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(1) The interim rate for services provided to youths as the term "youth" is defined at ARM 37.87.102 for PRTF providers located in the state of Montana is composed of:

(a) the psychiatric service rate provided in the department's Medicaid Mental Health and Mental Health Services Plan, Individuals Under 18 Years of Age Fee Schedule adopted in ARM 37.86.2207;

(b) a direct care wage add-on through a contract with the department or in the psychiatric service rate in (1)(a), as applicable; and

(c) a facility specific ancillary add-on rate for Medicaid services provided in and by the PRTF, not already included in the base psychiatric service rate in (1)(a).

(2) Medicaid services included in the ancillary add-on rate in (1)(c) must be provided by individuals employed by or under contract with the PRTF who have appropriate credentials and who will be subject to the Montana Medicaid program's prevailing payment methodology and/or fee schedule for reimbursement. At a minimum, covered ancillary services include:

(a) the professional component of physician, psychiatrist, and mid-level practitioner services;

(b) licensed addiction counselor services;

(c) lab and pharmacy services not related to the youth's psychiatric condition; and

(d) other Medicaid services approved by the department to address the youth's treatment needs in the facility.

(3) The ancillary add-on rate in (1)(c) will be adjusted retrospectively when:

(a) allowable ancillary costs are reported using auditable data, standardized forms, instructions, definitions, and timelines supplied by the department; and

(b) ancillary costs in the facility-specific aggregate for all discharges, for Montana Medicaid paid youth, in a state fiscal year exceed or are less than the reimbursement that the facility received as an interim rate:

(i) the department will reimburse the facility for costs exceeding 100% of the aggregate; and

(ii) the facility will reimburse the department for costs less than 100% of the aggregate.

(4) The psychiatric service rate in (1)(a) is a bundled per diem rate, and includes:

(a) services, therapies, and items related to the youth's psychiatric condition;

(b) services provided by licensed psychologists, licensed clinical social workers, and licensed professional counselors; and

(c) lab and pharmacy services related to the youth's psychiatric condition.

(5) Emergency medical conditions treated by providers outside the PRTF will be reimbursed using state funds at the prevailing Montana Medicaid rate, and must be billed by an enrolled provider directly to the Montana Medicaid program. Emergency medical conditions treated outside the PRTF may be reimbursed when provided in a hospital emergency room. If the youth's condition requires admission to a hospital, the youth must be discharged from the PRTF for Medicaid or state funded reimbursement to be available for the hospitalization.

(6) For purposes of this rule "emergency medical condition" means:

(a) a medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain) such that the absence of immediate medical attention could reasonably be expected to result in:

(i) placing the health of the individual in serious jeopardy;

(ii) serious impairment to bodily functions; or

(iii) serious dysfunction of any bodily organ or part.

(7) Additional outside services that may be reimbursed using state funds to pay the prevailing Montana Medicaid rate for youth in a PRTF are:

(a) emergency dental services in accordance with the Montana Medicaid Dental Program as identified in ARM 37.86.1006 for adults ages 21 and over with basic Medicaid;

(b) eyeglasses and vision examinations;

(c) durable medical equipment; and

(d) hearing aids and hearing examinations.

(8) If a youth receiving in-patient care in a PRTF has an unusually expensive medical condition that requires a higher ancillary rate, prior to the cost settlement process, the PRTF may request interim reimbursement for the ancillary care. The department at its discretion may grant the youth specific request if the PRTF:

(a) submits a request in writing to the department with documentation of the expenses; and

(b) interim payments must be requested within 90 days of the date of service and will be taken into consideration during the ancillary cost settlement process described in (3). Payment of these claims will be made by the department within 90 days from the date all requirements for payment are met.

(9) Reimbursement will be made to a PRTF provider for reserving a bed while the youth is temporarily absent for a therapeutic home visit if:

(a) the youth's plan of care documents the medical need for therapeutic home visits as part of a therapeutic plan to transition the youth to a less restrictive level of care;

(b) the youth is temporarily absent on a therapeutic home visit;

(c) the provider clearly documents staff contact and youth achievements or regressions during and following the therapeutic home visit; and

(d) the youth is absent from the provider's facility for no more than three patient days per therapeutic home visit, unless additional days are authorized by the department.

(10) No more than 14 patient days per youth in each state fiscal year will be allowed for therapeutic home visits.

(11) Providers must bill for PRTF services using the revenue codes designated by the department.

(12) Notice of the youth's admission and discharge dates must be submitted to the department or its designee the day of admission or discharge. A $100 fine may be imposed against the facility for each instance where the department does not receive timely notification.


History: 53-2-201, 53-6-113, MCA; IMP, 53-2-201, 53-6-101, 53-6-111, MCA; NEW, 2008 MAR p. 2674, Eff. 1/1/09; AMD, 2009 MAR p. 2486, Eff. 1/1/10.

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