Mont. Admin. R. 37.85.410 - DETERMINATION OF MEDICAL NECESSITY
(1) The
department shall only make payment for those services which are medically
necessary as determined by the department or by the designated review
organization.
(2) In determining
medical necessity the department or designated review organization may consider
the type or nature of the service, the provider of the service, the setting in
which the service is provided and any additional requirements applicable to the
specific service or category of service.
(3) The department may review the medical
necessity of services or items at any time either before or after payment. If
the department determines that services or items were not medically necessary
or otherwise in compliance with applicable requirements, the department may
deny payment or may recover any overpayment in accordance with applicable
requirements. The department is not precluded by an earlier screening, prior
authorization, certification or similar process from reviewing and determining
medical necessity of any service or item, or from denying payment or recovering
any overpayment based upon any such review or determination. This rule does not
require the department to notify a provider or recipient of a medical necessity
determination until and unless the department completes its review and takes an
adverse action against the provider based upon the determination.
(4) The provider must upon request provide to
the department or its designated review organization without charge any records
related to services or items provided to a recipient.
Notes
53-2-201, 53-6-113, MCA; IMP, 53-2-201, 53-6-101, 53-6-111, 53-6-113, 53-6-141, MCA;
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