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. 

 

History: 53-2-201, 53-6-113, MCA; IMP, 53-6-101, 53-6-113, MCA; NEW, 1980 MAR p. 1765, Eff. 6/27/80; AMD, 1981 MAR p. 559, Eff. 6/12/81; AMD, 1981 MAR p. 1975, Eff. 1/1/82; AMD, 1982 MAR p. 1289, Eff. 7/1/82; AMD, 1989 MAR p. 859, Eff. 6/30/89; AMD, 1990 MAR p. 1479, Eff. 7/27/90; AMD, 1991 MAR p. 1040, Eff. 7/1/91; AMD, 1993 MAR p. 2819, Eff. 11/1/93; AMD, 1995 MAR p. 1218, Eff. 7/1/95; AMD, 1998 MAR p. 2168, Eff. 8/14/98; AMD, 1999 MAR p. 1379, Eff. 7/1/99; TRANS, from SRS, 2000 MAR p. 481; AMD, 2000 MAR p. 1664, Eff. 6/30/00; AMD, 2001 MAR p. 1119, Eff. 6/22/01; AMD, 2001 MAR p. 1183, Eff. 7/6/01; AMD, 2001 MAR p. 1476, Eff. 8/10/01; AMD, 2001 MAR p. 2156, Eff. 10/26/01; EMERG, AMD, 2002 MAR p. 2665, Eff. 9/27/02; AMD, 2003 MAR p. 1314, Eff. 7/1/03; AMD, 2003 MAR p. 1652, Eff. 8/1/03; AMD, 2006 MAR p. 1894, Eff. 7/28/06; AMD, 2007 MAR p. 1824, Eff. 11/9/07; AMD, 2008 MAR p. 1156, Eff. 7/1/08; AMD, 2009 MAR p. 145, Eff. 2/13/09; AMD, 2009 MAR p. 2029, Eff. 10/30/09; AMD, 2010 MAR p. 1533, Eff. 7/1/10; AMD, 2011 MAR p. 1384, Eff. 7/29/11; AMD, 2013 MAR p. 1111, Eff. 7/1/13; AMD, 2014 MAR p. 1405, 7/1/14; AMD, 2017 MAR p. 2287, Eff. 1/1/18; AMD, 2018 MAR p. 2057, Eff. 10/20/18.