Mont. Admin. R. 37.86.2605 - AMBULANCE SERVICES, REIMBURSEMENT
(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.
(2) The department adopts and incorporates by
reference the Montana Medicaid Fee Schedule, Ambulance as provided in ARM
37.85.105(3)
and ARM
37.85.105(2)
for drugs.
(3) For items and
services for which no fee has been set in the department's fee schedule
referred to in (2), reimbursement will be set by the following method:
(a) if Medicare sets a fee, the Medicare fees
are applicable as the Medicaid fee; or
(b) if Medicare does not set a fee, the
Medicaid fees are set by evaluating the fees of services similar in scope to
the new code.
(4) For
supplies or equipment, where there is no Medicare or Medicaid set fee, the
provider's usual and customary charge in (1)(a) will be considered reasonable
if set at 75% of the manufacturer's suggested retail price. For items without a
manufacturer's suggested retail price, the charge will be considered reasonable
if the provider's acquisition cost from the manufacturer is at least 50% of the
charge amount.
(5) The department
may reimburse providers for ambulance services to transport patients to and
from out-of-state facilities at negotiated fees where the department or its
designee in its discretion determines that the in-state reimbursement rates are
inadequate to assure that the person will receive medically necessary services.
Notes
AUTH: 53-2-201, 53-6-113, MCA; IMP: 53-6-101, 53-6-113, MCA
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