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(1) Providers must bill for prosthetic devices, durable medical equipment, medical supplies and related maintenance, repair and 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 Department of Public Health and Human Services, Health Resources Division, 1401 East Lockey, P.O. Box 202951, Helena, MT 59620-2951.

(2) Prosthetic devices, durable medical equipment, and medical supplies will be reimbursed in accordance with the department's Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) Fee Schedule, as provided in ARM 37.85.105(3), which is adopted and incorporated by reference.

(3) The department's DMEPOS Fee Schedule for items other than those billed under generic or miscellaneous codes as described in (1) will include fees set and maintained according to the following methodology:

(a) 100% of the Medicare region D allowable fee;

(b) 100% of the Medicaid allowable fee established by the department if there is no Medicare region D allowable fee established; or

(c) Except as provided in (4), for all items for which no Medicare or Medicaid allowable fee is available, the department's fee schedule amount will be 75% of the provider's usual and customary charge.

(i) For purposes of (3)(c) and (4), the amount of the provider's usual and customary charge may not exceed the reasonable charge usually and customarily charged by the provider to all payers.

(A) The charge will be considered reasonable if less than or equal to the manufacturer's suggested list price.

(B) For items without a manufacturer's suggested list price, the charge will be considered reasonable if the provider's acquisition cost from the manufacturer is at least 50% of the charge amount.

(C) For items that are custom fabricated at the place of service, the amount charged will be considered reasonable if it does not exceed the average charge of all Medicaid providers by more than 20%.

(D) For rental items, the reasonable monthly charge may not exceed a percentage of the reasonable purchase charge, as specified in ARM 37.86.1806(3).

(ii) Items having no product retail list price, such as items customized by the provider, will be reimbursed at 75% of the provider's usual and customary charge as defined in (3)(b)(i).

(4) The department's DMEPOS Fee Schedule, referred to in ARM 37.86.1807(2), for items billed under generic or miscellaneous codes as described in (1) will be 75% of the provider's usual and customary charge as defined in (3)(b)(i).


History: 53-2-201, 53-6-113, MCA; IMP, 53-2-201, 53-6-101, 53-6-113, MCA; NEW, 1981 MAR p. 1977, Eff. 1/1/82; AMD, 1982 MAR p. 1289, Eff. 7/1/82; AMD, 1986 MAR p. 1911, Eff. 1/1/87; AMD, 1990 MAR p. 1951, Eff. 11/1/90; AMD, 1991 MAR p. 1030, Eff. 7/1/91; AMD, 1993 MAR p. 1112, Eff. 7/1/93; AMD, 1994 MAR p. 2546, Eff. 9/9/94; AMD, 1995 MAR p. 1970, Eff. 10/1/95; AMD, 1998 MAR p. 497, Eff. 2/13/98; AMD, 1998 MAR p. 2168, Eff. 8/14/98; AMD, 1999 MAR p. 1379, Eff. 7/1/99; TRANS, from SRS, 2000 MAR p. 481; AMD, 2000 MAR p. 1664, Eff. 6/30/00; AMD, 2001 MAR p. 604, Eff. 4/27/01; AMD, 2001 MAR p. 986, Eff. 6/8/01; AMD, 2001 MAR p. 1476, Eff. 8/10/01; AMD, 2001 MAR p. 2156, Eff. 10/26/01; AMD, 2002 MAR p. 1779, Eff. 6/28/02; EMERG, AMD, 2002 MAR p. 2665, Eff. 9/27/02; EMERG, AMD, 2003 MAR p. 999, Eff. 5/9/03; AMD, 2003 MAR p. 1314, Eff. 7/1/03; AMD, 2004 MAR p. 82, Eff. 1/1/04; AMD, 2005 MAR p. 385, Eff. 3/18/05; AMD, 2006 MAR p. 1894, Eff. 7/28/06; AMD, 2007 MAR p. 1824, Eff. 11/9/07; AMD, 2007 MAR p. 2134, Eff. 1/1/08; AMD, 2008 MAR p. 2672, Eff. 1/1/09; AMD, 2009 MAR p. 2485, Eff. 1/1/10; AMD, 2010 MAR p. 2986, Eff. 1/1/11; AMD, 2011 MAR p. 2825, Eff. 1/1/12; AMD, 2012 MAR p. 2494, Eff. 1/1/13; AMD, 2013 MAR p. 1111, Eff. 7/1/13; AMD, 2017 MAR p. 2287, Eff. 1/1/18; AMD, 2018 MAR p. 458, Eff. 3/1/18; AMD, 2018 MAR p. 2057, Eff. 10/20/18.

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