(1) Providers of services may request enrollment in the plan and may participate in the plan only upon approval of enrollment and according to the written provider agreement between the provider and the department and the requirements of this subchapter.

(a) The provisions of ARM 37.85.402 shall apply for purposes of provider enrollment in the plan. Providers must enroll with the department's Medicaid fiscal agent in the same manner and according to the same requirements applicable under the Montana Medicaid Program. The department may accept current Medicaid enrollment for purposes of enrollment under the plan, if the provider agrees, in a form acceptable to the department, to be bound by applicable plan requirements.

(b) For purposes of enrollment in the plan, providers must be and remain enrolled in the Montana Medicaid Program for the same category of service and must meet the same qualifications and requirements that apply to the provider's category of service under the Montana Medicaid Program.

(2) Providers in the following categories may request enrollment in the plan:

(a) licensed mental health centers;

(b) psychiatrists;

(c) physicians;

(d) mid-level practitioners as defined in ARM 37.86.202;

(e) licensed psychologists employed by a mental health center;

(f) licensed clinical social workers employed by a mental health center;

(g) licensed professional counselors employed by a mental health center;

(h) outpatient pharmacies;

(i) labs; and

(j) rural health clinics and federally qualified clinics as defined in 42 CFR 491.

(3) The department may, in its discretion, enroll as providers individuals or entities in the categories of providers specified in (2) if they apply for enrollment, if they are appropriately licensed, certified, or otherwise meet the minimum qualifications required by the department for the category of service, and if they agree to the terms of the provider agreement.

(a) Nothing in these rules requires the department to enroll any particular provider or category of provider to provide services under the plan. The department, in its discretion, may deny enrollment to any provider or category of provider. The department may, in its discretion, limit services, rates, eligibility or the number of persons determined eligible under the plan based upon such factors as availability of funding, the degree of financial need, the degree of medical need or other factors.

(i) If the department determines with respect to the plan that it is necessary to reduce, limit, suspend or terminate eligibility or benefits, reduce provider reimbursement rates, reduce or eliminate service coverage or otherwise limit services, benefits or provider participation, in a manner other than provided in this subchapter, the department may implement such changes by providing ten days advance notice published in Montana major daily newspapers with statewide circulation, and by providing:

(A) ten days advance written notice of any individual eligibility and coverage changes to affected members; and

(B) ten days advance written notice of coverage, rate and provider participation changes to affected providers.

(b) A provider who is denied enrollment has no right to an administrative review or fair hearing as provided in ARM 37.5.304, et seq. or any other department rule.

(c) Enrollment does not imply or create any guarantee of or right to any level of utilization or reimbursement for any provider.

(4) The provisions of ARM Title 37, chapter 85, subchapter 4 and other Medicaid program laws, rules, and regulations regarding particular categories of service apply to participating providers and the services provided under the plan, except as specifically provided in this subchapter or the provider agreement.

(a) The provisions of ARM 37.85.414 regarding maintenance of records and related issues apply to providers of mental health services under the plan.

(i) The department and any legally authorized agency of the state or federal government may inspect any facilities and records pertaining to services provided under the plan, including those of any provider participating in the plan.

(ii) Upon request, providers must provide complete copies of medical records to the department or its agents.

(b) For all members, providers must comply with the same confidentiality requirements that apply to information regarding Medicaid recipients.

(c) The department may collect from a provider any overpayment under the plan as provided with respect to Medicaid overpayments in ARM 37.85.406(9) through (10)(b). The department may recover overpayments by withholding or offset as provided in ARM 37.85.513.

(i) The notice and hearing provisions of ARM 37.5.310 and 37.85.512 apply to a department overpayment determination under (4)(c).

(d) The department may sanction a provider based upon the same grounds that sanctions may be imposed against a provider under the Montana Medicaid Program, except that a sanction may not be imposed with respect to a provider's conduct or omission under the plan based upon a Medicaid requirement or prohibition that is not applicable to the plan under these rules.

(i) Sanctions imposed under (4)(d) may include termination or suspension from plan participation and required attendance at provider education sessions at the provider's expense.

(ii) The department must consider the factors listed in ARM 37.85.505 in determining whether to impose a sanction and what sanction, if any, to impose. The provisions of ARM 37.85.506 and 37.85.507 shall apply to any sanction imposed under (4)(d).

(iii) The notice and hearing provisions of ARM 37.5.310 and 37.85.512 apply to a department sanction determination under (4)(d).

(5) An enrolled provider has no right to an administrative review or fair hearing as provided in ARM Title 37, chapter 5, 37.85.411 or any other department rule for:

(a) a determination by the department or its agent that a particular service, item or treatment is not medically necessary;

(b) a denial of approval, authorization, certification or coverage of a service available from the provider or provided by the provider to a member; or

(c) any other issues related to the provider agreement, the provision of services to recipients or the plan, except as specifically permitted by this subchapter.

(6) An enrolled provider shall be provided an opportunity for administrative review and fair hearing as provided in ARM 37.5.310 to contest a denial of correct payment by the department to the provider for a service provided to a member if:

(a) the department has determined that the particular service, including the amount, duration and frequency of the service, is medically necessary for the member to treat a covered diagnosis and has authorized the particular service for the member according to applicable requirements; and

(b) the department has determined that the member is eligible for the plan according the requirements of ARM 37.89.106.

(7) For purposes of applying the provisions of any Medicaid rule as required by this subchapter, references in the Medicaid rule to "Medicaid" or the "Montana Medicaid Program" or similar references, shall be deemed to apply to the plan as the context permits.

History: 2-4-201, 41-3-1103, 53-2-201, 53-6-113, 53-21-703, MCA; IMP, 2-4-201, 41-3-1103, 53-1-601, 53-1-602, 53-1-603, 53-2-201, 53-6-113, 53-6-116, 53-6-701, 53-6-705, 53-21-202, 53-21-701, 53-21-702, MCA; NEW, 1997 MAR p. 548, Eff. 3/25/97; AMD, 1999 MAR p. 1809, Eff. 7/1/99; TRANS, from SRS, 2001 MAR p. 27; EMERG, EMERG, AMD, 2002 MAR p. 3423, Eff. 12/13/02; AMD, 2003 MAR p. 653, Eff. 3/28/03; AMD, 2008 MAR p. 1988, Eff. 9/12/08; AMD, 2011 MAR p. 322, Eff. 3/11/11.