(1) The department adopts and incorporates by reference the Medicaid Adult Mental Health fee schedule as provided in ARM 37.85.105(5). A copy of the department's fee schedule is posted at the Montana Medicaid provider web site at www.dphhs.mt.gov/amdd/services/index.shtml. A copy may be obtained from the Department of Public Health and Human Services, Addictive and Mental Disorders Division, PO Box 202905, Helena, MT 59620-2905. Medicaid reimbursement for mental health center services will be the lowest of:
(a) the provider's actual (submitted) charge for the service; or
(b) the department's fee for the service as specified in the department's fee schedules.
(2) The provider reimbursement rate for a covered service for mental health centers is stated in the department's fee schedule adopted and effective at ARM 37.85.105(5). These fees are calculated based on:
(a) the biennial legislative appropriation; and
(b) the estimated demand for covered services during the biennium.
(3) For services for which Medicare does not specify Relative Value Unit as provided in ARM 37.85.105, the department determines the Medicaid fee for adult 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 procedure code, then the Medicaid fee is determined by multiplying the average charges by the payment-to-charge ratio;
(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 procedure code in an SFY, then 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 lesser severity component or fewer resources are required than when compared to the similar procedure code or average of similar procedure codes, the reimbursement rate will equal the comparable procedure code or average of similar procedure codes less 10%.