(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; or
(b) the pregnancy is the result of an act of rape or incest.
(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) 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.
(12) 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.