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37.86.5110    PASSPORT TO HEALTH PROGRAM: SERVICES

(1) An enrollee must obtain the services in (a) , except as provided in (b) , directly from or through authorization by the enrollee's primary care provider:

(a) medicaid services requiring authorization:

(i) inpatient hospital services as defined in ARM 37.86.2901;

(ii) surgery, physical therapy, occupational therapy, speech therapy, and home health services delivered as outpatient hospital services as defined in ARM 37.86.3001;

(iii) ambulatory surgical center services as defined in ARM 37.86.1401;

(iv) physician services as defined in ARM 37.86.101;

(v) federally qualified health center services as defined in ARM 37.86.4401;

(vi) rural health clinic services as defined in ARM 37.86.4401;

(vii) mid-level practitioner services as defined in ARM 37.86.202;

(viii) the following EPSDT services for enrollees under 21 years of age:

(A) screening services for children as defined in ARM 37.86.2005;

(B) chiropractic services as defined in ARM 37.86.2206;

(C) respiratory therapy as defined in ARM 37.86.2206;

(D) private duty nursing as defined in ARM 37.86.2206; and

(E) nutrition services as defined in ARM 37.86.2206.

(ix) physician services provided through a developmental diagnostic center as defined in ARM 37.86.1401;

(x) public health departments as defined in ARM 37.86.1401;

(xi) organ transplantation services as defined in ARM 37.86.4701;

(xii) physical therapy services as defined in ARM 37.86.601;

(xiii) occupational therapy services as defined in ARM 37.86.601;

(xiv) speech therapy services as defined in ARM 37.86.601;

(xv) home health services as defined in ARM 37.40.701;

(xvi) podiatry services as defined in ARM 37.86.501; and

(xvii) emergency room services for emergent conditions as defined in ARM 37.82.102(5) .

(b) aspects of services listed in (1) (a) that do not require prior authorization by the enrollee's primary care provider:

(i) obstetrical services, both inpatient and outpatient;

(ii) inpatient and outpatient services for which the primary diagnosis is one of the following ICD-9 codes: 290 through 302, 306 through 314, or 316;

(iii) family planning services as defined in Social Security Act 1905(a) (4) (c) ;

(iv) anesthesiology services;

(v) radiology services;

(vi) pathology services;

(vii) ophthalmology services for medical conditions of the eye;

(viii) immunization;

(ix) testing and treatment for sexually transmitted diseases;

(x) testing for lead blood levels; and

(xi) dental, vision and hearing services portion of the screening services for children.

(2) The primary care provider's authorization is not required for any of the following medicaid services:

(a) swing bed hospital services as defined in ARM 37.40.401;

(b) podiatry services as defined in ARM 37.86.501;

(c) audiology services as defined in ARM 37.86.702;

(d) hearing aid services as defined in ARM 37.86.801;

(e) personal care services as defined in ARM 37.40.1101, except for personal care services as provided pursuant to ARM 37.86.2232;

(f) home dialysis services for end stage renal disease as defined in ARM 37.40.901;

(g) mental health center services as provided in ARM 37.88.901 and 37.88.905 through 37.88.907;

(h) family planning services provided by a local delegate agency of the department of public health and human services as defined in ARM 37.86.1701;

(i) licensed psychologists services provided in ARM 37.88.601, 37.88.605 and 37.88.606;

(j) licensed clinical social work services provided in ARM 37.88.201, 37.88.205 and 37.88.206;

(k) dental services as defined in ARM 37.86.1001;

(l) licensed professional counselor services provided in ARM 37.88.301, 37.88.305 and 37.88.306;

(m) outpatient drugs services as defined in ARM 37.86.1102;

(n) prosthetic devices, durable medical equipment and medical supplies as defined in ARM 37.86.1801;

(o) optometric services as defined in ARM 37.86.2001;

(p) eyeglasses as defined in ARM 37.86.2101;

(q) transportation and per diem as defined in ARM 37.86.2401;

(r) specialized nonemergency medical transportation as defined in ARM 37.86.2501;

(s) ambulance services as defined in ARM 37.86.2601;

(t) skilled care facility services as defined in ARM 37.50.105;

(u) intermediate care facility services as defined in ARM 37.40.106;

(v) institution for mental disease services as provided in ARM 37.88.1401, 37.88.1402, 37.88.1405, 37.88.1406, 37.88.1410, 37.88.1411 and 37.88.1420;

(w) home and community services as defined in ARM 37.40.1406;

(x) freestanding dialysis clinic for end stage renal disease services as defined in ARM 37.86.4201;

(y) case management services as defined in ARM 37.86.3305 et seq.;

(z) nonhospital laboratory and radiology (x-ray) as defined in ARM 37.86.3201;

(aa) admission for inpatient psychiatric services as provided in ARM 37.88.1101, 37.88.1105 through 37.88.1107, 37.88.1115 and 37.88.1116;

(ab) therapeutic youth group home or therapeutic youth family care services under the EPSDT program;

(ac) hospice as defined in ARM 37.40.801 and 37.40.806.

(ad) dietician as provided in ARM 37.40.1475; and

(ae) respiratory therapy as provided in ARM 37.40.1463.

(3) The requirement that services listed in (1) (a) be authorized by the primary care provider does not replace or eliminate other regulatory or statutory requirements for or limits on obtaining and being reimbursed for medicaid services.

(4) Nothing in this rule reduces or otherwise affects the requirements that must be met under ARM 37.88.101, to obtain or access mental health services as provided in this chapter.

History: Sec. 53-2-201 and 53-6-113, MCA; IMP, Sec. 53-2-201, 53-6-101, 53-6-111, 53-6-113 and 53-6-116, MCA; NEW, 1992 MAR p. 2288, Eff. 10/16/92; AMD, 1994 MAR p. 313, Eff. 2/11/94; AMD, 1994 MAR p. 2983, Eff. 11/11/94; AMD, 1996 MAR p. 2193, Eff. 8/9/96; AMD, 1997 MAR p. 548, Eff. 3/25/97; AMD, 1997 MAR p. 1269, Eff. 7/22/97; AMD, 1997 MAR p. 2085, Eff. 11/18/97; AMD, 1998 MAR p. 2045, Eff. 7/31/98; AMD, 1999 MAR p. 1301, Eff. 7/1/99; TRANS, from SRS, 2000 MAR p. 481; AMD, 2000 MAR p. 1338, Eff. 3/31/00; AMD, 2003 MAR p. 1203, Eff. 6/13/03.

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