reglab/statecodes huggingface dataset:
Administrative Rules of Montana › Department 37 - PUBLIC HEALTH AND HUMAN SERVICES › Chapter 37.86 - MEDICAID PRIMARY CARE SERVICES › Subchapter 37.86.26 - Ambulance Services › Rule 37.86.2605 - AMBULANCE SERVICES, REIMBURSEMENT

Current through Register Vol. 13, July 5, 2024
(1)
				Except as provided in (4), the department pays the lowest of the following for
				ambulance services:
(a) the provider's usual
				and customary charge for the service; or
(b) the amount listed in the department's
				Ambulance Fee Schedule.
Administrative Rules of Montana › Department 37 - PUBLIC HEALTH AND HUMAN SERVICES › Chapter 37.86 - MEDICAID PRIMARY CARE SERVICES › Subchapter 37.86.26 - Ambulance Services › Rule 37.86.2606 - AMBULANCE SERVICES, QUALIFIED RATE ADJUSTMENT, PAYMENT ELIGIBILITY AND COMPUTATION

Current through Register Vol. 13, July 5, 2024
(1) 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 either owned or operated by a local government
				unit.
(2) For an eligible provider
				to receive a QRA payment, the following conditions must be met:
(a) local government funds must be
				transferred in accordance with the contract required by (2)(d);
(b) the funds must be certified by the city
				or county treasurer, or an authorized local government official, as an
				intergovernmental transfer of public funds that qualifies as a payment of
				services eligible for federal financial participation (FFP, the federal
				government's share of a state's expenditures under the Medicaid program) in
				accordance with
				42 CFR
				433.51(2004);
(c) the provider must be in compliance with a
				signed, written contract with the department; and
(d) the written contract covering the
				requirements for the QRA payment must be executed prior to the issuance of the
				QRA payment. A retroactive effective date on the written agreement will not be
				allowed.
Administrative Rules of Montana › Department 37 - PUBLIC HEALTH AND HUMAN SERVICES › Chapter 37.86 - MEDICAID PRIMARY CARE SERVICES › Subchapter 37.86.28 - Reimbursement › Rule 37.86.2801 - ALL HOSPITAL REIMBURSEMENT, GENERAL

Current through Register Vol. 13, July 5, 2024
(1)
				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
				outpatient hospital services is set forth in ARM
				37.86.3005,
				37.86.3006,
				37.86.3007,
				37.86.3009,
				37.86.3014,
				37.86.3016,
				37.86.3018,
				37.86.3020,
				37.86.3022,
				37.86.3025,
				37.86.3037, and
				37.86.3109. Cost of hospital
				services will be determined for inpatient and outpatient care separately.
				Administratively necessary days are not a benefit of the Montana Medicaid
				program.
(2) The department may
				require providers of inpatient or outpatient hospital services to obtain
				authorization from the department or its designated review organization either
				prior to provision of services, prior to admission, or prior to
				payment.
(3) Medicaid reimbursement
				shall not be made or shall be reduced unless the provider has obtained
				authorization from the department or its designated review organization prior
				to providing any of the following services:
(a) inpatient psychiatric services provided
				in an acute care psychiatric hospital, acute care general hospital or a
				distinct part psychiatric unit of an acute care general hospital, and
				outpatient partial hospitalization as required by ARM
				37.88.101:
(i) if prior authorization is not obtained,
				the claim will be denied;
(ii)
				Medicare crossover claims do not need prior authorization; and
(iii) third party liability claims must be
				prior authorized.
Administrative Rules of Montana › Department 37 - PUBLIC HEALTH AND HUMAN SERVICES › Chapter 37.86 - MEDICAID PRIMARY CARE SERVICES › Subchapter 37.86.28 - Reimbursement › Rule 37.86.2803 - ALL HOSPITAL REIMBURSEMENT, COST REPORTING

Current through Register Vol. 13, July 5, 2024
(1) Allowable costs will be determined in
				accordance with generally accepted accounting principles as defined by the
				American Institute of Certified Public Accountants.
(a) The department adopts and incorporates by
				reference CMS Publication 15, which is a manual published by the United States
				Department of Health and Human Services, Centers for Medicare and Medicaid
				Services (CMS), which provides guidelines and policies to implement Medicare
				regulations which set forth principles for determining the reasonable cost of
				provider services furnished under the Health Insurance for Aged Act of 1965, as
				amended. A copy of CMS Publication 15 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.
(b) For cost report periods occurring on or
				after May 1, 2010, such definition of allowable costs is further defined in
				accordance with the Medicare Provider Reimbursement Manual, CMS Publication 15,
				Form 2552-10, subject to the exceptions and limitations provided in the
				department's administrative rules.
(c) For cost report periods occurring prior
				to May 1, 2010, such definition of allowable costs is further defined in
				accordance with the Medicare Provider Reimbursement Manual, CMS Publication 15,
				Form 2552-96, subject to the exceptions and limitations provided in the
				department's administrative rules.
(d) For cost report periods ending January 1,
				2006 through December 31, 2017, for each hospital which is a critical access
				hospital, as defined in ARM
				37.86.2901,
				reimbursement for reasonable costs of inpatient and outpatient hospital
				services shall be limited to 101% of allowable costs, as determined in
				accordance with (1).
(e) For cost
				report periods ending January 1, 2018 through June 30, 2018, for each hospital
				which is a critical access hospital, as defined in ARM 37.86.2901,
				reimbursement for reasonable costs of inpatient and outpatient hospital
				services will be limited to 97.98% of allowable costs, as determined in
				accordance with (1).
(f) For cost
				report periods ending on or after July 1, 2018, for each hospital which is a
				critical access hospital, as defined in ARM 37.86.2901, reimbursement for
				reasonable costs of inpatient and outpatient hospital services will be limited
				to 101% of allowable costs, as determined in accordance with (1).
Administrative Rules of Montana › Department 37 - PUBLIC HEALTH AND HUMAN SERVICES › Chapter 37.86 - MEDICAID PRIMARY CARE SERVICES › Subchapter 37.86.28 - Reimbursement › Rule 37.86.2806 - COST-BASED HOSPITAL, GENERAL REIMBURSEMENT

Current through Register Vol. 13, July 5, 2024
(1) Cost-based reimbursement shall be applied
				as follows:
(a) 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 January 1,
				2018 through June 30, 2018, CAH interim reimbursement is based on a
				hospital-specific Medicaid inpatient cost-to-charge ratio (CCR), less 2.99%,
				not to exceed 100%.
(b) For cost
				report periods ending on or prior to December 31, 2017, CAH final reimbursement
				is for reasonable costs of hospital services limited to 101% of allowable
				costs, as determined in accordance with ARM
				37.86.2803(1).
				For cost report periods ending January 1, 2018 through June 30, 2018, CAH final
				reimbursement is for reasonable costs of hospital services limited to 97.98% of
				allowable costs as determined in accordance with ARM
				37.86.2803(1).
				For cost report periods ending on or after July 1, 2018, CAH final
				reimbursement is for reasonable costs of hospital services limited to 100% of
				allowable costs as determined in accordance with ARM
				37.86.2803(1).
Administrative Rules of Montana › Department 37 - PUBLIC HEALTH AND HUMAN SERVICES › Chapter 37.86 - MEDICAID PRIMARY CARE SERVICES › Subchapter 37.86.28 - Reimbursement › Rule 37.86.2810 - INPATIENT AND OUTPATIENT HOSPITAL SERVICES, QUALIFIED RATE ADJUSTMENT PAYMENT, ELIGIBILITY, AND COMPUTATION (REPEALED)

Current through Register Vol. 13, July 5, 2024
53-6-113,
					 MCA; IMP,
					 53-2-201,
					 53-6-101,
					 53-6-111,
					 53-6-113,
					 MCA;
Administrative Rules of Montana › Department 37 - PUBLIC HEALTH AND HUMAN SERVICES › Chapter 37.86 - MEDICAID PRIMARY CARE SERVICES › Subchapter 37.86.28 - Reimbursement › Rule 37.86.2820 - DESK REVIEWS, OVERPAYMENTS, AND UNDERPAYMENTS

Current through Register Vol. 13, July 5, 2024
(1) 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 underpayment has resulted.
(2) For cost reporting purposes where the
				department finds that an overpayment has occurred, the department will notify
				the provider of the overpayment.
(a) The
				provider will have 60 days from the date of the initial notification to repay
				the amount of the overpayment or to have an agreed upon repayment schedule. If
				the provider does not repay the whole overpayment within 60 days or defaults on
				a payment schedule, the department will withhold any future payments the state
				of Montana makes to the provider. Recovery will be undertaken even though the
				provider disputes in whole or part the department's determination of the
				overpayment and requests a fair hearing.
(b) The amount of the overpayment constitutes
				a debt due the department as of the date of the initial notification to the
				provider and may be recovered from any person, party, transferee, or fiduciary
				who has benefited from either the payment or from the transfer of
				assets.
Administrative Rules of Montana › Department 37 - PUBLIC HEALTH AND HUMAN SERVICES › Chapter 37.86 - MEDICAID PRIMARY CARE SERVICES › Subchapter 37.86.29 - Inpatient Hospital Services › Rule 37.86.2901 - INPATIENT HOSPITAL SERVICES, DEFINITIONS

Current through Register Vol. 13, July 5, 2024
(1) "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 age of 21 and licensed as a hospital by:
(a) the department; or
(b) an equivalent agency in the state in
				which the facility is located.
Administrative Rules of Montana › Department 37 - PUBLIC HEALTH AND HUMAN SERVICES › Chapter 37.86 - MEDICAID PRIMARY CARE SERVICES › Subchapter 37.86.29 - Inpatient Hospital Services › Rule 37.86.2902 - INPATIENT HOSPITAL SERVICES, REQUIREMENTS

Current through Register Vol. 13, July 5, 2024
(1) These
				requirements are in addition to those contained in rule provisions generally
				applicable to Medicaid providers.
(2) Except as otherwise permitted by federal
				law, inpatient hospital services must be ordered by a physician or dentist
				licensed under state law.
(3)
				Inpatient hospital services include:
(a) bed
				and board;
(b) nursing services and
				other related services;
(c) use of
				hospital facilities;
(d) medical
				social services;
(e) drugs,
				biologicals, supplies, appliances, and equipment;
(f) other diagnostic or therapeutic items, or
				services provided in the hospital and not specifically excluded in ARM
				37.85.207; and
(g) medical or surgical services provided by
				interns or residents-in-training in hospitals with teaching programs approved
				by the Council on Medical Education of the American Medical Association, the
				Bureau of Professional Education of the American Osteopathic Association, the
				Council on Dental Education of the American Dental Association or the Council
				on Podiatry Education of the American Podiatry Association.
Administrative Rules of Montana › Department 37 - PUBLIC HEALTH AND HUMAN SERVICES › Chapter 37.86 - MEDICAID PRIMARY CARE SERVICES › Subchapter 37.86.29 - Inpatient Hospital Services › Rule 37.86.2903 - INPATIENT HOSPITAL SERVICES, EXCLUSIONS

Current through Register Vol. 13, July 5, 2024
(1) Inpatient hospital services do not
				include:
(a) services excluded from coverage
				by the Medicaid program under ARM
				37.85.207;
(b) experimental or investigational services
				such as, the use of off-label drugs where this usage is not a national standard
				of practice, or non-FDA approved use of drugs, biologicals, and
				devices;
(c) services that do not
				comply with national standards of medical care; and
(d) inpatient hospital services provided
				outside the borders of the United States will not be covered or reimbursed by
				the Montana Medicaid program.
Administrative Rules of Montana › Department 37 - PUBLIC HEALTH AND HUMAN SERVICES › Chapter 37.86 - MEDICAID PRIMARY CARE SERVICES › Subchapter 37.86.29 - Inpatient Hospital Services › Rule 37.86.2904 - INPATIENT HOSPITAL SERVICES, BILLING REQUIREMENTS

Current through Register Vol. 13, July 5, 2024
(1) 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 attending physician that the physician has received the following
				notice: "Notice to physicians: Medicaid payment to hospitals is based on all of
				each patient's diagnoses and the procedures performed on the patient, as
				attested to by the patient's attending physician by virtue of his or her
				signature in the medical record. Anyone who misrepresents, falsifies or
				conceals essential information required for payment of federal funds, may be
				subject to fine, imprisonment or civil penalty under applicable federal
				laws."
(2) The acknowledgment must
				be completed by the physician at the time that the physician is granted
				admitting privileges at the hospital, or before or at the time the physician
				admits his or her first patient to the hospital.
(3) Existing acknowledgments signed by
				physicians already on staff remain in effect as long as the physician has
				admitting privileges at the hospital.
(4) The provider may, at its discretion, add
				to the language of this statement the word "Medicare" so that two separate
				forms will not be required by the provider to comply with both state and
				federal requirements.
(5) Except
				for hospital resident cases, a provider may not submit a claim until the
				recipient has been either:
(a) discharged
				from the hospital;
(b) a patient at
				least 30 days, in which case the hospital may bill on the 31st day and every 30
				days thereafter;
(c) transferred to
				another hospital; or
(d) designated
				by the department as a hospital resident as set forth in ARM
				37.86.2921.
Administrative Rules of Montana › Department 37 - PUBLIC HEALTH AND HUMAN SERVICES › Chapter 37.86 - MEDICAID PRIMARY CARE SERVICES › Subchapter 37.86.29 - Inpatient Hospital Services › Rule 37.86.2905 - INPATIENT HOSPITAL SERVICES, GENERAL REIMBURSEMENT

Current through Register Vol. 13, July 5, 2024
(1) 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 will be reimbursed under the All Patient
				Refined Diagnosis Related Groups (APR-DRG) prospective payment system described
				in ARM
				37.86.2907,
				37.86.2912,
				37.86.2916,
				37.86.2918,
				and
				37.86.2920.
(2) Interim reimbursement for cost-based
				facilities is based on a hospital-specific Medicaid inpatient cost-to-charge
				ratio, not to exceed 100%. For dates of service January 1, 2018 through June
				30, 2018, the interim reimbursement is based on a hospital-specific Medicaid
				inpatient cost-to-charge ratio, less 2.99%, not to exceed 100%. Cost-based
				facilities will be reimbursed their allowable costs as determined according to
				ARM
				37.86.2803.
				For cost report periods ending on or prior to December 31, 2017 final cost
				settlements for CAH facilities will be reimbursed at 101% of allowable costs.
				For cost report periods ending January 1, 2018 through June 30, 2018, final
				cost settlements for CAH facilities will be reimbursed at 97.98% of allowable
				costs. For cost report periods ending on or after July 1, 2018 final cost
				settlements for CAH facilities will be reimbursed at 101% of allowable
				costs.
(3) Except as otherwise
				specified in these rules, facilities reimbursed under the APR-DRG prospective
				payment system may be reimbursed for the following:
(a) cost outliers as set forth in ARM
				37.86.2916;
(b) readmissions,
				partial eligibility, and transfers, as set forth in ARM 37.86.2918;
(c) hospital residents, as set forth in ARM
				37.86.2920;
(d) disproportionate
				share hospital payments as provided in ARM
				37.86.2925;
				and
(e) hospital reimbursement
				adjustor payments as provided in ARM
				37.86.2928.
Administrative Rules of Montana › Department 37 - PUBLIC HEALTH AND HUMAN SERVICES › Chapter 37.86 - MEDICAID PRIMARY CARE SERVICES › Subchapter 37.86.29 - Inpatient Hospital Services › Rule 37.86.2907 - INPATIENT HOSPITAL PROSPECTIVE REIMBURSEMENT, APR-DRG PAYMENT RATE DETERMINATION

Current through Register Vol. 13, July 5, 2024
(1) The
				department's APR-DRG prospective payment rate for inpatient hospital services
				is based on the classification of inpatient hospital discharges to APR-DRGs.
				The provider reimbursement rates for inpatient hospital services, except as
				otherwise provided in ARM
				37.85.206, is
				stated in the department's APR-DRG fee schedule adopted and effective at ARM
				37.85.105.
				The procedure for determining the APR-DRG prospective payment rate is as
				follows:
(a) The department will assign an
				APR-DRG to each Medicaid client discharge in accordance with the current
				APR-grouper program version, as developed by 3M Health Information Systems. The
				assignment and reimbursement of each APR-DRG is based on:
(i) the ICD-9-CM principal diagnoses for
				dates of discharge prior to and including September 30, 2015, and the ICD-10-CM
				principal diagnoses for dates of discharge October 1, 2015 and
				thereafter;
(ii) all ICD-9-CM
				secondary diagnoses for dates of discharge prior to and including September 30,
				2015, and the ICD-10-CM secondary diagnoses for dates of discharge October 1,
				2015 and thereafter;
(iii) all
				ICD-9-CM medical procedures performed during the client's hospital stay for
				dates of discharge prior to and including September 30, 2015, and the
				ICD-10-PCS medical procedures performed during the client's hospital stay for
				dates of discharge October 1, 2015 and thereafter;
(iv) the client's age;
(v) the client's gender;
(vi) the client's discharge status;
				and
(vii) diagnosis codes related
				to hospital-acquired conditions that are not present or undetermined to be
				present on admission.
Administrative Rules of Montana › Department 37 - PUBLIC HEALTH AND HUMAN SERVICES › Chapter 37.86 - MEDICAID PRIMARY CARE SERVICES › Subchapter 37.86.29 - Inpatient Hospital Services › Rule 37.86.2910 - INPATIENT HOSPITAL REIMBURSEMENT, QUALIFIED RATE ADJUSTMENT PAYMENT (REPEALED)

Current through Register Vol. 13, July 5, 2024
53-2-201,
					 53-6-113,
					 MCA; IMP,
					 53-2-201,
					 53-6-101,
					 53-6-111,
					 53-6-113,
					 MCA;
Administrative Rules of Montana › Department 37 - PUBLIC HEALTH AND HUMAN SERVICES › Chapter 37.86 - MEDICAID PRIMARY CARE SERVICES › Subchapter 37.86.29 - Inpatient Hospital Services › Rule 37.86.2912 - INPATIENT HOSPITAL PROSPECTIVE REIMBURSEMENT, CAPITAL-RELATED COSTS

Current through Register Vol. 13, July 5, 2024
(1) 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.
(2) The
				interim payment made to CAHs is based on the hospital-specific cost-to-charge
				ratio and includes capital costs. For dates of service January 1, 2018 through
				June 30, 2018, the interim payment made is based on the hospital-specific
				cost-to-charge ratio, less 2.99%, and includes capital costs. For dates of
				service on or after July 1, 2018, the interim payment made is based on the
				hospital-specific cost-to-charge ratio, and includes capital costs.
(3) The department adopts and incorporates by
				reference
				42 CFR
				412.113(a) and (b), and will
				calculate as provided in (1) and (2) capital-related costs that are allowable
				under Medicare cost reimbursement principles as established in
				42 CFR
				412.113(a) and (b) (March
				29, 1985). Copies of the cited regulation may be obtained from the Department
				of Public Health and Human Services, Health Resources Division, 1400 Broadway,
				P.O. Box 202951, Helena, MT 59620-2951.
AUTH:
					 2-4-201,
					 53-2-201,
					 53-6-113,
					 MCA; IMP:
					 2-4-201,
					 53-2-201,
					 53-6-101,
					 53-6-111,
					 53-6-113,
					 MCA
Administrative Rules of Montana › Department 37 - PUBLIC HEALTH AND HUMAN SERVICES › Chapter 37.86 - MEDICAID PRIMARY CARE SERVICES › Subchapter 37.86.29 - Inpatient Hospital Services › Rule 37.86.2914 - INPATIENT HOSPITAL PROSPECTIVE REIMBURSEMENT, MEDICAL EDUCATION COSTS (REPEALED)

Current through Register Vol. 13, July 5, 2024
2-4-201,
					 53-2-201,
					 53-6-113,
					 MCA; IMP,
					 2-4-201,
					 53-2-201,
					 53-6-101,
					 53-6-111,
					 53-6-113,
					 MCA;
Administrative Rules of Montana › Department 37 - PUBLIC HEALTH AND HUMAN SERVICES › Chapter 37.86 - MEDICAID PRIMARY CARE SERVICES › Subchapter 37.86.29 - Inpatient Hospital Services › Rule 37.86.2916 - INPATIENT HOSPITAL PROSPECTIVE REIMBURSEMENT, COST OUTLIERS

Current through Register Vol. 13, July 5, 2024
(1) 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.
(2) To receive payment
				for a cost outlier, the combined costs of the medically necessary days and
				services of the inpatient hospital stay, as determined by the department, must
				exceed the cost outlier threshold established by the department for the
				APR-DRG.
(3) The department
				determines the outlier reimbursement for cost outliers for all hospitals and
				distinct part units, entitled to receive cost outlier reimbursement, as
				follows:
(a) computing an estimated cost for
				the inpatient hospital stay by multiplying the allowed charges for the stay by:
(i) the facility-specific cost-to-charge
				ratio as set forth in ARM
				37.86.2905; or
(ii) for non-Center of Excellence
				out-of-state facilities, their statewide average cost-to-charge
				ratio;
Administrative Rules of Montana › Department 37 - PUBLIC HEALTH AND HUMAN SERVICES › Chapter 37.86 - MEDICAID PRIMARY CARE SERVICES › Subchapter 37.86.29 - Inpatient Hospital Services › Rule 37.86.2918 - INPATIENT HOSPITAL READMISSIONS, PARTIAL ELIGIBILITY, OUTPATIENT BUNDLING, AND TRANSFERS FOR PROSPECTIVE PAYMENT SYSTEM (PPS) FACILITIES

Current through Register Vol. 13, July 5, 2024
(1) All readmissions occurring within 30 days
				will be subject to review to determine whether additional payment as a new
				APR-DRG or as an outlier is warranted. As a result of the readmission review,
				the following payment changes will be made:
(a) If it is determined that complications
				have arisen because of premature discharge and/or other treatment errors, then
				the APR-DRG payment for the first admission must be altered by combining the
				two admissions into one for payment purposes.
(b) If it is determined that the readmission
				is for the treatment of conditions that could or should have been treated
				during the previous admission, the department will combine the two admissions
				into one for payment purposes.
(c)
				A client readmission occurring in an inpatient rehabilitation hospital or a
				rehabilitation distinct part unit three days after the initial date of
				discharge must be combined into one admission for payment purposes, with the
				exception of discharge to an acute care hospital for surgical
				APR-DRGs.
(d) Inpatient
				readmissions within 24 hours of discharge must be combined if the same
				condition is diagnosed.
(e)
				Services that are performed at a second hospital because the services are not
				available at the first hospital (e.g., a CT scan) are included in the first
				hospital's payment. This includes transportation to the second hospital and
				back to the first hospital. Arrangement for payment to the transportation
				provider and the second hospital where the services were actually performed
				must be between the first and second hospital and the transportation provider.
Administrative Rules of Montana › Department 37 - PUBLIC HEALTH AND HUMAN SERVICES › Chapter 37.86 - MEDICAID PRIMARY CARE SERVICES › Subchapter 37.86.29 - Inpatient Hospital Services › Rule 37.86.2920 - INPATIENT HOSPITAL PROSPECTIVE REIMBURSEMENT, HOSPITAL RESIDENTS

Current through Register Vol. 13, July 5, 2024
(1) Payment for hospital residents will be
				made as follows:
(a) the hospital must
				request residency status from the department prior to submission of the first
				claim;
(b) prior to obtaining
				hospital residency status, claims for that recipient may be billed on an
				interim basis as provided in ARM
				37.86.2905(4);
(c) final payment for the first hospital stay
				will be paid the APR-DRG payment for the case as computed in ARM
				37.86.2907 plus any appropriate
				outlier and add-on payments:
(i) the hospital
				stay is from admit through the request for residency, if approved by the
				department; and
(ii) the length of
				stay must be greater than or equal to 180 days of inpatient care at the same
				facility.
(d) final
				payment for all client care subsequent to the request date, which must be
				greater than 180 days will be reimbursed at 80% of the hospital specific
				estimated cost-to-charge ratio as computed by the department without cost
				settlement; and
(e) the hospital
				must provide medical records upon request of the department or the department's
				designated review organization for continued stay reviews.
Administrative Rules of Montana › Department 37 - PUBLIC HEALTH AND HUMAN SERVICES › Chapter 37.86 - MEDICAID PRIMARY CARE SERVICES › Subchapter 37.86.29 - Inpatient Hospital Services › Rule 37.86.2921 - HOSPITAL RESIDENCY REQUIREMENTS

Current through Register Vol. 13, July 5, 2024
(1) To
				obtain hospital residency status, the client must meet the following
				requirements:
(a) a client who is unable to
				be cared for in a setting other than the acute care hospital is eligible for
				hospital residency status;
(b) the
				client must utilize a ventilator for a continuous period of not less than eight
				hours in a 24-hour period or require at least ten hours of direct nursing care
				in a 24-hour period; and
(c) the
				client must have been an inpatient in the same hospital as the requesting
				hospital for a minimum of six continuous months.
Administrative Rules of Montana › Department 37 - PUBLIC HEALTH AND HUMAN SERVICES › Chapter 37.86 - MEDICAID PRIMARY CARE SERVICES › Subchapter 37.86.29 - Inpatient Hospital Services › Rule 37.86.2924 - INPATIENT HOSPITAL COST BASED REIMBURSEMENT, CERTIFIED REGISTERED NURSE ANESTHETISTS

Current through Register Vol. 13, July 5, 2024
(1) 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 of 1986, as amended by section 608(c) of the Family Support
				Act of 1988 ( Public Law 100-485 ), the department shall reimburse cost based
				inpatient hospital service providers for certified registered nurse anesthetist
				costs on a reasonable cost basis as provided in ARM
				37.86.2803.
2-4-201,
					 53-2-201,
					 53-6-113,
					 MCA; IMP,
					 2-4-201,
					 53-2-201,
					 53-6-101,
					 53-6-111,
					 53-6-113,
					 MCA;
Administrative Rules of Montana › Department 37 - PUBLIC HEALTH AND HUMAN SERVICES › Chapter 37.86 - MEDICAID PRIMARY CARE SERVICES › Subchapter 37.86.29 - Inpatient Hospital Services › Rule 37.86.2925 - INPATIENT HOSPITAL REIMBURSEMENT, DISPROPORTIONATE SHARE HOSPITAL (DSH) PAYMENTS

Current through Register Vol. 13, July 5, 2024
(1) 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:
(a) 4% for rural
				hospitals; or
(b) 10% for urban
				hospitals.
Administrative Rules of Montana › Department 37 - PUBLIC HEALTH AND HUMAN SERVICES › Chapter 37.86 - MEDICAID PRIMARY CARE SERVICES › Subchapter 37.86.29 - Inpatient Hospital Services › Rule 37.86.2928 - INPATIENT HOSPITAL REIMBURSEMENT, HOSPITAL REIMBURSEMENT ADJUSTOR

Current through Register Vol. 13, July 5, 2024
(1) 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 services. Eligibility for an HRA payment
				will be determined based on a hospital's year-end reimbursement
				status.
(2) Revenue generated from
				the inpatient hospital utilization fee plus applicable federal financial
				participation (FFP) is utilized to calculate the following supplemental
				payments:
(a) the continuity of care payment
				described in ARM
				37.87.1224;
(b) Part 1 of the HRA; and
(c) Part 2 of the HRA.
Administrative Rules of Montana › Department 37 - PUBLIC HEALTH AND HUMAN SERVICES › Chapter 37.86 - MEDICAID PRIMARY CARE SERVICES › Subchapter 37.86.29 - Inpatient Hospital Services › Rule 37.86.2931 - ROUTINE DISPROPORTIONATE SHARE HOSPITAL

Current through Register Vol. 13, July 5, 2024
(1) A hospital is deemed a routine
				disproportionate share hospital if:
(a) it
				has a Medicaid inpatient utilization rate of at least one standard deviation
				above the mean Medicaid inpatient utilization rate for all hospitals receiving
				Medicaid payments in Montana or a low income utilization rate exceeding 20%;
				and
(b) it has a Medicaid
				inpatient utilization rate of at least 1%.
Administrative Rules of Montana › Department 37 - PUBLIC HEALTH AND HUMAN SERVICES › Chapter 37.86 - MEDICAID PRIMARY CARE SERVICES › Subchapter 37.86.29 - Inpatient Hospital Services › Rule 37.86.2932 - MEDICAID UTILIZATION RATE

Current through Register Vol. 13, July 5, 2024
(1) 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 period.
(2) The period
				used to determine whether a hospital is deemed a routine disproportionate share
				hospital will be the most recent calendar year for which final cost reports are
				available for all hospital providers.
AUTH:
					 53-2-201,
					 53-6-113,
					 MCA; IMP:
					 53-2-201,
					 53-6-101,
					 53-6-111,
					 53-6-113,
					 MCA
Administrative Rules of Montana › Department 37 - PUBLIC HEALTH AND HUMAN SERVICES › Chapter 37.86 - MEDICAID PRIMARY CARE SERVICES › Subchapter 37.86.29 - Inpatient Hospital Services › Rule 37.86.2935 - CALCULATING LOW INCOME UTILIZATION RATE, FOR ROUTINE DISPROPORTIONATE SHARE HOSPITALS

Current through Register Vol. 13, July 5, 2024
(1) 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:
(a) LIUR=((A + B)/C) + (D/E) where:
(i) "LIUR" is the low income utilization
				rate;
(ii) "A" is the total revenue
				paid to the hospital to determine patient services under the Medicaid state
				plan regardless of whether the services were furnished on a fee-for-service
				basis or through a managed care program in the hospital's fiscal
				year;
(iii) "B" is the cash
				subsidies received directly from state and local governments for patient
				services in the hospital's fiscal year;
(iv) "C" is the total revenues of the
				hospital for patient services, including the amount of such cash subsidies in
				the hospital's fiscal year;
(v) "D"
				is the total hospital charges for inpatient hospital services attributable to
				charity care in the hospital's fiscal year, less any amount received for
				payment of these charges attributable to inpatient services. This amount shall
				not include contractual allowances and discounts (other than for indigent
				patients not eligible for public assistance); and
(vi) "E" is the hospital's total charges for
				inpatient hospital services in the hospital's fiscal year.
Administrative Rules of Montana › Department 37 - PUBLIC HEALTH AND HUMAN SERVICES › Chapter 37.86 - MEDICAID PRIMARY CARE SERVICES › Subchapter 37.86.29 - Inpatient Hospital Services › Rule 37.86.2940 - INPATIENT HOSPITAL REIMBURSEMENT ADJUSTOR (HRA), DATA SOURCES

Current through Register Vol. 13, July 5, 2024
(1) 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.
(2) Data sources for the department to
				determine which hospitals meet the criteria to receive HRA payments, and the
				amount of the payments, may include, but are not limited to:
(a) the Montana Hospital Association (MHA)
				database;
(b) the Medicaid paid
				claims database;
(c) filed or
				settled cost reports; and
(d)
				reports from the Licensure Bureau of the Quality Assurance
				Division.
Administrative Rules of Montana › Department 37 - PUBLIC HEALTH AND HUMAN SERVICES › Chapter 37.86 - MEDICAID PRIMARY CARE SERVICES › Subchapter 37.86.29 - Inpatient Hospital Services › Rule 37.86.2943 - BORDER HOSPITAL REIMBURSEMENT

Current through Register Vol. 13, July 5, 2024
(1)
				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.
53-2-201,
					 53-6-113,
					 MCA; IMP,
					 53-2-201,
					 53-6-101,
					 53-6-111,
					 53-6-113,
					 MCA;
Administrative Rules of Montana › Department 37 - PUBLIC HEALTH AND HUMAN SERVICES › Chapter 37.86 - MEDICAID PRIMARY CARE SERVICES › Subchapter 37.86.29 - Inpatient Hospital Services › Rule 37.86.2947 - OUT-OF-STATE HOSPITAL AND CENTERS OF EXCELLENCE REIMBURSEMENT

Current through Register Vol. 13, July 5, 2024
(1) 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.
(2) Medicaid reimbursement for inpatient
				services shall not be made to hospitals located more than 100 miles outside the
				borders of Montana or Centers of Excellence unless the provider has obtained
				authorization from the department or its designated review organization prior
				to providing services or prior to admission. All inpatient services provided in
				an emergent situation must be authorized as described in ARM
				37.86.2801(4)(d).
(a) Should prior authorization not be
				obtained, reimbursement will be 50% of the amount as calculated in ARM
				37.86.2905, 37.86.2907, 37.86.2912, 37.86.2916, 37.86.2918, and 37.86.2920 for
				services determined to be medically necessary.
Administrative Rules of Montana › Department 37 - PUBLIC HEALTH AND HUMAN SERVICES › Chapter 37.86 - MEDICAID PRIMARY CARE SERVICES › Subchapter 37.86.29 - Inpatient Hospital Services › Rule 37.86.2950 - GRADUATE MEDICAL EDUCATION PAYMENT PROGRAM

Current through Register Vol. 13, July 5, 2024
(1) 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 payments provided for 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,
				a Graduate Medical Education (GME) payment for the purpose of partially funding
				primary care and psychiatry residency programs for eligible hospitals located
				in Montana.
(2) Revenue for the GME
				payment will be generated through a transfer of funds from the Montana
				University System to the department through an Intergovernmental Transfer
				contract agreement. The transfer of funds from the University System will occur
				prior to July 31 of each year.
(3)
				The department will make an annual payment to each eligible hospital on or
				before August 31 of each year.
(a) The
				payment will be calculated based upon the eligible hospital's inpatient
				Medicaid utilization per year, as calculated in (4).
(b) If an eligible hospital reports no
				primary care or psychiatry resident full time equivalents (FTE) participating
				in the GME program for any given program year or portion thereof, the eligible
				hospital will not receive payment for those time periods of nonparticipation.
				FTE totals include residents conducting rural rotations. For purposes of this
				rule, a rural rotation is a period of one month where a primary care or
				psychiatry resident is working in a rural location, outside of their primary
				facility and urbanized area, with the express purpose of the resident being
				available to provide care to the rural area's patient population.
Administrative Rules of Montana › Department 37 - PUBLIC HEALTH AND HUMAN SERVICES › Chapter 37.86 - MEDICAID PRIMARY CARE SERVICES › Subchapter 37.86.30 - Outpatient Hospital Services › Rule 37.86.3001 - OUTPATIENT HOSPITAL SERVICES, DEFINITIONS

Current through Register Vol. 13, July 5, 2024
(1) "Ambulatory payment classification (APC)"
				means Medicare's ambulatory payment classification assignment groups of CPT or
				HCPCS codes.
(2) "Bad debt" means
				inpatient and outpatient hospital services provided in which full payment is
				not received from the patient or from a third party payor, for which the
				provider expected payment and the persons are unable or unwilling to pay their
				bill. Bad debts may be for services provided to patients who have no health
				insurance or patients who are underinsured and are net of payments made toward
				these services. For the purpose of uncompensated care, bad debt is measured on
				the basis of revenue forgone, at full established rates, and bad debt does not
				include either provider discounts or Medicare bad debt.
(3) "Birthing center" means a facility that
				provides comprehensive obstetrical care for women in which births are planned
				to occur away from the mother's usual residence following normal,
				uncomplicated, low risk pregnancy and is either:
(a) a licensed outpatient center for primary
				care with medical resources as defined at
				50-5-101,
				MCA; or
(b) a private office of a
				physician or certified nurse midwife that is accredited by a national
				organization as an alternative to a homebirth or a hospital
				birth.
Administrative Rules of Montana › Department 37 - PUBLIC HEALTH AND HUMAN SERVICES › Chapter 37.86 - MEDICAID PRIMARY CARE SERVICES › Subchapter 37.86.30 - Outpatient Hospital Services › Rule 37.86.3002 - OUTPATIENT HOSPITAL SERVICES, SCOPE AND REQUIREMENTS

Current through Register Vol. 13, July 5, 2024
(1) 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.
(2) Outpatient hospital
				services are services that would also be covered by Medicaid if provided in a
				nonhospital setting and are limited to the following diagnostic and therapeutic
				services furnished by hospitals to outpatients:
(a) diagnostic services, including:
(i) the services of nurses, psychologists and
				technicians;
(ii) drugs and
				biologicals;
(iii) laboratory and
				imaging services;
(iv)
				psychological tests;
(v) supplies
				and equipment; and
(vi) other tests
				to determine the nature and severity of a medical condition;
Administrative Rules of Montana › Department 37 - PUBLIC HEALTH AND HUMAN SERVICES › Chapter 37.86 - MEDICAID PRIMARY CARE SERVICES › Subchapter 37.86.30 - Outpatient Hospital Services › Rule 37.86.3003 - OUTPATIENT HOSPITAL SERVICES, EXCLUSIONS

Current through Register Vol. 13, July 5, 2024
(1) Outpatient
				hospital services do not include:
(a)
				services excluded from coverage by the Medicaid program under ARM
				37.85.207;
(b) exercise programs and programs primarily
				educational in nature unless covered as preventative outpatient services,
				including, but not limited to independent exercise programs, such as pool
				therapy, swim programs, or health club memberships;
(c) outpatient physical therapy, occupational
				therapy, and speech therapy services that are primarily maintenance therapy as
				defined in ARM
				37.86.601;
(d) experimental or investigational services
				such as the use of off-label drugs where this usage is not a national standard
				of practice, or non-FDA-approved use of drugs, biologicals, and devices;
(e) services that do not comply
				with national standards of medical care; and
(f) outpatient hospital services provided
				outside the borders of the United States will not be covered or reimbursed by
				the Montana Medicaid program.
Administrative Rules of Montana › Department 37 - PUBLIC HEALTH AND HUMAN SERVICES › Chapter 37.86 - MEDICAID PRIMARY CARE SERVICES › Subchapter 37.86.30 - Outpatient Hospital Services › Rule 37.86.3005 - OUTPATIENT HOSPITAL SERVICES, REIMBURSEMENT

Current through Register Vol. 13, July 5, 2024
(1) The department will reimburse for
				outpatient hospital services and birthing center services compensable under the
				Montana Medicaid program as provided in this rule.
(2) Outpatient hospital services that are not
				provided by critical access hospitals as defined in ARM
				37.86.2901 will be reimbursed
				under ARM 37.86.3007,
				37.86.3009,
				37.86.3016,
				37.86.3018,
				37.86.3020,
				37.86.3025,
				37.86.3109, and
				37.86.3037 for medically necessary
				services.
(3) Birthing center
				services as defined in ARM
				37.86.3001 will be reimbursed
				under ARM 37.86.3007, 37.86.3016, 37.86.3018, and 37.86.3020, for medically
				necessary services.
(4) For
				critical access hospitals, interim reimbursement for outpatient hospital
				services is based on hospital-specific Medicaid outpatient cost-to-charge
				ratio, not to exceed 100%. Critical access hospitals will be reimbursed their
				actual allowable costs determined according to ARM
				37.86.2803.
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 37.86 - MEDICAID PRIMARY CARE SERVICES › Subchapter 37.86.30 - Outpatient Hospital Services › Rule 37.86.3006 - MENTAL HEALTH OUTPATIENT PARTIAL HOSPITAL SERVICES, REQUIREMENTS

Current through Register Vol. 13, July 5, 2024
(1) Medicaid reimbursement is not available
				for outpatient partial hospitalization services unless:
(a) the person is experiencing psychiatric
				symptoms of sufficient severity to create severe impairments in educational,
				social, vocational, or interpersonal functioning;
(b) the person cannot be safely and
				appropriately treated in a less restrictive level of care;
(c) proper treatment of the person's
				psychiatric condition requires acute treatment services on an outpatient basis
				under the direction of a physician; and
(d) the services can reasonably be expected
				to improve the person's condition or prevent further regression.
Administrative Rules of Montana › Department 37 - PUBLIC HEALTH AND HUMAN SERVICES › Chapter 37.86 - MEDICAID PRIMARY CARE SERVICES › Subchapter 37.86.30 - Outpatient Hospital Services › Rule 37.86.3007 - OUTPATIENT HOSPITAL SERVICES, PROSPECTIVE PAYMENT METHODOLOGY, CLINICAL DIAGNOSTIC LABORATORY SERVICES

Current through Register Vol. 13, July 5, 2024
(1)
				Clinical diagnostic laboratory services, including automated multichannel test
				panels (commonly referred to as "ATPs") and lab panels, will be reimbursed on a
				fee basis as follows with the exception of hospitals reimbursed under ARM
				37.86.3005
				and specific lab codes which are paid under ARM
				37.86.3020:
(a) The fee for a clinical diagnostic
				laboratory service is the applicable percentage of the Medicare fee schedule as
				follows:
(i) 60% of the prevailing Medicare
				fee schedule for a birthing center or where a hospital laboratory acts as an
				independent laboratory, i.e., performs tests for persons who are nonhospital
				patients;
(ii) 62% of the
				prevailing Medicare fee schedule for a hospital designated as a sole community
				hospital as defined in ARM
				37.86.2901;
				or
(iii) 60% of the prevailing
				Medicare fee schedule for a hospital that is not designated as a sole community
				hospital as defined in ARM 37.86.2901.
Administrative Rules of Montana › Department 37 - PUBLIC HEALTH AND HUMAN SERVICES › Chapter 37.86 - MEDICAID PRIMARY CARE SERVICES › Subchapter 37.86.30 - Outpatient Hospital Services › Rule 37.86.3009 - OUTPATIENT HOSPITAL SERVICES, PAYMENT METHODOLOGY, EMERGENCY VISIT SERVICES

Current through Register Vol. 13, July 5, 2024
(1) 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 APC methodology in ARM
				37.86.3020, except emergency room
				visits with CPT codes 99281 and 99282 will be reimbursed based on the clinical
				APC weight.
(a) Passport to Health provider
				authorization is not required for emergency room visits.
Administrative Rules of Montana › Department 37 - PUBLIC HEALTH AND HUMAN SERVICES › Chapter 37.86 - MEDICAID PRIMARY CARE SERVICES › Subchapter 37.86.30 - Outpatient Hospital Services › Rule 37.86.3011 - OUTPATIENT HOSPITAL SERVICES, PROSPECTIVE PAYMENT METHODOLOGY, NONEMERGENT EMERGENCY ROOM SERVICES (REPEALED)

Current through Register Vol. 13, July 5, 2024
53-2-201,
					 53-6-113,
					 MCA; IMP,
					 53-2-201,
					 53-6-101,
					 53-6-111,
					 53-6-113,
					 MCA;
Administrative Rules of Montana › Department 37 - PUBLIC HEALTH AND HUMAN SERVICES › Chapter 37.86 - MEDICAID PRIMARY CARE SERVICES › Subchapter 37.86.30 - Outpatient Hospital Services › Rule 37.86.3014 - OUTPATIENT HOSPITAL SERVICES, PROSPECTIVE PAYMENT METHODOLOGY, DIALYSIS SERVICES (REPEALED)

Current through Register Vol. 13, July 5, 2024
53-2-201,
					 53-6-113,
					 MCA; IMP,
					 53-2-201,
					 53-6-101,
					 53-6-111,
					 53-6-113,
					 MCA;