37.89.125 MENTAL HEALTH SERVICES PLAN, PROVIDER REIMBURSEMENT

(1) Reimbursement of enrolled providers for mental health services covered under the plan and provided to plan members is as provided in ARM 37.40.307, 37.85.212, and Title 37, chapters 86 and 88 for the same service or category of service under the Montana Medicaid Program, except as otherwise provided in this subchapter.

(a) For services covered under the plan, reimbursement under the plan is subject to the same requirements, restrictions, limitations, rates, fees and other provisions that would apply to the service if it were provided to a Medicaid person, except as otherwise provided in these rules. However, if a service is not covered under the plan, the fact that the service is or would be covered by Medicaid if provided to a Medicaid person, does not entitle the provider, member, or any other person or entity to coverage or reimbursement of the service under the plan.

(i) For purposes of applying Medicaid rules to plan services, a person eligible for the plan under ARM 37.89.106 need not be Medicaid eligible.

(2) Provider claims for mental health services provided by the following provider types to members under the plan must be submitted to the department's Medicaid Management Information System (MMIS) contractor according to requirements set forth in ARM 37.85.406. Payments will be made to the provider through the department's Medicaid MMIS contractor:

(a) psychiatrists;

(b) physicians;

(d) outpatient pharmacies;

(e) labs; and

(f) rural health clinics and federally qualified health clinics.

(3) Licensed mental health centers contracted with the department for mental health center services to adults enrolled in the plan will be reimbursed according to the provisions of their contract.

(4) Providers must accept the amounts payable under this rule as payment in full for services provided to members. For purposes of this rule, the requirements of ARM 37.85.406 regarding payment in full apply to the provider, except as provided in this subchapter.

(a) Providers may bill a member who fails to show up for a scheduled service if such billing is consistent with a written policy maintained and posted by the provider, if the member has been informed of the policy in writing and if the policy applies equally to private pay patients and members.

(5) The provisions of ARM 37.85.407 apply with respect to third party resources and seeking payment from these sources.

(6) The provider reimbursement rate for services under the Mental Health Services Plan is stated in the department's fee schedule as provided in ARM 37.85.104. These fees are calculated based on:

(a) the biennial legislative appropriation; and

(b) the estimated demand for covered demand for covered services during the biennium.

History: 53-2-201, 53-6-113, 53-21-703, MCA; IMP, 53-1-601, 53-2-201, 53-6-101, 53-6-116, 53-6-701, 53-6-705, 53-21-202, 53-21-702, MCA; NEW, 1997 MAR p. 548, Eff. 3/25/97; AMD, 1999 MAR p. 355, Eff. 3/1/99; AMD, 1999 MAR p. 1301, Eff. 7/1/99; TRANS & AMD, from SRS, 2001 MAR p. 27, Eff. 1/12/01; AMD, 2002 MAR p. 3423, Eff. 12/13/02; AMD, 2011 MAR p. 322, Eff. 3/11/11; AMD, 2011 MAR p. 1394, Eff. 7/29/11; AMD, 2013 MAR p. 1111, Eff. 7/1/13.