(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 using a provider rate of reimbursement which is a percentage of the reimbursement for physicians provided in accordance with the methodologies described in ARM 37.85.212. The effective date and percentage are as provided in ARM 37.85.105(2).

(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 effective date and citation for the Medicare Average Sale Price (ASP) as provided in ARM 37.85.105(2);

(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 Medicaid fee as determined in (7).

(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.

(7) A Medicaid fee is determined for physician services and anesthesia services as defined at ARM 37.85.212 and birth attendant services as defined at ARM 37.86.1201 for services without fees.

(a) The Medicaid fee is determined for procedure codes that are new (less than one year in existence), or have no or low utilization, or have inconsistent charges by reviewing cost information for the service if available, or by reviewing the reimbursement of similar services if cost information is not available.

(b) Otherwise, the Medicaid fee in (7) is determined by multiplying the average charge for the service by the payment-to-charge ratio.

(8) Reimbursement for primary care services performed by confirmed primary care physicians:

(a) for E&M procedure codes and vaccine administration codes not part of the VFC program, in calendar year 2013, is the 2013 Montana Medicare reimbursement amount or the amount determined by multiplying the 2009 Medicare conversion factor by the 2013 relative value unit for Montana, whichever is greater;

(b) for vaccine administration codes for the VFC program in calendar year 2013 is the lesser of the 2013 Montana Medicare reimbursement amount or the maximum regional VFC amount;

(c) for E&M procedure codes and vaccine administration codes not part of the VFC program, in calendar year 2014, is the 2014 Montana Medicare reimbursement amount or the amount determined by multiplying the 2009 Medicare conversion factor by the 2014 relative value unit for Montana, whichever is greater; and

(d) for vaccine administration codes for the VFC program in calendar year 2014 is the lesser of the 2014 Montana Medicare reimbursement amount or the maximum regional VFC amount.

(9) Claims for child delivery must have one of the following line procedure code modifiers or the line will be denied:

(a) CG-cesarean section/induction prior to 39 weeks;

(b) GK-spontaneous vaginal delivery prior to 39 weeks (noninduced);

(c) KX-vaginal delivery at or after 39 weeks (induced or not induced; or

(d) SC - cesarean section at or after 39 weeks.

(10) The maternity policy adjustor is not applied to early elective delivery.

(11) Gestational age must be determined and documented in medical records. The department accepts the following American Congress of Obstetricians and Gynecologists guidelines for determining gestational age:

(a) fetal heart tones documented for 20 weeks by nonelectronic fetoscope or 30 weeks by Doppler;

(b) a positive serum or urine pregnancy test by a reliable laboratory at least 36 weeks prior to delivery;

(c) an ultrasound prior to 20 weeks gestation that confirms the gestational age of at least 39 weeks at delivery; or

(d) when pregnancy care is not initiated within 20 weeks of gestation, the gestational age may be documented from the first day of the last menstrual period (LMP).