reglab/statecodes huggingface dataset:
Administrative Rules of Montana › Department 37 - PUBLIC HEALTH AND HUMAN SERVICES › Chapter 37.85 - GENERAL MEDICAID SERVICES › Subchapter 37.85.4 - Provider Requirements › Rule 37.85.403 - ICD CLINICAL MODIFICATION (CM) AND PROCEDURAL CODING SYSTEM (PCS) SERVICES

Current through Register Vol. 13, July 5, 2024
(1) 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 a health care classification system for
				diseases and health conditions.
(a) For dates
				of service on or before September 30, 2015, the ICD edition being utilized will
				be the ninth revision (ICD-9) to code the diagnosis of services.
(b) For dates of service October 1, 2015 and
				thereafter the ICD edition being utilized will be the tenth revision (ICD-10)
				to code the diagnosis of services. ICD-10 consists of the following codes sets:
(i) ICD-Clinical Modification (CM); and
(ii) ICD-Procedure Coding System
				(PCS).
(c) For inpatient
				claims with a discharge date on or after October 1, 2015, the tenth revision
				(ICD-10) must be utilized.
(d)
				Outpatient claims with dates of service that span the utilization dates must be
				split based on date of service in order to utilize the appropriate edition as
				noted in (a) and (b).
(e) Per
				45 CFR
				162.1002, ICD-10 will replace ICD-9 for dates
				of service October 1, 2015 and after. A copy of the ICD codes may be obtained
				at
http://www.medicalcodingbooks.com/
.
Administrative Rules of Montana › Department 37 - PUBLIC HEALTH AND HUMAN SERVICES › Chapter 37.85 - GENERAL MEDICAID SERVICES › Subchapter 37.85.4 - Provider Requirements › Rule 37.85.406 - BILLING, REIMBURSEMENT, CLAIMS PROCESSING, AND PAYMENT

Current through Register Vol. 13, July 5, 2024
(1) Providers must submit clean claims to
				Medicaid within the latest of:
(a) 12 months
				from the latest of:
(i) the date of
				service;
(ii) the date retroactive
				eligibility is determined; or
(iii)
				the date disability was determined;
Administrative Rules of Montana › Department 37 - PUBLIC HEALTH AND HUMAN SERVICES › Chapter 37.85 - GENERAL MEDICAID SERVICES › Subchapter 37.85.4 - Provider Requirements › Rule 37.85.407 - THIRD PARTY LIABILITY

Current through Register Vol. 13, July 5, 2024
(1) 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.
(2) For purposes of this section, the
				following definitions apply:
(a) A third
				party is defined as an individual, institution, corporation, or public or
				private agency that is or may be liable to pay all or part of the cost of
				medical treatment and medical-related services for personal injury, disease,
				illness, or disability of a recipient of medical assistance from the department
				or a county and includes but is not limited to insurers, health service
				organizations, and parties liable or who may be liable in tort. Indian health
				services is not a third party within the meaning of this definition.
(b) A known third party is a third party for
				which the provider has sufficient information to submit a claim and which if
				billed for a medical service is likely to pay the claim within a reasonable
				time.
(c) A potential third party
				is a third party for which the provider either has insufficient information to
				submit a claim or which if billed for a medical service, is likely to deny the
				claim as having no contractual or legal obligation to pay.
Administrative Rules of Montana › Department 37 - PUBLIC HEALTH AND HUMAN SERVICES › Chapter 37.85 - GENERAL MEDICAID SERVICES › Subchapter 37.85.4 - Provider Requirements › Rule 37.85.410 - DETERMINATION OF MEDICAL NECESSITY

Current through Register Vol. 13, July 5, 2024
(1) The
				department shall only make payment for those services which are medically
				necessary as determined by the department or by the designated review
				organization.
(2) In determining
				medical necessity the department or designated review organization may consider
				the type or nature of the service, the provider of the service, the setting in
				which the service is provided and any additional requirements applicable to the
				specific service or category of service.
(3) The department may review the medical
				necessity of services or items at any time either before or after payment. If
				the department determines that services or items were not medically necessary
				or otherwise in compliance with applicable requirements, the department may
				deny payment or may recover any overpayment in accordance with applicable
				requirements. The department is not precluded by an earlier screening, prior
				authorization, certification or similar process from reviewing and determining
				medical necessity of any service or item, or from denying payment or recovering
				any overpayment based upon any such review or determination. This rule does not
				require the department to notify a provider or recipient of a medical necessity
				determination until and unless the department completes its review and takes an
				adverse action against the provider based upon the determination.
(4) The provider must upon request provide to
				the department or its designated review organization without charge any records
				related to services or items provided to a recipient.
53-2-201,
					 53-6-113,
					 MCA; IMP,
					 53-2-201,
					 53-6-101,
					 53-6-111,
					 53-6-113,
					 53-6-141,
					 MCA;
Administrative Rules of Montana › Department 37 - PUBLIC HEALTH AND HUMAN SERVICES › Chapter 37.85 - GENERAL MEDICAID SERVICES › Subchapter 37.85.4 - Provider Requirements › Rule 37.85.411 - PROVIDER RIGHTS

Current through Register Vol. 13, July 5, 2024
(1) 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 and according to the procedures specified in ARM
				37.5.304,
				37.5.305,
				37.5.307,
				37.5.310,
				37.5.311,
				37.5.313,
				37.5.316,
				37.5.322,
				37.5.325,
				37.5.328,
				37.5.331,
				37.5.334 and
				37.5.337.
(2) Except as otherwise provided in these
				rules, a provider who is aggrieved by an adverse department action affecting
				the applicant's or recipient's eligibility under the Montana Medicaid program,
				may request a hearing to the extent provided and according to the procedures
				specified in ARM 37.5.304, 37.5.305, 37.5.307, 37.5.310, 37.5.311, 37.5.313,
				37.5.316, 37.5.322, 37.5.325, 37.5.328, 37.5.331, 37.5.334 and
				37.5.337.
(3) This rule does not
				grant to providers any right to notice of actions affecting recipients,
				including but not limited to eligibility determinations.
2-4-201,
					 53-6-113,
					 MCA; IMP,
					 2-4-201,
					 53-2-201,
					 53-6-101,
					 53-6-111,
					 53-6-113,
					 53-6-141,
					 MCA;
Administrative Rules of Montana › Department 37 - PUBLIC HEALTH AND HUMAN SERVICES › Chapter 37.85 - GENERAL MEDICAID SERVICES › Subchapter 37.85.4 - Provider Requirements › Rule 37.85.412 - INTERPRETATION OF RULES

Current through Register Vol. 13, July 5, 2024
(1) 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
				department before the service is billed to Medicaid, or the provider may not
				rely on it.
(2) Documentation of
				the clarification must contain:
(a) the date
				of the response;
(b) the identity
				of the person providing the clarification; and
(c) the specifics of the text of the
				provider's inquiry.
Administrative Rules of Montana › Department 37 - PUBLIC HEALTH AND HUMAN SERVICES › Chapter 37.85 - GENERAL MEDICAID SERVICES › Subchapter 37.85.4 - Provider Requirements › Rule 37.85.413 - LIMITATIONS ON CODING ADVICE

Current through Register Vol. 13, July 5, 2024
(1) 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 provider
				retains responsibility for selecting and submitting the proper code to describe
				the service or item provided. If an employee of the department or of a
				contractor or agent of the department suggests, recommends, or directs the
				provider to use a particular code from the choices available or gives other
				specific coding advice, the provider may not rely on such advice unless the
				advice is provided in writing before the provider submits a claim for the
				service or item.
53-6-113,
					 MCA; IMP,
					 53-6-101,
					 MCA;
Administrative Rules of Montana › Department 37 - PUBLIC HEALTH AND HUMAN SERVICES › Chapter 37.85 - GENERAL MEDICAID SERVICES › Subchapter 37.85.4 - Provider Requirements › Rule 37.85.415 - MEDICAL ASSISTANCE MEDICAID PAYMENT

Current through Register Vol. 13, July 5, 2024
(1)
				Medicaid will pay only for medical expenses:
(a) incurred by a person eligible for the
				Medicaid program;
(b) for services
				provided for and to the extent provided for under the Medicaid
				program;
(c) for which third party
				payment is not available;
(d) not
				used to meet the incurrment requirement at ARM
				37.82.1101 and following rules for
				persons who are medically needy;
(e) which are not the cost sharing provided
				for in ARM
				37.85.204; and
(f) to the extent allowed by
				Medicaid.
Administrative Rules of Montana › Department 37 - PUBLIC HEALTH AND HUMAN SERVICES › Chapter 37.85 - GENERAL MEDICAID SERVICES › Subchapter 37.85.4 - Provider Requirements › Rule 37.85.416 - STATISTICAL SAMPLING AUDITS

Current through Register Vol. 13, July 5, 2024
(1) 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 by the provider during the period of time under review. Statistical
				sampling and extrapolation shall not be used to determine overpayments for
				inpatient hospital services, outpatient hospital services, or hospital
				inpatient psychiatric services, or in cases where the number of line items in
				the review period does not equal 500 or more.
(a) A line item consists of a single service,
				under one procedure rate with one or more units of service, procedure or item
				on a Medicaid claim form for which a provider has received payment.
Administrative Rules of Montana › Department 37 - PUBLIC HEALTH AND HUMAN SERVICES › Chapter 37.85 - GENERAL MEDICAID SERVICES › Subchapter 37.85.5 - Provider Sanctions › Rule 37.85.502 - SANCTIONS

Current through Register Vol. 13, July 5, 2024
(1) The following sanctions may be invoked
				against providers based on the grounds specified in ARM
				37.85.501:
(a) Termination from participation in the
				Medical Assistance program.
(b)
				Suspension of participation in the Medical Assistance program.
(c) Suspension or withholding of payments to
				a provider.
(d) Shortening of an
				existing provider agreement as permitted by the terms of such
				agreement.
(e) Required attendance
				at provider education sessions, the cost of which shall not be reimbursed by
				the department or any of its programs.
(f) Required prior authorization for
				provision of services.
(g) 100%
				review of the provider's claims prior to payment.
(h) Referral to the Department of Revenue for
				any action deemed necessary.
(i) In
				addition to the sanctions listed above, intermediate care facilities for the
				mentally retarded, skilled nursing and nursing facilities shall be subject to
				termination of participation when the deficiencies resulting from failure to
				meet conditions or standards of participation pose immediate jeopardy or the
				denial of payments for new admissions if the facility's deficiencies resulting
				from failure to meet conditions or standards of participation do not pose
				immediate jeopardy. Federal laws regarding termination from participation and
				intermediate sanctions provided in
				42 CFR
				442.2,
				42
				CFR 442.117 through
				442.119,
				and 42 CFR Part 483 and 488, updated through February 2004 are incorporated by
				reference. A copy of
				42 CFR
				442.2,
				42
				CFR 442.117 through
				442.119,
				and 42 CFR Part 483 and 488, updated through February 2004 may be obtained from
				the Department of Public Health and Human Services, Quality Assurance Division,
				2401 Colonial Drive, Helena, MT 59620-2953; or
(j) Notification to the public of sanctions
				taken against a provider.
Administrative Rules of Montana › Department 37 - PUBLIC HEALTH AND HUMAN SERVICES › Chapter 37.85 - GENERAL MEDICAID SERVICES › Subchapter 37.85.5 - Provider Sanctions › Rule 37.85.505 - FACTORS GOVERNING IMPOSITION OF SANCTION

Current through Register Vol. 13, July 5, 2024
(1) The decision to impose sanctions and
				which sanctions to impose shall be within the discretion of the department
				except as provided in (3).
(2) The
				following factors shall be considered in determining the sanction(s) to be
				imposed:
(a) seriousness of the
				offense(s);
(b) extent of
				violations;
(c) history of prior
				violations;
(d) prior imposition of
				sanctions;
(e) prior provision of
				provider education;
(f) provider
				willingness to comply with program rules;
(g) whether a lesser sanction will be
				sufficient to remedy the problem;
(h) actions taken or recommended by peer
				review groups or licensing boards.
Administrative Rules of Montana › Department 37 - PUBLIC HEALTH AND HUMAN SERVICES › Chapter 37.85 - GENERAL MEDICAID SERVICES › Subchapter 37.85.5 - Provider Sanctions › Rule 37.85.506 - SCOPE OF SANCTION

Current through Register Vol. 13, July 5, 2024
(1) 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 inadequacy of performance may be imputed to an affiliate where such conduct
				was accomplished within the course of the affiliate's official duty or was
				effectuated by the provider with the knowledge or approval of the
				affiliate.
(2) Suspension or
				termination from participation of any provider shall preclude such provider
				from submitting claims for payment, either personally or through claims
				submitted by any clinic, group, corporation or other association to the
				department or its fiscal agents for any services or supplies provided to
				persons eligible for the Montana Medical Assistance program except for those
				services or supplies provided prior to the suspension or termination. Providers
				of long term care facility services may submit claims for supplies and services
				provided for up to 30 days after the date of termination to allow for the
				transfer of recipients.
(3) No
				clinic, group, corporation, or other association which is a provider of
				services shall submit claims for payment to the department or its fiscal agents
				for any services or supplies provided by a person within such organization who
				has been suspended or terminated from participation in the Montana Medical
				Assistance program except for those services or supplies provided prior to the
				suspension or termination. Providers of long term care facility services may
				submit claims for supplies and services provided for up to 30 days after the
				date of termination to allow for the transfer of recipients.
(4) When the provisions of (3) of this rule
				are violated by a provider of services which is a clinic, group, corporation,
				the department may suspend or terminate such organization and/or any individual
				person within said organization who is responsible for such
				violation.
53-2-201,
					 53-2-803,
					 53-4-111,
					 53-6-111,
					 53-6-113,
					 MCA; IMP,
					 53-2-306,
					 53-2-801,
					 53-4-112,
					 53-6-111,
					 MCA;
Administrative Rules of Montana › Department 37 - PUBLIC HEALTH AND HUMAN SERVICES › Chapter 37.85 - GENERAL MEDICAID SERVICES › Subchapter 37.85.5 - Provider Sanctions › Rule 37.85.507 - NOTICE OF SANCTION

Current through Register Vol. 13, July 5, 2024
(1) 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.
53-6-111,
					 MCA; IMP,
					 53-6-111,
					 MCA;
Administrative Rules of Montana › Department 37 - PUBLIC HEALTH AND HUMAN SERVICES › Chapter 37.85 - GENERAL MEDICAID SERVICES › Subchapter 37.85.5 - Provider Sanctions › Rule 37.85.511 - PROVIDER EDUCATION

Current through Register Vol. 13, July 5, 2024
(1) 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.
(2) Provider education programs may include
				any of the following at the discretion of the department:
(a) instruction in claim form
				completion;
(b) instruction on the
				use and format of provider manuals;
(c) instruction on the use of procedure
				codes;
(d) instruction on statutes
				and regulations governing the Montana Medicaid program;
(e) instruction on reimbursement
				rates;
(f) instructions on how to
				inquire about coding or billing problems;
(g) any other matter as determined by the
				department.
Administrative Rules of Montana › Department 37 - PUBLIC HEALTH AND HUMAN SERVICES › Chapter 37.85 - GENERAL MEDICAID SERVICES › Subchapter 37.85.5 - Provider Sanctions › Rule 37.85.512 - NOTICE OF ADVERSE ACTION

Current through Register Vol. 13, July 5, 2024
(1) 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
				provider is not entitled, or where the department has verified a credible
				allegation of fraud, as that term is defined at ARM
				37.5.304. The notice must address
				all of the following:
(a) a description of
				the fraud, allegation, improper billing, waste, abuse, or
				overpayments;
(b) the dollar value
				of any overpayment;
(c) the adverse
				action to be taken or sanction to be imposed by the department;
(d) explanation of any actions required of
				the provider; and
(e) the
				provider's right to submit written evidence for consideration by the
				department, an administrative review, and fair hearing.
Administrative Rules of Montana › Department 37 - PUBLIC HEALTH AND HUMAN SERVICES › Chapter 37.85 - GENERAL MEDICAID SERVICES › Subchapter 37.85.5 - Provider Sanctions › Rule 37.85.513 - SUSPENSION OR WITHHOLDING OF PAYMENTS

Current through Register Vol. 13, July 5, 2024
(1)
				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 to approximate the amounts in question or may suspend all
				payments pending the outcome of a departmental or law enforcement
				investigation.
(2) Where the
				department intends to withhold or suspend payments not regarding a credible
				allegation of fraud, as that term is defined at ARM
				37.5.304, it shall notify the
				provider in writing at least ten days prior to commencement of withholding and
				shall include a statement of the provider's right to request an informal
				reconsideration of such decision as provided in ARM
				37.5.305. This rule does not
				require that an informal reconsideration or any hearing be conducted prior to
				the withholding or suspension of payments.
(3) Where the department suspends payments
				based on a credible allegation of fraud in accordance with
				42 CFR
				455.23, the department may suspend payments
				without first notifying the provider.
(a) The
				department must send notice of its suspension of payments within the following
				timeframes:
(i) five days of taking such
				action unless requested in writing by a law enforcement agency to temporarily
				withhold such notice;
(ii) thirty
				days if requested by law enforcement in writing to delay sending such notice,
				which request for delay may be renewed in writing up to twice and in no event
				exceed 90 days.
Administrative Rules of Montana › Department 37 - PUBLIC HEALTH AND HUMAN SERVICES › Chapter 37.85 - GENERAL MEDICAID SERVICES › Subchapter 37.85.9 - Physician-Administered Drugs › Rule 37.85.903 - PHYSICIAN-ADMINISTERED DRUGS, DEFINITIONS

Current through Register Vol. 13, July 5, 2024
(1) "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
				PL
				102-585,
				section
				602, of the Veterans Health Care Act of
				1992.
(2) "Carve out" means the
				process by which qualified entities may remove Medicaid clients from 340B
				program activities and, therefore, purchase pharmaceuticals at a non-340B
				cost.
(3) "Healthcare Common
				Procedures Coding System (HCPCS)" means the national uniform coding method
				maintained by the CMS that incorporates the American Medical Association (AMA)
				Physicians Current Procedural Terminology (CPT) and the three HCPCS unique
				coding levels, I, II, and III.
(a) For
				purposes of physician-administered drugs, HCPCS refers to billable codes with
				corresponding rebatable National Drug Codes (NDC).
Administrative Rules of Montana › Department 37 - PUBLIC HEALTH AND HUMAN SERVICES › Chapter 37.85 - GENERAL MEDICAID SERVICES › Subchapter 37.85.9 - Physician-Administered Drugs › Rule 37.85.905 - PHYSICIAN-ADMINISTERED DRUGS, BILLING REQUIREMENTS

Current through Register Vol. 13, July 5, 2024
(1)
				Billable claim lines submitted for reimbursement of physician-administered
				drugs must:
(a) include a valid 11 digit
				NDC;
(b) include the drug quantity
				billed for each code;
(c) state the
				NDC unit of measure as one of the following:
(i) international unit - F2;
(ii) gram - GR;
(iii) milliliter - ML;
(iv) units - UN; or
(v) milligram - ME;
(d) include corresponding CPT/HCPCS codes;
				and
(e) include a drug
				price.
Administrative Rules of Montana › Department 37 - PUBLIC HEALTH AND HUMAN SERVICES › Chapter 37.85 - GENERAL MEDICAID SERVICES › Subchapter 37.85.11 - Montana Medicaid Provider Incentive Program for Electronic Healthcare Records › Rule 37.85.1101 - PURPOSE

Current through Register Vol. 13, July 5, 2024
(1) The rules in this chapter implement the
				Montana Medicaid Provider Incentive Program (MMPIP). The purpose of the program
				is to provide incentive payments to eligible health care and hospital providers
				to adopt, implement, or upgrade certified electronic health record (EHR)
				technology and demonstrate the meaningful use of such technology. This
				incentive program is designed to encourage eligible health care providers to
				improve health information technology capabilities and accelerate the use of
				EHRs in meaningful ways to help Montana improve the quality, safety, and
				efficiency of patient health care.
53-6-113,
					 MCA; IMP,
					 53-6-111,
					 MCA;
Administrative Rules of Montana › Department 37 - PUBLIC HEALTH AND HUMAN SERVICES › Chapter 37.85 - GENERAL MEDICAID SERVICES › Subchapter 37.85.11 - Montana Medicaid Provider Incentive Program for Electronic Healthcare Records › Rule 37.85.1105 - ELIGIBLE PROVIDER REGISTRATION WITH CENTERS FOR MEDICARE AND MEDICAID (CMS) NATIONAL LEVEL REPOSITORY (NLR)

Current through Register Vol. 13, July 5, 2024
(1)
				Medicaid Eligible Providers (EPs) and Eligible Hospitals (EHs) that choose to
				participate in the MMIP, will register through the Centers for Medicare and
				Medicaid (CMS) National Level Repository (NLR) indicating the program (Medicare
				or Medicaid) and the state selected. EPs may choose to participate in either
				the Medicare incentive program or a state Medicaid Incentive Program, but not
				both. EHs may participate in both the Medicare and Medicaid Incentive Programs.
				The department will use the NLR system to confirm provider eligibility and
				prevent duplication of payments. CMS will notify the department electronically
				of EPs and EHs who are electing to participate in MMIP.
53-6-113,
					 MCA; IMP,
					 53-6-111,
					 MCA;
Administrative Rules of Montana › Department 37 - PUBLIC HEALTH AND HUMAN SERVICES › Chapter 37.85 - GENERAL MEDICAID SERVICES › Subchapter 37.85.11 - Montana Medicaid Provider Incentive Program for Electronic Healthcare Records › Rule 37.85.1107 - ELIGIBLE PROVIDER AND ELIGIBLE HOSPITAL ELIGIBILITY VERIFICATION BY DPHHS

Current through Register Vol. 13, July 5, 2024
(1) The following
				information will be verified by the department upon receipt of notification
				from the CMS that a Montana EP enrolled:
(a)
				the EP has no sanctions preventing participation;
(b) the EP is alive;
(c) the EP is not hospital-based;
(d) the EP is an eligible provider type
				(e.g., physician, dentist, nurse practitioner, certified nurse midwife,
				physician assistant practicing in a FQHC or RHC led by a physician assistant,
				critical access hospital, or acute care hospital);
(e) the EP is appropriately licensed by the
				state of Montana; and
(f) the EP is
				listed on the NLR correctly.
Administrative Rules of Montana › Department 37 - PUBLIC HEALTH AND HUMAN SERVICES › Chapter 37.85 - GENERAL MEDICAID SERVICES › Subchapter 37.85.11 - Montana Medicaid Provider Incentive Program for Electronic Healthcare Records › Rule 37.85.1109 - ELIGIBLE HOSPITAL ELIGIBILITY VERIFICATION BY DPHHS

Current through Register Vol. 13, July 5, 2024
(1) The following information will be
				verified by the department upon receipt of notification from the CMS NLR that a
				Montana EH enrolled:
(a) the EH has no
				sanctions preventing participation;
(b) the EH is appropriately licensed by the
				state of Montana;
(c) the provider
				is listed on the NLR correctly;
(d)
				the EH has a 10% Medicaid patient volume; and
(e) the EH is an eligible provider type
				(e.g., acute care hospital including critical access hospitals, cancer
				hospital, or children's hospital).
Administrative Rules of Montana › Department 37 - PUBLIC HEALTH AND HUMAN SERVICES › Chapter 37.85 - GENERAL MEDICAID SERVICES › Subchapter 37.85.11 - Montana Medicaid Provider Incentive Program for Electronic Healthcare Records › Rule 37.85.1111 - REGISTRATION, ATTESTATIONS, AND CERTIFICATION

Current through Register Vol. 13, July 5, 2024
(1) Upon receipt of notification from the CMS
				NLR of a Montana EP or EH registration, the department will accept the
				provider's request to register for the department's MMPIP program via secure
				web portal application.
(2) An EP
				must attest to qualifying patient volume threshold calculation as specified by
				42 CFR
				495.306 (2011), calculated as follows: (Total
				Medicaid (or needy individuals) Patient Encounters in any 90-day period in the
				review calendar Year) divided by (All Patient Encounters over the Same Period).
				Provider will submit the timeframe for the 90-day time period selected for the
				patient encounters measure, identify the source the information was obtained
				from, and submit the numerator and denominator with the resulting percentage
				for the Medicaid and/or needy patient volume.
(a) For all EPs except pediatricians, the
				minimum patient volume threshold is 30%. For pediatrician EPs, the minimum
				patient volume threshold is 20%.
(b) Group practices or clinics (GP/C) will be
				permitted to calculate patient volume at the GP/C level if all the following
				requirements are met:
(i) The GP/C patient
				volume is appropriate as a measure of patient volume for each EP;
(ii) Each EP working in the GP/C accepts
				Medicaid and/or needy individuals as patients;
(iii) There is an auditable data source to
				support the GP/C patient volume determination;
(iv) All EPs in GP/C use the same methodology
				for the payment year;
(v) The GP/C
				uses the entire practice or clinic's patient volume and does not limit patient
				volume in any way; and
(vi) If an
				EP works inside and outside of the GP/C practice, the patient volume
				calculation only includes patient encounters associated with the clinic or
				group practice, and not the EP's outside encounters.
(c) EPs practicing at FQHC or RHC must
				demonstrate that more than 50% of their clinical encounters occurred at an
				FQHC/RHC over a six-month period and that a minimum of 30% of their patient
				volume consists of needy individuals. EPs practicing predominantly at FQHC/RHC
				must provide the clinic location, the needy patient encounters for the
				location, the EP's total patient encounters, and the resulting percentage. This
				information must be for an identified six-month period.
Administrative Rules of Montana › Department 37 - PUBLIC HEALTH AND HUMAN SERVICES › Chapter 37.85 - GENERAL MEDICAID SERVICES › Subchapter 37.85.11 - Montana Medicaid Provider Incentive Program for Electronic Healthcare Records › Rule 37.85.1113 - REPORTING REQUIREMENTS IN FIRST AND SUBSEQUENT YEARS

Current through Register Vol. 13, July 5, 2024
(1) For the first year of participation the
				EP or EH must provide proof of EHR certification as described in ARM
				37.85.1115, identify the system
				and date and attest to the adoption, implementation, or upgrade of a certified
				EHR.
(2) During the second and
				subsequent years of participation an EP must meet 20 of 25 meaningful use
				objectives as defined in
				42
				CFR 495.6 (2011) and
				42 CFR
				495.8.
(3) During the second and subsequent years of
				participation an EH must meet 19 of 24 meaningful use objectives as defined in
				42
				CFR 495.6 (2011) and 42 CFR 295.8.
53-6-113,
					 MCA; IMP,
					 53-6-111,
					 MCA;
Administrative Rules of Montana › Department 37 - PUBLIC HEALTH AND HUMAN SERVICES › Chapter 37.85 - GENERAL MEDICAID SERVICES › Subchapter 37.85.11 - Montana Medicaid Provider Incentive Program for Electronic Healthcare Records › Rule 37.85.1115 - PROOF OF ELECTRONIC HEALTH RECORDS CERTIFICATION

Current through Register Vol. 13, July 5, 2024
(1) Proof of EHR certification must be filed
				simultaneously with the provider's or hospital's attestation and certification.
				The attestation and certification will be verified prior to any payments being
				made. If a provider omits information necessary to determine eligibility or
				payment, the provider will be notified that participation in the MMPIP program
				is denied based on the omission of required information.
53-6-113,
					 MCA; IMP,
					 53-6-111,
					 MCA;
Administrative Rules of Montana › Department 37 - PUBLIC HEALTH AND HUMAN SERVICES › Chapter 37.85 - GENERAL MEDICAID SERVICES › Subchapter 37.85.11 - Montana Medicaid Provider Incentive Program for Electronic Healthcare Records › Rule 37.85.1117 - COMMUNICATION WITH PROVIDERS

Current through Register Vol. 13, July 5, 2024
(1) Upon
				notification by the CMS NLR that an EP or EH has applied for the MMPIP, and
				after initial verification of eligibility, the department will notify the
				provider of approval or denial of eligibility in the MMPIP program. All
				notifications regarding continued eligibility, payment, or other notifications
				will be done electronically.
53-6-113,
					 MCA; IMP,
					 53-6-111,
					 MCA;
Administrative Rules of Montana › Department 37 - PUBLIC HEALTH AND HUMAN SERVICES › Chapter 37.85 - GENERAL MEDICAID SERVICES › Subchapter 37.85.11 - Montana Medicaid Provider Incentive Program for Electronic Healthcare Records › Rule 37.85.1119 - APPLICATION FOR PAYMENTS BY AN ELIGIBLE PROVIDER OR ELIGIBLE HOSPITAL

Current through Register Vol. 13, July 5, 2024
(1) An EP qualifying to receive payment must
				submit the following provider identification information:
(a) name;
(b) National Provider Identification Number
				(NPI);
(c) business address and
				phone number; and
(d) Taxpayer
				Identification Number (TIN).
Administrative Rules of Montana › Department 37 - PUBLIC HEALTH AND HUMAN SERVICES › Chapter 37.85 - GENERAL MEDICAID SERVICES › Subchapter 37.85.11 - Montana Medicaid Provider Incentive Program for Electronic Healthcare Records › Rule 37.85.1121 - ELIGIBLE PROVIDER INCENTIVE PAYMENT SCHEDULE

Current through Register Vol. 13, July 5, 2024
(1) The department adopts and incorporates by
				reference the EP incentive payment schedule specified in
				42 CFR
				495.310 (2011), a copy of which is posted at
				www.medicaidprovider.hhs.mt.gov/providerpages/ehrincentives.shtml and may also
				be obtained by writing DPHHS Director's Office, PO Box 4210, Helena, MT
				59604.
(2) Pediatricians who do not
				meet the 30% threshold, but meet the 20% threshold will receive reduced
				payments as specified in
				42 CFR
				495.310 (2011). Also, an EP's payment may be
				adjusted downward depending on net average allowable costs.
(3) Each year the EP will attest to the
				receipt of funds from sources other than state or local government to offset
				the cost of the certified electronic health record. If the EP received funds
				from other sources, the EP must identify the calendar year of receipt, the
				amount, and the source. For the first year, any amount over $29,000 will reduce
				the payment by a like amount. For years two through six any amount over $10,610
				will reduce the payment by a like amount.
(4) Assignment of payment - EPs must choose
				either direct payment or may assign payment to the provider's group practice or
				clinic. If the EP is a member of a group and chooses to assign the incentive
				payment to the group, payment will be made to a group consistent with existing
				MMIS capabilities. If a member of a group chooses to retain the incentive
				payment, the payment will be made directly to the EP through an existing
				process in the MMIS. Due to existing MMIS limitations, Montana Medicaid will
				not make direct incentive payments to any entity (individual, group, or clinic)
				that is not recognized as a Montana Medicaid provider. For example, EHR system
				vendors are not recognized as Montana Medicaid providers, and as such cannot be
				assigned payment.
53-6-113,
					 MCA; IMP,
					 53-6-111,
					 MCA;
Administrative Rules of Montana › Department 37 - PUBLIC HEALTH AND HUMAN SERVICES › Chapter 37.85 - GENERAL MEDICAID SERVICES › Subchapter 37.85.11 - Montana Medicaid Provider Incentive Program for Electronic Healthcare Records › Rule 37.85.1123 - ELIGIBLE HOSPITAL INCENTIVE PAYMENT CALCULATION

Current through Register Vol. 13, July 5, 2024
(1) Payment of the EH's incentive payment
				will be made over a four year period with 50% of the amount paid in year one,
				30% in year two, 20% in year three, and 10% in year four.
(2) The department adopts and incorporates by
				reference the formula to calculate an EH's incentive payment amount found in 42
				CFR Part 495.310 (2011).
(3)
				Assignment of payment - a multisite hospital with one CMS certification number
				is considered one hospital for purposes of calculating payment. Payments will
				be made to EHS consistent with existing MMIS capabilities. Due to existing MMIS
				limitations, Montana Medicaid will not make direct incentive payments to any
				entity that is not recognized as a Montana Medicaid provider.
53-6-113,
					 MCA; IMP,
					 53-6-111,
					 MCA;
Administrative Rules of Montana › Department 37 - PUBLIC HEALTH AND HUMAN SERVICES › Chapter 37.85 - GENERAL MEDICAID SERVICES › Subchapter 37.85.11 - Montana Medicaid Provider Incentive Program for Electronic Healthcare Records › Rule 37.85.1125 - DENIALS AND APPEALS

Current through Register Vol. 13, July 5, 2024
(1) A provider
				participating in the MMPIP and aggrieved by the department's denial of
				eligibility, incentive payments, demonstration of efforts to adopt, implement,
				upgrade, or meaningful use of certified EHR technology, may request a fair
				hearing in accordance with ARM
				37.5.310.
53-6-113,
					 MCA; IMP,
					 53-6-111,
					 MCA;
Administrative Rules of Montana › Department 37 - PUBLIC HEALTH AND HUMAN SERVICES › Chapter 37.86 - MEDICAID PRIMARY CARE SERVICES › Subchapter 37.86.1 - Physician Services › Rule 37.86.101 - PHYSICIAN SERVICES, DEFINITIONS

Current through Register Vol. 13, July 5, 2024
(1) "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.
(2) "Physician services" means those services
				provided by individuals licensed under the State Medical Practice Act to
				practice medicine or osteopathy which, as defined by state law, are within the
				scope of their practice.
(3)
				"Usual and customary" means those charges that the billing physician would
				charge for a particular service in a majority of cases, including Medicaid and
				non-Medicaid patients.
(4) The
				department hereby adopts and incorporates by reference the definitions found in
				the introduction to Physicians Current Procedural Terminology, fourth edition
				(CPT4), published by the American Medical Association of Chicago, Illinois.
				These materials set forth meanings of terms commonly used by the Montana
				Medicaid program in implementation of the program's physician fee schedule. A
				copy of the definitions herein incorporated may be obtained through the
				Department of Public Health and Human Services, Health Resources Division, 1400
				Broadway, P.O. Box 202951, Helena, MT 59620-2951.
(5) Payment-to-charge ratio means the percent
				determined by dividing the previous state fiscal year's total Medicaid
				reimbursement for RBRVS provider covered services as defined in ARM
				37.85.212 by the previous state
				fiscal year's total Medicaid charges for RBRVS provider covered services. The
				effective date and payment-to-charge ratio are as provided in ARM
				37.85.105(2).
AUTH:
					 53-6-113,
					 MCA; IMP:
					 53-6-101,
					 53-6-113,
					 MCA
Administrative Rules of Montana › Department 37 - PUBLIC HEALTH AND HUMAN SERVICES › Chapter 37.86 - MEDICAID PRIMARY CARE SERVICES › Subchapter 37.86.1 - Physician Services › Rule 37.86.104 - PHYSICIAN SERVICES, REQUIREMENTS

Current through Register Vol. 13, July 5, 2024
(1)
				These requirements are in addition to those rule provisions generally
				applicable to Medicaid providers.
(2) The department or its designated review
				organization may conduct utilization and peer review of physician
				services.
(3) Physician services
				for conditions or ailments that are generally considered cosmetic in nature are
				not a benefit of the Medicaid program except in such cases where it can be
				demonstrated that the physical and psycho-social well being of the recipient is
				severely affected in a detrimental manner by the condition or ailment. Such
				services must be prior authorized by the Medicaid services bureau, based on
				recommendations of the designated peer review organization.
(a) A request for prior authorization must
				include all relevant information to justify the need for the service. This
				information includes statements from a physician qualified in the area of
				concern and a potential provider.
(b) The information must clearly document the
				necessity for the service and include assurances that the plan will be followed
				to completion.
Administrative Rules of Montana › Department 37 - PUBLIC HEALTH AND HUMAN SERVICES › Chapter 37.86 - MEDICAID PRIMARY CARE SERVICES › Subchapter 37.86.1 - Physician Services › Rule 37.86.105 - PHYSICIAN SERVICES, REIMBURSEMENT/GENERAL REQUIREMENTS AND MODIFIERS

Current through Register Vol. 13, July 5, 2024
(1) 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
				Common Procedure Coding System (HCPCS). Information regarding billing codes,
				modifiers, and HCPCS is available upon request from the Health Resources
				Division at the address stated in ARM
				37.86.101(3).
(2) Reimbursement for physician
				services, except as otherwise provided in this rule, is the lower of:
(a) the provider's usual and customary
				charges (billed charges); or
(b)
				the department's fee schedule maintained in accordance with the methodologies
				described in ARM
				37.85.212.
Administrative Rules of Montana › Department 37 - PUBLIC HEALTH AND HUMAN SERVICES › Chapter 37.86 - MEDICAID PRIMARY CARE SERVICES › Subchapter 37.86.1 - Physician Services › Rule 37.86.108 - MENTAL HEALTH SERVICES PLAN, APPLICATION FORMS, INCOME VERIFICATION

Current through Register Vol. 13, July 5, 2024
(1) Application forms and information
				regarding eligibility for the plan are available at all local county human
				services departments.
(2) The
				applicant must submit with the application form a completed and signed income
				statement and the necessary documentation to verify the income
				reported.
(3) For purposes of (2),
				necessary income verification may include one or more of the following or other
				appropriate and persuasive documentation:
(a)
				pay stubs or other pay statements;
(b) employee's W-2 forms;
(c) state or federal income tax returns and
				associated forms and schedules;
(d)
				union records;
(e) check
				copies;
(f) self-employment
				bookkeeping records;
(g) sales and
				expenditure records;
(h) employer's
				wage or payroll records;
(i) award
				notices or award letters;
(j)
				correspondence specifying a benefit;
(k) records of any government
				payer;
(l) court records or
				correspondence from attorneys;
(m)
				financial institution records;
(n)
				insurance company correspondence or records; or
(o) college or university financial aid
				correspondence or records.
Administrative Rules of Montana › Department 37 - PUBLIC HEALTH AND HUMAN SERVICES › Chapter 37.86 - MEDICAID PRIMARY CARE SERVICES › Subchapter 37.86.1 - Physician Services › Rule 37.86.110 - MENTAL HEALTH SERVICES PLAN, ELIGIBILITY REDETERMINATIONS, MEMBERS REQUIRED TO NOTIFY DEPARTMENT OF CHANGES, REPAYMENT OF BENEFITS

Current through Register Vol. 13, July 5, 2024
(1) Eligibility determinations under ARM
				37.89.106 are effective until the
				earlier of:
(a) one year; or
(b) the effective date of any
				redetermination.
Administrative Rules of Montana › Department 37 - PUBLIC HEALTH AND HUMAN SERVICES › Chapter 37.86 - MEDICAID PRIMARY CARE SERVICES › Subchapter 37.86.1 - Physician Services › Rule 37.86.112 - MENTAL HEALTH SERVICES PLAN, EMERGENCY MENTAL HEALTH SERVICES, LIABILITY FOR FAILURE TO COMPLETE APPLICATION

Current through Register Vol. 13, July 5, 2024
(1) A
				nonmember receiving covered emergency mental health services, which do not
				include hospital emergency room or other hospital services, is eligible on an
				emergency basis for the plan and may receive covered medically necessary
				services for a covered diagnosis unless the provider determines that the
				individual has the means, financially or otherwise, by which to make payment.
				If the individual is subsequently determined ineligible for the plan or fails
				to complete an application for plan eligibility within 60 days following
				completion of emergency treatment, the individual is liable for and may be
				billed by the provider at its usual and customary (billed charges) private pay
				charges or by the department for the amount of payments actually made by the
				department or its agents to the provider for the services provided.
41-3-1103,
					 53-2-201,
					 53-6-113,
					 53-6-131,
					 53-6-701,
					 53-6-706,
					 MCA; IMP,
					 41-3-1103,
					 53-1-601,
					 53-1-602,
					 53-2-201,
					 53-6-101,
					 53-6-113,
					 53-6-116,
					 53-6-117,
					 53-6-131,
					 53-6-701,
					 53-6-705,
					 53-6-706,
					 53-21-139,
					 53-21-202,
					 MCA;
Administrative Rules of Montana › Department 37 - PUBLIC HEALTH AND HUMAN SERVICES › Chapter 37.86 - MEDICAID PRIMARY CARE SERVICES › Subchapter 37.86.2 - Mid-level Practitioner Services › Rule 37.86.201 - MID-LEVEL PRACTITIONER SERVICES, REQUIREMENTS

Current through Register Vol. 13, July 5, 2024
(1) 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.
53-2-201,
					 53-6-113,
					 MCA; IMP,
					 53-6-101,
					 MCA;
Administrative Rules of Montana › Department 37 - PUBLIC HEALTH AND HUMAN SERVICES › Chapter 37.86 - MEDICAID PRIMARY CARE SERVICES › Subchapter 37.86.2 - Mid-level Practitioner Services › Rule 37.86.202 - MID-LEVEL PRACTITIONER SERVICES, DEFINITIONS

Current through Register Vol. 13, July 5, 2024
For the purpose of these rules, the following definitions
				  will apply:
(1) "Advanced practice
				registered nurse" means a registered professional nurse licensed as provided in
				Title 37, chapter 8, MCA and ARM Title 24, chapter 159, subchapter 14 and
				includes nurse practitioner, nurse anesthetist, and nurse midwife and clinical
				nurse specialist.
(2) "Clinical
				nurse specialist" means a person who is licensed in accord with
				37-8-405
				through
				37-8-407, MCA
				and ARM 24.159.1412,
				24.159.1413,
				24.159.1414, and
				24.159.1485.
(3) "Delivery services" means services
				necessary to protect the health and safety of the woman and fetus from the
				onset of labor through delivery.
(4) "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.
(5) "Independent employment status" means
				that a separate federal tax identification number is obtained for the mid-level
				practitioner and the billed services are not provided in the course of the
				mid-level practitioner's employment by or contract with a physician, hospital,
				or ambulatory surgical center.
(6)
				"Mid-level practitioner" means the following professionals:
(a) advanced practice registered nurse;
				and
(b) physician
				assistant.