Mont. Admin. R. 37.87.901 - MEDICAID MENTAL HEALTH SERVICES FOR YOUTH, REIMBURSEMENT
(1) Medicaid
reimbursement for mental health services will be the lowest of:
(a) the provider's actual (submitted) charge
for the service; or
(b) the rate
established in the department's fee schedule. Reimbursement fees are as
provided in ARM
37.85.105(6).
(2) For services for which
Medicare does not specify Relative Value Unit (RVU) as provided in ARM
37.85.212, the department
determines the Medicaid fee for children's mental health services as follows:
(a) if there is use resulting in Medicaid
reimbursements totaling at least $10,000 in a state fiscal year (SFY), and a
minimum of four separate providers have billed the code, then the Medicaid fee
is determined by multiplying the average charges by the payment-to-charge
ratio; or
(b) if there is use
resulting in Medicaid reimbursements totaling less than $10,000 in an SFY and
fewer than four separate providers have billed the code in an SFY, the Medicaid
fee will be determined by:
(i) reviewing
similar procedure codes within the same service scope and adjusting the rate to
be equal to a comparable procedure code or the average of similar procedure
codes if there is more than one; or
(ii) reviewing similar procedure codes within
the same service scope and adjusting the rate to be equal to a comparable
procedure code or the average of similar codes plus 10% when severity is higher
or increased resources are needed for the service. If the code is determined to
have a lower severity component or fewer resources are required than when
compared to the similar procedure code or average of similar procedure codes,
the rate will equal the comparable procedure code or average of similar
procedure codes less 10%.
Notes
AUTH: 53-2-201, 53-6-113, MCA; IMP: 53-2-201, 53-6-101, 53-6-111, MCA
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