Administrative Rules of Montana › Department 37 - PUBLIC HEALTH AND HUMAN SERVICES › Chapter 37.86 - MEDICAID PRIMARY CARE SERVICES › Subchapter 37.86.44 - Rural Health Clinics and Federally Qualified Health Centers › Rule 37.86.4406 - RURAL HEALTH CLINICS AND FEDERALLY QUALIFIED HEALTH CENTERS, SERVICE REQUIREMENTS

Current through Register Vol. 13, July 5, 2024
(1) The Montana
				Medicaid program will cover and reimburse under the RHC or FQHC programs only
				those services that are RHC services or FQHC services as defined in ARM
				37.86.4401
				and subject to the provisions of this subchapter.
(2) The Montana Medicaid program will not
				reimburse an RHC or FQHC for RHC or FQHC services that are services covered by
				a health maintenance organization for an enrolled member, as provided in ARM
				Title 37, chapter 86, subchapter 50, except as provided in ARM
				37.86.4414.
(3) RHC or FQHC services are covered by
				Montana Medicaid when provided in accordance with these rules to a member in an
				outpatient setting, including the RHC or FQHC, other medical facility
				(including a dental office), or a member's place of residence. A member's place
				of residence may be a nursing facility or other institution.
(4) Services provided to a member in a
				hospital setting are not reimbursed in accordance with these rules.
(5) The Montana Medicaid program will cover
				and reimburse RHC or FQHC services only if the services are provided in
				accordance with the same requirements that would apply if the service were
				provided by an individual or entity other than an RHC or an FQHC, except as
				specifically provided otherwise in this subchapter. These requirements include
				but are not limited to the following:
(a) The
				health professional providing the RHC or FQHC service must meet the same
				requirements that would apply if the health professional were to enroll
				directly in the Montana Medicaid program in the category of service to be
				provided. Such requirements include but are not limited to applicable
				licensure, certification and registration requirements, and applicable
				restrictions upon the form of entity or category of individual provider that
				may provide particular services. The health professional is not required to
				enroll separately as a Medicaid provider.
(b) The RHC or FQHC services are subject to
				any applicable limitations on the amount, scope, or duration of services
				covered by the Medicaid program, e.g., scope of practice restrictions under
				state licensure law, coverage exclusions, e.g., noncoverage of physical therapy
				maintenance services, limits on the number of hours, visits, or other units of
				service covered in a particular period or on the frequency of services covered,
				limits on the type of items or services covered within a particular category,
				medical necessity requirements, including specific medical necessity criteria
				applicable to a particular item or service, and early and periodic screening,
				diagnostic and treatment services (EPSDT) program requirements and
				restrictions.
(c) In addition to
				general record requirements under ARM
				37.85.414,
				RHCs and FQHCs must comply with any additional particular record or
				documentation requirements applicable to the particular category or type of
				service, e.g., requirements for documentation of compliance with supervision
				and protocol requirements, requirements for written documentation of
				prescription or referral, requirements for written care plans and prerequisites
				for receipt of a particular item or service by a particular recipient.
(d) Providers must bill for RHC or
				FQHC services using the revenue codes specified in the department's RHC/FQHC
				services provider manual. The department must provide 30 days prior written
				notice to providers of any changes in revenue codes.
(e) RHCs and FQHCs must comply with
				requirements for Medicaid program authorization prior to provision of services
				or prior to payment, as applicable to the particular category of services being
				provided.
(f) Reimbursement will be
				made to RHCs and FQHCs for RHC and FQHC services as provided in ARM
				37.86.4412
				through 37.86.4414, 37.86.4420, 37.86.4408, 37.86.4409, and 37.86.4410, rather
				than as provided in the rules applicable to the particular category of
				services. This rule does not permit reimbursement of services provided by
				health professionals under ARM
				37.86.4412
				through 37.86.4414, 37.86.4420, 37.86.4408, 37.86.4409, and 37.86.4410 when the
				services are not provided as an RHC or FQHC service and when the health
				professional is separately enrolled in and providing services under a
				particular Medicaid service category, subject to the rules applicable to the
				particular service category.