MEDICAID PRIMARY CARE SERVICES

37.86.3001 OUTPATIENT HOSPITAL SERVICES, DEFINITIONS "Ambulatory payment classification (APC)" means Medicare's ambulatory payment classification assignment groups of CPT or HCPCS codes. "Bad debt" means inpatient and outpatient hospital services provided in which full payment is…

37.86.3002 OUTPATIENT HOSPITAL SERVICES, SCOPE AND REQUIREMENTS The requirements of ARM 37.86.2801, 37.86.2803, 37.86.3001, 37.86.3005 and this rule are in addition to those contained in rule provisions generally applicable to Medicaid providers. Outpatient hospital services are …

37.86.3003 OUTPATIENT HOSPITAL SERVICES, EXCLUSIONS Outpatient hospital services do not include: services excluded from coverage by the Medicaid program under ARM 37.85.207; exercise programs and programs primarily educational in nature unless covered as preventative outpatient s…

37.86.3005 OUTPATIENT HOSPITAL SERVICES, REIMBURSEMENT The department will reimburse for outpatient hospital services and birthing center services compensable under the Montana Medicaid program as provided in this rule. Outpatient hospital services that are not provided by critic…

37.86.3006 MENTAL HEALTH OUTPATIENT PARTIAL HOSPITAL SERVICES, REQUIREMENTS Medicaid reimbursement is not available for outpatient partial hospitalization services unless: the person is experiencing psychiatric symptoms of sufficient severity to create severe impairments in educa…

37.86.3007 OUTPATIENT HOSPITAL SERVICES, PROSPECTIVE PAYMENT METHODOLOGY, CLINICAL DIAGNOSTIC LABORATORY SERVICES Clinical diagnostic laboratory services, including automated multichannel test panels (commonly referred to as "ATPs") and lab panels, will be reimbursed on a fee bas…

37.86.3009 OUTPATIENT HOSPITAL SERVICES, PAYMENT METHODOLOGY, EMERGENCY VISIT SERVICES For emergency visits that are not provided by exempt hospitals or critical access hospitals as defined in ARM 37.86.2901, reimbursement will be based on the ambulatory payment classifications A…

37.86.3011 OUTPATIENT HOSPITAL SERVICES, PROSPECTIVE PAYMENT METHODOLOGY, NONEMERGENT EMERGENCY ROOM SERVICES (REPEALED) Authorizing statute(s): 53-2-201, 53-6-113, MCA Implementing statute(s): 53-2-201, 53-6-101, 53-6-111, 53-6-113, MCA History: NEW, 2001 MAR p. 27, Eff. 1/12/01…

37.86.3014 OUTPATIENT HOSPITAL SERVICES, PROSPECTIVE PAYMENT METHODOLOGY, DIALYSIS SERVICES (REPEALED) Authorizing statute(s): 53-2-201, 53-6-113, MCA Implementing statute(s): 53-2-201, 53-6-101, 53-6-111, 53-6-113, MCA History: NEW, 2001 MAR p. 27, Eff. 1/12/01; AMD, 2003 MAR p.…

37.86.3015 OUTPATIENT HOSPITAL REIMBURSEMENT, OUTPATIENT HOSPITAL REIMBURSEMENT ADJUSTOR The outpatient hospital reimbursement adjustor (HRA) payment is payable to a PPS hospital or critical access hospital, as those terms are defined in 50-5-101, MCA, that provides outpatient ho…

37.86.3016 OUTPATIENT HOSPITAL SERVICES, PROSPECTIVE PAYMENT METHODOLOGY, IMAGING SERVICES Imaging services will be reimbursed with the exception of hospitals reimbursed under ARM 37.86.3005(3) as follows: For each imaging service or procedure, the fee will be the APC rate as in …

37.86.3018 OUTPATIENT HOSPITAL SERVICES, PROSPECTIVE PAYMENT METHODOLOGY, OTHER DIAGNOSTIC SERVICES Other diagnostic services will be reimbursed as follows with the exception of hospitals reimbursed under ARM 37.86.3005(4): the fee will be the APC rate as in ARM 37.86.3020 or the…

37.86.3020 OUTPATIENT HOSPITAL SERVICES, OUTPATIENT PROSPECTIVE PAYMENT SYSTEM (OPPS) METHODOLOGY, AMBULATORY PAYMENT CLASSIFICATION Outpatient hospital or birthing center services that are not provided by critical access hospitals will be reimbursed on a rate-per-service basis u…

37.86.3022 OUTPATIENT HOSPITAL SERVICES, PARTIAL HOSPITALIZATION SERVICES Partial hospitalization services will be reimbursed on a prospective per diem rate which shall be the lesser of the amount specified in the department's Medicaid Mental Health Fee Schedule or the provider's…

37.86.3025 OUTPATIENT HOSPITAL SERVICES, REIMBURSEMENT FOR SERVICES NOT PAID UNDER THE AMBULATORY PAYMENT CLASSIFICATION SYSTEM Therapy services will be paid the facility fee in accordance with the RBRVS methodologies in ARM 37.85.212 using the allied services conversion factor. …

37.86.3031 PROVIDER BASED ENTITY SERVICES, GENERAL (REPEALED) Authorizing statute(s): 53-2-201, 53-6-113, MCA Implementing statute(s): 53-6-101, MCA History: NEW, 2006 MAR p. 3078, Eff. 1/1/07; AMD, 2012 MAR p. 1382, Eff. 7/13/12; REP, 2018 MAR p. 458, Eff. 3/1/18.

37.86.3033 PROVIDER-BASED ENTITY SERVICES, RECIPIENT ACCESS AND NOTIFICATION (REPEALED) Authorizing statute(s): 53-2-201, 53-6-113, MCA Implementing statute(s): 53-6-101, MCA History: NEW, 2006 MAR p. 3078, Eff. 1/1/07; AMD, 2012 MAR p. 1382, Eff. 7/13/12; REP, 2018 MAR p. 458, E…

37.86.3035 PROVIDER BASED ENTITY SERVICES, COMPLIANCE, AND PENALTIES (REPEALED) Authorizing statute(s): 53-6-101, 53-6-113, MCA Implementing statute(s): 53-6-101, MCA History: NEW, 2006 MAR p. 3078, Eff. 1/1/07; REP, 2018 MAR p. 458, Eff. 3/1/18.

37.86.3037 PROVIDER-BASED ENTITY SERVICES, REIMBURSEMENT (REPEALED) Authorizing statute(s): 53-6-101, 53-6-113, MCA Implementing statute(s): 53-6-101, MCA History: NEW, 2006 MAR p. 3078, Eff. 1/1/07; AMD, 2012 MAR p. 1382, Eff. 7/13/12; REP, 2018 MAR p. 458, Eff. 3/1/18.

37.86.3101 OUTPATIENT HOSPITAL SERVICES, CARDIAC AND PULMONARY REHABILITATION SERVICES Coverage for medically necessary outpatient cardiac and pulmonary rehabilitation services is effective January 1, 2006. All cardiac and pulmonary rehabilitative services must be medically neces…

37.86.3103 OUTPATIENT HOSPITAL SERVICES, CARDIAC REHABILITATION SERVICES Cardiac rehabilitation services are limited to the following cardiac events and diagnoses: myocardial infarction within the preceding 12 months; coronary artery bypass surgery; heart-lung transplant; current…

37.86.3105 OUTPATIENT HOSPITAL SERVICES, PULMONARY REHABILITATION SERVICES Pulmonary rehabilitation services are limited to members with moderate to severe COPD, defined as GOLD classification II, III, and IV. If applicable, the patient must have ceased smoking or be in a smoking…

37.86.3107 OUTPATIENT HOSPITAL SERVICES, CARDIAC AND PULMONARY REHABILITATION, WAIVER OF SERVICE LIMITATIONS The service limitations provided in ARM 37.86.3103 and 37.86.3105 may be waived for extenuating circumstances on a case-by-case basis by the department. Authorizing statut…

37.86.3109 OUTPATIENT CARDIAC AND PULMONARY REHABILITATION REIMBURSEMENT Critical access hospital (CAH) interim reimbursement is based on a hospital-specific Medicaid outpatient cost-to-charge ratio, not to exceed 100%. For dates of service January 1, 2018 through June 30, 2018, …

37.86.3201 NONHOSPITAL LABORATORY AND RADIOLOGY (X-RAY) SERVICES, REQUIREMENTS "Nonhospital laboratory and radiology (x-ray) services" are professional and technical laboratory and radiology services which are ordered and provided by a physician, dentist, or other practitioner li…

37.86.3205 NONHOSPITAL LABORATORY AND RADIOLOGY (X-RAY) SERVICES, REIMBURSEMENT These reimbursement requirements are in addition to those contained in ARM 37.85.212 and 37.86.105. Independent laboratory providers must meet the following requirements to receive Medicaid reimbursem…

37.86.3301 CASE MANAGEMENT SERVICES, GENERAL DEFINITIONS "Case management" means the process of planning and coordinating care and services to meet individual needs of a client and to assist the client in obtaining necessary medical, social, nutritional, educational, and other se…

37.86.3305 CASE MANAGEMENT SERVICES, GENERAL PROVISIONS Case management services assure healthy outcomes by assisting recipients to access needed services and by coordinating between all agencies and providers responsible for service delivery. A case management plan sets goals fo…

37.86.3306 CASE MANAGEMENT SERVICES, GENERAL ELIGIBILITY Persons who are Medicaid recipients and are from the following groups are eligible for case management services: high risk pregnant women; adults with severe disabling mental illness; persons age 16 and over with developmen…

37.86.3401 TARGETED CASE MANAGEMENT SERVICES FOR HIGH RISK PREGNANT WOMEN, DEFINITIONS The definitions of targeted case management services for high risk pregnant women are as follows: "Care plan" means a specific written plan that is based on the information collected through th…

37.86.3402 TARGETED CASE MANAGEMENT SERVICES FOR HIGH RISK PREGNANT WOMEN, ELIGIBILITY A member is eligible for targeted case management as a high risk pregnant woman if: the person is receiving Medicaid or is presumptively eligible for Medicaid; and the member's pregnancy outcom…

37.86.3405 TARGETED CASE MANAGEMENT SERVICES FOR HIGH RISK PREGNANT WOMEN, COVERAGE Reimbursable targeted case management services for high risk pregnant women are: comprehensive assessment and periodic reassessment; care plan development; care coordination and referral for other…

37.86.3410 TARGETED CASE MANAGEMENT SERVICES FOR HIGH RISK PREGNANT WOMEN, PROVIDER REQUIREMENTS These requirements are in addition to those requirements contained in rule and statutory provisions generally applicable to Medicaid providers. To be qualified as a provider of target…

37.86.3411 CASE MANAGEMENT SERVICES FOR HIGH RISK PREGNANT WOMEN, FINANCIAL RECORDS, AND REPORTING (REPEALED) Authorizing statute(s): 53-6-113, MCA Implementing statute(s): 2-4-201, 53-2-201, 53-2-606, 53-6-101, 53-6-111, 53-6-113, MCA History: NEW, 1991 MAR p. 1295, Eff. 7/26/91…

37.86.3415 TARGETED CASE MANAGEMENT SERVICES FOR HIGH RISK PREGNANT WOMEN, REIMBURSEMENT Targeted case management services for high risk pregnant women are reimbursed at the lower of the following: the provider's customary charge to the general public for the service; or the depa…

37.86.3501 CASE MANAGEMENT SERVICES FOR ADULTS WITH SEVERE DISABLING MENTAL ILLNESS, DEFINITIONS (REPEALED) Authorizing statute(s): 53-2-201, 53-6-113, MCA Implementing statute(s): 53-2-201, 53-6-101, MCA History: NEW, 1999 MAR p. 1301, Eff. 7/1/99; TRANS, from SRS, 2000 MAR p. 4…

37.86.3502 CASE MANAGEMENT SERVICES FOR ADULTS WITH SEVERE DISABLING MENTAL ILLNESS, ELIGIBILITY (REPEALED) Authorizing statute(s): 53-2-201, 53-6-113, 53-21-703, MCA Implementing statute(s): 53-6-101, 53-21-701, MCA History: NEW, 1999 MAR p. 1806, Eff. 7/1/99; TRANS, from SRS, 2…

37.86.3503 CASE MANAGEMENT SERVICES FOR ADULTS WITH SEVERE DISABLING MENTAL ILLNESS, SEVERE DISABLING MENTAL ILLNESS (REPEALED) Authorizing statute(s): 53-2-201, 53-6-113, MCA Implementing statute(s): 53-2-201, 53-6-101, MCA History: NEW, 2010 MAR p. 424, Eff. 2/12/10; AMD, 2015 …

37.86.3505 CASE MANAGEMENT SERVICES FOR ADULTS WITH SEVERE DISABLING MENTAL ILLNESS, SERVICE COVERAGE (REPEALED) Authorizing statute(s): 53-2-201, 53-6-113, MCA Implementing statute(s): 53-2-201, 53-6-101, 53-6-113, MCA History: NEW, 1999 MAR p. 1301, Eff. 7/1/99; TRANS, from SRS…

37.86.3506 CASE MANAGEMENT SERVICES FOR ADULTS WITH SEVERE DISABLING MENTAL ILLNESS, SERVICE REQUIREMENTS (REPEALED) Authorizing statute(s): 53-2-201, 53-6-113, MCA Implementing statute(s): 53-2-201, 53-6-101, MCA History: NEW, 1999 MAR p. 1301, Eff. 7/1/99; TRANS, from SRS, 2000…

37.86.3507 CASE MANAGEMENT SERVICES FOR ADULTS WITH SEVERE DISABLING MENTAL ILLNESS, PROVIDER REQUIREMENTS (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, 1999 MAR p. 1301, Eff. 7/1/99; …

37.86.3515 TARGETED CASE MANAGEMENT SERVICES FOR ADULTS WITH SEVERE DISABLING MENTAL ILLNESS, REIMBURSEMENT Targeted case management services for adults with severe disabling mental illness will be reimbursed on a fee per unit of service basis as follows. For purposes of this rul…

37.86.3601 CASE MANAGEMENT SERVICES FOR PERSONS AGE 16 AND OVER WITH DEVELOPMENTAL DISABILITIES, DEFINITIONS The definitions of case management services for persons with developmental disabilities age 16 years of age and over are as follows: "Developmental disability" means a dis…

37.86.3602 CASE MANAGEMENT SERVICES FOR PERSONS AGE 16 AND OVER WITH DEVELOPMENTAL DISABILITIES, ELIGIBILITY A person is eligible for case management as a person with developmental disabilities if the person: is receiving Medicaid; is 16 years of age or over; and has a developmen…

37.86.3605 CASE MANAGEMENT SERVICES FOR PERSONS AGE 16 AND OVER WITH DEVELOPMENTAL DISABILITIES, COVERAGE Reimbursable case management services for persons age 16 and over with developmental disabilities are: service coordination which includes the following: assessment and evalu…

37.86.3606 CASE MANAGEMENT SERVICES FOR PERSONS WITH DEVELOPMENTAL DISABILITIES, PROVIDER REQUIREMENTS These requirements are in addition to those contained in rule and statutory provisions generally applicable to Medicaid providers. The case management provider for persons age 1…

37.86.3607 CASE MANAGEMENT SERVICES FOR PERSONS WITH DEVELOPMENTAL DISABILITIES, REIMBURSEMENT Reimbursement for the delivery by provider entities of Medicaid funded targeted case management services to persons with developmental disabilities is provided as specified in the Monta…

37.86.3701 CASE MANAGEMENT SERVICES FOR YOUTH WITH SERIOUS EMOTIONAL DISTURBANCE, DEFINITIONS (REPEALED) Authorizing statute(s): 53-2-201, 53-6-113, MCA Implementing statute(s): 53-6-101, MCA History: NEW, 1999 MAR p. 1301, Eff. 7/1/99; TRANS, from SRS, 2000 MAR p. 481; AMD, 2007…

37.86.3702 CASE MANAGEMENT SERVICES FOR YOUTH WITH SERIOUS EMOTIONAL DISTURBANCE, ELIGIBILITY (REPEALED) Authorizing statute(s): 53-2-201, 53-6-113, MCA Implementing statute(s): 53-6-101, MCA History: NEW, 1999 MAR p. 1301, Eff. 7/1/99; TRANS, from SRS, 2000 MAR p. 481; AMD, 2001…

37.86.3705 CASE MANAGEMENT SERVICES FOR YOUTH WITH SERIOUS EMOTIONAL DISTURBANCE, SERVICE COVERAGE (REPEALED) Authorizing statute(s): 53-2-201, 53-6-113, MCA Implementing statute(s): 53-2-201, 53-6-101, 53-6-113, MCA History: NEW, 1999 MAR p. 1301, Eff. 7/1/99; TRANS, from SRS, 2…