(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;

(c) direct medical services, including counseling or the transportation or escort of members;

(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.


History: 53-6-113, MCA; IMP, 53-6-101, MCA; NEW, 1991 MAR p. 1295, Eff. 7/26/91; AMD, 1996 MAR p. 1997, Eff. 6/7/96; TRANS, from SRS, 2000 MAR p. 481; AMD, 2017 MAR p. 1906, Eff. 10/14/17.