37.34.3001 REIMBURSEMENT FOR SERVICES: GENERALLY
(1) The following requirements and limitations govern the reimbursement of providers for the provision of services and items delivered to persons who are currently eligible for and accepted into one or more of the developmental disabilities services programs administered by the department. These requirements are in addition to any other federal and state requirements governing the funding and delivery of the various services provided through the program.
(2) Reimbursement for services and items is only available:
(a) through payments made to providers that have a current contract with the department authorizing the provider to deliver developmental disabilities services;
(b) for services and items that are authorized in rule or federal agreements for delivery through the particular developmental disabilities services program that the person is authorized by the DDP to participate in;
(c) when the particular services and items delivered are authorized for delivery to the person through the person's individual cost plan (ICP) as provided for in ARM 37.34.3002, or if the ICP is not applicable, the planning and authorization procedures applicable to the particular program;
(d) if the person has received the services and items authorized; and
(e) when delivered in accordance with applicable professional and facility licensing authorities.
(3) The contracted provider must be:
(a) currently enrolled in conformance with ARM 37.85.402 as a Montana Medicaid provider as evidenced by a signed current provider enrollment agreement, unless the type of provider is expressly exempted from the requirement by the department; and
(b) designated by the Developmental Disabilities Program (DDP) to be a qualified developmental disabilities provider, unless the program does not require the provision of the particular type of service or item by or through a qualified provider process.
(4) The department reimburses for a service or item at the lower of:
(a) the rate applicable to the particular service or item as established through rule; or
(b) the provider's usual and customary fee that is charged to any and all parties for the delivery of the service or item.
(5) Reimbursement for the delivery of a service or item delivered to a person through the department's DDP is payment in full and the provider may not receive further reimbursement for the service or item from the program, other departmental programs, or the person, or other parties.
(6) A provider in order to receive reimbursement for a service or item must properly invoice for the service or item through the DDP's electronic billing system unless the service or item is not reimbursed through that payment system.
(7) A provider may seek reimbursement from a person receiving services for a service or an item only if the service or item is not covered for Medicaid purposes and the billing is allowed for and conducted in accordance with ARM 37.85.406(11)(a).
(8) A provider may not seek or obtain reimbursement from the person for a service or item that, though reimbursable by the DDP as a service or item, has not been reimbursed by the program due to the failure of the provider to properly seek reimbursement for the service or item or due to the failure of the provider to properly deliver the service or item to the person.
(9) Reimbursement is not available for services and items:
(a) the DDP determines are not delivered in accordance with the quality assurance standards applicable to those services and items;
(b) provided while a person is a resident of an intermediate care facility for the developmentally disabled, an intermediate nursing care facility, or a skilled nursing care facility, as those facilities are defined in 50-5-101, MCA; or
(c) reimbursable as either a Medicaid state plan service or through any other local government, state, or federal program for which the person is eligible or would be eligible upon application.
(10) The department has the right to recover as a sum owing to the department reimbursement received by a provider that is an overpayment or is improperly obtained.
(11) Overpayments and improper payments include but are not limited to any departmental reimbursement obtained by a provider that:
(a) does not conform to the requirements and limitations of this rule or any other rules governing the administration and delivery of the services and items for which the reimbursement is obtained;
(b) does not compensate for actual delivery of the services and items for which the reimbursement is obtained;
(c) is the consequence of mistaken, improper, or fraudulent billing;
(d) is due to departmental mistake; or
(e) is due to other circumstances.
(12) The department or its agents may recover overpayments by any available means including withholding of further reimbursement payments.
(13) Reimbursement for services and items is not made directly to persons receiving DDP funded services.