reglab/statecodes huggingface dataset:
Administrative Rules of Montana › Department 37 - PUBLIC HEALTH AND HUMAN SERVICES › Chapter 37.86 - MEDICAID PRIMARY CARE SERVICES › Subchapter 37.86.2 - Mid-level Practitioner Services › Rule 37.86.205 - MID-LEVEL PRACTITIONER SERVICES, REQUIREMENTS AND REIMBURSEMENT

Current through Register Vol. 13, July 5, 2024
(1) These requirements are in addition to
				those rule provisions generally applicable to Medicaid providers.
(2) Medicaid coverage of mid-level
				practitioner services is available according to the requirements and procedures
				specified for physicians under ARM
				37.86.101,
				37.86.104,
				and
				37.86.105.
(3) Mid-level practitioner
				services must be medically necessary as defined in ARM
				37.82.102
				and
				37.85.410.
(4) Coverage of mid-level
				practitioner services is limited to the provision of services by the following
				providers:
(a) mid-level practitioners who
				are considered to have an independent employment status;
(b) hospitals employing or contracting with
				certified registered nurse anesthetists if:
(i) the Secretary of Health and Human
				Services has not granted the hospital 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 );
(ii) the hospital
				obtains from the department or its fiscal agent a provider number for certified
				registered nurse anesthetist services; and
(iii) the hospital bills for services on form
				CMS 1500 or CMS 837P electronic transaction.
(c) physicians, ambulatory surgical centers,
				diagnostic centers or public health departments, employing or contracting with
				mid-level practitioners if:
(i) the physician
				or the provider entity obtains from the department or its fiscal agent a
				provider number for the mid-level practitioner; and
(ii) the physician or the provider entity
				bills for services on form CMS 1500 or CMS 837P electronic transaction.
Administrative Rules of Montana › Department 37 - PUBLIC HEALTH AND HUMAN SERVICES › Chapter 37.86 - MEDICAID PRIMARY CARE SERVICES › Subchapter 37.86.5 - Podiatry Services › Rule 37.86.501 - PODIATRY SERVICES, DEFINITIONS

Current through Register Vol. 13, July 5, 2024
(1)
				"Orthotic" means a mechanical device to assist in restoring normal function of
				the foot, applied to the foot or used with the shoe either as an insert for the
				shoe or as an attachment to the exterior of the shoe.
(2) "Podiatry services" means those services
				provided by individuals licensed under state law to practice podiatry which are
				within the scope of their practice.
(3) "Routine podiatric care" means the
				cutting or removing of corns and calluses, the trimming of nails or the
				application of skin creams and other hygienic, preventive maintenance care and
				debridement of nails.
(4) The
				definitions found in the introduction to Physicians Current Procedural
				Terminology, fourth edition (CPT4), published by the American Medical
				Association of Chicago, Illinois and adopted at ARM
				37.86.101 defines the terms
				commonly used by the Montana Medicaid program in implementation of the
				program's podiatry fee schedule.
(5) The "Physician-Related Services Manual"
				means the physician-related services manual adopted at ARM 37.86.101. It
				governs the administration of the Podiatry program.
53-6-113,
					 MCA; IMP,
					 53-6-101,
					 53-6-141,
					 MCA;
Administrative Rules of Montana › Department 37 - PUBLIC HEALTH AND HUMAN SERVICES › Chapter 37.86 - MEDICAID PRIMARY CARE SERVICES › Subchapter 37.86.5 - Podiatry Services › Rule 37.86.505 - PODIATRY 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 podiatry
				services.
53-6-113,
					 MCA; IMP,
					 53-6-101,
					 53-6-141,
					 MCA;
Administrative Rules of Montana › Department 37 - PUBLIC HEALTH AND HUMAN SERVICES › Chapter 37.86 - MEDICAID PRIMARY CARE SERVICES › Subchapter 37.86.5 - Podiatry Services › Rule 37.86.506 - PODIATRY SERVICES, REIMBURSEMENT

Current through Register Vol. 13, July 5, 2024
(1)
				Reimbursement for podiatry services is in accordance with the methodologies
				described in ARM
				37.85.212
				and
				37.86.105.
AUTH:
					 53-2-201,
					 53-6-113,
					 MCA; IMP:
					 53-6-101,
					 53-6-111,
					 53-6-131,
					 53-6-141,
					 MCA
Administrative Rules of Montana › Department 37 - PUBLIC HEALTH AND HUMAN SERVICES › Chapter 37.86 - MEDICAID PRIMARY CARE SERVICES › Subchapter 37.86.6 - Therapy Services › Rule 37.86.605 - THERAPY SERVICES, PROVIDER 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) As a condition of
				participation in the Montana Medicaid program, a therapist must:
(a) maintain a current license issued by the
				applicable Montana licensing board for the category of therapy being provided,
				or, if the provider is serving recipients outside the state of Montana,
				maintain a current license in the equivalent category under the laws of the
				state in which the services are provided;
(b) enter into and maintain a current
				provider enrollment form under the provisions of ARM
				37.85.402 with the department's
				fiscal agent to provide the category of therapy services being
				provided.
Administrative Rules of Montana › Department 37 - PUBLIC HEALTH AND HUMAN SERVICES › Chapter 37.86 - MEDICAID PRIMARY CARE SERVICES › Subchapter 37.86.6 - Therapy Services › Rule 37.86.606 - THERAPY SERVICES, SERVICE REQUIREMENTS AND RESTRICTIONS

Current through Register Vol. 13, July 5, 2024
(1) The
				requirements and restrictions in this rule apply for purposes of coverage and
				reimbursement of therapy services under the Montana Medicaid program.
(2) Except as otherwise provided by these
				rules, therapy services must be provided by a therapist or assistant/aide
				within the scope of practice permitted by state law. The provider's records
				maintained under ARM
				37.85.414 must demonstrate
				compliance with applicable supervision and protocol requirements.
(a) Services provided by an assistant/aide
				may only be billed by a supervising therapist..
Administrative Rules of Montana › Department 37 - PUBLIC HEALTH AND HUMAN SERVICES › Chapter 37.86 - MEDICAID PRIMARY CARE SERVICES › Subchapter 37.86.6 - Therapy Services › Rule 37.86.610 - THERAPIES, REIMBURSEMENT

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 Health Care Financing
				Administration's Common Procedure Coding System (HCPCS). Information regarding
				billing codes, modifiers and HCPCS is available upon request from the
				Department of Public Health and Human Services, Health Resources Division, 1400
				Broadway, P.O. Box 202951, Helena, MT 59620-2951.
(2) Subject to the requirements of this rule,
				the Montana Medicaid program pays the following for therapy services:
(a) For patients who are eligible for
				Medicaid, the lower of:
(i) the provider's
				usual and customary charge for the service;
(ii) the reimbursement provided in accordance
				with the methodologies described in ARM
				37.85.212; or
(iii) for items or services where no RBRVS or
				Medicare fee is available, the fee schedule amount will be calculated using the
				following methodology:
(A) Establishing a fee
				for a service that has been billed at least 50 times by all providers in the
				aggregate during the previous 12-month period. The department will set each fee
				at the payment-to-charge ratio in accordance with ARM
				37.85.105(2)(d).
(B) For services where utilization cannot
				meet the methodology outlined in (A), the fee will be set at the same rate as a
				service similar in scope.
Administrative Rules of Montana › Department 37 - PUBLIC HEALTH AND HUMAN SERVICES › Chapter 37.86 - MEDICAID PRIMARY CARE SERVICES › Subchapter 37.86.7 - Audiology Services › Rule 37.86.701 - AUDIOLOGY SERVICES, PROVIDER 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) Audiology service
				providers, as a condition of participation in the Montana Medicaid program,
				must:
(a) maintain a current audiology
				license issued by the Montana Board of Speech-Language Pathologists and
				Audiologists, or, if the provider is serving recipients outside the state of
				Montana, maintain a current license in the equivalent category under the laws
				of the state in which the services are provided;
(b) enter into and maintain a current
				provider enrollment form under the provisions of ARM
				37.85.402 with the department's
				fiscal agent to provide audiology services.
Administrative Rules of Montana › Department 37 - PUBLIC HEALTH AND HUMAN SERVICES › Chapter 37.86 - MEDICAID PRIMARY CARE SERVICES › Subchapter 37.86.7 - Audiology Services › Rule 37.86.702 - AUDIOLOGY SERVICES, SERVICE REQUIREMENTS, AND RESTRICTIONS

Current through Register Vol. 13, July 5, 2024
(1) The following requirements and
				restrictions apply for purposes of coverage and reimbursement of audiology
				services under the Montana Medicaid program.
(2) Audiology services are hearing aid
				evaluations and basic audio assessments provided within the scope of practice
				permitted by state law to recipients with hearing disorders. Audiology services
				must be provided by a licensed practitioner within the scope of the practice
				permitted by state law. The provider's records maintained under ARM
				37.85.414 must demonstrate the
				medical necessity for the service, and compliance with applicable supervision
				and protocol requirements.
(a) Medicaid
				coverage and reimbursement for dispensing of hearing aids is available to
				licensed hearing aid dispensers and audiologists, subject to the requirements
				of ARM 37.86.801 through
				37.86.805 and the requirements
				generally applicable to Medicaid providers.
Administrative Rules of Montana › Department 37 - PUBLIC HEALTH AND HUMAN SERVICES › Chapter 37.86 - MEDICAID PRIMARY CARE SERVICES › Subchapter 37.86.7 - Audiology Services › Rule 37.86.705 - AUDIOLOGY SERVICES, REIMBURSEMENT

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 Health Care Financing
				Administration's Common Procedure Coding System (HCPCS). Information regarding
				billing codes, modifiers, and HCPCS is available upon request from the
				Department of Public Health and Human Services, Health Resources Division, 1401
				East Lockey, P.O. Box 202951, Helena, MT 59620-2951.
(2) Subject to the requirements of this rule,
				the Montana Medicaid program pays the following for audiology services:
(a) For patients who are eligible for
				Medicaid, the lowest of:
(i) the provider's
				usual and customary charge for the service;
(ii) the reimbursement provided in accordance
				with the methodologies described in ARM
				37.85.212;
(iii) 100% of the Medicare Region D allowable
				fee; or
(iv) for items or services
				where no RBRVS fee is available, the fee schedule amount will be calculated
				using the following methodology:
(A)
				Establishing a fee for a service or item that has been billed at least 50 times
				by all providers in the aggregate during the previous 12-month period. The
				department will set each fee at the payment-to-charge ratio under ARM
				37.85.105(2)(d).
(B) For services where utilization cannot
				meet the methodology outlined in (A), the fee shall be set at the same rate as
				a service similar in scope.
Administrative Rules of Montana › Department 37 - PUBLIC HEALTH AND HUMAN SERVICES › Chapter 37.86 - MEDICAID PRIMARY CARE SERVICES › Subchapter 37.86.8 - Hearing Aid Services › Rule 37.86.801 - HEARING AID SERVICES, DEFINITIONS

Current through Register Vol. 13, July 5, 2024
(1)
				"Hearing aid" means an instrument or device designed for or represented as
				aiding or improving defective human hearing and includes the parts,
				attachments, or accessories of the instrument or device.
(2) "Hearing aid dispenser" or "dispenser"
				means a person holding a current license issued by the Montana Board of Hearing
				Aid Dispensers under Title 37, chapter 16, MCA to engage in selling,
				dispensing, or fitting hearing aids. The term does not include any person to
				the extent that the person acts beyond the scope of the person's hearing aid
				dispenser license.
(3) "Dispenser"
				also means a person holding a current audiology license issued by the Montana
				Board of Speech-Language Pathologists and Audiologists under Title 37, chapter
				15, MCA to engage in selling, dispensing, or fitting hearing aids.
53-6-113,
					 MCA; IMP,
					 53-6-101,
					 53-6-141,
					 MCA;
Administrative Rules of Montana › Department 37 - PUBLIC HEALTH AND HUMAN SERVICES › Chapter 37.86 - MEDICAID PRIMARY CARE SERVICES › Subchapter 37.86.8 - Hearing Aid Services › Rule 37.86.802 - HEARING AID SERVICES, REQUIREMENTS, AND LIMITATIONS

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) Medicaid payment for
				purchase of hearing aids will be made only to a licensed hearing aid dispenser
				or audiologist for Medicaid covered services provided in accordance with all
				applicable Medicaid requirements and within the scope of practice permitted
				under the dispenser's license.
(3)
				A hearing aid may be covered under the Medicaid program if:
(a) the recipient has been referred by a
				physician or mid-level practitioner for an audiological examination and the
				physician or mid-level practitioner has determined that there is no medical
				reason for which a hearing aid would not be effective in correcting the
				recipient's hearing loss;
(b) the
				examination by a licensed audiologist results in a determination that a hearing
				aid or aids are needed; and
(c) the
				following criteria are met:
(i) for persons
				over 21 years of age, the audiological examination results show that there is
				an average pure tone loss of at least 40 decibels for each of the frequencies
				of 500, 1000, 2000, and 3000 Hertz in the better ear and word recognition or
				speech discrimination scores obtained at a level to ensure pb max. The
				following criteria shall apply to adults aged 21 years or older for binaural
				hearing aids:
(A) the two frequency average
				at 1khz and 2khz must be greater than 40db in both ears;
(B) the two frequency average at 1khz and
				2khz must be less than 90db in both ears;
(C) the two frequency average at 1khz and
				2khz must have an interaural difference of less than 15db;
(D) the interaural word recognition or speech
				discrimination score must have a difference of not greater than 20%;
(E) demonstrated success in using a monaural
				hearing aid for at least six months; and
(F) documented need to understand speech with
				a high level comprehension based on an educational or vocational
				need.
(ii) for persons
				under 21 years of age, the department or its designee determines after review
				of the audiology report that the hearing aid would be appropriate for the
				person. Persons under 21 years of age will be evaluated under the early
				periodic screening and testing program.
(d) the original hearing aid no longer meets
				the needs of the individual, and a new hearing aid is determined to be
				medically necessary by a licensed audiologist.
Administrative Rules of Montana › Department 37 - PUBLIC HEALTH AND HUMAN SERVICES › Chapter 37.86 - MEDICAID PRIMARY CARE SERVICES › Subchapter 37.86.8 - Hearing Aid Services › Rule 37.86.805 - HEARING AID SERVICES, REIMBURSEMENT

Current through Register Vol. 13, July 5, 2024
(1) The
				department will pay the lowest of the following for covered hearing aid
				services and items:
(a) the provider's
				reasonable usual and customary charge for the service or item;
(b) the amount specified for the particular
				service or item in the department's fee schedule. The department adopts and
				incorporates by reference the department's Hearing Aid Fee Schedule as provided
				in ARM
				37.85.105(3);
				or
(c) 100% of the Medicare Region
				D allowable fee.
Administrative Rules of Montana › Department 37 - PUBLIC HEALTH AND HUMAN SERVICES › Chapter 37.86 - MEDICAID PRIMARY CARE SERVICES › Subchapter 37.86.9 - Collaborative Practice Drug Therapy Management › Rule 37.86.901 - COLLABORATIVE PRACTICE DRUG THERAPY MANAGEMENT - DEFINITIONS

Current through Register Vol. 13, July 5, 2024
(1) "Clinical
				pharmacist practitioner" means a pharmacist who meets the requirements outlined
				in ARM 24.174.526 and is licensed in the
				State of Montana.
(2)
				"Collaborative practice drug therapy management" means face-to-face direct
				member care, provided by a clinical pharmacist practitioner as outlined in ARM
				24.174.524. The care provided must
				be within the scope of practice for clinical pharmacist
				practitioners.
(3) "Medical
				practitioner" means a medical practitioner as defined in
				37-2-101,
				MCA.
AUTH:
					 53-2-201,
					 53-6-113,
					 MCA; IMP:
					 53-2-201,
					 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 37.86.9 - Collaborative Practice Drug Therapy Management › Rule 37.86.902 - COLLABORATIVE PRACTICE DRUG THERAPY MANAGEMENT - REQUIREMENTS AND ELIGIBILITY

Current through Register Vol. 13, July 5, 2024
(1) These
				requirements are in addition to those requirements contained in administrative
				rule and statutory provisions generally applicable to Medicaid
				providers.
(2) A clinical
				pharmacist practitioner who provides collaborative practice drug therapy
				management must:
(a) have a collaborative
				practice agreement with a medical practitioner, as provided in ARM
				24.174.524;
(b) manage a member's drug therapy by
				providing face-to-face, direct care; and
(c) provide care through employment or
				contract with a medical practitioner or facility.
Administrative Rules of Montana › Department 37 - PUBLIC HEALTH AND HUMAN SERVICES › Chapter 37.86 - MEDICAID PRIMARY CARE SERVICES › Subchapter 37.86.9 - Collaborative Practice Drug Therapy Management › Rule 37.86.905 - COLLABORATIVE PRACTICE DRUG THERAPY MANAGEMENT - REIMBURSEMENT

Current through Register Vol. 13, July 5, 2024
(1) Reimbursement
				for collaborative practice drug therapy management is reimbursed only to the
				medical practitioner or facility, at the lower of the following:
(a) the provider's usual and customary charge
				to the general public for the service; or
(b) the department's current fee schedule in
				ARM 37.85.105 for the appropriate
				provider type.
Administrative Rules of Montana › Department 37 - PUBLIC HEALTH AND HUMAN SERVICES › Chapter 37.86 - MEDICAID PRIMARY CARE SERVICES › Subchapter 37.86.10 - Dental Services › Rule 37.86.1001 - DENTAL SERVICES, DEFINITIONS

Current through Register Vol. 13, July 5, 2024
For purposes of this subchapter, the following definitions
				  apply:
(1) "By-report method" means
				the department reimburses a percent of the provider's usual and customary
				charges for a procedure code for which no fee has been assigned.
(2) "Conversion factor" means the multiplier
				used to convert the relative value unit or units of a procedure to a
				reimbursement rate a provider may receive in payment from Montana Medicaid. The
				dental conversion factor approximates the amount the Legislature has
				appropriated for one unit of value of dental services.
(3) "Dental service" means medically
				necessary treatment of the teeth and associated structures of the oral cavity.
				Dental service includes the provision of orthodontia and prostheses.
(4) "Dental hygiene" means services performed
				by a licensed preventive oral health practitioner known as a dental hygienist,
				that are therapeutic, prophylactic, or preventive procedures in
				nature.
(5) "Dental hygienist"
				means a licensed preventive oral health practitioner practicing in compliance
				with the provisions of Title 37, chapter 4, MCA.
(6) "Policy adjustor" means a factor by which
				the product of the relative valueunits of a procedure or the conversion factor
				is multiplied to increase or decrease the fees paid by Montana Medicaid for
				certain categories of services.
(7)
				"Procedure code" means the number identifying a particular procedure. Montana
				Medicaid has adopted national uniform procedure codes.
(8) "Public health supervision" means the
				provision of limited dental hygiene preventative services without the prior
				authorization or presence of a licensed dentist in a public health
				facility.
(9) "Relative Values for
				Dentists (RVD) Scale" means the scale published biennially by Relative Value
				Studies Inc., 1675 Larimer, Suite 410, Denver, CO 80202, listing the relative
				value of dental services provided by dentists and denturists.
(10) "Relative value unit (RVU)" means a
				numerical value assigned in the resource based relative value scale to each
				procedure code for which a relative value is available. The RVD is a
				comprehensive relative value system that lists dental procedures used by
				dentists, denturists, and hygienists as an expression of the relative effort
				and expense expended by a provider in providing one service as compared to
				another service.
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 37.86.10 - Dental Services › Rule 37.86.1002 - DENTAL 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 and the provision of services under Medicaid
				coverage.
(2) Medicaid
				reimbursement for dental care is limited to those services specified in ARM
				37.86.1006.
53-6-113,
					 MCA; IMP,
					 53-6-101,
					 53-6-141,
					 MCA;
Administrative Rules of Montana › Department 37 - PUBLIC HEALTH AND HUMAN SERVICES › Chapter 37.86 - MEDICAID PRIMARY CARE SERVICES › Subchapter 37.86.10 - Dental Services › Rule 37.86.1004 - REIMBURSEMENT METHODOLOGY FOR RESOURCE BASED RELATIVE VALUE FOR DENTISTS (RVD)

Current through Register Vol. 13, July 5, 2024
(1) For procedures
				listed in the relative values for dentists scale, reimbursement rates shall be
				determined using the following methodology:
(a) The fee for a covered service shall be
				the amount determined by multiplying the relative value unit specified in the
				relative values for dentists scale by the conversion factor specified in
				(1)(c). The department adopts and incorporates by reference the Relative Values
				for Dentists (RVDs) as provided in ARM
				37.85.105(3).
(b) The conversion factor and provider fees
				for dentists, dental hygienists, and denturists procedures are calculated as
				follows:
(i) The total units of each
				procedure code paid in a prior period is multiplied by the RVU as published in
				(1)(a) to equal the RVD for each procedure code. Typically, the prior period
				used is the prior state fiscal year.
(ii) The sum of all RVDs calculated in
				(1)(b)(i) equals the total units of dental service.
(iii) The Montana Legislature's appropriation
				for dental service during the appropriation period is divided by the total
				units of dental service calculated in (1)(b)(ii). The resulting dollar value is
				equal to one unit of dental value and is the dental conversion
				factor.
(iv) The RVU as published
				in (1)(a) for each dental procedure is multiplied by the dental conversion
				factor calculated in (1)(b)(iii) to calculate the Medicaid reimbursement for
				the procedure. When this calculation is made for all covered procedures the
				Montana Medicaid Dental, Dental Hygienist, and Denturist Fee Schedules are
				generated.
(v) A policy adjuster
				may be applied to some fees calculated in (1)(b)(iv) for certain categories of
				services or to the conversion factor to increase or decrease the fees paid by
				Medicaid.
(c) The
				conversion factor used to determine the Medicaid payment amount for services
				provided to eligible individuals is provided in ARM
				37.85.105(3).
Administrative Rules of Montana › Department 37 - PUBLIC HEALTH AND HUMAN SERVICES › Chapter 37.86 - MEDICAID PRIMARY CARE SERVICES › Subchapter 37.86.10 - Dental Services › Rule 37.86.1005 - DENTAL SERVICES, REIMBURSEMENT

Current through Register Vol. 13, July 5, 2024
(1) For dental
				services listed in the department's fee schedule, the department will pay the
				lowest of the following for dental services covered by the Medicaid program:
(a) the provider's usual and customary charge
				for the service;
(b) the amount
				determined using the methodology described in ARM
				37.86.1004; or
(c) for items or services when there is no
				RVD, the department will set the fee at the same rate as a service similar in
				scope.
Administrative Rules of Montana › Department 37 - PUBLIC HEALTH AND HUMAN SERVICES › Chapter 37.86 - MEDICAID PRIMARY CARE SERVICES › Subchapter 37.86.10 - Dental Services › Rule 37.86.1006 - DENTAL SERVICES, COVERED PROCEDURES

Current through Register Vol. 13, July 5, 2024
(1)
				For purposes of specifying coverage of dental services through the Medicaid
				program, the department adopts and incorporates by reference the Dental and
				Denturist Program Provider Manual as provided in ARM
				37.85.105(3).
				The Dental and Denturist Program Provider Manual informs the providers of the
				requirements applicable to the delivery of services. Copies of the manual are
				available on the Montana Medicaid provider web site at
				http://medicaidprovider.mt.gov and from the Department of Public Health and
				Human Services, Health Resources Division, 1400 Broadway, P.O. Box 202951,
				Helena, MT 59620-2951.
(2)
				Dentists who are Medicaid provider participants under ARM
				37.85.401
				may bill medical CPT procedure codes as provided in ARM
				37.85.212
				and
				37.86.101
				for any Medicaid covered medical procedure that they are allowed to provide
				under the Dental Practice Act that is not otherwise listed in the Dental and
				Denturist Program Provider Manual.
(3) All services which require prior
				authorization from the designated review organization are identified in the
				department's fee schedule. Reimbursement is not provided for such services
				unless prior authorization has been given by the designated review
				organization.
(4) A licensed
				dental hygienist practicing under public health supervision may provide dental
				hygiene preventative services as defined by the Board of Dentistry.
(5) Covered services for adults age 21 and
				over include:
(a) diagnostic;
(b) preventative;
(c) basic restorative services including
				prefabricated crown;
(d)
				extractions; and
(e) porcelain
				fused to base metal crowns, and porcelain/ceramic crowns are limited to two per
				person per year, total. For second molars, base metal crowns only.
Administrative Rules of Montana › Department 37 - PUBLIC HEALTH AND HUMAN SERVICES › Chapter 37.86 - MEDICAID PRIMARY CARE SERVICES › Subchapter 37.86.11 - Outpatient Drug Services › Rule 37.86.1101 - OUTPATIENT DRUGS, DEFINITIONS

Current through Register Vol. 13, July 5, 2024
(1)
				"Acquisition cost" means the actual price paid by a provider for a drug.
(2) "Active pharmaceutical
				ingredient (API)" means a nonrebatable bulk drug substance, defined in
				21
				CFR 207.3(a)(4) (2011) as
				any substance that is represented for use in a drug and that, when used in
				manufacturing, processing, or packaging of a drug, becomes an active ingredient
				of the drug product.
(3) "Allowed
				ingredient cost" means the "Average Acquisition Cost (AAC)" or "submitted
				ingredient cost," whichever is lower. If AAC is not available, drug
				reimbursement is determined at the lesser of "Wholesale Acquisition Cost
				(WAC)", "Federal Maximum Allowable Cost (FMAC)," or the "submitted ingredient
				cost."
(4) "Average acquisition
				cost (AAC)" means the calculated average drug ingredient cost per drug
				determined by direct pharmacy survey, wholesale survey, and other relevant cost
				information.
(5) "Average
				manufacturer price" means the price as defined at 42 CFR Part 447.504(a).
(6) "Best price" means with
				respect to a single source drug or innovator multiple source drug of a
				manufacturer the lowest price available from the manufacturer during the rebate
				period to any wholesaler, retailer, provider, health maintenance organization,
				nonprofit entity, or governmental entity within the United States. Best price
				includes the lowest price available to any entity for any such drug of a
				manufacturer that is sold under an approved new drug application.
(7) "Federal maximum allowable cost" (FMAC)
				means the per unit amount the department reimburses a provider for a
				prescription drug included in the federal upper-limit program. FMAC is the
				federal upper limit the department will pay for multi-source drugs as published
				by the Centers for Medicare and Medicaid Services (CMS) at:
				https://www.medicaid.gov/medicaid-chip-program-information/by-topics/benefits/prescription-drugs/pharmacy-pricing.html.
(8) "Legend drugs" means drugs that federal
				law prohibits dispensing without a prescription.
(9) "Maintenance medications" means oral
				tablet or capsule drugs that:
(a) have a low
				probability for dosage or therapy changes due to side effects;
(b) are subject to serum drug concentration
				monitoring or therapeutic response of a course of prolonged therapy;
(c) the most common use is to treat a chronic
				disease state;
(d) therapeutically
				are not considered curative or promoting of recovery; and
(e) are administered continuously rather than
				intermittently.
Administrative Rules of Montana › Department 37 - PUBLIC HEALTH AND HUMAN SERVICES › Chapter 37.86 - MEDICAID PRIMARY CARE SERVICES › Subchapter 37.86.11 - Outpatient Drug Services › Rule 37.86.1102 - OUTPATIENT DRUGS, REQUIREMENTS

Current through Register Vol. 13, July 5, 2024
(1) These
				requirements are in addition to those contained in ARM
				37.85.401
				through
				37.85.415.
(2) For purposes of Medicaid reimbursement,
				outpatient drugs may not be filled or refilled without the authorization of the
				physician or other licensed practitioner who is authorized by law to prescribe
				drugs and is recognized by the Medicaid program.
(3) The department will only participate in
				the payment of legend and over-the-counter drugs listed on the department drug
				formulary, as determined by the Medicaid Drug Formulary Committee established
				by the department. The formulary committee is the Drug Use Review Board,
				established and operating in accordance with
				42 USC
				1396r-8 (2016), which governs Medicaid drug
				programs. The drug formulary includes a preferred drug list. Prescribers must
				prescribe from the preferred drug list if medically appropriate.
(a) The PDL includes drugs subject to a
				Centers for Medicare and Medicaid Services (CMS) approved supplemental rebate
				agreement between the manufacturer and the department. Drugs in the same
				therapeutic class as those identified on the preferred drug list but not
				identified as a preferred drug are subject to prior authorization as outlined
				in (6)(c).
Administrative Rules of Montana › Department 37 - PUBLIC HEALTH AND HUMAN SERVICES › Chapter 37.86 - MEDICAID PRIMARY CARE SERVICES › Subchapter 37.86.11 - Outpatient Drug Services › Rule 37.86.1103 - OUTPATIENT DRUGS, FRAUD, WASTE, AND ABUSE

Current through Register Vol. 13, July 5, 2024
(1) Medicaid, Healthy Montana Kids, and
				Mental Health Services Plan members may be subject to investigation for
				prescription fraud and abuse in accordance with 42 CFR 455.
(2) "Fraud" means the intentional deception
				or misrepresentation with knowledge that the deception could result in some
				unauthorized benefit to the individual or some other person. Examples include:
(a) doctor shopping;
(b) reported cash payment for drugs of abuse
				where it is suspected that the member has circumvented the Medicaid benefit
				system to avoid detection; and
(c)
				reports from providers of suspected drug misuse or diversion.
Administrative Rules of Montana › Department 37 - PUBLIC HEALTH AND HUMAN SERVICES › Chapter 37.86 - MEDICAID PRIMARY CARE SERVICES › Subchapter 37.86.11 - Outpatient Drug Services › Rule 37.86.1105 - OUTPATIENT DRUGS, REIMBURSEMENT

Current through Register Vol. 13, July 5, 2024
(1)
				Outpatient drugs are reimbursed at the lower of:
(a) the provider's "usual and customary
				charge"; or
(b) the "allowed
				ingredient cost" plus a dispensing fee.
Administrative Rules of Montana › Department 37 - PUBLIC HEALTH AND HUMAN SERVICES › Chapter 37.86 - MEDICAID PRIMARY CARE SERVICES › Subchapter 37.86.11 - Outpatient Drug Services › Rule 37.86.1106 - CALCULATION OF THE AVERAGE ACQUISITION COST

Current through Register Vol. 13, July 5, 2024
(1) The Average
				Acquisition Cost (AAC) is the cost per drug determined by direct pharmacy
				survey, wholesale survey, and other relevant cost information.
(a) The department reviews AAC rates on an
				ongoing basis and adjusts the rates as necessary to reflect prevailing market
				conditions and ensure reasonable access by providers to drugs at or below the
				applicable AAC rate.
(b) Pharmacies
				and providers that are enrolled in Montana Medicaid are required, as a
				condition of participation, to submit, upon request, to the department, or its
				designee, acquisition cost information, product availability information, and
				other information deemed relevantby the department for the efficient operation
				of the pharmacy benefit. Information is provided in the format requested by the
				department or its designee. Providers are not reimbursed for this information
				and must submit information to the department or its designee within 30 days
				following a request for such information unless the department or its designee
				grants an extension upon written request of the pharmacy or provider.
Administrative Rules of Montana › Department 37 - PUBLIC HEALTH AND HUMAN SERVICES › Chapter 37.86 - MEDICAID PRIMARY CARE SERVICES › Subchapter 37.86.11 - Outpatient Drug Services › Rule 37.86.1111 - OPPORTUNITY FOR HEARING

Current through Register Vol. 13, July 5, 2024
(1) In any quarter
				in which a discrepancy in Medicaid utilization information is discovered by the
				manufacturer, which the manufacturer and the department are unable to resolve,
				the manufacturer will provide written notice of the discrepancy, by NDC number,
				to the department prior to the due date specified in ARM
				37.86.1102.
(2) If the manufacturer asserts the
				department's Medicaid utilization information is erroneous, the manufacturer
				shall pay the department that portion of the rebate amount that is not disputed
				by the required due date in ARM 37.86.1102. The balance due, if any, plus a
				reasonable rate of interest as set forth in
				42 USC
				1396 b(d)(5)(2008), will be paid or credited
				by the manufacturer or the department by the due date of the next quarterly
				payment in ARM
				37.86.1102(8) 
				after resolution of the dispute.
(3) Adjustments to rebate payments shall be
				made if information indicates that either Medicaid utilization information,
				Average Manufacturer Price (AMP), or Best Price were greater or less than the
				amount previously specified.
(4)
				The department and the manufacturer will use their best efforts to resolve the
				discrepancy within 60 days of receipt of disputes noted by the manufacturer in
				ARM 37.86.1102. In the event that the department and the manufacturer are not
				able to resolve a discrepancy within 60 days, the department shall make
				available to the manufacturer the department's hearing mechanism as set forth
				in Title 37, chapter 5, subchapter 3.
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 37.86.12 - Birth Attendant Services › Rule 37.86.1201 - LICENSED DIRECT-ENTRY MIDWIFE

Current through Register Vol. 13, July 5, 2024
(1) "Direct-entry
				midwife" means a person that is licensed as defined in Title 37, chapter 27,
				MCA and ARM Title 24, chapter 111, subchapter 6.
(2) Direct-entry midwives may only provide
				prenatal labor and delivery or postpartum care in a birthing center as defined
				at ARM 37.86.3001.
(3) Reimbursement for direct-entry midwives
				will be determined in accordance with ARM
				37.85.212 and
				37.86.105.
(4) The definitions found in the introduction
				to Physicians Current Procedural Terminology, fourth edition (CPT4), published
				by the American Medical Association of Chicago, Illinois and adopted at ARM
				37.86.101 describe the terms
				commonly used by the Montana Medicaid Program in implementation of the
				program's direct-entry midwife fee schedule.
(5) The "Physician-Related Services Manual"
				adopted at ARM
				37.86.101 governs the
				administration of the Direct-Entry Midwife Program.
AUTH:
					 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 37.86.14 - Ambulatory Surgical Centers › Rule 37.86.1401 - CLINIC SERVICES, DEFINITIONS

Current through Register Vol. 13, July 5, 2024
(1)
				"Clinic services" means preventive diagnostic, therapeutic, rehabilitative, or
				palliative items or services provided under the direction of a physician by an
				outpatient facility that is not part of a hospital, but is organized and
				operated to provide medical care to outpatients independent of a hospital.
				Clinic services may be provided in surgical centers and public health
				departments. Clinic services do not include mental health center services as
				defined in ARM
				37.88.901.
(2) "Ambulatory surgical center services"
				means clinic services which are provided in a licensed, freestanding ambulatory
				surgical center, but do not include physicians services, anesthesiologists
				services, ambulance services, or major prosthetic appliances such as
				intraocular lenses.
53-2-201,
					 53-6-113,
					 MCA; IMP,
					 53-6-101,
					 53-6-141,
					 MCA;
Administrative Rules of Montana › Department 37 - PUBLIC HEALTH AND HUMAN SERVICES › Chapter 37.86 - MEDICAID PRIMARY CARE SERVICES › Subchapter 37.86.14 - Ambulatory Surgical Centers › Rule 37.86.1402 - CLINIC SERVICES, REQUIREMENTS

Current through Register Vol. 13, July 5, 2024
(1)
				These requirements are in addition to those requirements contained in ARM
				37.85.401
				through
				37.85.414.
(2) Clinic services must be
				provided by a clinic which is licensed as an outpatient facility by the
				appropriate licensing entity of the state where the facility is located and
				meet the requirement for participation in Medicare.
(3) Clinic services must be provided by, or
				under the direction of a licensed physician or, where appropriate a licensed
				dentist.
(4) Conditions for
				coverage of listed ambulatory surgical center procedures:
(a) Subject to the exclusions in (b), covered
				surgical procedures are surgical procedures that would not be expected to pose
				a significant safety risk to a member when performed in an ambulatory surgical
				center and for which standard medical practice dictates that the member would
				not typically be expected to require active medical monitoring more than 24
				hours following an admission. Active medical monitoring includes the monitoring
				or assessment of respiratory function, cardiovascular function, mental status,
				pain, temperature, or post-operative hydration at least every 30
				minutes.
(b) Covered surgical
				procedures do not include those that:
(i)
				generally result in extensive blood loss;
(ii) requires a major or prolonged invasion
				of body cavities;
(iii) directly
				involves major blood vessels;
(iv)
				are generally emergency or life threatening in nature; or
(v) can safely be performed in a physician's
				or dentist's office.
(c)
				Covered surgical procedures can only be rendered by a licensed ambulatory
				surgical center.
Administrative Rules of Montana › Department 37 - PUBLIC HEALTH AND HUMAN SERVICES › Chapter 37.86 - MEDICAID PRIMARY CARE SERVICES › Subchapter 37.86.14 - Ambulatory Surgical Centers › Rule 37.86.1405 - CLINIC SERVICES, COVERED PROCEDURES

Current through Register Vol. 13, July 5, 2024
(1)
				Ambulatory surgical center (ASC) services:
(a) are services that will be covered by
				Medicaid if provided in an outpatient ASC setting incident to provision of
				physician or dental services to the patient where the services and supplies are
				furnished in the ASC on a physician's or dentist's order by ASC personnel under
				the supervision of ASC medical staff;
(b) are limited as provided by ARM
				37.86.1402(1) through
				(4) with the term clinic taken to mean
				ASC.
Administrative Rules of Montana › Department 37 - PUBLIC HEALTH AND HUMAN SERVICES › Chapter 37.86 - MEDICAID PRIMARY CARE SERVICES › Subchapter 37.86.14 - Ambulatory Surgical Centers › Rule 37.86.1406 - CLINIC SERVICES, REIMBURSEMENT

Current through Register Vol. 13, July 5, 2024
(1)
				Ambulatory surgical center (ASC) services as defined in ARM
				37.86.1401(2)
				provided by an ASC will be reimbursed on a fee basis as follows:
(a) 100% of the Medicare allowable amount.
				For purposes of determining the Medicare allowable amount for ASC services to
				Medicaid members under this rule, the department adopts and incorporates by
				reference the methodology at 42 CFR part 416, subpart F, and the schedule
				listing the allowable amounts for ASC services in the Medicare Claims
				Processing Manual. The cited authorities are federal regulations and manuals
				specifying the methods and rules used to determine reasonable cost for purposes
				of the Medicare program. The Medicare Claims Processing Manual can be found on
				the Centers for Medicare and Medicaid website at
www.cms.gov
. The Code of Federal Regulations can be
				found at
www.gpo.gov
.
(i) For purposes of applying the provisions
				of 42 CFR part 416, subpart F, and the Medicare Claims Processing Manual, any
				reference in such authorities to Medicare, Medicare beneficiary, beneficiary,
				intermediary or secretary shall be deemed to refer also to Medicaid, Medicaid
				member, member, or the department.
Administrative Rules of Montana › Department 37 - PUBLIC HEALTH AND HUMAN SERVICES › Chapter 37.86 - MEDICAID PRIMARY CARE SERVICES › Subchapter 37.86.15 - Home Infusion Therapy Services › Rule 37.86.1501 - HOME INFUSION THERAPY SERVICES, DEFINITIONS

Current through Register Vol. 13, July 5, 2024
In ARM
				  37.86.1501,
				  37.86.1502,
				  37.86.1505, and
				  37.86.1506, the following
				  definitions apply:
(1) "Agency staff
				services" means all services provided by the home infusion therapy agency's
				staff, as provided in ARM
				37.106.2405, including all
				professional and nonprofessional employed and contracted individuals. Agency
				staff services include:
(a) preparation and
				revision of the plan of care;
(b)
				coordination of treatment with other health care providers;
(c) recipient and/or care giver
				training;
(d) clinical monitoring
				of laboratory values and therapy progression;
(e) reporting clinical information to the
				recipient's physician and other health care providers;
(f) delivery, pick up, and disposal of
				equipment, supplies, or drugs;
(g)
				24-hour on call status; and
(h) any
				other services provided by the agency staff related to the recipient's home
				infusion therapy services.
Administrative Rules of Montana › Department 37 - PUBLIC HEALTH AND HUMAN SERVICES › Chapter 37.86 - MEDICAID PRIMARY CARE SERVICES › Subchapter 37.86.15 - Home Infusion Therapy Services › Rule 37.86.1502 - HOME INFUSION THERAPY SERVICES, PROVIDER 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) Home infusion
				therapy service providers, as a condition of participation in the Montana
				Medicaid program, must:
(a) maintain a
				current home infusion therapy agency license issued by the department's quality
				assurance division, and meet the standards set forth in ARM
				37.106.2422, or if the provider is
				serving recipients outside the state of Montana, maintain a current license in
				the equivalent category under the laws of the state in which the services are
				provided; and
(b) enter into and
				maintain a current provider enrollment form under the provisions of ARM
				37.85.402 with the department's
				fiscal agent to provide home infusion therapy services.
Administrative Rules of Montana › Department 37 - PUBLIC HEALTH AND HUMAN SERVICES › Chapter 37.86 - MEDICAID PRIMARY CARE SERVICES › Subchapter 37.86.15 - Home Infusion Therapy Services › Rule 37.86.1505 - HOME INFUSION THERAPY SERVICES, REQUIREMENTS

Current through Register Vol. 13, July 5, 2024
(1) The requirements and restrictions in
				these rules apply for purposes of coverage and reimbursement of home infusion
				therapy services under the Montana Medicaid program.
(2) Medicaid coverage and reimbursement of
				home infusion therapy services is available, subject to applicable
				requirements, for services provided to recipients that are residing in their
				own home, a nursing facility or any setting other than a hospital. Medicaid
				coverage and reimbursement of home infusion therapy services is not available
				to recipients who are receiving infusion therapy as a hospital inpatient or
				outpatient service.
(3) Except as
				otherwise provided by these rules, home infusion therapy services must be
				provided within the scope of practice permitted by applicable state
				law.
(4) For those services subject
				to prior authorization, the Montana Medicaid program will not cover or
				reimburse home infusion therapy services unless the department or its
				designated agent has approved a prior authorization request. The department
				will determine the specific home infusion therapy services that require prior
				authorization in consultation with the department's Drug Use Review Board
				established pursuant to 42 USCA 1396r-8(g). A list of the specific services
				subject to prior authorization will be provided upon request made to the
				Department of Public Health and Human Services, Health Resources Division, 1400
				Broadway, P.O. Box 202951, Helena, MT 59620-2951.
(5) The Montana Medicaid program will not
				cover or reimburse home infusion therapy services for the following:
(a) medications which can be appropriately
				administered orally, through intramuscular or subcutaneous injection, or
				through inhalation; and
(b) drug
				products that are not FDA approved or whose use in the nonhospital setting
				presents an unreasonable health risk to the patient.