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Rule Title: 72-HOUR PRESUMPTIVE ELIGIBILITY FOR ADULT CRISIS STABILIZATION SERVICES: CLAIMS AND REIMBURSEMENT
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Department: PUBLIC HEALTH AND HUMAN SERVICES
Chapter: MENTAL HEALTH SERVICES
Subchapter: 72-Hour Presumptive Eligibility for Adult Crisis Stabilization Services
 
Latest version of the adopted rule presented in Administrative Rules of Montana (ARM):

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37.89.509    72-HOUR PRESUMPTIVE ELIGIBILITY FOR ADULT CRISIS STABILIZATION SERVICES: CLAIMS AND REIMBURSEMENT

(1) All provider claims for crisis stabilization services delivered under this subchapter 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.

(2) Providers must accept the amounts payable under this subchapter as payment in full for services delivered to eligible individuals.

(3) The provisions of ARM 37.85.407 apply with respect to third party resources and seeking payment from those sources. Providers are responsible for due diligence to identify and bill other payment sources.

(4) Reimbursement for crisis stabilization services delivered under this subchapter is subject to post payment review and audit by the department, including record management and audit as provided in ARM 37.85.414.

(5) The department may collect from a provider any payment under this subchapter as provided with respect to Medicaid overpayments in ARM 37.85.406(9) through (10)(b).

(6) The department may recover overpayments by withholding or offset as provided in ARM 37.85.513(1).

(7) Services delivered to individuals experiencing a crisis may not be reimbursed if:

(a) they are delivered to an individual within seven days following discharge from crisis stabilization services delivered by this or another provider;

(b) the services delivered were not approved for reimbursement by the department; or

(c) the provider is not enrolled with the department.

(8) If reimbursement is denied because services were delivered to an individual within seven days following discharge from crisis stabilization services delivered by another provider, the provider may request a review to determine whether payment is warranted. A written request for review must be received by the Department of Public Health and Human Services, Addictive and Mental Disorders Division, P.O. Box 202905, Helena, MT 59620-2905 within 30 days after the date of a notice denying a claim. The department will conduct an informal administrative review and may grant full or partial reimbursement for services if it determines that:

(a) complications have arisen because of premature discharge, treatment errors, or omissions in the previous crisis stabilization plan;

(b) the crisis stabilization services are for a condition that could not have been treated during the previous crisis stabilization plan; or

(c) the provider could not have discovered the previous stabilization plan using due diligence.

History: 53-6-101, 53-6-113, MCA; IMP, 53-6-101, MCA; NEW, 2008 MAR p. 1489, Eff. 4/11/08; AMD, 2015 MAR p. 2283, Eff. 12/25/15.


 

 
MAR Notices Effective From Effective To History Notes
37-724 12/25/2015 Current History: 53-6-101, 53-6-113, MCA; IMP, 53-6-101, MCA; NEW, 2008 MAR p. 1489, Eff. 4/11/08; AMD, 2015 MAR p. 2283, Eff. 12/25/15.
37-429 4/11/2008 12/25/2015 History: 53-6-101, 53-6-113, MCA; IMP , 53-6-101, MCA; NEW , 2008 MAR p. 1489, Eff. 4/11/08.
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