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37.86.3415    CASE MANAGEMENT SERVICES FOR HIGH RISK PREGNANT WOMEN, REIMBURSEMENT

(1) Case management services for high risk pregnant women provided on or after January 1, 1996 are reimbursed at the lower of the following:

(a) the provider's customary charge for the service; or

(b) $6.00 for each 15 minutes of service.

(2) Case management services for high risk pregnant women provided prior to January 1, 1996 are reimbursed, in accordance with (2)(a) through (2)(d), for the allowable costs of providing case management services to eligible Medicaid recipients.

(a) The amount of reimbursement due a provider will be determined retrospectively by the department based upon the reporting period cost report required under ARM 37.86.3411. An overpayment or underpayment for the reporting period is calculated by finding the difference between the total of the incurred allowable costs reported and the total of the interim payments received by the provider. The department will notify the provider in writing of any overpayment or underpayment determination.

(b) The department will establish interim rates for each service. An interim rate will be determined for a fiscal year by dividing the estimated total allowable costs on a statewide basis for the service during the fiscal year by estimated total of service units to be delivered on a statewide basis during that fiscal year.

(i) The department may, but is not required to, review and adjust the interim rates established during the reporting period to assure that interim payments approximate allowable costs for case management services if:

(A) there is a significant change in the utilization of case management services;

(B) the incurred allowable costs vary materially from the estimated allowable costs; or

(C) the department in its discretion determines that other circumstances warrant an adjustment.

(c) No cost shall be allowable unless the department determines that it has been incurred and that it is reasonable and necessarily related to the provision of case management services. Profit is not an allowable cost.

(d) Reimbursement shall not exceed the provider's customary charge to the general public for the service.

History: Sec. 53-6-113, MCA; IMP, Sec. 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.

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