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37.86.105    PHYSICIAN SERVICES, REIMBURSEMENT/GENERAL REQUIREMENTS AND MODIFIERS

(1) Providers must bill for services using the procedure codes and modifiers set forth, and according to the definitions contained, in the Centers for Medicare and Medicaid Services' (CMS) Healthcare Common Procedure Coding System (HCPCS). Information regarding billing codes, modifiers, and HCPCS is available upon request from the Health Resources Division at the address stated in ARM 37.86.101(3).

(2) Reimbursement for physician services, except as otherwise provided in this rule, is the lower of:

(a) the provider's usual and customary charges (billed charges); or

(b) the department's fee schedule maintained in accordance with the methodologies described in ARM 37.85.212.

(3) Reimbursement for services of a psychiatrist, except as otherwise provided in this rule, is the lower of:

(a) the provider's usual and customary charges (billed charges); or

(b) to address problems of access to mental health services, subject to funding, mental health services performed by a psychiatrist are reimbursed up to 125% of the reimbursement for physicians provided in accordance with the methodologies described in ARM 37.85.212.

(4) Reimbursement to physicians for physician-administered drugs which are billed under HCPCS "J" and "Q" codes is made according to the department's fee schedule or the provider's usual and customary charge, whichever is lower. The department's fee schedule is updated at least annually based upon:

(a) the Medicare Average Sale Price (ASP) set at 42 CFR 414.904 (2012) if there is an ASP fee;

(b) the RBRVS fee as defined in ARM 37.85.212 if there is an RBRVS fee;

(c) the estimated acquisition cost (EAC) as defined in ARM 37.86.1101 if there is an EAC; or

(d) the by-report amount as defined in ARM 37.85.212.

(5) The maximum allowable cost limitation shall not apply in those cases where the physician certifies in their own handwriting that in their medical judgment a specific brand name drug is medically necessary for a particular patient. Acceptable certification statements are "brand necessary" or "brand required". A check-off box on a form or a rubber stamp is not acceptable.

(6) Reimbursement and claim completion instructions for Medicaid designated provider based entities are found in ARM 37.86.3031, 37.86.3033, 37.86.3035, and 37.86.3037.

History: 53-6-101, 53-6-113, MCA; IMP, 53-6-101, 53-6-113, MCA; NEW, 1980 MAR p. 1808, Eff. 6/27/80; AMD, 1981 MAR p. 559, Eff. 6/12/81; AMD, 1981 MAR p. 1976, Eff. 1/1/82; AMD, 1982 MAR p. 1289, Eff. 7/1/82; AMD, 1987 MAR p. 1496, Eff. 8/28/87; AMD, 1988 MAR p. 1255, Eff. 7/1/88; AMD, 1989 MAR p. 881, Eff. 6/30/89; AMD, 1989 MAR p. 880, Eff. 7/1/89; AMD, 1990 MAR p. 1179, Eff. 6/15/90; AMD, 1990 MAR p. 1608, Eff. 8/17/90; AMD, 1990 MAR p. 2305, Eff. 12/28/90; AMD, 1991 MAR p. 824, Eff. 5/31/91; AMD, 1991 MAR p. 1030, Eff. 7/1/91; AMD, 1997 MAR p. 1269, Eff. 7/22/97; AMD, 1998 MAR p. 676, Eff. 3/13/98; TRANS, from SRS, 2000 MAR p. 481; AMD, 2001 MAR p. 27, Eff. 1/12/01; AMD, 2001 MAR p. 1476, Eff. 8/10/01; AMD, 2001 MAR p. 2156, Eff. 10/26/01; AMD, 2007 MAR p. 206, Eff. 1/1/07; AMD, 2009 MAR p. 1012, Eff. 7/1/09; AMD, 2010 MAR p. 433, Eff. 3/1/10; AMD, 2011 MAR p. 1700, Eff. 8/26/11; AMD, 2012 MAR p. 1266, Eff. 6/22/12.

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