(1) As a condition of participation in the HELP Plan, all providers must comply with all applicable state and federal statutes, rules, and regulations governing the Montana Medicaid Program and all applicable Montana statutes and rules governing licensure and certification.

(2) Any health care provider that is currently subject to exclusion by the U.S. Department of Health and Human Services (HHS) or that is suspended or terminated by the Medicaid or the Medicare program or by a state Medicaid program may not be enrolled as a HELP Plan provider or receive reimbursement from the department for the delivery of health care or other services to participants.

(3) Participating providers must be licensed or certified in Montana. Out-of-state providers must be licensed in the state in which they practice.

(4) Physicians, APRNs, and PAs must either have admitting privileges to at least one general or critical access hospital or must have a mechanism in place to ensure that participant hospitalization may occur when appropriate.

(5) Providers that are delivering services to participants outside of the TPA provider network must be enrolled as a Montana Medicaid Program provider. Providers that are enrolled with the TPA network and are not delivering services to participants or other Medicaid eligible persons outside of the TPA network need not be enrolled as a Medicaid provider.

(6) A TPA may not prohibit a participating provider from:

(a) discussing a treatment option with a participant, parent of a minor, spouse, legal guardian, or other responsible representative; or

(b) advocating on behalf of a participant within the utilization review or grievance processes established by the TPA or the department.