MEDICAID PRIMARY CARE SERVICES

37.86.2217 EARLY AND PERIODIC SCREENING, DIAGNOSTIC AND TREATMENT SERVICES (EPSDT), PRIVATE DUTY NURSING SERVICES Private duty nursing services are limited to: skilled nursing services provided directly to a child; and patient-specific training provided to a registered nurse or l…

37.86.2219 EARLY AND PERIODIC SCREENING, DIAGNOSTIC AND TREATMENT SERVICES (EPSDT) , THERAPEUTIC YOUTH GROUP HOME SERVICES (REPEALED) Authorizing statute(s): 53-2-201, 53-6-113, MCA Implementing statute(s): 53-2-201, 53-6-101, 53-6-111, 53-6-113, MCA History: NEW, 2001 MAR p. 27,…

37.86.2221 EARLY AND PERIODIC SCREENING, DIAGNOSTIC AND TREATMENT SERVICES (EPSDT) , THERAPEUTIC FAMILY CARE TREATMENT SERVICES (REPEALED) Authorizing statute(s): 53-2-201, 53-6-113, MCA Implementing statute(s): 53-2-201, 53-6-101, 53-6-111, 53-6-113, MCA History: NEW, 2001 MAR p…

37.86.2224 EARLY AND PERIODIC SCREENING, DIAGNOSTIC, AND TREATMENT SERVICE (EPSDT), COMPREHENSIVE SCHOOL AND COMMUNITY TREATMENT (REPEALED) Authorizing statute(s): 53-2-201, 53-6-113, MCA Implementing statute(s): 53-2-201, 53-6-101, 53-6-111, 53-6-113, MCA History: EMERG, NEW, 20…

37.86.2225 EARLY AND PERIODIC SCREENING, DIAGNOSTIC AND TREATMENT SERVICES (EPSDT), CSCT PROGRAM BILLING (REPEALED) Authorizing statute(s): 53-2-201, 53-6-113, MCA Implementing statute(s): 50-5-103, 53-2-201, 53-6-101, 53-6-111, 53-6-113, MCA History: NEW, 2005 MAR p. 1786, Eff. …

37.86.2230 EARLY AND PERIODIC SCREENING, DIAGNOSTIC AND TREATMENT SERVICES (EPSDT), SCHOOL-BASED HEALTH RELATED SERVICES School-based services for the purposes of Medicaid are defined as medically necessary services provided through a public school district, joint board, or coope…

37.86.2231 EARLY AND PERIODIC SCREENING, DIAGNOSTIC AND TREATMENT SERVICES (EPSDT) , ELIGIBILITY AND SCOPE OF SCHOOL BASED HEALTH RELATED SERVICES Only public school districts, full-service education cooperatives (established under 20-3-351 , MCA) and joint boards are eligible fo…

37.86.2232 EARLY AND PERIODIC SCREENING, DIAGNOSTIC AND TREATMENT SERVICES (EPSDT) , SCHOOL BASED PERSONAL CARE PARAPROFESSIONAL SERVICES Personal care paraprofessional services are medically necessary in-school services provided to Medicaid clients whose health conditions cause …

37.86.2233 EARLY AND PERIODIC SCREENING, DIAGNOSTIC AND TREATMENT SERVICES (EPSDT) , SCHOOL PSYCHOLOGIST SERVICES School psychologist services are those services provided by an individual with a class 6 specialist license with a school psychologist endorsement, as required by ARM…

37.86.2234 EARLY AND PERIODIC SCREENING, DIAGNOSTIC AND TREATMENT SERVICES (EPSDT) , SCHOOL-BASED SPECIALIZED TRANSPORTATION SERVICES Coverage of specialized transportation is limited to school-based transportation of clients with disabilities for the purpose of obtaining nonemer…

37.86.2235 EARLY AND PERIODIC SCREENING, DIAGNOSTIC AND TREATMENT SERVICES (EPSDT), ORIENTATION AND MOBILITY SPECIALIST SERVICES Orientation and Mobility Specialist Services are those services provided by an individual with: a certification from the Academy for Certification of V…

37.86.2401 TRANSPORTATION AND PER DIEM, DEFINITIONS "Per diem" means financial assistance with expenses for a Medicaid recipient's meals and lodging enroute to and from, and while receiving medically necessary medical care. "Prior authorization" means the department or its design…

37.86.2402 TRANSPORTATION AND PER DIEM, REQUIREMENTS These requirements are in addition to those rule provisions generally applicable to Medicaid providers. Coverage of transportation and per diem is limited to transportation and per diem necessary to obtain necessary medical ser…

37.86.2405 TRANSPORTATION AND PER DIEM, REIMBURSEMENT The department pays the lower of the following reimbursement rates for transportation services: the provider's actual submitted charge; or the department's Personal and Commercial Transportation Fee Schedule adopted in this ru…

37.86.2501 SPECIALIZED NONEMERGENCY MEDICAL TRANSPORTATION, DEFINITIONS Specialized nonemergency transportation means transportation service by a provider with a class B public service commission license allowing the provider to transport physically disabled individuals. A motor …

37.86.2502 SPECIALIZED NONEMERGENCY MEDICAL TRANSPORTATION, REQUIREMENTS These requirements are in addition to those rule provisions generally applicable to Medicaid providers. Coverage of specialized nonemergency medical transportation is limited to transportation of persons wit…

37.86.2505 SPECIALIZED NONEMERGENCY MEDICAL TRANSPORTATION, REIMBURSEMENT The department pays the lower of the following for specialized nonemergency medical transportation services: the provider's usual and customary charge; or the department's fee schedule. The department adopt…

37.86.2601 AMBULANCE SERVICES, DEFINITIONS "Air ambulance services" means ambulance services provided by aircraft. There are two categories of air ambulance services, namely, fixed wing (airplane) and rotary wing (helicopter) aircraft. Fixed wing air ambulance services are furnis…

37.86.2602 AMBULANCE SERVICES, REQUIREMENTS These requirements are in addition to those rule provisions generally applicable to Medicaid providers. Ambulance services must be provided by a licensed ambulance provider. Coverage of ambulance services is limited to transportation ne…

37.86.2604 AMBULANCE SERVICES, COVERAGE AND BILLABLE SERVICES Except as provided in (2), the base charge specified in the department's fee schedule referred to in ARM 37.86.2605 for both basic life support (BLS) and advanced life support (ALS) ambulance services includes charges …

37.86.2605 AMBULANCE SERVICES, REIMBURSEMENT Except as provided in (4), the department pays the lowest of the following for ambulance services: the provider's usual and customary charge for the service; or the amount listed in the department's Ambulance Fee Schedule. The departme…

37.86.2606 AMBULANCE SERVICES, QUALIFIED RATE ADJUSTMENT, PAYMENT ELIGIBILITY AND COMPUTATION Eligible Montana ambulance providers may receive a qualified rate adjustment (QRA) from the department for ambulance services. Eligible providers are ambulance service providers that are…

37.86.2801 ALL HOSPITAL REIMBURSEMENT, GENERAL Reimbursement for inpatient hospital services is set forth in ARM 37.86.2806, 37.86.2905, 37.86.2907, 37.86.2912, 37.86.2916, 37.86.2918, 37.86.2920, 37.86.2924, 37.86.2925, 37.86.2928, 37.86.2943, and 37.86.2947. Reimbursement for o…

37.86.2803 ALL HOSPITAL REIMBURSEMENT, COST REPORTING Allowable costs will be determined in accordance with generally accepted accounting principles as defined by the American Institute of Certified Public Accountants. The department adopts and incorporates by reference CMS Publi…

37.86.2806 COST-BASED HOSPITAL, GENERAL REIMBURSEMENT Cost-based reimbursement shall be applied as follows: Critical access hospital (CAH) interim reimbursement is based on a hospital specific Medicaid inpatient cost-to-charge ratio (CCR), not to exceed 100%. For dates of service…

37.86.2810 INPATIENT AND OUTPATIENT HOSPITAL SERVICES, QUALIFIED RATE ADJUSTMENT PAYMENT, ELIGIBILITY, AND COMPUTATION (REPEALED) Authorizing statute(s): 53-6-113, MCA Implementing statute(s): 53-2-201, 53-6-101, 53-6-111, 53-6-113, MCA History: NEW, 2002 MAR p. 1991, Eff. 7/26/0…

37.86.2820 DESK REVIEWS, OVERPAYMENTS, AND UNDERPAYMENTS Upon receipt of the cost report, the department will instruct the Medicare intermediary to consider Medicaid data when they perform a desk review or audit of the cost report and determine whether a Medicaid overpayment or u…

37.86.2901 INPATIENT HOSPITAL SERVICES, DEFINITIONS "Acute care psychiatric hospital" means a psychiatric facility accredited by the Joint Commission on Accreditation of Health Care Organizations that is devoted to the provision of inpatient psychiatric care for persons under the…

37.86.2902 INPATIENT HOSPITAL SERVICES, REQUIREMENTS These requirements are in addition to those contained in rule provisions generally applicable to Medicaid providers. Except as otherwise permitted by federal law, inpatient hospital services must be ordered by a physician or de…

37.86.2903 INPATIENT HOSPITAL SERVICES, EXCLUSIONS Inpatient hospital services do not include: services excluded from coverage by the Medicaid program under ARM 37.85.207; experimental or investigational services such as, the use of off-label drugs where this usage is not a natio…

37.86.2904 INPATIENT HOSPITAL SERVICES, BILLING REQUIREMENTS Inpatient hospital service providers shall be subject to the billing requirements set forth in ARM 37.85.406. At the time a claim is submitted, the hospital must have on file a signed and dated acknowledgment from the a…

37.86.2905 INPATIENT HOSPITAL SERVICES, GENERAL REIMBURSEMENT Prospective payment system (PPS) hospitals including in-state PPS facilities, distinct part units, border facilities, all out-of-state facilities, acute care psychiatric hospitals, and Center of Excellence facilities w…

37.86.2907 INPATIENT HOSPITAL PROSPECTIVE REIMBURSEMENT, APR-DRG PAYMENT RATE DETERMINATION The department’s all patient refined diagnosis related group (APR-DRG) prospective payment rate for inpatient hospital services is based on the classification of inpatient hospital dischar…

37.86.2910 INPATIENT HOSPITAL REIMBURSEMENT, QUALIFIED RATE ADJUSTMENT PAYMENT (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, 2000 MAR p. 2034, Eff. 7/28/00; AMD, 2001 MAR p. 1119, Eff.…

37.86.2912 INPATIENT HOSPITAL PROSPECTIVE REIMBURSEMENT, CAPITAL-RELATED COSTS Capital expenses are included within the APR-DRG base payment and will not be paid separately to PPS facilities and will not be cost settled. The interim payment made to CAHs is based on the hospital-s…

37.86.2914 INPATIENT HOSPITAL PROSPECTIVE REIMBURSEMENT, MEDICAL EDUCATION COSTS (REPEALED) Authorizing statute(s): 2-4-201, 53-2-201, 53-6-113, MCA Implementing statute(s): 2-4-201, 53-2-201, 53-6-101, 53-6-111, 53-6-113, MCA History: NEW, 2004 MAR p. 482, Eff. 2/27/04; AMD, 200…

37.86.2916 INPATIENT HOSPITAL PROSPECTIVE REIMBURSEMENT, COST OUTLIERS In addition to the APR-DRG payment, providers reimbursed under the APR-DRG prospective payment system may receive payment as provided in this rule for cost outliers for APR-DRGs. To receive payment for a cost …

37.86.2918 INPATIENT HOSPITAL, READMISSIONS, PARTIAL ELIGIBILITY, OUTPATIENT BUNDLING, AND TRANSFERS FOR PROSPECTIVE PAYMENT SYSTEM (PPS) FACILITIES All readmissions occurring within 30 days will be subject to review to determine whether additional payment as a new APR-DRG or as …

37.86.2920 INPATIENT HOSPITAL PROSPECTIVE REIMBURSEMENT, HOSPITAL RESIDENTS Payment for hospital residents will be made as follows: the hospital must request residency status from the department prior to submission of the first claim; prior to obtaining hospital residency status,…

37.86.2921 HOSPITAL RESIDENCY REQUIREMENTS To obtain hospital residency status, the client must meet the following requirements: a client who is unable to be cared for in a setting other than the acute care hospital is eligible for hospital residency status; the client must utili…

37.86.2924 INPATIENT HOSPITAL COST BASED REIMBURSEMENT, CERTIFIED REGISTERED NURSE ANESTHETISTS If the Secretary of Health and Human Services has granted the facility authorization for continuation of cost pass-through under section 9320 of the Omnibus Budget Reconciliation Act o…

37.86.2925 INPATIENT HOSPITAL REIMBURSEMENT, DISPROPORTIONATE SHARE HOSPITAL (DSH) PAYMENTS Routine disproportionate share hospitals (RDSH) will receive an additional payment amount equal to the product of the hospital's prospective base rate times the adjustment percentage of: 4…

37.86.2928 INPATIENT HOSPITAL REIMBURSEMENT, HOSPITAL REIMBURSEMENT ADJUSTOR The inpatient 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 inpatient hospital service…

37.86.2931 ROUTINE DISPROPORTIONATE SHARE HOSPITAL A hospital is deemed a routine disproportionate share hospital if: it has a Medicaid inpatient utilization rate of at least one standard deviation above the mean Medicaid inpatient utilization rate for all hospitals receiving Med…

37.86.2932 MEDICAID UTILIZATION RATE A hospital's Medicaid inpatient utilization rate is the hospital's percentage rate computed by dividing the total number of Medicaid inpatient days in the hospital's fiscal year by the total number of the hospital's inpatient days in that same…

37.86.2935 CALCULATING LOW INCOME UTILIZATION RATE, FOR ROUTINE DISPROPORTIONATE SHARE HOSPITALS The low income utilization rate is used to determine whether a hospital is deemed a routine disproportionate share hospital. The percentage rate is computed as follows: LIUR=((A + B)/…

37.86.2940 HOSPITAL REIMBURSEMENT ADJUSTOR (HRA), DATA SOURCES An inpatient hospital reimbursement adjustor (HRA) payment will be made to a Montana PPS hospital or critical access hospital, as those terms are defined in 50-5-101, MCA, that provides inpatient hospital services. Da…

37.86.2943 BORDER HOSPITAL REIMBURSEMENT Inpatient hospital services provided in border hospitals will be reimbursed under the APR-DRG prospective payment system described in ARM 37.86.2905, 37.86.2907, 37.86.2912, 37.86.2916, 37.86.2918, and 37.86.2920. Authorizing statute(s): 5…

37.86.2947 OUT-OF-STATE HOSPITAL AND CENTERS OF EXCELLENCE REIMBURSEMENT Inpatient hospital services provided in border hospitals will be reimbursed under the APR-DRG prospective payment system described in ARM 37.86.2905, 37.86.2907, 37.86.2912, 37.86.2916, 37.86.2918, and 37.86…

37.86.2950 GRADUATE MEDICAL EDUCATION PAYMENT PROGRAM Subject to the availability of funding, restrictions imposed by federal law, and the approval of the state plan by the Centers for Medicare and Medicaid Services (CMS), the department will pay, in addition to the Medicaid paym…