Administrative Rules of Montana
Department 37 - PUBLIC HEALTH AND HUMAN SERVICES
Chapter 37.55 - END STAGE RENAL DISEASE (ESRD)
Subchapter 37.55.7 - Claims Procedures and Payments
Rule 37.55.701 - DOCUMENTATION OF CLAIMS

Universal Citation: MT Admin Rules 37.55.701

Current through Register Vol. 18, September 20, 2024

(1) A claim for ESRD reimbursement, in order to be reimbursable, must contain, or be accompanied by, the documentation required by this rule.

(2) Each claim for any reimbursable service or supply must contain:

(a) the patient's name and address; and

(b) the provider's federal tax identification number.

(3) A physician service claim must be:

(a) submitted and itemized on a completed universal health insurance claim form approved by the American medical association's council on medical services; and

(b) have a completed medicare EOB and an EOB from any private insurance which the patient might have which covers the service in question attached.

(4) A hospital service claim (inpatient or outpatient) must be:

(a) submitted on the universal hospital insurance form approved by the health insurance association of America and accepted for hospital use by the American hospital association; and

(b) have an itemized statement, medicare EOB, and an EOB from any private insurance which the patient might have which covers the service in question attached.

(5) A claim for dialysis supplies must have an itemized statement from the supplier, proper invoice numbers, medicare EOB's and the EOB's from any private insurance which the patient might have which covers purchase of the supplies in question attached.

(6) A drug/pharmacy claim must be submitted on the medicaid MA-5 form or, in the case of a hospital pharmacy, the MA-5 form or the appropriate medicare form.

(7) A claim for any ESRD-eligible service or supply other than one of those listed in (2) through (5) above must be submitted with an itemized statement or bill, plus a medicare EOB.

Sec. 50-44-102 and 53-6-202, MCA; IMP, Sec. 50-44-102 and 53-6-202, MCA;

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