Current through Register Vol. 18, September 20, 2024
(1) These requirements are in addition to
those rule provisions generally applicable to Medicaid providers.
(2) The department or its designated review
organization may conduct utilization and peer review of physician
services.
(3) Physician services
for conditions or ailments that are generally considered cosmetic in nature are
not a benefit of the Medicaid program except in such cases where it can be
demonstrated that the physical and psycho-social well being of the recipient is
severely affected in a detrimental manner by the condition or ailment. Such
services must be prior authorized by the Medicaid services bureau, based on
recommendations of the designated peer review organization.
(a) A request for prior authorization must
include all relevant information to justify the need for the service. This
information includes statements from a physician qualified in the area of
concern and a potential provider.
(b) The information must clearly document the
necessity for the service and include assurances that the plan will be followed
to completion.
(4)
Coverage of physician services for sterilization is limited as follows:
(a) The recipient to be sterilized must not
be declared mentally incompetent by a federal, state, or local court of
law.
(b) The recipient to be
sterilized must be 21 years of age or older at the time informed consent to
sterilization is obtained from the recipient.
(c) The recipient to be sterilized must not
be institutionalized in a corrective, penal, mental, or rehabilitative
facility.
(5) Physician
services for sterilization must meet the following requirements in order to
receive Medicaid reimbursement:
(a) The
recipient to be sterilized must give informed consent, in accordance with the
Medicaid approved informed consent to sterilization form, not less than 30 days
nor more than 180 days prior to sterilization except in the case of premature
delivery or emergency abdominal surgery. For these exceptions, at least 72
hours must pass between informed consent and the sterilization procedure. In
cases of premature delivery, informed consent must be given at least 30 days
before the expected delivery date.
(b) The recipient to be sterilized, the
person who obtained the consent, and the interpreter (if required) must sign
the informed consent form at least 30 days but not more than 180 days prior to
the sterilization. The physician performing the sterilization must sign and
date the informed consent form after the sterilization has been
performed.
(c) A copy of the
informed consent to sterilization form must be attached to the Medicaid claim
when billing for sterilization procedures.
(6) Coverage of physician services for
hysterectomies is limited as follows:
(a) The
surgery must not be solely for the purpose of rendering the recipient incapable
of reproducing; and
(b) The surgery
must be medically necessary to treat injury or pathology.
(7) Physician services for hysterectomies
must meet the following requirements in order to receive Medicaid
reimbursement:
(a) The physician must inform
the recipient that the hysterectomy will render her permanently incapable of
reproducing;
(b) A completed copy
of the approved acknowledgment of receipt of hysterectomy information form must
be attached to the Medicaid claim when billing for hysterectomy
services;
(c) In a case where the
recipient is sterile before the hysterectomy or there is a life-threatening
emergency that precludes the recipient from giving prior acknowledgment of
receipt of hysterectomy information, the requirements in (7)(a) and (7)(b) do
not apply. Instead, the physician who performed the hysterectomy either:
(i) must certify in writing that the
recipient was sterile before the hysterectomy and state the cause of sterility;
or
(ii) must certify in writing
that the hysterectomy was performed during a life-threatening emergency
situation that precluded the recipient from giving prior acknowledgment of
receipt of hysterectomy information and gives a description of the nature of
the emergency.
(8) Coverage of physician services for
abortions is limited as follows:
(a) the life
of the mother will be endangered if the fetus is carried to term;
(b) the pregnancy is the result of an act of
rape or incest; or
(c) to the
extent required by statute, when an abortion is a medically necessary service,
even if the abortion does not meet the standard in (8)(a) and (9).
(9) Physician services for
abortions, in a case of endangerment of the mother's life, must meet the
following requirements in order to receive Medicaid reimbursement:
a) The physician must find, and certify in
writing, that in the physician's professional judgement, the life of the mother
will be endangered if the fetus is carried to term. The certification must
contain the name and address of the patient and must be on or attached to the
Medicaid claim.
(10)
Physician services for abortions in cases of pregnancy resulting from an act of
rape or incest must meet the following requirements in order to receive
Medicaid reimbursement:
(a) the recipient
certifies in writing that the pregnancy resulted from an act of rape or incest;
and
(b) the physician certifies in
writing either that:
(i) the recipient has
stated to the physician that she reported the rape or incest to a law
enforcement or protective services agency having jurisdiction over the matter,
or if the recipient is a child enrolled in a school, to a school counselor;
or
(ii) in the physician's
professional opinion, the recipient was and is unable for physical or
psychological reasons to report the act of rape or incest.
(11) Abortion is a medically
necessary service and eligible for coverage under the Montana Medicaid program
when:
(a) a woman suffers from a physical
disorder, physical injury, or physical illness, including a life-endangering
physical condition caused by or arising from the pregnancy itself, that would,
as certified by a physician, place the woman in danger of death unless an
abortion is performed; or
(b)
although it does not place the woman in danger of death unless an abortion is
performed, a woman suffers from:
(i) a
physical condition that would, as certified by a physician, be significantly
aggravated by the pregnancy; or
(ii) a psychological condition that would, as
certified by a physician, be significantly aggravated by the
pregnancy.
(12) Physician services for abortions require
prior authorization. If prior authorization is not obtained, due to an
emergency situation or otherwise, a claim for payment for such physician
services will undergo post-service, prepayment review. The request for prior
authorization or the claim for payment must be accompanied by a completed and
signed Physician Certification for Abortion Services Form (MA-037
form).
(13) Supporting
documentation must be submitted for abortions covered under (8)(a) or (c). The
following documentation must be submitted with the prior authorization request
or with any claim for payment for which prior authorization was not received to
support the determination of medical necessity:
(a) History and Physical, which should
include (at a minimum) as it relates to the pregnancy:
(i) medical history, including age, current
medications and allergies, number of times the patient has been pregnant and
number of times she has had a live birth, last menstrual period, status and
results of any pregnancy test, allergies, chronic illnesses, surgeries,
behavioral health issues, smoking, substance abuse, and obstetric
history;
(ii) brief review of
systems to identify symptoms a patient may be experiencing;
(iii) the results of a physical examination,
including vital signs, heart, lungs, abdomen, extremities, and estimate of
gestational age (if imaging is not available);
(iv) results of laboratory tests (if
available), including Rh factor, Hemoglobin, and Human Chorionic
Gonadotropin;
(v) imaging (if
available), to estimate gestational age;
(vi) documentation that the diagnosis of the
physical or psychological condition leading to the medical necessity
determination has been made by a medical professional qualified by education,
training, and/or experience to make such diagnosis and that the woman is
receiving care for such condition;
(vii) reason for the abortion
procedure;
(viii) for
medication/chemical abortions, documentation confirming review of
contraindications, adequate patient education, and compliance with the
requirements of the Physician-Related Services Manual;
(ix) treatment plan; and
(x) signed informed consent for the proposed
abortion procedure.
(14) Physician services for abortions must be
performed by a physician as defined in
37-3-102, MCA.
(15) Prior authorization is not required for
treatments for incomplete abortions, miscarriages, or septic
abortions.
(16) Physician services
for routine podiatric care and orthotics must be in accord with the definitions
of ARM 37.86.501 and meet the requirements of ARM 37.86.505.
(17) The department adopts and incorporates
by reference the Physician-Related Services Manual governing the administration
of the Physician program dated December 1, 2017. The Physician-Related Services
Manual is available for public viewing at the Department of Public Health and
Human Services, Health Resources Division, 1400 Broadway, P.O. Box 202951,
Helena, MT 59620-2951 and at the department's web site at
http://medicaidprovider.mt.gov.
AUTH:
53-2-201,
53-6-113, MCA; IMP:
53-2-201,
53-6-101,
53-6-111,
53-6-113,
53-6-141,
MCA
