37.86.3205 NONHOSPITAL LABORATORY AND RADIOLOGY (X-RAY) SERVICES, REIMBURSEMENT
(1) These reimbursement requirements are in addition to those contained in ARM 37.85.212 and 37.86.105.
(2) Independent laboratory providers must meet the following requirements to receive Medicaid reimbursement:
(a) the independent laboratory provider must be certified by Medicare;
(b) the independent laboratory provider must meet any state licensing requirements for laboratory facilities; and
(c) the independent laboratory service must have been ordered by a physician, dentist, or other practitioner licensed to practice in Montana.
(i) Medicaid does not reimburse services ordered by chiropractors.
(3) Independent radiology (x-ray) services must meet the following requirements to receive Medicaid reimbursement:
(a) the independent radiology provider must meet any state licensing requirements for radiology facilities;
(b) the independent radiology service must be ordered by a physician, dentist, or other practitioner licensed within the scope of his practice as defined by state law;
(c) technical components of diagnostic and therapeutic radiology services must be performed by an appropriately licensed provider within the scope of his practice as defined by state law and under the supervision of a physician; and
(d) the physician with supervisory responsibilities for the radiology services must meet state licensing requirements; and
(e) technical components of the radiology (x-ray) service must be billed by and reimbursed to the supervising physician.
(4) For clinical laboratory services, the department pays the lower of:
(a) the provider's usual and customary charges for the service;
(b) 60% of the Medicare fee schedule for physician offices and independent labs and hospitals functioning as independent labs; or
(c) the Medicaid fee as determined at ARM 37.86.105(7) if there is no fee determined at (4)(b).
History: 53-6-113, MCA; IMP, 53-6-113, MCA; NEW, 1988 MAR p. 2228, Eff. 10/14/88; AMD, 1997 MAR p. 1269, Eff. 7/22/97; TRANS, from SRS, 2000 MAR p. 481; AMD, 2000 MAR p. 1664, Eff. 6/30/00; AMD, 2014 MAR p. 1407, Eff. 7/1/14; AMD, 2017 MAR p. 2287, Eff. 1/1/18; AMD, 2018 MAR p. 2057, Eff. 10/20/18.