Montana Administrative Code

37.85.1105 ELIGIBLE PROVIDER REGISTRATION WITH CENTERS FOR MEDICARE AND MEDICAID (CMS) NATIONAL LEVEL REPOSITORY (NLR) (REPEALED) (REPEALED) Authorizing statute(s): 53-6-113, MCA Implementing statute(s): 53-6-111, MCA History: NEW, 2011 MAR p. 1374, Eff. 7/29/11; REP, 2025 MAR, 3…

37.85.1107 ELIGIBLE PROVIDER AND ELIGIBLE HOSPITAL ELIGIBILITY VERIFICATION BY DPHHS (REPEALED) (REPEALED) Authorizing statute(s): 53-6-113, MCA Implementing statute(s): 53-6-111, MCA History: NEW, 2011 MAR p. 1374, Eff. 7/29/11; REP, 2025 MAR, 37-1102, Eff. 2/22/25.

37.85.1109 ELIGIBLE HOSPITAL ELIGIBILITY VERIFICATION BY DPHHS (REPEALED) (REPEALED) Authorizing statute(s): 53-6-113, MCA Implementing statute(s): 53-6-111, MCA History: NEW, 2011 MAR p. 1374, Eff. 7/29/11; REP, 2025 MAR, 37-1102, Eff. 2/22/25.

37.85.1111 REGISTRATION, ATTESTATIONS, AND CERTIFICATION (REPEALED) (REPEALED) Authorizing statute(s): 53-6-113, MCA Implementing statute(s): 53-6-111, MCA History: NEW, 2011 MAR p. 1374, Eff. 7/29/11; REP, 2025 MAR, 37-1102, Eff. 2/22/25.

37.85.1113 REPORTING REQUIREMENTS IN FIRST AND SUBSEQUENT YEARS (REPEALED) (REPEALED) Authorizing statute(s): 53-6-113, MCA Implementing statute(s): 53-6-111, MCA History: NEW, 2011 MAR p. 1374, Eff. 7/29/11; REP, 2025 MAR, 37-1102, Eff. 2/22/25.

37.85.1115 PROOF OF ELECTRONIC HEALTH RECORDS CERTIFICATION (REPEALED) (REPEALED) Authorizing statute(s): 53-6-113, MCA Implementing statute(s): 53-6-111, MCA History: NEW, 2011 MAR p. 1374, Eff. 7/29/11; REP, 2025 MAR, 37-1102, Eff. 2/22/25.

37.85.1117 COMMUNICATION WITH PROVIDERS (REPEALED) (REPEALED) Authorizing statute(s): 53-6-113, MCA Implementing statute(s): 53-6-111, MCA History: NEW, 2011 MAR p. 1374, Eff. 7/29/11; REP, 2025 MAR, 37-1102, Eff. 2/22/25.

37.85.1119 APPLICATION FOR PAYMENTS BY AN ELIGIBLE PROVIDER OR ELIGIBLE HOSPITAL (REPEALED) (REPEALED) Authorizing statute(s): 53-6-113, MCA Implementing statute(s): 53-6-111, MCA History: NEW, 2011 MAR p. 1374, Eff. 7/29/11; REP, 2025 MAR, 37-1102, Eff. 2/22/25.

37.85.1121 ELIGIBLE PROVIDER INCENTIVE PAYMENT SCHEDULE (REPEALED) (REPEALED) Authorizing statute(s): 53-6-113, MCA Implementing statute(s): 53-6-111, MCA History: NEW, 2011 MAR p. 1374, Eff. 7/29/11; REP, 2025 MAR, 37-1102, Eff. 2/22/25.

37.85.1123 ELIGIBLE HOSPITAL INCENTIVE PAYMENT CALCULATION (REPEALED) (REPEALED) Authorizing statute(s): 53-6-113, MCA Implementing statute(s): 53-6-111, MCA History: NEW, 2011 MAR p. 1374, Eff. 7/29/11; REP, 2025 MAR, 37-1102, Eff. 2/22/25.

37.85.1125 DENIALS AND APPEALS (REPEALED) (REPEALED) Authorizing statute(s): 53-6-113, MCA Implementing statute(s): 53-6-111, MCA History: NEW, 2011 MAR p. 1374, Eff. 7/29/11; REP, 2025 MAR, 37-1102, Eff. 2/22/25.

37.85.201 SELECTION OF PROVIDER Except as otherwise provided in ARM Title 37, chapters 40, 80, 82, 83, 85, 86, 88 any individual eligible for medical assistance may obtain the services available from any institution, agency, pharmacy, or practitioner, qualified to perform such se…

37.85.204 MEMBER REQUIREMENTS, COST SHARING Effective for claims paid on or after January 1, 2020, members covered under Medicaid or Medicaid Expansion will not be assessed a copayment, as defined in ARM 37.84.102, for any covered service. The total of Medicaid or Medicaid Expans…

37.85.205 RECIPIENT RESTRICTION OF ACCESS TO MEDICAL SERVICES (REPEALED) Authorizing statute(s): 53-6-113, MCA Implementing statute(s): 53-6-104, MCA History: NEW, 1979 MAR p. 1122, Eff. 9/28/79; AMD, 1983 MAR p. 354, Eff. 4/29/83; AMD, 1985 MAR p. 249, Eff. 3/15/85; TRANS & AMD,…

37.85.206 SERVICES PROVIDED Except as otherwise provided in this rule, the following medical or remedial care and services are available to all persons who are eligible for Medicaid benefits under this chapter, including deceased persons, categorically related, who would have bee…

37.85.207 SERVICES NOT PROVIDED BY THE MEDICAID PROGRAM Items or medical services not specifically included within these rules as covered benefits of the Montana Medicaid program are not reimbursable. The following medical and nonmedical services are explicitly excluded from the …

37.85.212 RESOURCE BASED RELATIVE VALUE SCALE (RBRVS) REIMBURSEMENT FOR SPECIFIED PROVIDER TYPES For purposes of this rule, the following definitions apply: "Anesthesia units" means time and base units used to compute reimbursement under RBRVS for anesthesia services. Base units …

37.85.213 IN-TRAINING MENTAL HEALTH PROFESSIONAL SERVICES BILLING MEDICAID To bill and receive reimbursement for services rendered by an in-training mental health professional, a provider must be a licensed mental health center or meet the criteria outlined in this rule. For the …

37.85.219 MOBILE IMAGING/PORTABLE X-RAY SUPPLIER Any provider that is enrolled in the federal Medicare program as a Mobile Imaging Provider/Portable X-Ray Supplier may also enroll in the Montana Medicaid program as a Mobile Imaging Provider/Portable X-Ray Supplier. A Mobile Imagi…

37.85.220 INDEPENDENT DIAGNOSTIC TESTING FACILITIES Any facility that is enrolled in the federal Medicare program as an independent diagnostic testing facility (IDTF) may also enroll in the Montana Medicaid program as an IDTF. IDTFs enrolled in the Montana Medicaid program shall …

37.85.221 MEDICAID OVERPAYMENT AUDITOR EVALUATION HEARINGS; RECOVERY AUDIT CONTRACTOR (RAC) PROGRAM Within one year after the establishment of the contract auditor, and each subsequent year, the department will announce auditor evaluation hearing meetings via the department's web…

37.85.401 PROVIDER PARTICIPATION As a condition of participation in the Montana Medicaid program all providers must comply with all applicable state and federal statutes, rules and regulations, including but not limited to federal regulations and statutes found in Title 42 of the…

37.85.402 PROVIDER ENROLLMENT AND AGREEMENTS Providers must enroll in the Montana Medicaid program for each category of services to be provided. As a condition of granting enrollment approval or of allowing continuing enrollment, the department may require the provider to: comple…

37.85.403 ICD CLINICAL MODIFICATION (CM) AND PROCEDURAL CODING SYSTEM (PCS) SERVICES The department adopts and incorporates by reference the Diagnosis coding practice of International Classification of Diseases (ICD) published by the World Health Organization. The ICD is used as …

37.85.405 ELECTRONIC VISIT VERIFICATION REQUIREMENTS Montana Medicaid providers that provide home and community-based services subject to federal Electronic Visit Verification (EVV) requirements must ensure an EVV system is used to electronically document the delivery of EVV serv…

37.85.406 BILLING, REIMBURSEMENT, CLAIMS PROCESSING, AND PAYMENT Providers must submit clean claims to Medicaid within the latest of: 12 months from the latest of: the date of service; the date retroactive eligibility is determined; or the date disability was determined; six mont…

37.85.407 THIRD PARTY LIABILITY No payment shall be made by the department for any medical service for which there is a known third party who has a legal liability to pay for that medical service except for those services specified in (6) below. For purposes of this section, the …

37.85.410 DETERMINATION OF MEDICAL NECESSITY The department shall only make payment for those services which are medically necessary as determined by the department or by the designated review organization. In determining medical necessity the department or designated review orga…

37.85.411 PROVIDER RIGHTS Except as otherwise provided in these rules, a provider who is aggrieved by an adverse department action which directly affects the rights or entitlements of the provider under the Montana Medicaid program, may request a hearing to the extent provided an…

37.85.412 INTERPRETATION OF RULES The department will interpret its rules by giving meaning to the plain language of the rules. If a provider requests an interpretation of a rule to provide clarification of a perceived ambiguity, clarification must be received in writing from the…

37.85.413 LIMITATIONS ON CODING ADVICE Employees of the department, or of any contractor or agent of the department, may give a provider general information as to what codes are available for billing under Medicaid for a particular service or item being provided. However, the pro…

37.85.414 MAINTENANCE OF RECORDS AND AUDITING All providers of service must maintain records which fully demonstrate the extent, nature and medical necessity of services and items provided to Montana Medicaid recipients. The records must support the fee charged or payment sought …

37.85.415 MEDICAL ASSISTANCE MEDICAID PAYMENT Medicaid will pay only for medical expenses: incurred by a person eligible for the Medicaid program; for services provided for and to the extent provided for under the Medicaid program; for which third party payment is not available; …

37.85.416 STATISTICAL SAMPLING AUDITS At the option of the department, the amount of money erroneously paid to a provider for any given period of time may be determined by the use of statistical sampling and extrapolation, rather than by an audit of 100% of the claims submitted b…

37.85.501 GROUNDS FOR SANCTIONING Sanctions may be imposed by the department against a provider of medical assistance, provided under ARM Title 37, chapters 40, 80, 82, 83, 85, 86, 88, for any one or more of the following reasons: Presenting or causing to be presented for payment…

37.85.502 SANCTIONS The following sanctions may be invoked against providers based on the grounds specified in ARM 37.85.501: Termination from participation in the Medical Assistance program. Suspension of participation in the Medical Assistance program. Suspension or withholding…

37.85.505 FACTORS GOVERNING IMPOSITION OF SANCTION The decision to impose sanctions and which sanctions to impose shall be within the discretion of the department except as provided in (3). The following factors shall be considered in determining the sanction(s) to be imposed: se…

37.85.506 SCOPE OF SANCTION A sanction may be applied to all known affiliates of a provider, provided that each decision to include an affiliate is made on a case by case basis after giving due consideration to all relevant facts and circumstances. The violation, failure, or inad…

37.85.507 NOTICE OF SANCTION When a provider has been suspended or terminated, the department shall notify the appropriate professional society, board of registration or licensure, and federal or state agencies of the findings made and the sanctions imposed. Authorizing statute(s…

37.85.511 PROVIDER EDUCATION Except where termination has been imposed, the department may in its discretion direct each provider, who has been sanctioned, to participate in a provider education program as a condition of continued Medicaid participation. Provider education progra…

37.85.512 NOTICE OF ADVERSE ACTION As provided in this rule, the department must notify a provider of any adverse action it will take when the department has determined that the provider has engaged in fraud, improper billing, waste, abuse, has received payment to which the provi…

37.85.513 SUSPENSION OR WITHHOLDING OF PAYMENTS Where the department has notified a provider of a violation, sanction, or an overpayment pursuant to ARM 37.85.512 the department may withhold payments on pending and subsequently received claims in an amount reasonably calculated t…

37.85.903 PHYSICIAN-ADMINISTERED DRUGS, DEFINITIONS "340B Drug Pricing Program (340B)" means a federal program administered by the Health Resources and Services Administration (HRSA) which allows qualified entities to purchase pharmaceuticals at a substantially reduced cost under…

37.85.905 PHYSICIAN-ADMINISTERED DRUGS, BILLING REQUIREMENTS Billable claim lines submitted for reimbursement of physician-administered drugs must: include a valid 11 digit NDC; include the drug quantity billed for each code; state the NDC unit of measure as one of the following:…

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…