will calculate as provided in (1) and (2) capital-related costs that are allowable under Medicare cost reimbursement principles as established in 42 CFR 412.113(a) and (b) (March 29, 1985). Copies of the cited regulation may be obtained from the Department of Public Health and Human Services, Health Resources Division, 1400 Broadway, P.O. Box 202951, Helena, MT 59620-2951.

This rule has been repealed.

(1) In addition to the APR-DRG payment, providers reimbursed under the APR-DRG prospective payment system may receive payment as provided in this rule for cost outliers for APR-DRGs.

(2) To receive payment for a cost outlier, the combined costs of the medically necessary days and services of the inpatient hospital stay, as determined by the department, must exceed the cost outlier threshold established by the department for the APR-DRG.

(3) The department determines the outlier reimbursement for cost outliers for all hospitals and distinct part units, entitled to receive cost outlier reimbursement, as follows:

(a) computing an estimated cost for the inpatient hospital stay by multiplying the allowed charges for the stay by:

(i) the facility-specific cost-to-charge ratio as set forth in ARM 37.86.2905; or

(ii) for non-Center of Excellence out-of-state facilities, their statewide average cost-to-charge ratio;

(b) subtracting the cost outlier threshold amount from the estimated costs to compute the cost outlier amount; and

(1) All readmissions occurring within 30 days will be subject to review to determine whether additional payment as a new APR-DRG or as an outlier is warranted. As a result of the readmission review, the following payment changes will be made:

(a) If it is determined that complications have arisen because of premature discharge and/or other treatment errors, then the APR-DRG payment for the first admission must be altered by combining the two admissions into one for payment purposes.

(b) If it is determined that the readmission is for the treatment of conditions that could or should have been treated during the previous admission, the department will combine the two admissions into one for payment purposes.

(c) A client readmission occurring in an inpatient rehabilitation hospital or a rehabilitation distinct part unit three days after the initial date of discharge must be combined into one admission for payment purposes, with the exception of discharge to an acute care hospital for surgical APR-DRGs.

(d) Inpatient readmissions within 24 hours of discharge must be combined if the same condition is diagnosed.

(e) Services that are performed at a second hospital because the services are not available at the first hospital (e.g., a CT scan) are included in the first hospital's payment. This includes transportation to the second hospital and back to the first hospital. Arrangement for payment to the transportation provider and the second hospital where the services were actually performed must be between the first and second hospital and the transportation provider.

(2) A transfer, for the purpose of this rule, is limited to those instances in which a client is transferred for continuation of medical treatment between two hospitals or distinct part units, one of which is paid under the Montana Medicaid prospective payment system.

(a) A transferring hospital or distinct part unit reimbursed under the APR-DRG prospective payment system is paid for the services and items provided to the transferred recipient, the lesser of:

(i) a per diem rate of two times the average per diem amount for the first inpatient day plus one per diem payment for each subsequent day of inpatient care. The per diem payment is determined by dividing the sum of the APR-DRG payment for the case as computed in ARM 37.86.2907 by the national average length of stay for the DRG. Outlier and add-on payments are then added if applicable after the transfer payment is computed; or

(ii) the sum of the APR-DRG payment for the case as computed in ARM 37.86.2907 and the appropriate outlier, and add-ons, if applicable, as computed in ARM 37.86.2916, and 37.86.2925.

(b) A discharging hospital or distinct part unit (i.e., the hospital to which the recipient is transferred) reimbursed under ARM 37.86.2907 is paid the full APR-DRG payment plus any appropriate outliers and add-ons, if applicable.

(3) Outpatient hospital services, including emergency room services and diagnostics services (including clinical diagnostic laboratory tests) that are provided by an entity owned or operated by the hospital and occur the day of or the day before the inpatient hospital admission are deemed to be inpatient services and must be bundled into the inpatient claim.

(4) A hospital or distinct part unit reimbursed under the APR-DRG prospective payment system is paid for the services and items provided to a recipient who is eligible for only part of the inpatient stay, the lesser of:

(a) a rate of one per diem payment for each eligible day of inpatient care. The per diem payment is determined by dividing the sum of the APR-DRG payment for the case as computed in ARM 37.86.2907 plus outlier if applicable, by the national average length of stay for the DRG. Add-on payments are then added if applicable; or

(b) the sum of the APR-DRG payment for the case as computed in ARM 37.86.2907 and the appropriate outlier and add-ons, if applicable, as computed in ARM 37.86.2916 and 37.86.2925.

(1) Payment for hospital residents will be made as follows:

(a) the hospital must request residency status from the department prior to submission of the first claim;

(b) prior to obtaining hospital residency status, claims for that recipient may be billed on an interim basis as provided in ARM 37.86.2905(4);

(c) final payment for the first hospital stay will be paid the APR-DRG payment for the case as computed in ARM 37.86.2907 plus any appropriate outlier and add-on payments:

(i) the hospital stay is from admit through the request for residency, if approved by the department; and

(ii) the length of stay must be greater than or equal to 180 days of inpatient care at the same facility.

(d) final payment for all client care subsequent to the request date, which must be greater than 180 days will be reimbursed at 80% of the hospital specific estimated cost-to-charge ratio as computed by the department without cost settlement; and

(e) the hospital must provide medical records upon request of the department or the department's designated review organization for continued stay reviews.

(1) To obtain hospital residency status, the client must meet the following requirements:

(a) a client who is unable to be cared for in a setting other than the acute care hospital is eligible for hospital residency status;

(b) the client must utilize a ventilator for a continuous period of not less than eight hours in a 24-hour period or require at least ten hours of direct nursing care in a 24-hour period; and

(c) the client must have been an inpatient in the same hospital as the requesting hospital for a minimum of six continuous months.

(2) The provider will have the responsibility of determining whether services could be provided in a skilled nursing care facility or by the Home and Community-Based Waiver Program to a Medicaid client within the state of Montana.

(3) The provider shall maintain written records of inquiries and responses about the present and future availability of openings in nursing homes and the Home and Community-Based Waiver Program.

(4) A redetermination of nursing home or waiver availability must be made at least every six months.

(1) If the Secretary of Health and Human Services has granted the facility authorization for continuation of cost pass-through under section 9320 of the Omnibus Budget Reconciliation Act of 1986, as amended by section 608(c) of the Family Support Act of 1988 (Public Law 100-485), the department shall reimburse cost based inpatient hospital service providers for certified registered nurse anesthetist costs on a reasonable cost basis as provided in ARM 37.86.2803.

(1) Routine disproportionate share hospitals (RDSH) will receive an additional payment amount equal to the product of the hospital's prospective base rate times the adjustment percentage of:

(a) 4% for rural hospitals; or

(b) 10% for urban hospitals.

(2) DSH payments will be limited to the cap established by CMS for the state of Montana. The adjustment percentages specified in (1) will be ratably reduced as determined necessary by the department to avoid exceeding the cap.

(a) The department will submit an independent certified audit to CMS for each completed Medicaid state plan rate year, consistent with 42 CFR Part 455, Subpart D.

(b) To the extent that audit findings demonstrate that DSH payments exceed the documented hospital-specific limits, the department will collect overpayments and redistribute DSH payments.

(c) Beginning with state fiscal year (SFY) 2011, based on audit findings, should the department determine that there is an overpayment to a provider, the department will:

(i) recover the overpayment from the provider;

(ii) redistribute the amount in overpayment to providers that had not exceeded the hospital-specific limit during the period in which the DSH payments were determined utilizing the methodology used in the payment of the original allocation; and

(iii) ensure all payments will be subject to hospital-specific limits.

(d) Should the DSH overpayment exceed the aggregate hospital-specific limit, the federal amount of overpayment will be returned to CMS.

(e) Beginning with SFY 2011, facilities choosing not to participate in the annual DSH audit will forfeit 100% of their DSH payment allocated for that year. This allocation will be deemed an overpayment and will be recovered from the provider.

(f) Disproportionate share payments must not exceed the DSH state allotment, except as otherwise required by the Social Security Act. In no event is the department obligated to use state Medicaid funds to pay more than the state Medicaid allotment of DSH payments due a provider.

(3) Eligibility for RDSH payments will be determined based on a provider's year-end reimbursement status.

(1) The inpatient hospital reimbursement adjustor (HRA) payment is payable to a PPS hospital or critical access hospital, as those terms are defined in 50-5-101, MCA, that provides inpatient hospital services. Eligibility for an HRA payment will be determined based on a hospital's year-end reimbursement status.

(2) Revenue generated from the inpatient hospital utilization fee plus applicable federal financial participation (FFP) is utilized to calculate the following supplemental payments:

(a) the continuity of care payment described in ARM 37.87.1224;

(b) Part 1 of the HRA; and

(3) Part 1 of the HRA payment is payable to all hospitals, including critical access hospitals, as those terms are defined in 50-5-101, MCA. The payment will be based upon Medicaid inpatient utilization, and will be computed as follows: HRA1 = (M ÷ D) x P.

(a) For the purposes of calculating Part 1 of the HRA, the following apply:

(i) "HRA1" represents the calculated Part 1 HRA payment.

(ii) "M" equals the number of Medicaid inpatient days provided by the hospital for which the payment amount is being calculated.

(iii) "D" equals the total number of Medicaid inpatient days provided by all hospitals eligible to receive an HRA payment.

(iv) "P" equals the total amount to be paid via Part 1 of the HRA. "P" consists of a state-paid amount plus the applicable federal financial participation (FFP). The portion of "P" that is paid by the state will equal the amount of revenue generated by Montana's inpatient hospital utilization fee, less all the following:

(A) 4% of the total revenue generated by the inpatient hospital utilization fee, which will be expended as match for continuity of care adjustor payments, as provided in ARM 37.87.1224; and

(B) 8% of the total revenue generated by the inpatient hospital utilization fee, which will be expended as match for Part 2 of the HRA, as provided in (4).

(4) Part 2 of the HRA payment is limited to critical access hospitals to maintain access and quality in the most rural areas in Montana. Part 2 will be based upon total hospital Medicaid charges, and will be computed as follows: HRA2 = (I ÷ D) x P.

(a) For the purposes of calculating Part 2 of the HRA, the following apply:

(i) "HRA2" represents the calculated Part 2 HRA payment.

(ii) "I" equals the total hospital charges from Medicaid paid claims for which Montana Medicaid was the primary payer for the hospital for which the payment is being calculated.

(iii) "D" equals the total hospital charges from Medicaid paid claims for which Montana Medicaid was the primary payer for all hospitals eligible to receive Part 2 of the HRA payment.

(iv) "P" equals the total amount to be paid via Part 2 of the HRA. "P" will be 8% of the total revenue generated by Montana's inpatient hospital utilization fee plus applicable FFP.

(5) The numbers used in (3) through (4) must be from the department's paid claims data for the most recent calendar year.

(1) A hospital is deemed a routine disproportionate share hospital if:

(a) it has a Medicaid inpatient utilization rate of at least one standard deviation above the mean Medicaid inpatient utilization rate for all hospitals receiving Medicaid payments in Montana or a low income utilization rate exceeding 20%; and

(b) it has a Medicaid inpatient utilization rate of at least 1%.

(2) Urban hospitals must have at least two obstetricians with staff privileges who have agreed to provide obstetric services to Medicaid patients. Rural hospitals must have at least two physicians with staff privileges to perform nonemergent obstetric procedures who have agreed to provide obstetric services to Medicaid recipients.

(3) This rule does not apply to hospitals which:

(a) serve inpatients who are predominantly individuals under 18 years of age; or

(b) do not offer nonemergent obstetric services as of December 21, 1987.

(1) A hospital's Medicaid inpatient utilization rate is the hospital's percentage rate computed by dividing the total number of Medicaid inpatient days in the hospital's fiscal year by the total number of the hospital's inpatient days in that same period.

(2) The period used to determine whether a hospital is deemed a routine disproportionate share hospital will be the most recent calendar year for which final cost reports are available for all hospital providers.

(1) The low income utilization rate is used to determine whether a hospital is deemed a routine disproportionate share hospital. The percentage rate is computed as follows:

(a) LIUR=((A + B)/C) + (D/E) where:

(i) "LIUR" is the low income utilization rate;

(ii) "A" is the total revenue paid to the hospital to determine patient services under the Medicaid state plan regardless of whether the services were furnished on a fee-for-service basis or through a managed care program in the hospital's fiscal year;

(iii) "B" is the cash subsidies received directly from state and local governments for patient services in the hospital's fiscal year;

(iv) "C" is the total revenues of the hospital for patient services, including the amount of such cash subsidies in the hospital's fiscal year;

(v) "D" is the total hospital charges for inpatient hospital services attributable to charity care in the hospital's fiscal year, less any amount received for payment of these charges attributable to inpatient services. This amount shall not include contractual allowances and discounts (other than for indigent patients not eligible for public assistance); and

(vi) "E" is the hospital's total charges for inpatient hospital services in the hospital's fiscal year.

(b) The above amounts used in the formula must be from the hospital's most recent fiscal year for which initial cost reports are available for all hospital providers.

(1) An inpatient hospital reimbursement adjustor (HRA) payment will be made to a Montana PPS hospital or critical access hospital, as those terms are defined in 50-5-101, MCA, that provides inpatient hospital services.

(2) Data sources for the department to determine which hospitals meet the criteria to receive HRA payments, and the amount of the payments, may include, but are not limited to:

(a) the Montana Hospital Association (MHA) database;

(b) the Medicaid paid claims database;

(d) reports from the Licensure Bureau of the Quality Assurance Division.

(3) Eligibility evaluations, payment amount calculations, and payments will be made annually.

(4) The Montana State Hospital or a hospital or a facility operated by the state, a political subdivision of the state, the United States, or an Indian Tribe or any facility authorized under the Indian Health Care Improvement Act are not eligible for HRA.

(1) Inpatient hospital services provided in border hospitals will be reimbursed under the APR-DRG prospective payment system described in ARM 37.86.2905, 37.86.2907, 37.86.2912, 37.86.2916, 37.86.2918, and 37.86.2920.

(2) Medicaid reimbursement for inpatient services shall not be made to hospitals located more than 100 miles outside the borders of Montana or Centers of Excellence unless the provider has obtained authorization from the department or its designated review organization prior to providing services or prior to admission. All inpatient services provided in an emergent situation must be authorized as described in ARM 37.86.2801(4)(d).

(a) Should prior authorization not be obtained, reimbursement will be 50% of the amount as calculated in ARM 37.86.2905, 37.86.2907, 37.86.2912, 37.86.2916, 37.86.2918, and 37.86.2920 for services determined to be medically necessary.

(3) A Center of Excellence is an out-of-state or border acute care medical hospital as defined in ARM 37.86.2901 that:

(a) provides through its main hospital or on-site affiliate all specialty and subspecialty medical care; and

(i) has a medical school affiliation; or

(b) provides a specialized medical service not available elsewhere; and

(i) has a medical school affiliation; and

(ii) conducts bench to bedside research.

(1) Subject to the availability of funding, restrictions imposed by federal law, and the approval of the state plan by the Centers for Medicare and Medicaid Services (CMS), the department will pay, in addition to the Medicaid payments provided for in ARM 37.86.2806, 37.86.2905, 37.86.2907, 37.86.2912, 37.86.2916, 37.86.2918, 37.86.2920, 37.86.2924, 37.86.2925, 37.86.2928, 37.86.2943, and 37.86.2947, a Graduate Medical Education (GME) payment for the purpose of partially funding primary care and psychiatry residency programs for eligible hospitals located in Montana.

(2) Revenue for the GME payment will be generated through a transfer of funds from the Montana University System to the department through an Intergovernmental Transfer contract agreement. The transfer of funds from the University System will occur prior to July 31 of each year.

(3) The department will make an annual payment to each eligible hospital on or before August 31 of each year.

(a) The payment will be calculated based upon the eligible hospital's inpatient Medicaid utilization per year, as calculated in (4).

(b) If an eligible hospital reports no primary care or psychiatry resident full time equivalents (FTE) participating in the GME program for any given program year or portion thereof, the eligible hospital will not receive payment for those time periods of nonparticipation. FTE totals include residents conducting rural rotations. For purposes of this rule, a rural rotation is a period of one month where a primary care or psychiatry resident is working in a rural location, outside of their primary facility and urbanized area, with the express purpose of the resident being available to provide care to the rural area's patient population.

(4) To calculate an eligible hospital's GME payment, the department will:

(a) divide the total amount of GME funding, including federal match, by the total number of primary care and psychiatry resident full-time equivalents (FTE) participating in the program to establish the per-resident amount (PRA);

(b) divide the number of FTE residents at each eligible hospital by the total number of primary care and psychiatry resident FTEs at all eligible hospitals participating in the program to establish each hospital's resident FTE percentage;

(c) divide the eligible hospital's Medicaid inpatient days by its total inpatient days to determine each eligible hospital's Medicaid utilization percentage;

(d) multiply each eligible hospital's Medicaid utilization percentage by its resident FTE percentage and then add the results from all of the eligible hospitals to establish the weighted average Medicaid utilization percentage for all hospitals;

(e) divide an eligible hospital's Medicaid utilization percentage from (c) by the weighted Medicaid utilization percentage for all eligible hospitals to establish each eligible hospital's Medicaid utilization index;

(f) multiply the eligible hospital's Medicaid utilization index by the PRA in (a) to establish each eligible hospital's adjusted PRA; and

(g) multiply the eligible hospital's adjusted PRA by the number of resident FTEs at the hospital to determine the GME payment amount.

(5) The GME payment must comply with the following criteria:

(a) if the eligible hospital's cost of inpatient hospital services do not exceed the total Montana Medicaid allowed payments for inpatient care, the eligible hospital will receive a GME payment as calculated in (4);

(b) as-filed cost reports from eligible hospitals and information from the Medicaid paid claims database will be used for calculations;

(c) the GME payment must be for services derived from Medicaid paid claims. The dates of these services must occur within the eligible hospital's fiscal year end, and the hospital's fiscal year must be the year immediately prior to the payment date; and

(d) at the end of the contract period, the department will reconcile the total Medicaid payments including the Medicaid GME payments to ensure that the total of these payments do not exceed the Medicaid Upper Payment Limit (UPL) for the fiscal year.

(1) "Ambulatory payment classification (APC)" means Medicare's ambulatory payment classification assignment groups of CPT or HCPCS codes.

(2) "Bad debt" means inpatient and outpatient hospital services provided in which full payment is not received from the patient or from a third party payor, for which the provider expected payment and the persons are unable or unwilling to pay their bill. Bad debts may be for services provided to patients who have no health insurance or patients who are underinsured and are net of payments made toward these services. For the purpose of uncompensated care, bad debt is measured on the basis of revenue forgone, at full established rates, and bad debt does not include either provider discounts or Medicare bad debt.

(3) "Birthing center" means a facility that provides comprehensive obstetrical care for women in which births are planned to occur away from the mother's usual residence following normal, uncomplicated, low risk pregnancy and is either:

(a) a licensed outpatient center for primary care with medical resources as defined at 50-5-101, MCA; or

(b) a private office of a physician or certified nurse midwife that is accredited by a national organization as an alternative to a homebirth or a hospital birth.

(4) "Charity care" means inpatient and outpatient hospital services in which hospital policies determine the patient is unable to pay and did not expect to receive full reimbursement. Charity care results from a provider's policy to provide health care services free of charge (or where only partial payment is expected) to individuals who meet certain financial criteria. For the purpose of uncompensated care, charity care is measured on the basis of revenue forgone, at full established rates. Charity care does not include contractual write-offs.

(5) "Conversion factor" means a base rate initially calculated by CMS and used to translate APC relative weights into dollar payment rates.

(6) "Diagnostic service" means an examination or procedure performed on an outpatient or on materials derived from an outpatient to obtain information to aid in the assessment or identification of a medical condition.

(7) "Disproportionate share hospital-specific uncompensated care" means the costs of inpatient and outpatient hospital services provided to clients who have no health insurance or source of third-party coverage.

(8) "Full-day partial hospitalization program" means a partial hospitalization program providing services at least six hours per day, five days per week.

(9) "Early elective delivery" means either a nonmedically necessary labor induction or cesarean section that is performed prior to 39 weeks and 0/7 days gestation.

(10) "Half-day partial hospitalization program" means a partial hospitalization program providing services for at least four but less than six hours per day, at least four days per week.

(11) "Healthcare common procedures coding system (HCPCS)" means the national uniform coding method maintained by the Centers for Medicare and Medicaid Services (CMS) that incorporates the American Medical Association (AMA) Physicians Current Procedural Terminology (CPT) and the three HCPCS unique coding levels, I, II, and III.

(12) "ICD-9-CM" means the International Classification of Diseases, Ninth Revision based on the official version of the United Nations World Health Organization's Ninth Revision, effective for dates of service or discharge date prior to and including September 30, 2015.

(13) "ICD-10-CM" means the International Classification of Diseases, Tenth Revision based on the official version of the World Health Organization's Tenth Revision for diagnosis coding, effective for dates of service or discharge date October 1, 2015 and thereafter.

(14) "Imaging service" means diagnostic and therapeutic radiology, nuclear medicine, CT scan procedures, magnetic resonance imaging services, ultra-sound, and other imaging procedures.

(15) "Lactation services" means support through breastfeeding education and consultations with certified lactation providers to increase the health of both mother and baby.

(16) "Outpatient" means a person who:

(a) has not been admitted by a hospital or birthing center as an inpatient;

(b) is expected by the hospital or birthing center to receive services in the hospital for less than 24 hours;

(d) receives outpatient services from the hospital or birthing center, other than supplies or drugs alone, for nonemergency medical conditions.

(17) "Outpatient hospital reimbursement adjustor (HRA)" means a payment to a Montana PPS hospital or critical access hospital as specified in ARM 37.86.3015.

(18) "Outpatient hospital services" means preventive, diagnostic, therapeutic, rehabilitative, or palliative services provided to an outpatient by or under the direction of a physician, dentist, or other practitioner as permitted by federal law, by an institution that:

(a) is licensed or formally approved as a hospital by the officially designated authority in the state where the institution is located; and

(b) except as otherwise permitted by federal law, meets the requirements for participation in Medicare as a hospital.

(19) "Outpatient hospital utilization fee" means the utilization fee collected by the Department of Revenue as provided in 15-66-102, MCA.

(20) "Outpatient prospective payment system (OPPS)" means Medicare's outpatient prospective payment system mandated by the Balanced Budget Refinement Act of 1999 (BBRA) and the Medicare, Medicaid, SCHIP Benefits Improvement and Protection Act (BIPA) of 2000.

(21) "Outpatient revenue" means the gross revenue from a hospital's charges for services provided on an outpatient basis. Charges for professional services provided as part of an outpatient treatment are not included.

(22) "Partial hospitalization services" means an active treatment program that offers therapeutically intensive, coordinated, structured clinical services provided only to individuals who are determined to have a serious emotional disturbance or severe disabling mental illness. Partial hospitalization services are time-limited and provided within either an acute level program or a subacute level program. Partial hospitalization services include day, evening, night, and weekend treatment programs that employ an integrated, comprehensive, and complementary schedule of recognized treatment or therapeutic activities.

(23) "Prospective payment system (PPS) hospital" means a hospital reimbursed pursuant to the diagnosis related group (DRG) system. DRG hospitals are classified as such by the Centers for Medicare and Medicaid Services (CMS) in accordance with 42 CFR part 412.

(24) "Provider-based entity" means a provider that is either created by, or acquired by, a main provider for purposes of furnishing health care services under the name, ownership, and administrative and financial control of the main provider as in 42 CFR 413.65.

(25) "Uncompensated care" means hospital services provided in which no payment is received from the patient or from a third party payer. Uncompensated care includes charity care and bad debts.

(26) "Upper payment limit" means the federal limit placed on fee-for-service reimbursement of Medicaid providers.

(27) "340B drug pricing program" means a drug pricing program established under section 340B of the Veterans Health Care Act which offers outpatient pharmaceuticals at substantially reduced prices to qualified entities.

(1) The requirements of ARM 37.86.2801, 37.86.2803, 37.86.3001, 37.86.3005 and this rule are in addition to those contained in rule provisions generally applicable to Medicaid providers.

(2) Outpatient hospital services are services that would also be covered by Medicaid if provided in a nonhospital setting and are limited to the following diagnostic and therapeutic services furnished by hospitals to outpatients:

(a) diagnostic services, including:

(i) the services of nurses, psychologists and technicians;

(ii) drugs and biologicals;

(iii) laboratory and imaging services;

(iv) psychological tests;

(v) supplies and equipment; and

(vi) other tests to determine the nature and severity of a medical condition;

(b) therapeutic services and supplies, including:

(i) emergency room services;

(ii) clinic services; and

(iii) the use of hospital facilities incident to provision of physician services to the patient where the services and supplies are furnished in the hospital on a physician's order by hospital personnel under the supervision of hospital medical staff;

(d) services provided outside the hospital, as follows:

(i) diagnostic services provided by hospital personnel outside the hospital premises with or without direct personal supervision of a physician;

(ii) therapeutic services that are incidental to physician services and provided under the direct personal supervision of a physician. Outpatient physical therapy, occupational therapy, and speech therapy are not subject to the direct physician supervision requirement. Therapy services are limited as in ARM 37.86.606;

(e) diabetes education services provided by a hospital whose diabetes education programs are in compliance with ARM 37.86.5401 through 37.86.5404; and

(f) lactation services performed by nonphysician providers, i.e., certified lactation providers. These services will only be allowed to be billed by the facility effective January 1, 2016.

(1) Outpatient hospital services do not include:

(a) services excluded from coverage by the Medicaid program under ARM 37.85.207;

(b) exercise programs and programs primarily educational in nature unless covered as preventative outpatient services, including, but not limited to independent exercise programs, such as pool therapy, swim programs, or health club memberships;

(c) outpatient physical therapy, occupational therapy, and speech therapy services that are primarily maintenance therapy as defined in ARM 37.86.601;

(d) experimental or investigational services such as the use of off-label drugs where this usage is not a national standard of practice, or non-FDA-approved use of drugs, biologicals, and devices;

(e) services that do not comply with national standards of medical care; and

(f) outpatient hospital services provided outside the borders of the United States will not be covered or reimbursed by the Montana Medicaid program.

(1) The department will reimburse for outpatient hospital services and birthing center services compensable under the Montana Medicaid program as provided in this rule.

(2) Outpatient hospital services that are not provided by critical access hospitals as defined in ARM 37.86.2901 will be reimbursed under ARM 37.86.3007, 37.86.3009, 37.86.3016, 37.86.3018, 37.86.3020, 37.86.3025, 37.86.3109, and 37.86.3037 for medically necessary services.

(3) Birthing center services as defined in ARM 37.86.3001 will be reimbursed under ARM 37.86.3007, 37.86.3016, 37.86.3018, and 37.86.3020, for medically necessary services.

(4) For critical access hospitals, interim reimbursement for outpatient hospital services is based on hospital-specific Medicaid outpatient cost-to-charge ratio, not to exceed 100%. Critical access hospitals will be reimbursed their actual allowable costs determined according to ARM 37.86.2803.

(1) Medicaid reimbursement is not available for outpatient partial hospitalization services unless:

(a) the person is experiencing psychiatric symptoms of sufficient severity to create severe impairments in educational, social, vocational, or interpersonal functioning;

(b) the person cannot be safely and appropriately treated in a less restrictive level of care;

(c) proper treatment of the person's psychiatric condition requires acute treatment services on an outpatient basis under the direction of a physician; and

(d) the services can reasonably be expected to improve the person's condition or prevent further regression.

(2) Partial hospitalization services may include day, evening, night, and weekend treatment programs that must employ an integrated, comprehensive, and complementary schedule of recognized treatment or therapeutic activities.

(3) Acute level partial hospitalization is provided by programs which:

(a) are operated by a hospital as defined in 50-5-101, MCA, and are collocated with that hospital such that in an emergency a patient of the acute partial hospitalization program can be transported to the hospital′s inpatient psychiatric unit within 15 minutes;

(b) serve primarily persons being discharged from inpatient psychiatric treatment or inpatient psychiatric residential treatment; and

(c) provide psychotherapy services consisting of at least individual, family, and group sessions at a frequency designed to stabilize the person sufficiently to allow discharge to a less intensive level of care at the earliest appropriate opportunity.

(4) Acute level partial hospitalization is reimbursed according to ARM 37.86.3022.

(5) Subacute partial hospitalization is provided for in ARM 37.87.903(8).

(6) Prior authorization is not a guarantee of payment.

(1) Clinical diagnostic laboratory services, including automated multichannel test panels (commonly referred to as "ATPs") and lab panels, will be reimbursed on a fee basis as follows with the exception of hospitals reimbursed under ARM 37.86.3005 and specific lab codes which are paid under ARM 37.86.3020:

(a) The fee for a clinical diagnostic laboratory service is the applicable percentage of the Medicare fee schedule as follows:

(i) 60% of the prevailing Medicare fee schedule for a birthing center or where a hospital laboratory acts as an independent laboratory, i.e., performs tests for persons who are nonhospital patients;

(ii) 62% of the prevailing Medicare fee schedule for a hospital designated as a sole community hospital as defined in ARM 37.86.2901; or

(iii) 60% of the prevailing Medicare fee schedule for a hospital that is not designated as a sole community hospital as defined in ARM 37.86.2901.

(b) For clinical diagnostic laboratory services where no Medicare fee has been assigned, but a Medicaid fee has been assigned, the fee is the amount set in ARM 37.85.212; or

(c) if there is no Medicare or Medicaid fee, the service will be reimbursed at hospital specific outpatient cost to charge ratio as in ARM 37.86.2803. Birthing centers will be reimbursed the statewide outpatient cost to charge ratio.

(2) For purposes of this rule, clinical diagnostic laboratory services include the laboratory tests listed in codes defined in the HCPCS and listed in the Clinical Diagnostic Fee Schedule (CLAB) published January 1, 2018.

(3) Specimen collection will be reimbursed separately for drawing a blood sample through venipuncture or for collecting a urine sample by catheterization. Specimen collection will be reimbursed as specified in the department's outpatient fee schedule as adopted in ARM 37.86.3025, whether or not the specimens are referred to physicians or other laboratories for testing. No more than one collection fee may be allowed for each patient visit, regardless of the number of specimens drawn.

(1) For emergency visits that are not provided by exempt hospitals or critical access hospitals as defined in ARM 37.86.2901, reimbursement will be based on the ambulatory payment classifications APC methodology in ARM 37.86.3020, except emergency room visits with CPT codes 99281 and 99282 will be reimbursed based on the clinical APC weight.

(a) Passport to Health provider authorization is not required for emergency room visits.

(2) Physician services are separately billable according to the applicable rules governing billing for physician services.

This rule has been repealed.

(1) The outpatient hospital reimbursement adjustor (HRA) payment is payable to a PPS hospital or critical access hospital, as those terms are defined in 50-5-101, MCA, that provides outpatient hospital services. Eligibility to receive the outpatient HRA is based on a hospital's year-end reimbursement status.

(2) An individual hospital's outpatient HRA payment will be based upon total hospital Medicaid outpatient charges and will be computed as follows: HRA = (J ÷ D) x P.

(a) "HRA" represents the calculated hospital specific outpatient HRA payment.

(b) "J" equals the total outpatient hospital charges billed to Medicaid by the hospital for which the payment is calculated.

(c) "D" equals the total outpatient hospital charges billed to Medicaid by all hospitals eligible to receive an outpatient HRA payment.

(d) "P" equals the distributable revenue generated by the outpatient hospital utilization fee plus applicable federal financial participation.

(3) Data sources for the department to determine which hospitals meet the criteria to receive an outpatient HRA payment and the amount of the payment may include, but are not limited to:

(a) the Montana Hospital Association (MHA) database;

(b) the Medicaid paid claims database for the most recent calendar year;

(d) reports from the Licensure Bureau of the Quality Assurance Division.

(4) Eligibility evaluations, payment calculations, and payments will be made annually.

(5) The Montana State Hospital or a hospital or facility operated by the state, a political subdivision of the state, the United States, or an Indian Tribe or any facility authorized under the Indian Health Care Improvement Act are not eligible for the HRA payment.

(1) Imaging services will be reimbursed with the exception of hospitals reimbursed under ARM 37.86.3005(3) as follows:

(a) For each imaging service or procedure, the fee will be the APC rate as in ARM 37.86.3020 or Medicare fee if no APC rate exists. The imaging services reimbursed under this subsection are the individual imaging service codes defined in the CPT/HCPCS.

(b) For imaging services where no APC rate or Medicare fee has been assigned, a Medicaid fee will be set in accordance with the resource based relative value scale (RBRVS) methodology found at ARM 37.85.212.

(c) For imaging services where no APC rate, Medicare fee, or Medicaid fee has been assigned, outpatient hospital-specific percent of charges will be paid. Birthing centers and out-of-state hospitals will be reimbursed the statewide outpatient cost-to-charge ratio.

(1) Other diagnostic services will be reimbursed as follows with the exception of hospitals reimbursed under ARM 37.86.3005(4):

(a) the fee will be the APC rate as in ARM 37.86.3020 or the Medicare fee for the same service if no APC rate exists. The individual diagnostic services reimbursed under this subsection are those defined in the CPT/HCPCS;

(b) for other diagnostic services without an APC rate or Medicare fee, a Medicaid fee will be assigned in accordance with the RBRVS methodology in ARM 37.85.212; or

(c) for other diagnostic services where no APC rate, Medicare fee, or Medicaid fee has been assigned, outpatient hospital-specific percent of charges will be paid. Birthing centers and out-of-state hospitals will be reimbursed the statewide outpatient cost-to-charge ratio.

(1) Outpatient hospital or birthing center services that are not provided by critical access hospitals will be reimbursed on a rate-per-service basis using the Outpatient Prospective Payment System (OPPS) schedules. The provider reimbursement rates for outpatient hospital services is stated in the department's Outpatient Prospective Payment System (OPPS) Fee Schedule as provided in ARM 37.85.105(3). Under this system, Medicaid payment for outpatient services included in the OPPS is made at a predetermined, specific rate. These outpatient services are classified according to a list of APCs published annually in the Code of Federal Regulations (CFR). The rates for OPPS are determined as follows:

(a) The department uses a conversion factor for each APC group as defined in ARM 37.86.3001(5). The conversion factor is as provided in ARM 37.85.105(3). The APC-based fee equals the Medicare specific relative weight for the APC times the conversion factor that is the same for all APCs with the exceptions of services in ARM 37.86.3025. APCs are based on classification assignment of CPT/HCPCS codes.

(b) At the claim level, payment will be the lower of the provider's charge or the payment as calculated using OPPS. There will be no charge cap at the line level.

(c) APCs are an all-inclusive bundled payment per visit which covers all outpatient services provided to the patient, including but not limited to nursing, pharmacy, laboratory, imaging services, other diagnostic services, supplies and equipment, and other outpatient services. For purposes of OPPS, a visit includes all outpatient hospital or birthing center services related or incident to the outpatient visit that are provided the day before or the day of the outpatient visit.

(d) If two or more surgical procedures are performed at the same hospital on the same patient on the same day, payment for the most expensive procedure will be made at 100% of the APC for that service and payment for all other procedures will be made at 50% of the APC for those services.

(e) If the OPPS does not assign a Medicare fee or APC for a particular procedure code, a Medicaid fee will be assigned in accordance with the resource based relative value scale (RBRVS) methodology found at ARM 37.85.212. If there is not a Medicaid fee, the service will be reimbursed at hospital-specific outpatient cost-to-charge ratio as in ARM 37.86.2803. Birthing centers and out-of-state hospitals will be reimbursed the statewide outpatient cost-to-charge ratio:

(i) The Medicaid statewide average outpatient cost-to-charge ratio is as provided at ARM 37.85.105(3).

(f) The department will make separate payment for observation care procedure codes for Medicare qualifying conditions or obstetric complications. If an observation service does not meet these criteria for these services, payment for observation care will be considered bundled into the APC for other services.

(i) The diagnosis used to define a potential obstetric qualification will be taken from diagnosis-related groups 565 (false labor) and 566 (other antepartum diagnosis with medical complications).

(ii) The department will make separate payment for observation care procedure codes when billed as a direct admit or have a high level clinic visit, high level critical care, or high level emergency room visit.

(iii) The department will make separate payment for observation care procedure codes if billed using a qualifying diagnosis as per the CMS Claims Processing Manual.

(g) The department follows Medicare guidelines for procedures defined as "inpatient only". When these procedures are performed in the outpatient hospital or birthing center setting, the claim will be denied.

(h) Procedures started on patients but discontinued before completion will be reimbursed at 50% of the APC for those services.

(2) The department adopts and incorporates by reference the OPPS Schedules published by the Centers for Medicare and Medicaid Services (CMS) as provided in ARM 37.85.105(3).

(3) All outpatient hospitals including birthing centers are subject to the requirements in ARM 37.86.2801(9).

(1) Partial hospitalization services will be reimbursed on a prospective per diem rate which shall be the lesser of the amount specified in the department's Medicaid Mental Health Fee Schedule or the provider's usual and customary charges (billed charges). The per diem rates specified in the department's Medicaid Mental Health Fee Schedule are bundled prospective per diem rates for full-day programs and half-day programs, as defined in ARM 37.86.3001. The bundled prospective per diem rate includes all outpatient psychiatric and psychological treatments and services, laboratory and imaging services, drugs, biologicals, supplies, equipment, therapies, nurses, social workers, psychologists, licensed professional counselors, and other outpatient services, that are part of or incident to the partial hospitalization program, except as provided in the department's Medicaid Mental Health Fee Schedule.

(2) The professional component of physician services, including psychiatrist services, is separately billable according to the applicable department rules governing billing for physician services.

(1) Therapy services will be paid the facility fee in accordance with the RBRVS methodologies in ARM 37.85.212 using the allied services conversion factor. Therapy services include physical therapy, occupational therapy, and speech-language pathology and are subject to requirements and restrictions as in ARM 37.86.606.

(2) Dental services not grouping to an ambulatory payment classification (APC) will be reimbursed as specified in the department's outpatient fee schedule.

(3) Immunizations not grouping to an APC will be paid the same reimbursement provided in accordance with the RBRVS methodologies in ARM 37.85.212.

(a) If the recipient is under 19 years old and vaccine is available to providers for free under the Vaccines For Children program, then the payment to the hospital is zero.

(b) Immunization administration is considered an incidental service and will be bundled with other APCs on the claim and paid at zero.

(4) Professional services must bill separately on a professional billing form according to applicable rules governing billing for professional services.

(5) Interim payment for certified registered nurse anesthetists (CRNAs) will be reimbursed at hospital specific outpatient cost to charge ratio and settled as a pass through in the cost settlement, as provided in ARM 37.86.2924.

(6) The department adopts and incorporates by reference the Outpatient Hospital Fee Schedule which is updated each quarter and is posted on the Medicaid web site. A written copy may be obtained through the Department of Public Health and Human Services, Health Resources Division, 1400 Broadway, P.O. Box 202951, Helena, MT 59620-2951.

This rule has been repealed.

(1) Coverage for medically necessary outpatient cardiac and pulmonary rehabilitation services is effective January 1, 2006.

(2) All cardiac and pulmonary rehabilitative services must be medically necessary and prior authorized by the department's designated review organization.

(3) The following conditions are contraindications to cardiac or pulmonary rehabilitation, and except as provided in ARM 37.86.3107, patients with one or more contraindications are not eligible for cardiac or pulmonary rehabilitation:

(a) severe psychiatric disturbance including, but not limited to, dementia and organic brain syndrome; or

(b) significant or unstable medical conditions including, but not limited to, substance abuse, liver dysfunction, kidney dysfunction, and metastatic cancer.

(1) Cardiac rehabilitation services are limited to the following cardiac events and diagnoses:

(a) myocardial infarction within the preceding 12 months;

(b) coronary artery bypass surgery;

(d) current stable angina pectoris;

(e) percutaneous transluminal coronary angioplasty (PTCA) or coronary stenting;

(f) heart valve repair or replacement; and

(g) chronic stable heart failure.

(1) Pulmonary rehabilitation services are limited to members with moderate to severe COPD, defined as GOLD classification II, III, and IV.

(2) If applicable, the patient must have ceased smoking or be in a smoking cessation class.

(3) The following pulmonary rehabilitation services are not covered:

(a) education, treatment, and therapies that are not individualized to a specific patient need or are not an integral part of the treatment session;

(b) routine psychological screening and treatment where intervention is not indicated;

(d) duplicate services;

(e) maintenance care when there is no expectation of further improvement;

(f) treatment that is not medically necessary because the patient requires a general strengthening and endurance program only; and

(g) treatment that is not medically necessary because the patient is at an early stage of pulmonary disease as demonstrated by a lack of significant findings in diagnostic testing.

(1) The service limitations provided in ARM 37.86.3103 and 37.86.3105 may be waived for extenuating circumstances on a case-by-case basis by the department.

(1) Critical access hospital (CAH) interim reimbursement is based on a hospital-specific Medicaid outpatient cost-to-charge ratio, not to exceed 100%. For dates of service January 1, 2018 through June 30, 2018, the interim reimbursement is based on the hospital specific Medicaid outpatient cost-to-charge ratio (CCR), less 2.99% not to exceed 100%. For dates of service on or after July 1, 2018, the interim reimbursement is based on the hospital-specific Medicaid outpatient cost-to-charge ratio. CAHs will be reimbursed their actual allowable costs determined according to ARM 37.86.2803.

(2) Prospective payment hospitals will be reimbursed on a rate-per-service basis using the outpatient prospective payment system (OPPS) schedules as provided in ARM 37.86.3020.

(3) Out-of-state hospitals will not be reimbursed for these services.

(1) "Nonhospital laboratory and radiology (x-ray) services" are professional and technical laboratory and radiology services which are ordered and provided by a physician, dentist, or other practitioner licensed within the scope of his practice as defined by state law.

(2) Nonhospital laboratory and radiology (x-ray) services may be provided in an office or similar facility other than a hospital outpatient department or clinic.

(3) Providers must meet the following requirements:

(a) Providers of laboratory services must be:

(i) Medicare certified; and

(ii) meet licensing requirements of the state in which they are located.

(b) Providers of radiology services must:

(i) be supervised by a physician who is licensed to practice medicine within the state in which the services are provided; and

(ii) meet state facility licensing requirements, if applicable.

(5) The "Physician-Related Services Manual" adopted at ARM 37.86.101 governs the administration of the Nonhospital Laboratory and Radiology (X-ray) program.

(1) These reimbursement requirements are in addition to those contained in ARM 37.85.212 and 37.86.105.

(2) Independent laboratory providers must meet the following requirements to receive Medicaid reimbursement:

(a) the independent laboratory provider must be certified by Medicare;

(b) the independent laboratory provider must meet any state licensing requirements for laboratory facilities; and

(c) the independent laboratory service must have been ordered by a physician, dentist, or other practitioner licensed to practice in Montana.

(i) Medicaid does not reimburse services ordered by chiropractors.

(3) Independent radiology (x-ray) services must meet the following requirements to receive Medicaid reimbursement:

(a) the independent radiology provider must meet any state licensing requirements for radiology facilities;

(b) the independent radiology service must be ordered by a physician, dentist, or other practitioner licensed within the scope of his practice as defined by state law;

(c) technical components of diagnostic and therapeutic radiology services must be performed by an appropriately licensed provider within the scope of his practice as defined by state law and under the supervision of a physician; and

(d) the physician with supervisory responsibilities for the radiology services must meet state licensing requirements; and

(e) technical components of the radiology (x-ray) service must be billed by and reimbursed to the supervising physician.

(4) For clinical laboratory services, the department pays the lower of:

(a) the provider's usual and customary charges for the service;

(b) 60% of the Medicare fee schedule for physician offices and independent labs and hospitals functioning as independent labs; or

(1) "Case management" means the process of planning and coordinating care and services to meet individual needs of a client and to assist the client in obtaining necessary medical, social, nutritional, educational, and other services. Case management includes assessment, case plan development, monitoring, and service coordination. Case management provides coordination among agencies and providers in the planning and delivery of services.

(2) "Caregiver" means a parent, family member, foster parent, or guardian with legal responsibility for the well-being of the client.

(3) "Case management provider" or "provider" means an entity that as provided for in this subchapter may provide case management services to clients.

(4) "Case manager" means a person or a team of persons assigned by a case management provider to do case management for the client.

(5) "Client" means a person who is eligible for and is receiving case management services.

(6) "Presumptive eligibility" means the process of determining eligibility for pregnant women to receive ambulatory prenatal care services under the Medicaid presumptive eligibility program as provided at ARM 37.82.701.

(7) "Department" or "DPHHS" means the Department of Public Health and Human Services.

(1) Case management services assure healthy outcomes by assisting recipients to access needed services and by coordinating between all agencies and providers responsible for service delivery. A case management plan sets goals for meeting a client's needs and where appropriate the needs of the client's caregivers and identifies the means for implementing those goals with emphasis on the self-sufficiency of the client and caregivers in obtaining services.

(2) Case management services are available to persons who are determined by the department or its designees in accordance with this subchapter to be within the covered groups set forth in ARM 37.86.3306.

(3) Receipt of case management services does not restrict a client's right to receive other Montana Medicaid services from any certified Medicaid provider.

(4) Case management services cannot duplicate any other Medicaid service or other services available to the client.

(5) Case management services must be delivered by a case manager whose primary responsibility is the delivery of case management services to one or more of the populations identified in ARM 37.86.3306. Exceptions to this requirement may be approved by the department or its designee.

(6) Except as otherwise provided for in this subchapter, a client may select a case management service provider and other service providers whose services are received with the assistance of case management.

(7) A client in accordance with the following criteria may temporarily receive case management services from more than one case management service provider if:

(a) there is need for more than one case manager to manage the provision of services to the client;

(b) there is a single coordinated individualized plan for case management of the provision of services;

(d) there is an agreement as to which case management services provider will bill Medicaid; and

(e) the plan of care contains the following:

(i) designation of the lead case management service provider;

(ii) justification for the use of more than one case management service provider;

(iii) specification of roles and responsibilities each case management service provider is to undertake;

(iv) documentation of all the case management services provided on behalf of the client, including those not reimbursed by Medicaid;

(v) assurances of nonduplication of case management services; and

(vi) strategies for reducing case management to a single service provider.

(8) Medicaid reimbursement for case management services except as provided in ARM 37.86.3902, is only available for the case management services provided by the lead case management provider.

(9) Decisions as to which case management provider is to be the lead case management provider for a client, except as provided in ARM 37.86.3902, are made locally. If there is disagreement that cannot be resolved locally, the department contacts for each program involved are to make the necessary decision.

(10) A case management plan must be developed jointly by the case manager and the client and where appropriate the client's caregivers.

(a) The plan should be signed by the client and where appropriate the client's caregivers. If the plan is not signed, the reason for the lack of signature must be documented.

(b) Refusal to sign the plan will not result in a denial of case management services.

(c) A case management plan for a minor or for an adult who is subject to full guardianship must be signed by the parents or guardian.

(1) Persons who are Medicaid recipients and are from the following groups are eligible for case management services:

(a) high risk pregnant women;

(b) adults with severe disabling mental illness;

(d) youth with serious emotional disturbance;

(e) children at risk for abuse and neglect; and

(f) children with special health care needs.

The definitions of targeted case management services for high risk pregnant women are as follows:

(1) "Care plan" means a specific written plan that is based on the information collected through the comprehensive assessment and periodic reassessment that:

(a) specifies the goals and actions to address the medical, social, educational, and other services needed by the member;

(b) includes activities such as ensuring the active participation of the member, and working with the member and others to develop those goals; and

(2) "Comprehensive Assessment and Periodic Reassessment" means an evaluation to identify a member's need for any medical, educational, social, or other services. These assessment activities include:

(a) taking a member's history;

(b) identifying the member's needs and completing the related documentation; and

(3) "Monitoring and follow-up activity" means activities and contacts that are necessary to ensure the care plan is implemented and adequately addresses the member's needs. The activities may be with the member, family members, service providers, or other entities or individuals and may be conducted as frequently as necessary. Monitoring may be furnished through face-to-face visits, telephone calls, and telemedicine services.

(4) "Paraprofessional" means a person to whom a particular aspect of a professional task is delegated but who is not licensed to practice as a fully qualified professional.

(5) "Referral" means activities that help link the member with medical, social, or educational providers, and other programs and services that are capable of providing needed services to address identified needs and achieve goals specified in the care plan.

(6) "Targeted case management" means services that assist a member to access needed medical, social, or other resources and services by establishing and maintaining a referral process for needed and appropriate services and avoiding duplication of services.

(1) A member is eligible for targeted case management as a high risk pregnant woman if:

(a) the person is receiving Medicaid or is presumptively eligible for Medicaid; and

(b) the member's pregnancy outcome is considered high risk.

(2) A pregnancy is of high risk if the member:

(a) is age 17 or younger;

(b) has medical factors which indicate the potential for a poor pregnancy outcome;

(d) has someone in the member's immediate environment who abuses alcohol, tobacco, or drugs;

(e) is currently in an abusive relationship;

(f) is homeless;

(g) has had greater than three residences during pregnancy; or

(h) demonstrates an inability to obtain necessary resources and services and the person meets three of the following criteria:

(i) has a history of physical or sexual abuse;

(ii) has no support system or involvement of a spouse or other supporting person;

(iii) has not had a dental cleaning in the last year;

(iv) is not educated beyond the 12th grade level or does not have a GED;

(v) has a physical disability or mental impairment;

(vi) has had no prenatal care before or during the first 20 weeks of gestation;

(vii) is a refugee or a migrant worker;

(viii) is age 18 or 19;

(ix) is over the age of 35; or

(x) has limited English proficiency.

(3) The member is not eligible for targeted case management services if enrolled in a Medicaid Patient Centered Medical Home (PCMH) program, Comprehensive Primary Care Plus (CPC+), or Health Improvement Program (HIP).

(4) Targeted case management services may be delivered to the member, if Medicaid eligibility continues, until the last day of the month in which occurs the 60th day following the end of the pregnancy.

(1) Reimbursable targeted case management services for high risk pregnant women are:

(a) comprehensive assessment and periodic reassessment;

(b) care plan development;

(d) monitoring and follow up.

(2) Face-to-face comprehensive assessments must occur at least monthly during the pregnancy.

(3) Two post-partum reassessments must occur after delivery prior to the last day of the month in which the 60th day following delivery occurs.

(4) Monitoring must include at least one annual monitoring to determine if the following conditions are met:

(a) services are being furnished in accordance with the member's care plan;

(b) services in the care plan are adequate; and

(1) These requirements are in addition to those requirements contained in rule and statutory provisions generally applicable to Medicaid providers.

(2) To be qualified as a provider of targeted case management services for high risk pregnant women, an enrolled Montana Medicaid provider must:

(a) be approved by the department;

(b) meet the requirements in (3) through (8);

(d) demonstrate an understanding of the concept of prenatal care coordination services; and

(e) have developed collaborative working relationships with health care and other agencies in the area to be served.

(3) A targeted case management provider must use an interdisciplinary team that includes members from the professions of nursing, social work, and nutrition.

(a) The professional requirements are the following:

(i) nursing must be provided by a registered nurse who has a current Montana license and is either:

(A) a registered nurse whose education includes course work in public health; or

(B) a certified nurse practitioner;

(ii) social work must be provided by one of the following:

(A) a clinical social worker with a master's in social work (MSW), who has a current Montana license;

(B) a master's level counselor (LCPC), who has a current Montana license; or

(iii) nutrition services must be provided by a registered dietitian who is licensed as a nutritionist in Montana and has one year experience in public health and/or maternal-child health.

(b) The department must be notified within 30 days regarding any staff changes or updates.

(c) To accommodate special agency and geographic needs and circumstances, exceptions to the staffing requirements, including the use of paraprofessionals, may be allowed if approved by the department. If the targeted case management team includes a paraprofessional, that individual must have a minimum of an associate's degree in behavioral sciences or a related field with two years of closely related work experience, and complete a state-sponsored training for paraprofessional targeted case managers. Qualifying experience may be substituted, year for year, for education.

(4) The targeted case management provider must be able to provide the services of at least one of the professional disciplines listed in (3) directly. The other disciplines may be provided through subcontracts. Where services are provided through a subcontractor, the subcontract must be submitted to the department or designee for review and approval.

(5) A targeted case management provider must:

(a) conduct activities to inform the target population and health care and social service providers in the geographic area to be served of its prenatal care coordination services;

(b) deliver prenatal care coordination services appropriate to the individual member's level of need;

(d) perform assessments and develop care plans for the appropriate level of care and document services provided;

(e) schedule services to accommodate the member's situation;

(f) inform members regarding whom and when to call for pregnancy emergencies;

(g) establish working relationships with medical providers, community agencies, and other appropriate organizations;

(h) assure that ongoing communication and coordination of member care occurs within the targeted case management team and with the member's medical prenatal care provider at least quarterly or at the time of any medical referrals;

(i) provide services in a home, office, or clinic setting, with telephone contacts as appropriate;

(j) have a system for handling member grievances; and

(k) maintain an adequate and confidential records system. All services provided directly or through a subcontractor must be documented in this system.

(6) A case manager providing services for a targeted case management provider must have knowledge of:

(a) federal, state, and local programs for children and pregnant women such as WIC, immunizations, perinatal health care, family planning, genetic services, hepatitis B screening, and other healthcare related programs in Montana;

(b) individual health care plan development and evaluation;

(d) nationally recognized perinatal and child health care standards.

(7) A case manager providing services for a targeted case management provider must have the ability to:

(a) develop an individual care plan based on an assessment of a member's health, nutritional and psychosocial status, and personal and community resources;

(b) inform a member regarding health conditions and implications of risk factors;

(d) establish linkages with service providers.

(e) coordinate access to multiple agency services to the benefit of the member; and

(f) evaluate a member's progress in obtaining appropriate medical care and other needed services.

(8) Providers must maintain case records that meet the maintenance of records and auditing guidelines set forth in ARM 37.85.414 and that document for all members receiving targeted case management the following:

(a) the name of the member;

(b) the dates of the targeted case management services;

(d) the nature, content, and units of the targeted case management services received and whether goals specified in the care plan have been achieved;

(e) whether the member has declined services in the care plan;

(f) the need for, occurrences of, and coordination with other targeted case managers;

(g) a timeline for obtaining needed services; and

(h) a timeline for reevaluation of the plan.

This rule has been repealed.

(1) Targeted case management services for high risk pregnant women are reimbursed at the lower of the following:

(a) the provider's customary charge to the general public for the service; or

(b) the department's current fee schedule under ARM 37.85.105.

(2) The following activities may not be billed as targeted case management and are not reimbursable as a unit of targeted case management:

(a) outreach to the member or member's representative;

(b) application activities related to Medicaid services or eligibility;

(d) duplicate payments that are made to providers under Medicaid or other program authorities;

(e) writing, recording, or entering case notes for the member's files;

(f) travel to and from member activities;

(g) coordination of the investigation of any suspected abuse, neglect, or exploitation cases; and

(h) any service less than eight minutes duration if it is the only service provided that day.

(3) Targeted case management services are not separately billable for members enrolled in a Medicaid Patient Centered Medical Home (PCMH) program, Comprehensive Primary Care Plus (CPC+), or Health Improvement Program.

(4) All targeted case management services must meet the guidelines of medical necessity set forth in ARM 37.85.410.

This rule has been repealed.

(1) Targeted case management services for adults with severe disabling mental illness will be reimbursed on a fee per unit of service basis as follows. For purposes of this rule, a unit of service is a period of 15 minutes.

(2) The department adopts and incorporates by reference the department's fee schedule which sets forth the reimbursement rates for targeted case management. The provider reimbursement rate for targeted case management services for adults with severe disabling mental illness is stated in the department's fee schedule as provided in ARM 37.85.106.

The definitions of case management services for persons with developmental disabilities age 16 years of age and over are as follows:

(1) "Developmental disability" means a disability attributable to mental retardation, cerebral palsy, epilepsy, autism, or any other neurological handicapping condition closely related to mental retardation and requiring treatment similar to that required by mentally retarded persons if the disability originated before the person attained age 18, has continued or can be expected to continue indefinitely, and constitutes a substantial handicap of the person.

(2) "Developmental disabilities program" means the program of services administered by the department for persons with developmental disabilities.

(3) "Intermediate care facility for the mentally retarded (ICF/MR)" means a residential facility as defined at 42 USC 1396d(d) and licensed by the Montana Department of Public Health and Human Services to provide active treatment services to persons with developmental disabilities.

(4) "Nursing facility" means a residential facility as defined at 42 USC 1396r(a) and licensed by the Montana Department of Public Health and Human Services to provide nursing services.

(5) "Monitor" means periodic review of the implementation of services identified in the individual plan.

(6) "Individual plan (IP)" means a written plan developed with the client's participation for the provision and management of services in the least restrictive manner to recipients. The plan must contain:

(a) reference to all provided services including identification of providers;

(b) documentation of who was involved in developing the plan;

(d) short term services and objectives;

(e) schedules for service initiation and frequency; and

(f) schedules for updating the plan.

(1) A person is eligible for case management as a person with developmental disabilities if the person:

(a) is receiving Medicaid;

(b) is 16 years of age or over; and

(2) Case management services are not available to:

(a) a person residing in an intermediate care facility for the mentally retarded (ICF/MR) or in a Medicaid certified nursing facility except as provided for in (3); or

(b) a person receiving case management services under a home and community-based waiver program authorized under section 1915 (c) of the Social Security Act.

(3) A person residing in a Medicaid certified nursing facility or intermediate care facility for the mentally retarded (ICF/MR) may receive case management services during the 30 day period immediately preceding the scheduled discharge from a nursing facility in order to coordinate postdischarge services in a noninstitutional setting.

(1) Reimbursable case management services for persons age 16 and over with developmental disabilities are:

(a) service coordination which includes the following:

(i) assessment and evaluation of the appropriateness and need for case management and other community services for which the client might be eligible;

(ii) assistance in accessing and obtaining needed services as requested by the client;

(iii) assisting the client's entry into services; and

(iv) monitoring and follow up services received by the client.

(b) planning which includes the following:

(i) development, facilitation, coordination, and monitoring of an individual plan (IP) for the client.

(i) crisis intervention for personal, financial, social, legal, or medical crisis; and

(ii) preventative problem solving with the client and where appropriate the client's family to prevent a crisis.

(d) quality of life which includes the following:

(i) building of personal relationship, communication, trust, and a basic understanding of the client as a unique human being by establishing a rapport with the client and the client's family and friends;

(ii) getting an understanding for how the client is doing or for how client wants to be doing; and

(iii) conducting a quality of life assessment for the client.

(2) Case management services for persons age 16 and over with developmental disabilities are available without geographic limitation.

(1) These requirements are in addition to those contained in rule and statutory provisions generally applicable to Medicaid providers.

(2) The case management provider for persons age 16 and over with developmental disabilities is the Developmental Disabilities program of the department. The program may contract for the delivery of case management services.

(3) Contractors with the program for the provision of case management services must be either accredited by one of the national accreditation agencies for developmental disabilities services specified in ARM 37.34.1801 or licensed under 50-5-201 , MCA as a health care facility by the department.

(4) A case manager must be employed by the Developmental Disabilities program of the department or by a case management provider contracting with the program.

(5) A case manager must meet the following criteria:

(a) A case manager, except as otherwise provided for in (5)(b), must:

(i) have a bachelor's degree in social work or a related field from an accredited college; and

(ii) one year experience in developmental disabilities or other human services:

(A) if the experience is in a human service other than developmental disabilities, the case manager must have completed at least 40 hours of training in the delivery of services to persons with developmental disabilities under a training curriculum reviewed by the developmental disabilities program of the department within no more than three months of hire or designation as a case manager.

(6) All services provided to the client will be monitored by the case manager and the case manager's supervisor. The IP will be reviewed and revised according to the client's needs at least annually, or when major changes are needed.

(7) A provider of direct care services to persons with developmental disabilities may not act as the case management provider for clients for whom the provider delivers services.

(8) A case manager must participate in a minimum of 20 hours of advanced training in services to persons with developmental disabilities each year under a training curriculum reviewed by the Developmental Disabilities program of the department. On-going documentation of the qualifications of case managers and completions of mandated training must be maintained by the employer of the case manager.

(9) A case management provider must:

(a) have a system for handling client grievances; and

(b) protect the confidentiality of client records.

(1) Reimbursement for the delivery by provider entities of Medicaid funded targeted case management services to persons with developmental disabilities is provided as specified in the Montana Developmental Disabilities Program Manual of Service Reimbursement Rates and Procedures for Targeted Case Management Services for Individuals with Developmental Disabilities Enrolled in the 1915(c) 0208 Home and Community Based (HCBS) Comprehensive Waiver or Eligible Individuals Age 16 and Over, dated July 1, 2023.

(2) The department adopts and incorporates by this reference the Montana Developmental Disabilities Program Manual of Service Reimbursement Rates and Procedures for Targeted Case Management Services for Individuals with Developmental Disabilities Enrolled in the 1915(c) 0208 Home and Community Based (HCBS) Comprehensive Waiver or Eligible Individuals Age 16 and Over, dated July 1, 2023. The manual is posted at https://dphhs.mt.gov/bhdd/disabilityservices/developmentaldisabilities/ddpratesinf.

This rule has been repealed.

The definitions of targeted case management services for children and youth with special health care needs are as follows:

(1) "Care plan" means a specific written plan that is based on the information collected through the comprehensive assessment and periodic reassessment process that:

(a) specifies the goals and actions to address the medical, social, educational, and other services needed by the child;

(b) includes activities such as ensuring the active participation of the child and child's caregiver and working with the child and others to develop those goals; and

(2) "Comprehensive assessment and periodic reassessment" means an evaluation to identify a child's need for any medical, educational, social, or other services. These assessment activities include:

(a) taking a child's history;

(b) identifying the child's needs and completing the related documentation; and

(3) "Monitoring and follow-up activity" means activities and contacts that are necessary to ensure the care plan is implemented and adequately addresses the child's needs. The activities may be with the child, family members, service providers, or other entities or individuals and may be conducted as frequently as necessary. Monitoring may be furnished through face-to-face visits, telephone calls, and telemedicine services.

(4) "Paraprofessional" means a person to whom a particular aspect of a professional task is delegated but who is not licensed to practice as a fully qualified professional.

(5) "Referral" means activities that help link the child or child's caregiver with medical, social, or educational providers, and other programs and services that are capable of providing needed services to address identified needs and achieve goals specified in the care plan.

(6) "Targeted case management" means services that assist a child and a child's caregivers to access needed medical, social, or other resources and services by establishing and maintaining a referral process for needed and appropriate services and avoiding duplication of services.

(1) A child who is receiving Medicaid or is presumptively eligible for Medicaid is eligible for targeted case management services for children and youth with special health care needs if the child meets one of the requirements in (a) or (b) and meets one of the requirements in (c).

(a) The child is under the age of one and meets one of the following:

(i) was born to a mother who abused drugs or alcohol during her pregnancy;

(ii) was born prior to 37 weeks gestation;

(iii) was born at a birth weight of less than 2500 grams; or

(iv) the department has care and placement authority, a voluntary services agreement, an in-home service agreement or a voluntary placement agreement with the parent/guardians.

(b) The child is birth through 18 years of age and meets one of the following:

(i) is infected with the human immunodeficiency virus (HIV), as determined by a positive HIV antibody or antigen test, or who has a diagnosis of HIV disease or AIDS;

(ii) has been diagnosed with a congenital heart condition;

(iii) has been diagnosed with a neurological disorder or brain injury;

(iv) has been diagnosed with a condition that requires use of a ventilator;

(v) has been diagnosed with a condition that causes paraplegia or quadriplegia;

(vi) has been diagnosed with another chronic physical health condition that is expected to last at least 12 months and causes difficulty performing activities of daily living; or

(vii) has been diagnosed with failure to thrive in the past year.

(i) failure to take advantage of necessary health care services;

(ii) noncompliance with their prescribed medication regime; or

(iii) an inability to coordinate multiple medical, social, and other services.

(2) Initial assessment of children covered by these special health care needs targeted case management services may occur in the hospital following the infant's birth. This assessment must be followed by a referral to appropriate service providers in the community. Assessments by all professionals will be accepted, shared, and integrated into planning for all children covered by these services.

(1) The following services are reimbursable targeted case management services for children and youth with special health care needs:

(a) comprehensive assessment and periodic reassessment;

(b) care plan development;

(d) monitoring and follow up.

(2) Monitoring must be at least once annually to determine if the following conditions are being met:

(a) services are being furnished in accordance with the child's care plan;

(b) services in the care plan are adequate; and

(1) These requirements are in addition to those contained in rule and statutory provisions generally applicable to medicaid providers.

(2) To be qualified as a provider of targeted case management services for children and youth with special health care needs, an enrolled Montana Medicaid provider must:

(a) be approved by the department;

(b) meet the requirements in (3) through (8);

(c) have knowledge and experience in the delivery of home and community services to children and youth with special health care needs;

(d) demonstrate an understanding of service coordination for children up to 18 years of age; and

(e) have developed collaborative working relationships with health care and other providers in the area to be served.

(3) A targeted case management provider must use an interdisciplinary team that includes members from the professions of nursing and social work.

(a) The professional requirements are the following:

(i) nursing must be provided by a registered nurse, who has a current Montana license and is either:

(A) a registered nurse whose education includes course work in public health; or

(B) a certified nurse practitioner; and

(ii) social work must be provided by one of the following:

(A) clinical social worker with a master's in social work (MSW), who has a current Montana license;

(B) master's level counselor (LCPC), who has a current Montana license; or

(b) The department must be notified within 30 days regarding any staff changes or updates.

(4) The targeted case management provider must be able to directly provide services of at least one of the professional disciplines listed in (3) of this rule. The other disciplines may be provided through subcontracts. Where services are provided through a subcontractor, the subcontract must be submitted to the department or designee for review and approval.

(5) A targeted case management provider must:

(a) conduct activities to inform the target population and health care and social service providers in the geographic area to be served of its services for youth and children with special health care needs;

(b) deliver targeted case management services appropriate to the child and caregiver's level of need;

(d) perform assessments and develop care plans for the appropriate level of care and document the services provided;

(e) schedule services to accommodate the child's situation;

(f) inform a child and the child's caregivers regarding whom and when to call for health care emergencies;

(g) establish working relationships with medical providers, community agencies, and other appropriate organizations;

(h) assure ongoing communication and coordination of the child's care occur within the targeted case management team and the child's primary care provider at least quarterly or at the time of any medical referral;

(i) provide services in a home, office, or clinic setting with telephone contacts as appropriate;

(j) have a system for handling grievances; and

(k) maintain an adequate and confidential record system. All services provided must be documented in this system.

(6) A case targeted manager must have knowledge of:

(a) federal, state and local programs for children and youth such as WIC, immunizations, children's special health services, genetic services, hepatitis B screening, EPSDT, Montana Milestones (Part C Early Interventions), and other health care related programs in Montana;

(b) individual health care systems, plan development, and evaluation;

(d) nationally recognized early childhood health care and well child health standards.

(7) A targeted case manager must have the ability to:

(a) develop or participate in the development of an individual care plan based on assessment of a child's health, nutritional and psychosocial status, and personal and community resources;

(b) inform a child and the child's caregivers regarding health conditions and implications of risk factors;

(d) assist the child and the child's caregivers to establish linkages among service providers;

(e) coordinate access to multiple provider services to benefit the child and the child's caregivers; and

(f) evaluate a child's and the child's caregiver's progress in obtaining appropriate medical care and other needed services.

(8) Providers must maintain case records that meet the maintenance of records and auditing guidelines set forth in ARM 37.85.414 and that document, for all members receiving targeted case management, the following:

(a) the name of the member;

(b) the dates of the targeted case management services;

(d) the nature, content, and units of the targeted case management services received, and whether goals specified in the care plan have been achieved;

(e) whether the member has declined services in the care plan;

(f) the need for, and occurrences of, coordination with other targeted case managers;

(g) a timeline for obtaining needed services; and

(h) a timeline for reevaluation of the plan.

(1) Targeted case management services for children and youth with special health care needs are reimbursed at the lower of the following:

(a) the provider's customary charge to the general public for the service; or

(b) the department's current fee schedule under ARM 37.85.105.

(2) The following activities may not be billed as targeted case management and are not reimbursable as a unit of targeted case management:

(a) outreach to the child or child's caregiver(s);

(b) application activities related to Medicaid services or eligibility;

(d) duplicate payments that are made to providers under Medicaid or other program authorities;

(e) writing, recording, or entering case notes for the member's files;

(f) travel to and from member activities;

(g) coordination of the investigation of any suspected abuse, neglect, or exploitation cases; and

(h) any service less than eight minutes duration if it is the only service provided that day.

(4) All targeted case management services must meet the guidelines of medical necessity set forth in ARM 37.85.410.

(1) "Adult" means a person 21 years of age or older.

(2) "Assessment" and "periodic reassessment" means determining the need for any medical, educational, social, or other services. These assessment activities include the following:

(a) taking client history;

(b) identifying the needs of the individual and completing related documentation;

(c) gathering information from other sources, such as family members, medical providers, social workers, and educators (if necessary) to form a complete assessment of the eligible individual.

(3) "Case Planning" means the development and periodic revision of a specific care plan based on the information collected through the assessment, that includes the following:

(a) specifies the goals and actions to address the medical, social, education, and other services needed by the eligible individual.

(b) includes activities such as ensuring the active participation of the eligible individual and working with the individual, the individual's authorized health care decision maker, if appropriate, or others to develop those goals.

(4) "Coordination, referral, and related activities" means activities that help the eligible individual obtain needed services. The activities include ones that help link the individual with medical, social, and educational providers or other programs and services that are capable of providing needed services to address identified needs and achieve goals specified in the care plan.

(5) "Monitoring and follow-up activities" means activities and contacts necessary to ensure the care plan is effectively implemented and adequately addresses the needs of the eligible individual. These activities may be with the person, family members, service providers, or other entities or individuals and conducted as frequently as necessary to help determine whether the following conditions have occurred:

(a) services are being furnished in accordance with the person's care plan;

(b) services in the care plan are adequate to meet the needs of the person; or

(6) "SSA" means Social Security Act.

(7) "Substance Abuse" means a person meets requirements in DSM-IV-TR for diagnosis of: 305.00; 305.20; 305.30; 305.40; 305.50; 305.60; 305.70; or 305.90.

(8) "Substance Dependency" means a person meets requirements in DSM-IV-TR for diagnosis of: 303.90; 304.20; 304.30; 304.40; 304.60; 304.70; 304.80; 305.50; or 307.90.

(9) "Substance Use Disorders" means a person who has either a diagnosis of substance abuse and/or substance dependency.

(10) "TCM" means Targeted Case Management.

(11) "Youth" means a person from birth up to and including 20 years of age.

(1) TCM services are available under ARM 37.86.4001, 37.86.4002, 37.86.4005, 37.86.4006, 37.86.4007, and 37.86.4010 only to persons who meet the following criteria:

(a) Youth who are 20 years of age or younger with a diagnosis of substance dependency or substance abuse.

(b) Adults who are 21 years of age or older with a diagnosis of substance dependency.

(1) TCM services must meet all requirements found in ARM 37.86.3301 through 37.86.3306.

(2) TCM services for substance use disorders include those indicated in ARM 37.86.4001(2) through (5).

(3) TCM services for substance use disorders are provided by state-approved chemical dependency treatment programs in accordance with these rules and the provisions of ARM 37.27.901 through ARM 37.27.912, and 53-24-208, MCA.

(4) TCM services may include contacts with noneligible individuals for purposes related to identification of the person's needs, accessing needed services, identifying needs and supports to assist in obtaining identified services, providing case managers with useful feedback, and alerting case managers to changes in the person's needs.

(5) TCM does not include:

(a) direct delivery of medical, educational, social, or other services to which a person has been referred;

(b) when activities are an integral and inseparable component of another covered Medicaid service;

(d) writing, recording, or entering case notes for the person's file;

(e) coordination of the investigation of suspected abuse, neglect, and/or exploitation cases;

(f) travel to and from activities, with or without the person;

(g) any service that does not incorporate the allowable TCM components, even if written into the individualized TCM case plan;

(h) Medicaid determination and redetermination (arranging for appointments, monitoring completion of needed steps for determination are eligible TCM services); and

(i) activities for which a person may be eligible that are integral to the administration of another nonmedical program such as guardianship, child welfare/child protective services, parole, probation, foster care services, or specialized education programs except for case management that is included in an individualized education program or individualized family service plan consistent with SSA section 1903c for services furnished to a child with a disability or to an infant or toddler with a disability.

(1) Persons receiving TCM services are allowed the freedom of choice of any qualified Medicaid provider for targeted case management services.

(2) TCM service providers cannot restrict a person's access to other Medicaid services.

(3) TCM services will not duplicate payments made to public agencies or private entities under the Medicaid program and other program authorities.

(4) A person cannot be compelled to receive TCM services as a condition of receipt of other Medicaid services or condition of receipt of other Medicaid services on receipt of TCM services.

(5) TCM services must be supported by narrative documentation of all services provided.

(6) TCM services must be provided according to a TCM plan which must:

(a) be developed jointly by the case manager and the person;

(b) identify measurable objectives;

(d) identify agencies and contacts which will assist in meeting the objectives;

(e) be incorporated into the treatment plan;

(f) identify natural and community supports to be utilized and developed; and

(g) include an objective to serve the person in the least restrictive and most culturally appropriate therapeutic environment possible for the person. The TCM plan should also be directed toward facilitating preservation of the person in the family unit, preventing out-of-community placement, or facilitating the person's return from inpatient or residential care.

(7) Objectives in a TCM plan must have an identified date of review no more than 90 days after the plan date. Plans will be revised to reflect changes in personal goals and needs, and services provided to the person.

(8) TCM services must be delivered in accordance with the person's needs.

(9) Comprehensive TCM services must be provided on a one-to-one basis, to one person, and through one case manager.

(1) The requirement in (2) is in addition to those requirements contained in rules generally applicable to Medicaid providers.

(2) TCM services for substance use disorders must be provided by a state-approved substance use disorder treatment program that is enrolled in the Montana Medicaid program.

(1) TCM services for substance use disorders will be reimbursed on a fee per unit of service basis. For purposes of this rule, a unit of service is a period of 15 minutes.

(2) The department may, in its discretion, designate a single provider to provide targeted case management services in a designated geographical region. Any provider designated as the sole case management provider for a designated geographical region must, as a condition of such designation, agree to serve the entire designated geographical region.

(3) The provider reimbursement rate for case management services for substance use disorders is stated in the department's fee schedule provided in ARM 37.85.105(5).

(4) The department will pay the lower of the following for TCM services:

(a) the provider's actual submitted charge for services; or

(b) the amount specified in the State Approved Chemical Dependency Program Manual.

(5) Providers may bill TCM services for persons transitioning from an institution to a community setting as follows:

(a) With a covered inpatient stay, the person receiving services may be eligible for TCM services during the last 14 days prior to discharge to the community.

(b) TCM activities must be coordinated with and not duplicate inpatient discharge planning.

(c) Amount, duration, and scope of the case management activities will be documented in a person's plan of care including activities prior to and post-discharge, to facilitate a successful transition to community living.

(1) "Dialysis clinics (DC)" are facilities licensed by the officially designated authority in the state where the institution is located and certified by the Centers for Medicare and Medicaid Services (CMS) to:

(a) furnish outpatient maintenance dialysis directly to end stage renal disease (ESRD) patients; and

(b) provide training for self-dialysis and home dialysis.

(1) These requirements are in addition to those contained in ARM 37.85.401, 37.85.402, 37.85.406, 37.85.407, 37.85.410, 37.85.414, and 37.85.415.

(2) The provision of outpatient maintenance dialysis and related services by the Medicaid program will be coordinated with the Medicare renal disease program as provided in CFR Title 42 section 413.171 and 413.172.

(3) Outpatient maintenance dialysis and related services in a DC will be provided only to a person who has been diagnosed as suffering from chronic ESRD by a physician.

(1) Reimbursement for outpatient maintenance dialysis and other related services provided in a dialysis clinic to include the bundled Medicare composite rate is provided in ARM 37.85.105(3). The department will not allow add-on adjustments to the composite rate.

(1) "Allowable costs" are the costs incurred by an RHC or FQHC, which are reasonable in amount and necessary and proper to the efficient delivery of services. Allowable costs are defined in accordance with reasonable cost principles in 42 CFR Parts 405 and 413.

(2) "Baseline PPS rate" is defined as an RHC's or FQHC's current PPS rate established in accordance with ARM 37.86.4413, 37.86.4420(2), 37.86.4409, or 37.86.4410, as adjusted annually by the Medicare economic index (MEI).

(3) "Category of service" means a type of Medicaid covered service that is furnished in an RHC or FQHC.

(4) "Change in the scope of service" means a change that affects the type, intensity, duration, or amount of services provided by an RHC or FQHC. The change in the scope of service must reasonably be expected to last at least one year.

(5) "Crossover claim" means a claim for services provided to Medicare/Medicaid dual eligibles or qualified Medicare beneficiaries.

(6) "Federally qualified health center (FQHC)" means an entity as defined in 42 USC 1396d(l)(2). A copy of the cited statute is available upon request from the Department of Public Health and Human Services, Health Resources Division, Hospital and Physicians Services Bureau, 1400 Broadway, P.O. Box 202951, Helena, MT 59620-2951.

(7) "FQHC services" are as defined in 42 USC 1396d(l)(2).

(8) "Health professional" means services furnished by a:

(a) physician;

(b) nurse practitioner (NP);

(d) certified nurse-midwife (CNM);

(e) licensed clinical psychologist (LCP);

(f) licensed clinical social worker (LCSW);

(g) licensed professional counselor (LCPC);

(h) licensed marriage and family therapist (LMFT);

(i) licensed addiction counselor (LAC); and

(j) clinical pharmacist practitioner.

(9) "Incremental change" means a positive or negative adjustment to a baseline PPS rate.

(10) "Independent entity" means an RHC or an FQHC that is not a provider-based entity.

(11) "Interim PPS rate" is the rate established when an RHC or FQHC initially opens and is set in accordance with ARM 37.86.4413(1) and (2).

(12) "Provider" means the entity enrolled in the Montana Medicaid program as an RHC or FQHC.

(13) "Provider-based entity" means an FQHC or RHC that is an integral and subordinate part of a hospital, skilled nursing facility, or home health agency that is participating in the Medicare program and that is operated with other departments of the provider under common licensure, governance and professional supervision.

(14) "Reporting period" means a period of 12 consecutive months specified by an RHC or FQHC as the period for which the entity must report its costs and utilization. The reporting period must correspond to the provider's fiscal year. The first and last reporting periods may be less than 12 months.

(15) "Rural health clinic (RHC)" means an entity as defined in 42 USC 1396d(l)(1).

(16) "Rural health clinic (RHC) services" are as defined in 42 USC 1396(l)(1).

(17) "Temporary PPS rate" is the rate established in accordance with ARM 37.86.4410.

(18) "Visit" has the meaning set forth in ARM 37.86.4402.

(1) A visit is a face-to-face encounter between an RHC or FQHC patient and an RHC or FQHC health professional for the purpose of providing RHC or FQHC services. Reimbursement is available for one encounter per day per eligible member unless it is necessary for the member:

(a) to be seen by different health professionals with different specialties; or

(b) to be seen multiple times per day due to unrelated diagnoses.

(2) Encounters with the same primary diagnosis are not considered separately billable visits, regardless of the health professional providing the service.

(1) The requirements of this subchapter are in addition to those contained in rule provisions generally applicable to medicaid providers.

(2) As a condition of participation in the Montana medicaid program, a RHC or FQHC must maintain a current Montana medicaid provider enrollment according to the requirements of ARM 37.85.402.

(3) As a condition of participation in the Montana medicaid program, a rural health clinic must be and remain certified by the medicare program under the conditions of certification specified in 42 CFR Part 491, subpart A.

(4) As a condition of participation in the Montana medicaid program, an FQHC must be a federally qualified health center as defined in 42 USC 1396d(l) (2) (B) .

(1) The Montana Medicaid program will cover and reimburse under the RHC or FQHC programs only those services that are RHC services or FQHC services as defined in ARM 37.86.4401 and subject to the provisions of this subchapter.

(2) The Montana Medicaid program will not reimburse an RHC or FQHC for RHC or FQHC services that are services covered by a health maintenance organization for an enrolled member, as provided in ARM Title 37, chapter 86, subchapter 50, except as provided in ARM 37.86.4414.

(3) RHC or FQHC services are covered by Montana Medicaid when provided in accordance with these rules to a member in an outpatient setting, including the RHC or FQHC, other medical facility (including a dental office), or a member's place of residence. A member's place of residence may be a nursing facility or other institution.

(4) Services provided to a member in a hospital setting are not reimbursed in accordance with these rules.

(5) The Montana Medicaid program will cover and reimburse RHC or FQHC services only if the services are provided in accordance with the same requirements that would apply if the service were provided by an individual or entity other than an RHC or an FQHC, except as specifically provided otherwise in this subchapter. These requirements include but are not limited to the following:

(a) The health professional providing the RHC or FQHC service must meet the same requirements that would apply if the health professional were to enroll directly in the Montana Medicaid program in the category of service to be provided. Such requirements include but are not limited to applicable licensure, certification and registration requirements, and applicable restrictions upon the form of entity or category of individual provider that may provide particular services. The health professional is not required to enroll separately as a Medicaid provider.

(b) The RHC or FQHC services are subject to any applicable limitations on the amount, scope, or duration of services covered by the Medicaid program, e.g., scope of practice restrictions under state licensure law, coverage exclusions, e.g., noncoverage of physical therapy maintenance services, limits on the number of hours, visits, or other units of service covered in a particular period or on the frequency of services covered, limits on the type of items or services covered within a particular category, medical necessity requirements, including specific medical necessity criteria applicable to a particular item or service, and early and periodic screening, diagnostic and treatment services (EPSDT) program requirements and restrictions.

(c) In addition to general record requirements under ARM 37.85.414, RHCs and FQHCs must comply with any additional particular record or documentation requirements applicable to the particular category or type of service, e.g., requirements for documentation of compliance with supervision and protocol requirements, requirements for written documentation of prescription or referral, requirements for written care plans and prerequisites for receipt of a particular item or service by a particular recipient.

(d) Providers must bill for RHC or FQHC services using the revenue codes specified in the department's RHC/FQHC services provider manual. The department must provide 30 days prior written notice to providers of any changes in revenue codes.

(e) RHCs and FQHCs must comply with requirements for Medicaid program authorization prior to provision of services or prior to payment, as applicable to the particular category of services being provided.

(f) Reimbursement will be made to RHCs and FQHCs for RHC and FQHC services as provided in ARM 37.86.4412 through 37.86.4414, 37.86.4420, 37.86.4408, 37.86.4409, and 37.86.4410, rather than as provided in the rules applicable to the particular category of services. This rule does not permit reimbursement of services provided by health professionals under ARM 37.86.4412 through 37.86.4414, 37.86.4420, 37.86.4408, 37.86.4409, and 37.86.4410 when the services are not provided as an RHC or FQHC service and when the health professional is separately enrolled in and providing services under a particular Medicaid service category, subject to the rules applicable to the particular service category.

(6) A provider must notify the department, in writing, of a change in the scope of service offered by the RHC or FQHC to Medicaid members, in accordance with 37.86.4408, 37.86.4409, and 37.86.4410.

(7) The opening of new or additional service locations absent of a change in scope of service will be assigned the same baseline PPS rate as the primary RHC or FQHC.

(1) A provider must meet the record keeping and other requirements of ARM 37.85.414 in addition to the requirements of this rule.

(2) A provider must make and maintain adequate financial and statistical records in accordance with generally accepted accounting principles, as defined by the American institute of certified public accountants. The provider's records must be sufficient to allow the department and its agents to determine payment for the RHC or FQHC services provided to medicaid recipients and to provide a record that may be audited using generally accepted auditing standards. Such records must be maintained for a period of six years, three months after a cost report is filed with respect to the period covered by such records or until such cost report is finally settled, whichever is later.

(3) The records described in (2) must be available at the provider facility at all reasonable times and shall be subject to inspection, review and audit by the department or its agents, the United States department of health and human services, the general accounting office, the Montana legislative auditor, and other governmental agencies as authorized by law.

(4) Upon failure or refusal of the provider to make available and allow access to such records, or to report an increase or decrease in scope of services, the department may recover in full all payments made to the provider during the reporting period to which such records relate and may suspend any further payments to the provider until such time as the provider fully complies with this rule.

(5) No later than 30 days prior to the beginning of its initial reporting period as a new provider or following a change in ownership, a provider must submit to the department or its agent an estimate of budgeted costs and visits for RHC or FQHC services for the reporting period in the form and detail required by the department and such other information as the department may require to establish a rate as provided at ARM 37.86.4413.

(1) An RHC or FQHC experiences a change in scope of service if it has experienced a change in the type, intensity, duration, or amount of an RHC or FQHC service. A change in scope of service may result in an incremental change to the baseline PPS rate.

(2) An RHC or FQHC must apply to the department if it experiences a change in scope of service, even if the change in scope of service will not result in an incremental change to the baseline PPS rate. An RHC or FQHC must follow the procedures in ARM 37.86.4409 and ARM 37.86.4410 to apply for a change in scope of service.

(3) A change in scope of service is limited to the following circumstances, and an RHC or FQHC applying for a change in scope of service must demonstrate at least one of the following:

(a) the addition of a new service not incorporated in the baseline PPS rate or deletion of a service incorporated in the baseline PPS rate;

(b) the addition or deletion of a covered Medicaid RHC or FQHC service under the State Plan;

(d) a change in service due to a change in applicable technology or medical practices utilized by the RHC or FQHC not otherwise paid for through state or federal funds;

(e) a change in the types of patients served, including but not limited to, populations with HIV/AIDS, populations with other chronic diseases, or homeless, elderly, migrant, or other special populations that require more intensive and frequent care, corresponding to a change in the services provided by the RHC or FQHC;

(f) a change in operating costs attributable to capital expenditures corresponding to a change in the services provided by the RHC or FQHC; or

(g) a change in the provider mix, including, but not limited to:

(i) a transition from mid-level providers to physicians with a corresponding change in the services provided by the RHC or FQHC; or

(ii) the addition or removal of specialty providers with a corresponding change in the services provided by the RHC or FQHC.

(4) An RHC or FQHC must demonstrate how one or more of the circumstances in (3) impacts services provided by the RHC or FQHC and must demonstrate an overall change to the RHC or FQHC. For example, the RHC or FQHC may increase services to a high need population; however, this increase may be offset by growth in the number of lower intensity visits, thereby not warranting an incremental change to the baseline PPS rate.

(5) The following circumstances alone do not constitute a change in scope of service rate adjustment:

(a) a change in ownership, including acquisition by another healthcare entity or RHC or FQHC;

(b) a change in the number of staff furnishing an existing service;

(d) a change in the number of encounters;

(e) a change in the cost of supplies for existing services;

(f) a change in salaries and benefits not directly related to a change in scope of service;

(g) a change in patient type and/or volume without a corresponding change in the services provided;

(h) capital expenditures for losses covered by insurance;

(i) a change in office location or office space;

(j) a change in office hours not directly related to a change in the scope of service as described in (3);

(k) expansion or remodel not directly related to a change in the scope of service as described in (3); or

(l) the addition of a new site or removal of an existing site, which offers the same RHC or FQHC services.

(6) The circumstances in (5) may be factors in demonstrating a change in scope of service as long as the RHC or FQHC also demonstrates one or more of the circumstances in (3).

(7) RHCs or FQHCs that choose to participate in contracted programs to provide services outside of the PPS rate must meet the requirements and adhere to the rules outlined in the applicable contract.

(a) Contracts for services outside of RHC or FQHC services will be reimbursed outside the PPS rate and such services will not be included in calculation of the baseline PPS rate or in a request for change in scope of service. Providers who chose to enter contracted programs and meet all related requirements will receive a separate payment as established in the Montana Medicaid State Plan or Centers for Medicare and Medicaid Services approved waiver.

(b) If an RHC's or FQHC's existing baseline PPS rate includes costs associated with contracted programs, the RHC or FQHC must submit a change in scope of service to remove the contracted services from the baseline PPS rate.

(1) A prospective change in scope of service is a change the RHC or FQHC plans to implement in the future. An RHC or FQHC may file an application for a prospective change in scope of service and, if approved, may receive a temporary PPS rate, pending final approval of the incremental change to the baseline PPS rate.

(2) An application is deemed timely if the department receives the completed application for a prospective change in scope of service no later than 120 days in advance of the prospective change in scope of service, or otherwise the application is deemed untimely.

(3) An application is completed if it includes the information in (4), and, if applicable, (5).

(4) To apply for a prospective change in scope of service rate adjustment, an RHC or FQHC must submit the following application materials:

(a) a narrative description of each change in scope of service;

(b) the date on which the change in scope of service is scheduled to occur;

(d) the cost report for the fiscal year prior to the year in which the prospective change in scope of service is scheduled to be implemented; and

(e) a projected cost report for the fiscal year in which the change in scope of service is implemented, which considers the change in scope of service. If a projected cost report cannot be completed, the RHC or FQHC must provide sufficient cost and encounter information to establish a temporary rate.

(5) The department may request additional information from the RHC or FQHC. The requested information must be received by the department no later than 30 calendar days from the date of the request to be deemed timely. If the requested information is not received within that timeframe, the application for a prospective change in scope of service is deemed untimely.

(6) No later than 90 days after receiving a completed application, the department shall:

(a) establish the temporary PPS rate by calculating the RHC's or FQHC's allowable cost of services both with and without the added or removed services; and

(b) notify the RHC or FQHC of the temporary PPS rate.

(7) After the change in scope of service occurs, the RHC or FQHC shall notify the department in writing of the implementation date, even if the change is implemented on the scheduled date.

(8) For timely applications, the effective date of the temporary PPS rate is the date the change in scope of service is implemented.

(9) For untimely applications, the effective date of the temporary PPS rate is the later of:

(a) the date the department receives the RHC's or FQHC's completed application materials in (4) and, if applicable, (5); or

(b) the date the change in scope of service is implemented.

(10) No later than six months after the close of the RHC's or FQHC's fiscal year in which the change in scope of service occurred, the RHC or FQHC must supplement its application by filing with the department the following materials:

(a) a narrative description of each change in scope of service, including how the services were provided both before and after the change;

(b) the date on which the prospective change in scope of service was implemented;

(c) the RHC's or FQHC's as-filed Medicare cost reports for the fiscal year prior to the year in which the change in scope of service occurred and for the fiscal year in which the change in scope of service occurred;

(d) for the FQHCs the Uniform Data System reports for the calendar year prior to the change in scope of service, and the calendar year in which the change in scope of service occurred;

(e) a description of each cost center on the cost report affected by the change in scope of service;

(f) an attestation statement that certifies the accuracy, truth, and completeness of the information in the application signed by an officer or administrator of the RHC or FQHC; and

(g) any approved changes in scope of project as defined by the federal Health Resources and Service Administration (HRSA).

(11) The department may request additional information to process the application and must receive the additional information no later than 30 calendar days from the date of the request, or otherwise the application is deemed untimely. The request for additional information will include a notice that failure to submit the materials within the requested 30 calendar days will result in suspension of payments for Medicaid services billed to the department until such time as the supplemental materials are received by the department.

(12) The department must receive the supplemental materials no later than six months after the close of the RHC's or FQHC's fiscal year in which the change in scope of service occurred, or otherwise the application is deemed untimely. Thirty days prior to the expiration of the six-month deadline, if the department has not yet received the supplemental materials, the department shall send a notice to the RHC or FQHC and inform it that failure to submit the materials in a timely manner will result in suspension of payments for Medicaid services billed to the department until such time as the supplemental materials are received by the department.

(13) No later than 90 days after receiving the supplemental materials, the department shall:

(a) establish the incremental change in the baseline PPS rate by calculating the RHC's or FQHC's allowable costs of services both with and without the added or removed services; and

(b) notify the RHC or FQHC of the incremental change in the baseline PPS rate.

(14) For timely filed supplemental materials, the effective date of the incremental change to the baseline PPS rate is the date the change in scope of service was implemented. If the final PPS rate differs from the temporary PPS rate, the department shall calculate the amount of underpayment or overpayment to the RHC or FQHC and reimburse or recoup the amount from future payments to the RHC or FQHC.

(15) If an RHC or FQHC fails to timely submit supplemental materials, the department shall suspend all payments to the RHC or FQHC for Medicaid services billed to the department until such time as the supplemental materials are received. Once all required supplemental materials are received the effective date of the incremental change to the baseline PPS rate is the date the change in scope of service was implemented.

(1) A retrospective change in scope of service occurs when a change took place in the past and the RHC or FQHC is seeking to adjust its rate based on that change. An approved retrospective change in scope of service request may result in an incremental change to the baseline PPS rate.

(2) An RHC or FQHC may apply for an incremental change to the baseline PPS rate for a retrospective change in scope of service once per calendar year. In order to be deemed timely, the completed application must be received by the department no later than six months after the close of the RHC's or FQHC's fiscal year in which the change in scope of service occurred, or otherwise the application is untimely. A completed application must include the information in (3) and, if applicable, (4).

(3) To apply for an incremental change to the baseline PPS rate for a retrospective change in scope of service, an RHC or FQHC must submit the following application materials:

(a) a narrative description of each change in scope of service, including how services were provided both before and after the change;

(b) the RHC's or FQHC's as-filed Medicare cost reports for the fiscal year prior to the change in scope of service, and the fiscal year in which the change in scope of service occurred;

(c) for FQHCs the Uniform Data System reports for the calendar year prior to the change in scope of service, and the calendar year in which the change in scope of service occurred;

(d) a description of each cost center on the cost report affected by the change in scope of service;

(e) an attestation statement that certifies the accuracy, truth, and completeness of the information in the application signed by an officer or administrator of the RHC or FQHC; and

(f) any approved changes in scope of project as defined by the Health Resources and Services Administration (HRSA).

(4) The department may request additional information from the RHC or FQHC. The requested information must be received by the department no later than 30 calendar days from the date of the request, or otherwise the application is deemed untimely.

(5) After receiving a completed application, the department shall calculate the RHC's or FQHC's allowable cost of services both with and without the added or removed services to establish the incremental change to the baseline PPS rate. The department shall notify in writing the RHC or FQHC of the incremental change to the baseline PPS rate within 90 calendar days of receiving the information requested in (3) and (4).

(6) For timely applications, the effective date of the incremental change to the baseline PPS rate is the beginning of the facility's fiscal year following the retrospective change in scope of service. For untimely applications, the effective date of the incremental change to the baseline PPS rate is the date all required information is received by the department.

(1) This subchapter specifies requirements applicable to provision of and reimbursement for RHC and FQHC services. These rules are in addition to requirements generally applicable to Medicaid providers as otherwise provided in state and federal statute, rules, regulations, and policies.

(2) Unless otherwise provided in these rules, this subchapter applies to rate years beginning on or after January 1, 2001. Reimbursement and other substantive RHC and FQHC requirements for earlier periods are subject to the laws, regulations, rules, and policies then in effect. Procedural and other nonsubstantive provisions of these rules are effective upon adoption.

(3) All RHCs and FQHCs will be reimbursed on a prospective payment system (PPS) beginning January 1, 2001 and each succeeding calendar year. The PPS will apply equally to provider based and independent RHCs and FQHCs.

(4) On January 1 of each succeeding calendar year, the rate for the preceding year must be adjusted by the percentage increase in the medicare economic index (MEI) applicable to primary care services for that calendar year.

(5) The department will reimburse the RHC or FQHC for the rate change in (4) retroactive to the effective date of January 1 of the calendar year, beginning with January 1, 2002.

(6) For RHCs or FQHCs that had their initial Medicaid prospective payment system base visit rate calculated in 2001 or starting with the third fiscal year (for "new" RHCs or FQHCs as defined at ARM 37.86.4413), the prospective payment system per-visit rate may be adjusted to take into account any increase or decrease in the scope of service. The department uses the following calculations to determine the amount of an incremental change, if any, and the resulting new PPS rate:

A/B = C

D/E = F

F-C = IC

Current PPS rate + IC = New PPS rate

(a) "A" represents allowable costs before the change in scope of service;

(b) "B" represents total visits before the change in scope of service;

(d) "D" represents allowable costs after the change in scope of service;

(e) "E" represents total visits after the change in scope of service;

(f) "F" represents cost per visit after the change in scope of service; and

(g) "IC" represents the incremental change due to the change in scope of services.

(7) Effective July 1, 2017, approved RHCs and FQHCs participating in Promising Pregnancy Care (PPC) will be reimbursed an enhanced PPS rate. Therefore, RHCs and FQHCs will be reimbursed their existing PPS rate plus an additional amount, in accordance with the fee schedule adopted and effective as provided in ARM 37.85.105, whenever a member attends the educational aspect of the PPC session.

(8) Effective July 1, 2017, RHCs and FQHCs will be reimbursed separately for long-acting reversible contraceptives (LARCs) in addition to their PPS rate. LARCs include intrauterine devices (IUDs) and birth control implants.

(1) The interim Medicaid prospective payment system (PPS) base per-visit rate for a newly qualified RHC or FQHC or an FQHC shifting from non-state government operated to privately operated shall be equal to 100% of the average PPS rate for other RHCs or FQHCs located in the same or adjacent area with a similar caseload. In the event that there is no such RHC or FQHC, payment shall be made in accordance with the methodology provided in (2).

(2) If there is no RHC or FQHC located in the same or adjacent area with a similar caseload, the interim PPS rate shall be equal to the RHC's or FQHC's total projected allowable costs divided by the RHC's or FQHC's total projected allowable visits. The provider must submit to the department or its agent an estimate of budgeted costs and visits for the RHC or FQHC for the reporting period in the form and detail required by the department and such other information as the department may require to establish a rate. The projected allowable cost and allowable visit information is subject to a reasonableness review by the department.

(3) At the end of the RHC's or FQHC's first two complete fiscal years, the department will establish the facility specific baseline PPS rate.

(4) The department must receive the RHC's or FQHC's as-filed Medicare cost reports for the first two complete fiscal years no later than six months after the end of the RHC's or FQHC's first two complete fiscal years, or otherwise the request is deemed untimely.

(a) The department may request additional information from the RHC or FQHC, and the facility is required to submit the requested information within 30 days of the department's request. If the requested information is not received within that timeframe, the request is deemed untimely. The request for additional information will include a notice that failure to submit the materials within the requested 30 calendar days will result in suspension of payments for Medicaid services billed to the department until such time as the supplemental materials are received by the department.

(b) If the department has not received the materials in (4)(a) thirty days prior to the expiration of the six month deadline, the department shall send a notice to the RHC or FQHC and inform it that failure to submit the materials in a timely manner will result in suspension of payments for Medicaid services billed to the department until such time as the materials are received by the department.

(5) Upon receiving the RHC's or FQHC's as-filed Medicare cost reports and any additional information requested pursuant to (4)(a), the department will establish the RHC's and FQHC's baseline PPS rate by calculating the total allowable cost of RHC or FQHC services for the first two complete fiscal years divided by the total allowable visits for the first two complete fiscal years. The baseline PPS rate may be adjusted to take into account any increase or decrease in the scope of service as provided in ARM 37.86.4412.

(6) The department will provide written notification of the calculated baseline PPS rate to the RHC or FQHC within 90 days of receiving all information related to the request.

(7) The department shall reimburse the RHC or FQHC the baseline PPS rate for requests submitted within the timeframe specified in (4)(a) and (b) effective the date of the RHC or FQHC enrollment.

(8) If an RHC or FQHC fails to timely submit the materials in (4)(a), or if applicable (2)(b), the department shall suspend all payments to the RHC or FQHC for Medicaid services billed to the department until such time as the supplemental materials are received. Once all required materials are received the effective date of the baseline PPS rate is the effective date of the RHC or FQHC enrollment.

(9) Reimbursement after the baseline PPS rate is only modified through the processes outlined in ARM 37.86.4406, 37.86.4408, 37.86.4409, 37.86.4410, and 37.86.4412.

(1) In the case of services furnished by an RHC or FQHC pursuant to a contract between the RHC or FQHC and a managed care entity (as defined in section 1932(a) (1) (B) and 1932(a) (1) (C) of the Social Security Act) , payment to the RHC or FQHC shall be a supplemental payment equal to the amount (if any) by which the amount determined under medicaid prospective payment system exceeds the amount of the payments provided under the contract.

(2) The supplemental payment required shall be made quarterly.

(1) In the case of a catastrophic event or extraordinary circumstance that would directly impact the cost of medical services provided by an RHC or FQHC, or upon mutual agreement of the department and the RHC or FQHC the department may provide for payment in any year to an RHC or FQHC for services described in section 1905(a)(2)(B) and (C) of the Social Security Act in an amount determined under an alternative payment methodology that:

(a) is agreed to by the department and the RHC or FQHC; and

(b) results in payment to the RHC or FQHC of an amount which is at least equal to the amount otherwise required to be paid to the RHC or FQHC under the Medicaid prospective payment system.

(2) Beginning July 1, 2019, RHC or FQHC providers may elect to be reimbursed under an Alternative Payment Methodology (APM) equal to the per-visit cost as calculated utilizing the two most recently completed as-filed Medicare cost reports and/or other requested information. Examples include the Uniform Data Systems report, audited financial statements, and Electronic Health Record visit reconciliation.

(a) The APM per-visit rate will not be less than the RHC's or FQHC's existing baseline PPS rate.

(b) RHC or FQHC providers who choose to be reimbursed under the APM, must make the request to the department in writing no later than July 1, 2020.

(c) The department will provide a written notification of the calculated APM per-visit rate to the RHC or FQHC within 90 days of receiving all information related to the request.

(3) The effective date of the APM per-visit rate will be the later of the start of the facility's fiscal year following the most recent submitted Medicare as-filed cost report or July 1, 2019.

(4) If the required information as outlined in (2) is not received prior to July 1, 2020, the option to be reimbursed on the APM is not available.

(1) "Group prenatal care" means a combination of individual prenatal care with facilitated group education and support. The groups consist of four to twelve pregnant women with similar due dates.

(2) "Promising Pregnancy Care (PPC)" means the Montana Healthcare Programs reimbursable group prenatal care program. The Montana Healthcare Programs include:

(a) Montana Medicaid;

(b) Healthy Montana Kids (HMK);

(d) the Health and Economic Livelihood Plan (HELP).

(3) "Self-care activities" means activities that members complete on their own and includes activities such as measuring weight and blood pressure.

(4) "State approved program" means a program that meets the education requirement of the department or is Centering Certified through the Centering Healthcare Institute and has been approved for reimbursement by the department.

(1) These requirements are in addition to those requirements contained in rule and statutory provisions generally applicable to Medicaid providers.

(2) For purposes of Medicaid reimbursement, providers must be a state-approved program.

(3) Pregnant members of Montana Healthcare Programs are eligible for Promising Pregnancy Care.

(4) The department must approve educational materials.

(5) A pregnancy notebook that includes personal health tracking and education materials must be provided to class participants.

(6) Data on all pregnant Medicaid members under the provider's care must be collected and reported to the department. The required data elements are available at the department's website at http://medicaidprovider.mt.gov.

(7) Classes must be provided in a group setting.

(8) Individual assessment will occur in a private area of the group space.

(9) Each class must include time for the participants to interact with other participants.

(10) The classes must be facilitated and have a planned learning objective.

(11) Participants must engage in self-care activities.

(12) The program must include the following information:

(a) nutrition information;

(b) healthy lifestyle choices;

(d) body changes in pregnancy;

(e) stress management;

(f) family planning;

(g) labor education, including types of delivery;

(h) newborn care;

(i) preventing shaken baby syndrome;

(j) preventing sudden infant death syndrome (SIDS); and

(k) postpartum care and adjustments.

(13) The program must include a participant satisfaction survey. The results of this survey must be reported to the department semi-annually. A sample survey is posted at the department's web site at http://medicaidprovider.mt.gov.

(1) Promising Pregnancy Care is reimbursed at the lower of the following:

(a) the provider's usual and customary charge to the general public for the service; or

(b) the department's current fee schedule under ARM 37.85.105 for the appropriate provider type.

(1) "Organ transplantation" means the implantation of a functional human organ for the purpose of maintaining all or a major part of that organ function in the recipient.

(2) "Tissue transplantation" means the implantation of functional, human tissue. For purpose of the transplantation rules, tissue transplants include only corneal, bone marrow, and peripheral stem cell transplants.

(3) Organ and tissue transplantation includes the transplant surgery and those activities directly related to the transplantation. These activities may include:

(a) evaluation of the patient as a potential transplant candidate;

(b) pre-transplant preparation including histo-compatibility testing procedures;

(d) outpatient care, including Federal Drug Administration (FDA) approved medications deemed necessary for maintenance or because of resulting complications.

(1) This rule provides the requirements for Medicaid coverage of organ and tissue transplantations. The requirements in this rule are in addition to those contained in ARM 37.85.401, 37.85.402, 37.85.406, 37.85.407, 37.85.410, 37.85.412, 37.85.413, 37.85.414, and 37.85.415.

(2) General requirements for Medicaid coverage of transplantations are as follows:

(a) Medicaid will only cover medically necessary organ or tissue transplants.

(i) Services must comply with Medicare coverage guidelines for organ or tissue transplant service.

(ii) If Medicare coverage guidelines are not available, the department or the department's designated review organization will review the requested transplant surgery to determine whether the surgery is medically necessary and is not experimental or investigational.

(b) All cases presented for organ or tissue transplantation require prior authorization from the department's designated review organization, with the exception of corneal transplantation.

(c) Organ transplants must be performed in a Medicare certified center. If Medicare has not designated a certified center, the transplant must be performed by a program that is located in a hospital or parts of a hospital certified by the Organ Procurement and Transplantation Network (OPTN) for the specific organ being transplanted.

(3) Services considered experimental and/or investigational are not a benefit of the Montana Medicaid Program.

(a) Experimental and/or investigational services include:

(i) Procedures and items including prescription drugs, considered experimental and/or investigational by the U.S. Department of Health and Human Services or any other appropriate federal agency.

(ii) Procedures and items, including prescribed drugs, provided as part of a control study, approved by the Department of Health and Human Services or any other appropriate federal agency to demonstrate whether the item, prescribed drug, or procedure is safe and effective in caring, preventing, correcting, or alleviating the effects of certain medical conditions.

(iii) Procedures and items, including prescribed drugs, which may be subject to question, but are not covered in (3)(a)(i) and (ii), will be evaluated by the department or the department's designated medical review organization to determine whether they are experimental and/or investigational.

(1) Reimbursement for physician services in organ transplantation is provided in accordance with the methodologies described in ARM 37.85.212 and 37.86.105.

(2) All hospital services for organ and tissue transplantation are reimbursed as provided for in ARM 37.85.212, 37.86.2801, 37.86.2806, 37.86.2907, 37.86.2916, 37.87.3005, 37.87.3009, 37.87.3020, 37.87.3025, and 37.87.3037.

(1) "Administrative contractor for managed care" means the entity the department contracts with to perform certain administrative functions of the managed health care programs.

(2) "Basic medicaid" means the program of medicaid services for adults receiving medical assistance through the FAIM program who are 21 years and older and not pregnant. Basic medicaid excludes coverage for dental services, most durable medical equipment and supplies, eye examinations, eyeglasses, hearing aids, audiology services, and personal care services.

(3) "Capitation rate" means the fee the department pays monthly to an HMO for the provision of covered medical and health services to each enrolled recipient. The fee is reimbursed whether or not the enrolled recipient received services during the month for which the fee is intended. The fee may vary by age, eligibility category and region.

(4) "Community-based organizations" means local governmental and nonprofit organizations providing programs of preventive and other health related services. Community-based organizations include but are not limited to: local family planning services; local women, infants and children (WIC) projects; local projects of Montana initiative for the abatement of mortality of infants (MIAMI) ; HIV testing, partner notification and early intervention; childhood lead poisoning prevention services; cherish our Indian children; follow me programs for special needs children.

(5) "Complaint" means an informal, verbal communication which an enrollee or their authorized representative presents regarding what the enrollee or their authorized representative perceives to be an inappropriate or lack of appropriate action by the HMO or any of its providers.

(6) "Contract" means a contract between the department and an HMO for the provision of medical and health services to medicaid recipients.

(7) "County office" means the location people go to apply for medicaid benefits that is either the department's local office of human services or the human services or welfare office of a county.

(8) "Covered services" means all or a part of the medical and health services set forth in ARM 37.86.5007 that an HMO is responsible for delivering to enrolled recipients under a contract with the department.

(9) "Day" means calendar days, except where the term working days or business days is expressly used.

(10) "Department" means the Montana department of public health and human services.

(11) "Emergency medical condition" means a medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain) such that a prudent layperson, who possesses an average knowledge of health and medicine, could reasonably expect the absence of immediate medical attention to result in:

(a) placing the health of the individual (or, with respect to a pregnant woman, the health of the woman or her unborn child) in serious jeopardy;

(b) serious impairment to bodily functions; or

(12) "Emergency room screens" means a medical screening examination within the capacity of the hospital's emergency department, including stabilization when necessary, to determine whether an emergency medical condition exists.

(13) "Emergency services" means, as defined at ARM 37.82.102, inpatient and outpatient hospital services that are necessary to treat an emergency medical condition.

(14) "Enrollee" means a medicaid recipient who has been certified by the department as eligible to enroll with an HMO, and whose name appears on the HMO's enrollment information that the administrative contractor for managed care transmits to the HMO every month as specified in the contract.

(15) "Enrollment area" means the county or counties that an HMO's certificate of authority from the state of Montana permits it to serve and in which the HMO has service capability as required by the department and set forth in the contract. If a proposed enrollment area is other than an entire county or counties, the proposed enrollment area should correspond to the normal service delivery area.

(16) "Exempt" means medicaid recipients who are not ineligible for managed care and who can prove it would be a hardship to participate in a managed care program. The department has the discretion to determine hardship and to place time limits on all exemptions on a case by case basis.

(17) "Families achieving independence in Montana (FAIM) " is a comprehensive welfare reform package. Participation in FAIM affects medicaid coverage for able-bodied adults 21 years and older. FAIM participants who are 21 years and older and not pregnant:

(a) are only eligible for basic medicaid;

(b) are required to enroll in an HMO if one is available in their area. If there is no HMO available, they must enroll in the passport to health program. If there is neither a passport to health program nor an HMO available, recipients stay on regular fee-for-service medicaid.

(18) "Federally qualified HMO" means an HMO qualified under section 1315(a) of the Public Health Service Act as determined by the U.S. public health service.

(19) "Full medicaid" means the full scope of medicaid benefits as defined in ARM 37.85.206.

(20) "Grievance" means a formal, written communication which an enrollee or their authorized representative presents regarding what the enrollee or their authorized representative perceives to be an inappropriate action or lack of appropriate action by the HMO or its providers.

(21) "Health maintenance organization (HMO) " means a health maintenance organization or its parent corporation with a certificate of authority issued in accordance with 33-31-201 , et seq., MCA.

(22) "Ineligible" means medicaid recipients who are not allowed by the department to be under managed care and who must stay on regular medicaid. The following categories of recipients are ineligible:

(a) recipients with a spend down (medically needy) ;

(b) recipients living in a nursing home or institutional setting;

(d) recipients on the medicaid restricted card program;

(e) recipients who have medicare;

(f) recipients who live in an area without medicaid managed care;

(g) recipients in the medicaid eligibility subgroup of subsidized adoption;

(h) recipients whose eligibility period is only retroactive;

(i) recipients who cannot find a primary care provider who is willing to provide case management;

(j) recipients who are receiving medicaid home and community services for persons who are aged or disabled; and

(k) recipients who reside in a county in which there are not enough primary care providers to serve the medicaid population required to participate in the program.

(23) "Managed health care provider" means any one of the alternative systems for delivery of regular fee-for-service medicaid services. Managed health care provider includes health maintenance organizations (HMOs) and primary care case management programs.

(24) "Participating provider" means any person or entity that has entered into a contract with an HMO to provide medical care.

(25) "Primary care provider" means a physician, clinic, or mid-level practitioner other than a certified registered nurse anesthetist that is responsible by contract to serve an HMO's enrollees that has been designated by an enrollee as the provider through whom the enrollee obtains health care benefits provided by the HMO. A primary care provider attends to an enrollee's routine medical care, supervises and coordinates all of the enrollee's health care, determines the need for and initiates all referrals, determines the provider of medical services and determines the medical necessity of the medical services to be performed. Obstetrician or gynecologist means a physician who is board eligible or board certified by the American board of obstetrics and gynecology.

(26) "Recipient" means a person who is eligible for medicaid in accordance with the legal authorities governing eligibility.

(27) "Regular medicaid" means the program of medicaid services for medicaid recipients that would have been available to an enrollee if the enrollee were not enrolled in an HMO.

(28) "Routine care" means medical care for a condition that is not likely to substantially worsen in the absence of immediate medical intervention and is not an urgent condition or an emergency. Routine care can be provided through regularly scheduled appointments without risk of permanent damage to the person's health status.

(29) "School based provider" means a provider that provides services in a school setting.

(30) "Upper payment limit" means the cost to the department of providing the same services to an actuarially equivalent non-enrolled population.

(31) "Urgent care" means medical care necessary for a condition that is not life threatening but which requires treatment that cannot wait for a regularly scheduled clinical appointment because of the prospect of the condition worsening without timely medical intervention.

(32) "Usual manner" means obtaining medicaid benefits in the manner that medicaid recipients obtain them through the regular medicaid program.

(1) A recipient in any one of the following categories is eligible to enroll with an HMO contracting with the department:

(a) a FAIM or family-related recipient required by ARM 37.86.5103 to participate in a primary care case management program; or

(b) an SSI recipient or SSI-related recipient required by ARM 37.86.5103 to participate in a primary care case management program.

(2) A recipient who is ineligible to participate in a primary care case management program is not eligible to enroll with an HMO contracting with the department.

(1) Recipient enrollment with an HMO contracting with the department is voluntary, except as noted below.

(a) Individuals 21 years of age or older receiving medicaid or medically needy assistance as participants of the FAIM project, and who are not pregnant, are required to enroll in an HMO if one is available in the enrollment area and has not reached its maximum enrollment. If the HMOs in the enrollment area are at maximum enrollment, the individual must participate in the passport to health program as required in ARM 37.86.5101, et seq.

(2) An eligible recipient may request enrollment with a particular HMO.

(3) An eligible recipient may only enroll with an HMO contracting with the department to provide HMO services in the locality of the recipient's residence.

(4) An eligible recipient who is hospitalized, other than a newborn recipient, may enroll initially with an HMO contracting with the department only after the recipient's discharge from the hospital.

(5) Enrollment is requested either by completing a form designated by the administrative contractor for managed care or by a written or verbal request to the administrative contractor for managed care.

(a) The form must be available through the county office, the HMO office, the administrative contractor for managed care, or other locations designated by the department.

(b) An HMO or any entity responsible for making the form available, receiving a form or a request, must forward the form or request in writing to the administrative contractor for managed care within 3 working days.

(6) An HMO must accept without restriction eligible recipients in the order in which they are received for enrollment by the administrative contractor for managed care until the HMO's maximum enrollment under the contract is reached.

(7) The effective date of enrollment for an eligible recipient must be no later than the first day of the second month subsequent to the date on which the administrative contractor for managed care receives the designated managed health care choice form or written or verbal request. The effective date must be earlier than the second subsequent month if enrollment can be processed before the last 4 working days of the month.

(8) An HMO may issue an appropriate identification card to an enrollee. A medicaid card is issued to enrollees by the department.

(9) Enrollment with an HMO is indicated by the appearance of the HMO's name and 24-hour telephone number on the medicaid card.

(10) An enrollee must obtain covered services as defined in ARM 37.86.5007 through the HMO.

(11) An enrollee may obtain noncovered services as defined in ARM 37.86.5007 in the usual manner.

(1) An enrollee may request, without good cause, disenrollment from an HMO at any time, except that an individual required to enroll in an HMO per ARM 37.86.5005(1) (a) may disenroll only for good cause as defined in (11) of this rule.

(2) A disenrollment request must be accompanied by a choice for another managed health care provider.

(3) Disenrollment is requested by either completing a form designated by the administrative contractor for managed care or by a written or oral request to the administrative contractor for managed care.

(a) The form must be available through the same locations as specified in ARM 37.86.5005 for the enrollment form.

(b) An HMO or any other entity responsible for making the form available upon receiving a form or a request, must forward the form or request to the administrative contractor for managed care within 3 working days.

(4) An HMO, based on good cause, may request that the department disenroll a recipient. The request with the basis for the request must be in writing.

(a) Good cause does not include an adverse change in health status.

(b) An enrollee may be terminated from medical assistance for good cause if the enrollee:

(i) has committed acts of physical or verbal abuse that pose a threat to providers or other enrollees of the HMO;

(ii) has allowed a non-enrollee to use the HMO certification card to obtain services or has knowingly provided fraudulent information in applying for coverage;

(iii) has violated rules of the HMO stated in the evidence of coverage;

(iv) has violated rules adopted by the commissioner of insurance for enrollment in an HMO; or

(v) is unable to establish or maintain a satisfactory physician-patient relationship with the physician responsible for the enrollee's care. Disenrollment of an enrollee for this reason must be permitted only if the HMO can demonstrate that it provided the enrollee with the opportunity to select an alternate primary care physician, made a reasonable effort to assist the enrollee in establishing a satisfactory physician-patient relationship, and informed the enrollee that the enrollee may file a grievance on this matter.

(5) Disenrollment takes effect, at the earliest, the first day of the month after the month in which the administrative contractor for managed care receives the request for disenrollment, but no later than the first day of the second calendar month after the month in which the administrative contractor for managed care receives a request for disenrollment. The enrollee remains enrolled with the HMO and the HMO is responsible for services covered under the contract until the effective date of disenrollment which is always the first day of a month.

(6) The department will disenroll an enrollee from a particular HMO if:

(a) the contract between the department and the HMO is terminated; or

(b) the enrollee permanently moves outside the HMO's enrollment area.

(7) The department will disenroll an enrollee from an HMO if:

(a) the enrollee enters a medicaid eligibility group excluded from HMO enrollment; or

(b) the enrollee becomes ineligible for medicaid; or

(8) If an enrollee becomes ineligible for medicaid and is reinstated into medicaid within 1 month, the enrollee may be reenrolled with the same HMO.

(9) A recipient disenrolling or disenrolled from an HMO who remains medicaid eligible is eligible for regular medicaid.

(10) A person participating in the FAIM project who is required to enroll in an HMO under ARM 37.86.5005 is considered to have good cause to disenroll if the person:

(a) has a terminal illness;

(b) meets one of the conditions for exemption from or is ineligible for the passport to health program as defined in ARM 37.86.5103; or

(c) is under treatment by a physician or mid-level practitioner who is not affiliated with a medicaid HMO and the patient, provider, and department believe that a disruption of the patient/provider relationship may adversely affect treatment or cause unnecessary hardship to the patient.

(1) An HMO must provide the following services:

(a) inpatient hospital services as defined at ARM 37.86.2901 and 37.86.2902;

(b) outpatient hospital services as defined at ARM 37.86.3001 and 37.86.3002;

(d) family planning services as defined at ARM 37.86.1701 and 37.86.1705;

(e) home health services as defined at ARM 37.40.701 and 37.40.702;

(f) early periodic screening, diagnosis and treatment services for individuals under the age of 21 (EPSDT) as defined at ARM 37.86.1401, 37.86.1402, 37.86.2201, 37.86.2205 and 37.86.2206;

(g) non-hospital laboratory and x-ray services as defined at ARM 37.86.911;

(h) rural health clinic services as defined at ARM 37.86.4001;

(i) ambulance services as defined at ARM 37.86.2601 and 37.86.2602;

(j) ambulatory surgical center services as defined at ARM 37.86.1401, 37.86.1402 and 37.86.1405;

(k) chiropractor services as defined at ARM 37.86.2206(2) (b) ;

(l) diagnostic clinic services as defined at ARM 37.86.1401 and 37.86.1402;

(m) nutrition services as defined at ARM 37.86.2206(2) (a) ;

(n) federally qualified health center services as defined at ARM 37.86.4401;

(o) hospice services as defined at ARM 37.40.801 and 37.40.806;

(p) mid-level practitioner services as defined at ARM 37.86.201 and 37.86.202;

(q) immunizations recommended by the advisory committee on immunization practices;

(r) occupational therapy services as defined at ARM 37.86.601;

(s) physical therapy services as defined at ARM 37.86.601;

(t) podiatry services as defined at ARM 37.86.501 and 37.86.505;

(u) private duty nursing services as defined at ARM 37.86.2206(2) (f) ;

(v) county public health clinic services as defined at ARM 37.86.1401 and 37.86.1402;

(w) respiratory therapy services as defined at ARM 37.86.2206(2) (d) ;

(x) immunizations and well child screens provided by school based providers;

(y) speech therapy services as defined at ARM 37.86.601;

(z) targeted case management services for high risk pregnant women as defined at ARM 37.86.3301, 37.86.3305, 37.86.3006, 37.86.3401, 37.86.3402 and 37.86.3405; and

(aa) transplant services as defined at ARM 37.86.4701 and 37.86.4705.

(ab) prescription drugs supplied by a participating provider or a provider with a family planning and/or public health clinic;

(ac) durable medical equipment limited to diabetic supplies, oxygen, prosthetics, ostomy or incontinence supplies and only if supplied by a participating provider or a provider with a family planning and/or public health clinic;

(ad) optometric/ophthalmic services for medical conditions of the eye.

(2) An enrolled recipient may obtain the following covered services through self-referral to a participating or nonparticipating provider and the HMO must reimburse the provider of a service to which the enrollee may self-refer:

(a) family planning services:

(i) for enrollees with reproductive capacity, reproductive health exams comprised of taking history and conducting a physical assessment when such an exam is necessary to obtain birth control supplies or to determine the most appropriate birth control method or supply;

(ii) patient counseling and education for the following: contraception, sexuality, infertility, pregnancy, preconceptual care, pregnancy options, disease, HIV/AIDS, sterilizations, nutrition to maximize reproductive health, the need for rubella and hepatitis B immunizations, and other topics related to the patient's reproductive and general health;

(iii) lab tests to detect the presence of conditions affecting reproductive health, such as those involving the thyroid, cholesterol/triglycerides, prolactin, pregnancy tests, and diagnosis of infertility;

(iv) sterilizations as defined at ARM 37.86.104;

(v) screening, testing, and treatment of and pre- and post-test counseling for sexually transmitted diseases and HIV;

(vi) family planning supplies provided by Title X clinics; and

(vii) rubella and hepatitis B immunizations.

(b) immunizations provided by a public health clinic;

(d) emergency service.

(3) If a nonparticipating provider detects a problem outside the scope of family planning services as defined above, such provider shall refer the enrollee back to the HMO.

(4) An enrollee is eligible for all non-covered services and may obtain non-covered services in the usual manner.

(1) The department may enter into a contract with an HMO with a certificate of authority under the provisions of 33-31-201 , et seq., MCA, to provide any of the services specified in ARM 37.86.5007.

(2) An HMO, entering into a contract with the department, must meet the requirements in 53-6-705 , MCA.

(3) A contract for the provision of services through an HMO must meet the requirements of 42 CFR part 434. The department hereby adopts and incorporates by reference 42 CFR part 434, dated October 1998. A copy of the incorporated provisions may be obtained through the Department of Public Health and Human Services, Health Policy and Services Division, 1400 Broadway, P.O. Box 202951, Helena, MT 59620-2951.

(4) An HMO entering into a contract with the department for the delivery of services assumes the risk that the costs of performance may exceed the consideration available through the capitation rate and otherwise.

(5) An HMO must provide the department with documented assurances to show that the HMO is not likely to become insolvent. This requirement may be satisfied by documenting compliance with 33-31-216 , MCA.

(6) An HMO may not in any manner hold an enrollee responsible for the debts of the HMO.

(7) A contract with an HMO must:

(a) list the covered services to be provided by the HMO;

(b) specify the method and rate of reimbursement; and

(d) owners, directors, officers, or partners of the HMO must certify that they meet federal nondebarment requirements.

(8) A contract may be terminated for cause, if the contractor fails to:

(a) perform the services within the time limits specified in the contract;

(b) perform any requirement of the contract;

(c) perform its contractual duties or responsibilities specified in the standards of contractor performance defined in the contract;

(d) comply with any law, regulation or licensure and certification requirement; or

(e) comply with the restrictions and limitations placed on contractor activities under the contract and its attachments.

(9) Prior to termination of a contract or withholding of payments for cause, except as provided in (9) (a) , a notice to cure will be sent to the HMO, stating the failures in performance and specifying the HMO has 30 days to correct the failures. The department may proceed with the proposed termination or withholding of payments, if the HMO fails to correct the failures in performance in the specified time period for correction.

(a) A contract with an HMO may be terminated immediately in whole or in part by the department when:

(i) the HMO becomes insolvent;

(ii) the HMO loses a certificate of authority;

(iii) the department determines that termination is necessary to protect the health of enrollees;

(iv) the HMO applies for or consents to the appointment of a receiver, trustee, or liquidation for itself or any of its property;

(v) the HMO admits in writing that it is unable to pay its debts as they mature;

(vi) the HMO assigns for the benefit of creditors;

(vii) the HMO commences a proceeding in bankruptcy, reorganization, insolvency, or readjustment under a provision of a federal or state law or files an answer admitting the material allegations of a petition filed against the contract in any such proceeding; or

(viii) there is a commencement of an involuntary proceeding against the HMO under any bankruptcy, reorganization, insolvency, or readjustment in a provision of federal or state law that is not dismissed within 60 days.

(10) An HMO may not appeal a contractual matter through the fair hearing process provided at ARM 37.5.304, et seq.

(11) An HMO may specify in a contract a limit to the number of enrollees who can be enrolled with the HMO. If a limit is specified, the HMO must accept the number of voluntarily and assigned enrollees up to the limit specified in the contract.

(12) The department may contract with one or more HMO or other managed health care providers to provide managed health care in an enrollment area.

(13) The contract may contain proprietary information. An HMO entering into a contract with the department to provide HMO covered services does not constitute an agreement to release information, including information concerning the provider's information system, which is proprietary in nature.

(1) An HMO may impose the following requirements in the provision of services:

(a) the use of certain types of providers;

(b) the preauthorization for services and use of network providers other than emergency services, family planning, immunizations and blood lead testing at a public health clinic;

(d) directing an enrollee to the appropriate level of care for receipt of covered services; and

(e) denial of payment to a provider for services provided to an enrollee if the participation requirements in this rule are not met by the enrollee; or

(f) if a recipient is mandated into an HMO and chooses to go to an FQHC that is not on the provider panel, approval for services is not required, but the recipient must inform the HMO before receiving services.

(2) An enrollee must use the participating providers in the enrollee's HMO.

(3) An enrolled recipient may use a nonparticipating provider in the following circumstances:

(a) the HMO authorizes a nonparticipating provider to provide a service;

(b) the enrollee receives a family planning service provided by a family planning provider as specified in ARM 37.86.5007(3) ;

(d) the enrollee receives services provided for an urgent condition or emergency or emergency room screen.

(4) An HMO must provide covered services as listed in ARM 37.86.5007 to enrollees in the same manner as those services are provided to non-medicaid enrollees.

(5) An HMO must make a reasonable effort to inform enrollees of alternate providers for noncovered services.

(6) An HMO, at a minimum, must provide enrollees the same amount, scope and duration for covered services as would be available under regular medicaid for those covered services.

(7) An HMO may at its discretion offer services to enrollees beyond the scope of medicaid as defined in ARM 37.85.206.

(8) An HMO must ensure that services for urgent conditions and emergencies are available on an immediate basis 24 hours a day, 7 days a week.

(a) An HMO may require that follow-up treatment to an urgent condition or emergency be provided by HMO participating providers.

(1) An HMO, except as otherwise provided in this rule, may select the providers of medical services the HMO determines necessary to meet its contractual obligations with the department.

(2) The HMO must offer to:

(a) medicaid-enrolled targeted case managers for high risk pregnant women who serve recipients in the enrollment area, terms and conditions that are at least as favorable as those offered to other participating providers providing this service and that substantially meet the same access and credentialing criteria as like participating providers; and

(b) federally qualified health centers or rural health clinics which serve recipients in the enrollment area, terms and conditions, excluding reimbursement, that are at least as favorable as those offered to other primary care providers, providing the FQHC or RHC substantially meets the same access and credentialing criteria as the HMO's other primary care providers.

(3) An HMO must make a reasonable effort to cooperate, where appropriate and feasible, with community-based organizations in the referral for and delivery of services available through those organizations.

(4) An HMO may not contract for a service from a provider located over 125 miles distant from the Montana border if services of comparable cost and quality are available from a provider located within Montana.

(5) Upon written notice by the department, the HMO must exclude from providing covered services to medicaid enrollees a provider who has been terminated by the medicaid program in accordance with ARM 37.85.501(1) (a) .

(6) An HMO may set notification and claim filing time limitations relating to the provision of care by nonparticipating providers. Failure to give notice or file claims within those time limitations, however, does not invalidate any claim if it can be shown not to have been reasonably possible to give such notice and that notice was in fact given as soon as was reasonably possible.

(7) A participating provider has no right to an administrative hearing as provided in ARM 37.5.101 and 37.5.117 or other department rule for a denial of payment by the HMO to the provider for a service provided to an enrollee.

(8) A participating provider, in providing services under contract with an HMO, is not subject to any requirements or rights provided in ARM 37.85.402(1) , pertaining to medicaid provider enrollment, ARM 37.85.406 pertaining to medicaid billing and, ARM 37.85.411, pertaining to provider rights.

(9) An HMO must permit obstetricians/gynecologists to become primary care providers. An obstetrician or gynecologist seeking designation as a primary care provider must meet the same criteria with regard to credentials and other selection criteria for a participating primary care physician and other providers who are participating as primary care providers.

(10) An HMO may not prohibit a participating provider from discussing a treatment option with an enrollee or from advocating on behalf of an enrollee within the utilization review or grievance processes established by the HMO.

(1) An HMO must reimburse a federally qualified health center or a rural health clinic which is a participating provider either the same payment per enrollee or service made to other primary care providers or the facility specific medicaid interim rate for each enrollee visit.

(2) An HMO need not reimburse, except as otherwise provided in this rule, claims for medically necessary services provided by non-participating providers if the same service is covered by the HMO under its contract with the department.

(3) An HMO must reimburse medically necessary family planning services as defined in ARM 37.86.5007(3) provided by a nonparticipating family planning provider to an enrollee who sought the services without referral.

(4) An HMO must reimburse immunizations and blood lead testing provided by a public health clinic to an enrollee.

(5) An HMO must reimburse nonparticipating providers for services for urgent conditions, emergencies or emergency room screenings provided to an enrollee.

(6) An HMO, owned, controlled or sponsored by or affiliated with a religious organization, must reimburse a covered service received by an enrollee that the HMO does not make available due to the service constituting a violation of the religious tenets of the organization, to which the HMO is related.

(7) An HMO is not responsible for reimbursement of the disproportionate share payments for inpatient hospital services provided to an enrollee.

(8) An HMO must reimburse services for an urgent condition, emergency or emergency room screens in an amount that is not less than the department's medicaid rates for those services.

(1) In consideration for all services rendered by an HMO under a contract with the department, the HMO will receive a payment each month for each enrollee. This payment is the capitation rate. Except as otherwise provided in this rule, the capitation rate represents the total obligation of the department with respect to the costs of medical care and services provided to each enrollee under the contract.

(a) The capitation rate must be actuarially determined.

(b) The capitation rate must be:

(i) based on medicaid fee-for-service expenses incurred in the provision of the HMO-covered services to a non-HMO population of similar characteristics during the base fiscal year; and

(ii) based on services that are reasonably available to the enrollees of the HMO.

(c) The capitation rate may not exceed the cost to the department of providing the same services to an actuarially equivalent nonenrolled population group.

(d) The capitation rate may be updated annually.

(e) The capitation rate does not include:

(i) any amounts for the recoupment of losses suffered by an HMO for risks assumed under the contract or any previous risk contract;

(ii) any disproportionate share payments;

(iii) any payments made by the department reflecting the difference between the amounts paid to participating federally qualified health centers and rural health clinics by the HMO and the reasonable cost of providing services to enrollees; and

(iv) any payments made as a result of reinsurance purchased by an HMO from the department.

(f) At a minimum, the capitation rate must be 5% less than the upper payment limit. The department may reduce the capitation rates under the conditions set forth in the contract if there is a funding shortfall.

(2) The HMO may retain any savings realized by the HMO from the expenditures for necessary health services by the enrolled population totaling less than the capitation rate paid by the department.

(3) The department reimburses to federally qualified health centers and rural health clinics that are participating providers the difference between the amounts paid to them by the HMO and the reasonable cost of providing services to enrolled recipients.

(a) The department recoups from federally qualified health centers and rural health clinics that are participating providers any excess between the amounts paid to them by the HMO and the reasonable cost of providing services to enrollees, unless the provider notifies both the HMO and the department in writing that it forfeits cost-based reimbursement for enrollees in favor of the reimbursement paid by the HMO.

(b) If an HMO becomes a subcontractor to a federally qualified health center or rural health clinic, the department is under no obligation to pay reasonable costs to the HMO. Only the federally qualified health center or rural health clinic itself remains eligible for reasonable cost settlement for federally qualified health center and rural health clinic services.

(4) The department reimburses disproportionate share payments for inpatient hospital services provided to enrollees.

(5) The department will recoup the TANF-based capitation payments made for a newborn enrollee retroactively determined SSI eligible within 4 months of life and instead pay the SSI-based capitation rate for each month of enrollment.

(6) The department reimburses an HMO for 80% of regular medicaid reimbursement for cost above the reinsurance threshold chosen by the HMO if an HMO chooses to purchase reinsurance from the department.

(1) An enrollee must have the opportunity to choose a primary care provider to the extent possible and medically appropriate from any of the participating primary care providers in the enrollee's HMO. The HMO may assign an enrollee to a primary care provider when an enrollee fails to chose one after being notified to do so. The assignment must be appropriate to the enrollee's age, sex and residence. The HMO may limit an enrollee's ability to change primary care providers without cause.

(2) An HMO must have in effect the following arrangements which provide for adequate after hours call-in coverage by participating providers:

(a) An after hours call-in must include 24-hour-a-day phone coverage;

(b) If a medical provider is unavailable to answer the initial telephone call, there must be a written protocol specifying when the answering party must consult a medical provider;

(d) A response to each call which requires a medical decision must be provided by the medical provider within 60 minutes.

(1) An enrollee has the right of appeal as provided at ARM 37.5.304, 37.5.305, 37.5.307, 37.5.310, 37.5.311, 37.5.313, 37.5.316, 37.5.318, 37.5.322, 37.5.325, 37.5.328, 37.5.331, 37.5.334 and 37.5.337.

(2) An HMO must have a written procedure, approved in writing by the department prior to implementation, for resolution of grievances brought by enrollees either individually or as a class. Except as noted below, the HMO's grievance procedure must provide for resolution of a grievance within 45 days of receipt of the grievance. Resolution may be extended beyond 45 days only with the written approval of the department. In a situation requiring urgent care or emergency care, the department may require the HMO to expedite resolution.

(3) An enrollee must exhaust the HMO's grievance procedure before appeal of the matter may be made to the department under the provisions of ARM 37.5.304, 37.5.305, 37.5.307, 37.5.310, 37.5.311, 37.5.313, 37.5.316, 37.5.318, 37.5.322, 37.5.325, 37.5.328, 37.5.331, 37.5.334 and 37.5.337.

(4) For purposes of ARM 37.5.307(1) (c) , the 90 day appeal period starts on the day the enrollee files a grievance with the HMO.

(1) An HMO must comply with the provisions of ARM 37.86.414 regarding maintenance and retention of medical and fiscal records.

(2) An HMO must submit reports and maintain records as required in the contract with the department.

(3) An HMO must have in effect arrangements to provide for an adequate medical record-keeping system which includes a complete medical record for each enrollee in accordance with provisions set forth in the contract. The complete medical record may be maintained by an HMO's participating provider.

(4) HMOS, participating providers, and the department are subject to the disclosure requirements of Title 50, chapter 16, MCA, and 33-19-306 , MCA.

(1) An HMO must have written instructions for enrollees in the use of all services provided. The policy must include, but is not limited to, written information on service restrictions and limitations regarding appropriate use of the referral system, grievance procedure, after hours call-in system, provisions for emergency treatment, how the enrollee may obtain services that are the responsibility of the HMO under ARM 37.86.5007 and the contract between the HMO and the department but which are not available through the HMO due to religious objections and how to request a list of the HMO's participating providers.

(1) An HMO must have in effect an internal quality assurance system as specified in the contract.

(2) An internal quality assurance system must meet the requirements of 42 CFR 434.34. The department hereby adopts and incorporates by reference 42 CFR 434.34, dated October 1998.

(a) Copies of 42 CFR 434.34 may be obtained through the Department of Public Health and Human Services, Health Policy and Services Division, 1400 Broadway, P.O. Box 202951, Helena, MT 59620-2951.

(1) The HMO is responsible for investigating third party resources and seeking payment from these sources.

(2) The HMO may retain all funds collected from third party resources.

(3) A complete record of all payments received from third party sources must be maintained and reported as required in the contract.

(1) The department has been granted by the United States Department of Health and Human Services (HHS), as provided in 42 U.S.C. 1396n(b), the authority to establish a primary care case management program for Medicaid members.

(1) "Case management" means directing and overseeing the delivery of certain services to an enrollee.

(2) "Clinic" means a federally qualified health center, a rural health clinic, an Indian health service clinic on a reservation, or any other clinic as defined in ARM 37.86.1401 which can meet the requirements of ARM 37.86.5111.

(3) "Emergency service" means, as defined at ARM 37.82.102(11), inpatient and outpatient services that are necessary to treat an emergency medical condition.

(4) "Emergency medical condition" means a medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain) such that a prudent layperson, who possesses an average knowledge of health and medicine, could reasonably expect the absence of immediate medical attention to result in:

(a) placing the health of the individual (or, with respect to a pregnant woman, the health of the woman or her unborn child) in serious jeopardy;

(b) serious impairment to bodily functions; or

(5) "Enroll" means to choose a primary care provider.

(6) "Enrollee" means a Medicaid member participating in the program and who is enrolled with a primary care provider under the program.

(7) "Exempt" means a Medicaid member who is:

(a) eligible for managed care but able to establish that participating would be a hardship;

(b) enrolled in a health maintenance organization that provides case management services;

(d) residing in a county in which there are not enough primary care providers to serve the Medicaid population required to participate in the program. The department has the discretion to determine hardship and to place time limits on all exemptions described in (a) through (d) on a case-by-case basis.

(8) "Ineligible" means a Medicaid member who is not eligible to participate in a managed care program, such as the Passport Program, but is eligible for regular Medicaid. The following categories of members are ineligible for the Passport Program:

(a) eligible for Medicaid with a spend down (medically needy);

(b) living in a nursing home or institutional setting;

(d) eligible for Medicare;

(e) eligible for Medicaid adoption assistance or guardianship;

(f) eligible for pregnancy Medicaid;

(g) retroactive Medicaid eligibility;

(h) receiving Medicaid home and community-based services for persons who are aged or disabled;

(i) eligible for Plan First;

(j) receiving Medicaid under a presumptive eligibility program; and

(k) eligible for the Breast and Cervical Cancer program.

(9) "Medical care" means care provided to meet the medical and medically related needs of a person.

(10) "Participate" means compliance with the requirements of the program.

(11) "Passport to Health Program" or "the program" means the primary care case management (PCCM) program for Medicaid members.

(12) "Primary care" means medical care provided at a person's first point of contact with the health care system, except for emergencies. It includes treatment of illness and injury, health promotion and education, identification of persons at special risk, early detection of serious disease, promotion of preventive health care, and referral to specialists when appropriate.

(13) "Primary care case management" or "managed care" means promoting the access to, coordination of, quality of, and appropriate use of medical care, and containing the costs of medical care by having an enrollee obtain certain medical care from and through a primary care provider.

(14) "Primary care provider" means a physician, clinic, or midlevel practitioner other than a certified registered nurse anesthetist that is responsible by agreement with the department for providing primary care case management to enrollees in the Passport to Health Program.

(15) "Referral" means the approval by the Passport enrollee's primary care provider for the delivery by another provider of a service(s) that requires Passport referral. Referral is the provision of the primary care provider's Passport referral number to the other provider. The primary care provider shall establish the parameters of the referral.

(16) "Team Care" means a program for members identified as excessive or inappropriate utilizers of the Medicaid program as set forth in ARM 37.86.5303.

(1) The department may require a Medicaid member to enroll and participate in the Passport to Health Program, unless exempted from or ineligible for participation as defined by ARM 37.86.5102(7) or (8).

(2) At the department's discretion, Medicaid members who are exempted from participation, as defined in ARM 37.86.5102(7), may elect to enroll in the Passport to Health Program by choosing a primary care provider unless the member is ineligible.

(1) The department will notify a Medicaid member required by ARM 37.86.5103 to enroll in the program that the member must enroll in the program.

(2) The member required to enroll in the program must select a primary care provider within 45 days of being notified of the enrollment requirement. For Team Care Program members, enrollment with a provider will be as required at ARM 37.86.5303.

(3) If the member does not choose a provider within 45 days of the notification, the department will designate a primary care provider for the member. For Team Care Program members, enrollment with a provider will be as required in ARM 37.86.5303.

(4) An enrollee may choose a new primary care provider up to once per month. For Team Care Program members, a change of provider may be made in accordance with ARM 37.86.5303. The frequency of a member's request to change providers will be monitored by the department.

(5) Each enrollee in a household may choose a different primary care provider.

(1) A member must obtain services directly from, or through, a Passport referral by the member's primary care provider except for:

(a) obstetrical services, both inpatient and outpatient;

(b) family planning services as defined in Social Security Act 1905(a)(4)(c) and ARM 37.86.1701;

(d) pathology services;

(e) ophthalmology services for medical conditions of the eye;

(f) immunization;

(g) testing and treatment for sexually transmitted diseases as defined in ARM 37.114.101;

(h) testing for lead blood levels;

(i) dental, vision, hearing, and EPSDT screening and preventive services;

(j) school-based health services as defined in ARM 37.86.2230;

(k) swing-bed hospital services as defined in ARM 37.40.401;

(l) audiology services as defined in ARM 37.86.702;

(m) hearing aid services as defined in ARM 37.86.801;

(n) personal care services as defined in ARM 37.40.1101;

(o) home dialysis services for end-stage renal disease as defined in ARM 37.40.901;

(p) home infusion therapy services as defined in ARM 37.86.1501;

(q) mental health center services as provided in ARM 37.88.901 and 37.88.905 through 37.88.907;

(r) licensed psychologists services provided in ARM 37.88.601, 37.88.605, and 37.88.606;

(s) substance use disorder services as provided in ARM 37.27.102;

(t) licensed clinical social work services provided in ARM 37.88.201, 37.88.205, and 37.88.206;

(u) dental services as defined in ARM 37.86.1001;

(v) licensed professional counselor services provided in ARM 37.88.301, 37.88.305, and 37.88.306;

(w) outpatient drugs as defined in ARM 37.86.1101;

(x) prosthetic devices, durable medical equipment, and medical supplies as defined in ARM 37.86.1801;

(y) optometric services as defined in ARM 37.86.2001;

(z) eyeglasses as defined in ARM 37.86.2101;

(aa) transportation and per diem as defined in ARM 37.86.2401;

(ab) specialized nonemergency medical transportation as defined in ARM 37.86.2501;

(ac) ambulance services as defined in ARM 37.86.2601;

(ad) emergency services as defined in ARM 37.82.102;

(ae) skilled care facility services as defined in ARM 37.40.105;

(af) intermediate care facility services as defined in ARM 37.40.106;

(ag) institution for mental disease services as provided in ARM 37.88.1401, 37.88.1402, 37.88.1405, 37.88.1406, 37.88.1410, 37.88.1411, and 37.88.1420;

(ah) home and community-based services as defined in ARM 37.40.1406;

(ai) freestanding dialysis clinic for end-stage renal disease services as defined in ARM 37.86.4201;

(aj) case management services as defined in ARM 37.86.3301;

(ak) hospital inpatient laboratory and radiology (x-ray);

(al) admission for inpatient psychiatric services as provided in ARM 37.86.2901, 37.86.2902, 37.87.1201, and 37.87.1203;

(am) therapeutic youth group home or home support and therapeutic foster care services under the EPSDT program;

(an) hospice as defined in ARM 37.40.801 and 37.40.806; and

(ao) professional inpatient services.

(2) The requirement that specific services not listed in (1) be referred by the primary care provider does not replace or eliminate other regulatory or statutory requirements for or limits on obtaining and being reimbursed for Medicaid services.

(3) Nothing in this rule reduces or otherwise affects the requirements that must be met under ARM 37.88.101, to obtain or access adult mental health services as provided in this chapter.

(1) A primary care provider must meet the following requirements:

(a) enroll as a Medicaid provider;

(b) provide primary care;

(d) keep a paper or electronic log, spreadsheet, or other record of all Passport referrals given and received.

(2) A primary care provider may be subject to utilization review to determine that the care and services provided through the program are fulfilling the provisions of the primary care case management agreements with the program and are only those which are medically necessary or otherwise permissible.

(3) Passport providers who reach their specified caseloads of Passport patients, per their provider agreements with the department, will not be assigned additional members. Providers who have reached their capacity will be provided the opportunity to increase their caseloads. Providers that are not provider-based as described at ARM 37.86.3031 may request an exemption from this rule.

(1) Reimbursement for primary care case management services is as follows:

(a) $3.00 per enrollee per month for individuals categorically eligible for Aged, Blind, Disabled and Medically Frail Medicaid; or

(b) $1.00 per enrollee per month for all others who are members of Passport eligible populations.

(2) A primary care provider may be reimbursed for primary care case management for an enrollee for a month during which case management or medical care was not provided to the enrollee if the primary care provider is otherwise in compliance with the agreement with the program.

(3) Medicaid services authorized or provided by a primary care provider are reimbursed as provided in ARM Title 37, chapters 40, 82, 83, 85, 86, and 88.

(4) Services requiring Passport referral are not reimbursable unless referral is provided by a Passport enrollee's primary care provider.

(1) An enrollee or a provider has the right to appeal an adverse action in accordance with ARM 37.5.304, 37.5.305, 37.5.307, 37.5.310, 37.5.311, 37.5.313, 37.5.316, 37.5.318, 37.5.322, 37.5.325, 37.5.328, 37.5.331, 37.5.334 and 37.5.337.

This rule has been repealed.

(1) A recipient may be subject to restrictions on, or prior approval for, physician related services, pharmacy services or any other services covered by the medicaid program if the department determines that the recipient's utilization of service is excessive, inappropriate, or fraudulent with respect to medical need.

(2) The restrictions described in (1) may be imposed if any of the following events occur:

(a) the recipient seeks medical services that are not medically necessary;

(b) there is multiple provider usage that results in the receipt of unnecessary services;

(d) there is unwarranted multiple pharmacy usage, indicated by the use of more than three pharmacies, that results in the receipt of unnecessary prescriptions;

(e) there is admission of or conviction for forgery of medicaid drug prescriptions by the recipient; or

(f) the recipient utilizes a medicaid card in any unlawful or fraudulent manner.

(3) The department will use payment records, reports from medical consultants, provider referrals or other pertinent recipient or service information, to determine if recipient overutilization, or other abuses, have occurred.

(4) A recipient's restriction does not apply to other members of the household.

(5) Restriction of medicaid services may include limiting a recipient to a designated provider or providers or requiring the recipient to obtain department approval to receive non-emergent services. A recipient with restricted services is participating in the team care program. Medicaid payment for medical services provided to a team care participant will only be made to the recipient's designated provider(s) except:

(a) when emergency services, as defined at ARM 37.82.102(11) , are required;

(b) when the designated provider refers the recipient to another provider; or

(6) A recipient restricted to the team care program is required to participate in the passport to health program set forth in this subchapter unless the recipient is ineligible, as that term is defined in ARM 37.86.5102.

(7) A recipient whose medical service usage meets the criteria for restriction listed in (2) , but who is ineligible for the passport to health program for the reasons listed in ARM 37.86.5102, may be required to participate in the team care program. A recipient living in a nursing home or institutional setting or a recipient whose eligibility period is only retroactive cannot be required to participate in either the passport for health or the team care programs.

(8) The department will notify a recipient in writing at least 10 days prior to the date of the intended action restricting medical services paid by the medicaid program.

(9) The department will determine the provider type to which the recipient is restricted (pharmacy, physical health provider or both) . The recipient will have an opportunity to choose the recipient's primary care provider and pharmacy unless:

(a) the department determines that the selected provider has been sanctioned by the department in accordance with ARM 37.85.501;

(b) the designated review organization has determined that the selected provider has not properly managed the medical care of a recipient who has been restricted; or

(10) The recipient will have 10 days from the date of notification of restriction by the department to choose a primary care provider and a pharmacy provider. If the recipient does not choose a primary care provider and a pharmacy provider within 10 days, a primary care provider and a pharmacy will be selected for the recipient. If the department is unable to obtain a primary provider for the restricted recipient, all non-emergency services must be prior authorized by the department.

(11) A restricted recipient may request a change of provider. The request must be in writing and submitted to the department for approval. Provider changes will not be approved unless the department determines that there is good cause for the requested provider change. The department will have 30 days to take action on the request.

(12) The department will review all restricted recipients annually unless the recipient's medical service usage indicates an earlier review should occur. Restriction may be continued if:

(a) the department determines the recipient's use of services has remained excessive or unnecessary. Examples of excessive or unnecessary usage include, but are not limited to, those listed in (2) ;

(b) the designated provider recommends, with supporting rationale, that the recipient should remain restricted; or

(c) the recipient has received or attempted to receive medicaid services not authorized under the restricted card program.

(13) A recipient aggrieved by an adverse departmental action under this rule may request a fair hearing in accordance with ARM 37.5.304, 37.5.305, 37.5.307, 37.5.310, 37.5.311, 37.5.313, 37.5.316, 37.5.318, 37.5.322, 37.5.325, 37.5.328, 37.5.331, 37.5.334 and 37.5.337.