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(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


History: 53-2-201, 53-6-113, MCA; IMP, 53-6-101, MCA; NEW, 1982 MAR p. 1695, Eff. 9/17/82; AMD, 1989 MAR p. 877, Eff. 6/30/89; AMD, 1989 MAR p. 1850, Eff. 11/10/89; AMD, 1990 MAR p. 1479, Eff. 7/27/90; AMD, 1992 MAR p. 1404, Eff. 7/1/92; AMD, 1994 MAR p. 313, Eff. 2/11/94; AMD, 1997 MAR p. 548, Eff. 3/25/97; AMD, 1998 MAR p. 676, Eff. 3/13/98; AMD, 1999 MAR p. 1516, Eff. 7/2/99; TRANS, from SRS, 2000 MAR p. 481; AMD, 2000 MAR p. 1664, Eff. 6/30/00; AMD, 2001 MAR p. 1476, Eff. 8/10/01; AMD, 2001 MAR p. 2156, Eff. 10/26/01; EMERG, AMD, 2002 MAR p. 797, Eff. 3/15/02; EMERG, AMD, 2002 MAR 2665, Eff. 9/27/02; AMD, 2006 MAR p. 768, Eff. 3/24/06; AMD, 2014 MAR p. 1409, Eff. 7/1/14; AMD, 2017 MAR p. 2287, Eff. 1/1/18; AMD, 2018 MAR p. 2057, Eff. 10/20/18.

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