37.86.5012 HEALTH MAINTENANCE ORGANIZATIONS: 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.
History: Sec. 53-2-201 and 53-6-113, MCA; IMP, Sec. 53-2-201, 53-6-101, 53-6-113 and 53-6-116, MCA; NEW, 1995 MAR p. 1974, Eff. 9/29/95; AMD, 1997 MAR p. 1210, Eff. 7/8/97; TRANS & AMD, from SRS, 2000 MAR p. 1653, Eff. 6/30/00.