MEDICAID PRIMARY CARE SERVICES

37.86.1001 DENTAL SERVICES, DEFINITIONS For purposes of this subchapter, the following definitions apply: "By-report method" means the department reimburses a percent of the provider's usual and customary charges for a procedure code for which no fee has been assigned. "Conversio…

37.86.1002 DENTAL SERVICES, REQUIREMENTS These requirements are in addition to those rule provisions generally applicable to Medicaid providers and the provision of services under Medicaid coverage. Medicaid reimbursement for dental care is limited to those services specified in …

37.86.1004 REIMBURSEMENT METHODOLOGY FOR RESOURCE BASED RELATIVE VALUE FOR DENTISTS (RVD) For procedures listed in the relative values for dentists scale, reimbursement rates shall be determined using the following methodology: The fee for a covered service shall be the amount de…

37.86.1005 DENTAL SERVICES, REIMBURSEMENT For dental services listed in the department's fee schedule, the department will pay the lowest of the following for dental services covered by the Medicaid program: the provider's usual and customary charge for the service; the amount de…

37.86.1006 DENTAL SERVICES, COVERED PROCEDURES For purposes of specifying coverage of dental services through the Medicaid program, the department adopts and incorporates by reference the Dental and Denturist Program Provider Manual as provided in ARM 37.85.105(3). The Dental and…

37.86.101 PHYSICIAN SERVICES, DEFINITIONS "Early elective delivery" means either a nonmedically necessary labor induction or cesarean section that is performed prior to 39 weeks and 0/7 days gestation. "Physician services" means those services provided by individuals licensed und…

37.86.104 PHYSICIAN SERVICES, REQUIREMENTS These requirements are in addition to those rule provisions generally applicable to Medicaid providers. The department or its designated review organization may conduct utilization and peer review of physician services. Physician service…

37.86.105 PHYSICIAN SERVICES, REIMBURSEMENT/GENERAL REQUIREMENTS AND MODIFIERS 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 Commo…

37.86.108 MENTAL HEALTH SERVICES PLAN, APPLICATION FORMS, INCOME VERIFICATION Application forms and information regarding eligibility for the plan are available at all local county human services departments. The applicant must submit with the application form a completed and sig…

37.86.110 MENTAL HEALTH SERVICES PLAN, ELIGIBILITY REDETERMINATIONS, MEMBERS REQUIRED TO NOTIFY DEPARTMENT OF CHANGES, REPAYMENT OF BENEFITS Eligibility determinations under ARM 37.89.106 are effective until the earlier of: one year; or the effective date of any redetermination. …

37.86.1101 OUTPATIENT DRUGS, DEFINITIONS "Acquisition cost" means the actual price paid by a provider for a drug. "Active pharmaceutical ingredient (API)" means a nonrebatable bulk drug substance, defined in 21 CFR 207.3(a)(4) (2011) as any substance that is represented for use i…

37.86.1102 OUTPATIENT DRUGS, REQUIREMENTS These requirements are in addition to those contained in ARM 37.85.401 through 37.85.415. For purposes of Medicaid reimbursement, outpatient drugs may not be filled or refilled without the authorization of the physician or other licensed …

37.86.1103 OUTPATIENT DRUGS, FRAUD, WASTE, AND ABUSE Medicaid, Healthy Montana Kids, and Mental Health Services Plan members may be subject to investigation for prescription fraud and abuse in accordance with 42 CFR 455. "Fraud" means the intentional deception or misrepresentatio…

37.86.1105 OUTPATIENT DRUGS, REIMBURSEMENT Outpatient drugs are reimbursed at the lower of: the provider's "usual and customary charge"; or the "allowed ingredient cost" plus a dispensing fee. The FMAC limitation will not apply in a case where a physician certifies in their own h…

37.86.1106 CALCULATION OF THE AVERAGE ACQUISITION COST The Average Acquisition Cost (AAC) is the cost per drug determined by direct pharmacy survey, wholesale survey, and other relevant cost information. The department reviews AAC rates on an ongoing basis and adjusts the rates a…

37.86.1111 OPPORTUNITY FOR HEARING In any quarter in which a discrepancy in Medicaid utilization information is discovered by the manufacturer, which the manufacturer and the department are unable to resolve, the manufacturer will provide written notice of the discrepancy, by NDC…

37.86.112 MENTAL HEALTH SERVICES PLAN, EMERGENCY MENTAL HEALTH SERVICES, LIABILITY FOR FAILURE TO COMPLETE APPLICATION A nonmember receiving covered emergency mental health services, which do not include hospital emergency room or other hospital services, is eligible on an emerge…

37.86.1201 LICENSED DIRECT-ENTRY MIDWIFE "Direct-entry midwife" means a person that is licensed as defined in Title 37, chapter 27, MCA and ARM Title 24, chapter 111, subchapter 6. Direct-entry midwives may provide prenatal labor and delivery or postpartum care in a member's home…

37.86.1401 CLINIC SERVICES, DEFINITIONS "Clinic services" means preventive diagnostic, therapeutic, rehabilitative, or palliative items or services provided under the direction of a physician by an outpatient facility that is not part of a hospital, but is organized and operated …

37.86.1402 CLINIC SERVICES, REQUIREMENTS These requirements are in addition to those requirements contained in ARM 37.85.401 through 37.85.414. Clinic services must be provided by a clinic which is licensed as an outpatient facility by the appropriate licensing entity of the stat…

37.86.1405 CLINIC SERVICES, COVERED PROCEDURES Ambulatory surgical center (ASC) services: are services that will be covered by Medicaid if provided in an outpatient ASC setting incident to provision of physician or dental services to the patient where the services and supplies ar…

37.86.1406 CLINIC SERVICES, REIMBURSEMENT Ambulatory surgical center (ASC) services as defined in ARM 37.86.1401(2) provided by an ASC will be reimbursed on a fee basis as follows: 100% of the Medicare allowable amount. For purposes of determining the Medicare allowable amount fo…

37.86.1501 HOME INFUSION THERAPY SERVICES, DEFINITIONS In ARM 37.86.1501, 37.86.1502, 37.86.1505, and 37.86.1506, the following definitions apply: "Agency staff services" means all services provided by the home infusion therapy agency's staff, as provided in ARM 37.106.2405, incl…

37.86.1502 HOME INFUSION THERAPY SERVICES, PROVIDER REQUIREMENTS These requirements are in addition to those contained in rule provisions generally applicable to Medicaid providers. Home infusion therapy service providers, as a condition of participation in the Montana Medicaid p…

37.86.1505 HOME INFUSION THERAPY SERVICES, REQUIREMENTS The requirements and restrictions in these rules apply for purposes of coverage and reimbursement of home infusion therapy services under the Montana Medicaid program. Medicaid coverage and reimbursement of home infusion the…

37.86.1506 HOME INFUSION THERAPY SERVICES, REIMBURSEMENT Subject to the requirements of these rules, the Montana Medicaid program will pay for home infusion therapy services on a fee basis, as specified in the department's home infusion therapy services fee schedule. The departme…

37.86.1701 FAMILY PLANNING SERVICES Family planning services may be provided by a physician in accordance with ARM 37.86.101 through 37.86.105, mid-level practitioner in accordance with ARM 37.86.201 through 37.86.205, or a local family planning program defined at ARM 37.19.101. …

37.86.1705 FAMILY PLANNING SERVICES, REQUIREMENTS These requirements are in addition to those contained in ARM 37.85.401, 37.85.406, 37.85.407, 37.85.410, and 37.85.414. Contraceptive clinic services are the services of a physician, a mid-level practitioner, or a local family pla…

37.86.1706 FAMILY PLANNING SERVICES, REIMBURSEMENT Reimbursement for family planning services is as follows: for physicians reimbursement is provided in accordance with the methodologies described in ARM 37.85.212 and 37.86.105; for mid-level practitioners reimbursement is provid…

37.86.1707 1115 PLAN FIRST WAIVER "Plan First" refers to Montana's Social Security Act Section 1115 Waiver titled Plan First. This waiver is approved by the Centers for Medicare & Medicaid Services and managed by the Department of Public Health and Human Services (DPHHS) with eli…

37.86.1801 PROSTHETIC DEVICES, DURABLE MEDICAL EQUIPMENT, AND MEDICAL SUPPLIES, DEFINITIONS "Durable medical equipment and supplies" means the most economical equipment or supplies that are medically necessary to treat a health problem or a physical condition. The equipment or su…

37.86.1802 PROSTHETIC DEVICES, DURABLE MEDICAL EQUIPMENT, AND MEDICAL SUPPLIES, GENERAL REQUIREMENTS These requirements are in addition to those contained in rule provisions generally applicable to Medicaid providers. Requirements for prosthetic devices, durable medical equipment…

37.86.1806 PROSTHETIC DEVICES, DURABLE MEDICAL EQUIPMENT, AND MEDICAL SUPPLIES, REIMBURSEMENT REQUIREMENTS Requirements for the purchase or rental of prosthetic devices, durable medical equipment, medical supplies and related maintenance, repair, and services are as follows: Subj…

37.86.1807 PROSTHETIC DEVICES, DURABLE MEDICAL EQUIPMENT, AND MEDICAL SUPPLIES, FEE SCHEDULE 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 …

37.86.2001 OPTOMETRIC SERVICES, DEFINITIONS "Optometric services" means services provided by a licensed optometrist that are within the scope of practice. Optometric services include visual training. Authorizing statute(s): 53-6-113, MCA Implementing statute(s): 53-6-101, 53-6-14…

37.86.2002 OPTOMETRIC SERVICES, REQUIREMENTS These requirements are in addition to the rule provisions generally applicable to Medicaid providers. The department hereby adopts and incorporates by reference the definitions found in the introduction of Physicians Current Procedural…

37.86.2005 OPTOMETRIC SERVICES, REIMBURSEMENT Subject to the requirements of this rule, the department will pay the lowest of the following for optometric services: the provider's usual and customary charge for the service or item; the reimbursement provided in accordance with th…

37.86.201 MID-LEVEL PRACTITIONER SERVICES, REQUIREMENTS ARM 37.86.202 and 37.86.205 provide the requirements for Medicaid coverage of mid-level practitioner services. The requirements in these rules are in addition to those contained in ARM 37.85.401 through 37.85.414. Authorizin…

37.86.202 MID-LEVEL PRACTITIONER SERVICES, DEFINITIONS For the purpose of these rules, the following definitions will apply: "Advanced practice registered nurse" means a registered professional nurse licensed as provided in Title 37, chapter 8, MCA and ARM Title 24, chapter 159, …

37.86.205 MID-LEVEL PRACTITIONER SERVICES, REQUIREMENTS AND REIMBURSEMENT These requirements are in addition to those rule provisions generally applicable to Medicaid providers. Medicaid coverage of mid-level practitioner services is available according to the requirements and pr…

37.86.2101 EYEGLASSES, DEFINITIONS Eyeglasses mean corrective lens and/or frames prescribed by an ophthalmologist or by an optometrist, to aid and improve vision. Corrective lenses also include contact lenses. Authorizing statute(s): 53-6-113, MCA Implementing statute(s): 53-6-10…

37.86.2102 EYEGLASSES, SERVICES AND REQUIREMENTS These requirements are in addition to the rule provisions generally applicable to Medicaid providers. The dispensing service may be provided by an ophthalmologist, an optometrist, an optician, or their employees within the scope of…

37.86.2105 EYEGLASSES, REIMBURSEMENT Eyeglasses are paid by the department through a single volume purchase contract. Reimbursement for contact lenses or dispensing fees is as follows: The department pays the lower of the following: the provider's usual and customary charge for t…

37.86.2201 EARLY AND PERIODIC SCREENING, DIAGNOSTIC AND TREATMENT SERVICES (EPSDT) , PURPOSE, ELIGIBILITY, AND SCOPE The early and periodic screening, diagnostic and treatment services (EPSDT) are preventive health screenings, diagnostic services, and medically necessary treatmen…

37.86.2205 EARLY AND PERIODIC SCREENING, DIAGNOSTIC AND TREATMENT SERVICES (EPSDT) , REQUIRED SCREENING AND PREVENTIVE SERVICES EPSDT screening and preventive services are available in accordance with this rule. The number and timing of comprehensive health, vision, hearing and d…

37.86.2206 EARLY AND PERIODIC SCREENING, DIAGNOSTIC AND TREATMENT SERVICES (EPSDT) , MEDICAL AND OTHER SERVICES EPSDT eligible persons may receive any services otherwise available to persons eligible for Medicaid funded services. In addition to the services generally available to…

37.86.2207 EARLY AND PERIODIC SCREENING, DIAGNOSTIC AND TREATMENT (EPSDT) SERVICES, REIMBURSEMENT Reimbursement for an EPSDT service, except as otherwise provided in this rule, is the lowest of the following: the provider's usual and customary charge for the service; the reimburs…

37.86.2209 EARLY AND PERIODIC SCREENING, DIAGNOSTIC AND TREATMENT SERVICES (EPSDT) , NUTRITION SERVICES Nutrition services may include: nutrition counseling for counseling directly with a child, or with a responsible care giver, to explain the nutrition assessment and to implemen…

37.86.2211 EARLY AND PERIODIC SCREENING, DIAGNOSTIC AND TREATMENT SERVICES (EPSDT) , CHIROPRACTIC SERVICES Chiropractic services are limited to evaluation and management office visits, manual manipulation of the spine, and x-rays to support the diagnosis of subluxation of the spi…

37.86.2213 EARLY AND PERIODIC SCREENING, DIAGNOSTIC AND TREATMENT SERVICES (EPSDT) , OUTPATIENT CHEMICAL DEPENDENCY TREATMENT SERVICES (REPEALED) Authorizing statute(s): 53-2-201, 53-6-113, MCA Implementing statute(s): 53-2-201, 53-6-101, 53-6-111, 53-6-113, MCA History: NEW, 200…