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 37.55.702 - CONDITIONS OF CLAIM PAYMENT

(1) Payment of a claim will be made only when the amount payable by ESRD exceeds $20.

(2) Payment will be made, subject to (5) below, directly to the provider for that portion of the cost of eligible services or supplies which does not exceed either the amount allowed by medicare for the particular service or supply or the actual costs, whichever is less.

(3) Payment will be made only after all other reasonably available sources of payment, such as medicare or private insurance, have either paid in part or denied payment for the services or supplies.

(4) Payments for drugs will be made, subject to (5) below, only to the extent that the charges do not exceed the average wholesale price specified in the drug topics redbook for the specific drug. The department hereby adopts and incorporates by reference the most current version of the "Annual Pharmacists' Reference", referred to as the drug topics redbook which contains the average wholesale prices for most commercially available drugs. A copy of the drug topics redbook may be obtained from Drug Oradell, New York 07649. The average wholesale price for drugs used to treat end stage renal disease may be obtained from the Department of Public Health and Human Services, Health Policy and Services Division, ESRD Program, 1400 Broadway, P.O. Box 202951, Helena, MT 59620-2951.

(5) Benefit payments may not exceed $1000 per month per eligible claimant.