(1) Medicaid reimbursement for mental health services will be the lowest of:
(a) the provider's actual (submitted) charge for the service; or
(b) the rate established in the department's fee schedule. Reimbursement fees are as provided in ARM 37.85.105(6).
(2) For services for which Medicare does not specify Relative Value Unit (RVU) as provided in ARM 37.85.212, the department determines the Medicaid fee for children's mental health services as follows:
(a) if there is use resulting in Medicaid reimbursements totaling at least $10,000 in a state fiscal year (SFY), and a minimum of four separate providers have billed the code, then the Medicaid fee is determined by multiplying the average charges by the payment-to-charge ratio; or
(b) if there is use resulting in Medicaid reimbursements totaling less than $10,000 in an SFY and fewer than four separate providers have billed the code in an SFY, the Medicaid fee will be determined by:
(i) reviewing similar procedure codes within the same service scope and adjusting the rate to be equal to a comparable procedure code or the average of similar procedure codes if there is more than one; or
(ii) reviewing similar procedure codes within the same service scope and adjusting the rate to be equal to a comparable procedure code or the average of similar codes plus 10% when severity is higher or increased resources are needed for the service. If the code is determined to have a lower severity component or fewer resources are required than when compared to the similar procedure code or average of similar procedure codes, the rate will equal the comparable procedure code or average of similar procedure codes less 10%.