Administrative Rules of Montana
Department 37 - PUBLIC HEALTH AND HUMAN SERVICES
Chapter 37.86 - MEDICAID PRIMARY CARE SERVICES
Subchapter 37.86.1 - Physician Services
Rule 37.86.105 - PHYSICIAN SERVICES, REIMBURSEMENT/GENERAL REQUIREMENTS AND MODIFIERS

(1) Providers must bill for services using the procedure codes and modifiers set forth, and according to the definitions contained, in the Centers for Medicare and Medicaid Services' (CMS) Healthcare Common Procedure Coding System (HCPCS). Information regarding billing codes, modifiers, and HCPCS is available upon request from the Health Resources Division at the address stated in ARM 37.86.101(3).

(2) Reimbursement for physician services, except as otherwise provided in this rule, is the lower of:

(3) Reimbursement for services of a psychiatrist, except as otherwise provided in this rule, is the lower of:

(4) Reimbursement to physicians for physician-administered drugs billed under HCPCS "A", "J", "Q", or "S" codes will be paid according to the department's fee schedule or the provider's usual and customary charge, whichever is lower. The department's fee schedule is updated at least annually based upon:

(5) Physician administered compound drugs must be billed with the associated HCPCS; an invoice is required to be attached. The invoice must list each ingredient in the compound with the associated NDCs, and the quantity of each ingredient. Physician administered compound drugs are paid by invoice.

(6) The maximum allowable cost limitation does not apply in those cases where the physician certifies in their own handwriting that in their medical judgment a specific brand name drug is medically necessary for a particular patient. Acceptable certification statements are "brand necessary" or "brand required." A check-off box on a form or a rubber stamp is not acceptable.

(7) Reimbursement rates for adult and children vaccines are extracted from the Private/Sector Cost/Dose fee schedule maintained by the Center for Disease Control (CDC). Private sector vaccine pricing are reported by vaccine manufacturers annually to the CDC.

(8) A Medicaid fee for services without fees is determined for physician services and anesthesia services as defined at ARM 37.85.212 and licensed direct-entry midwife services as defined at ARM 37.86.1201.

(9) Claims for child delivery must have one of the following line procedure code modifiers or the line will be denied:

(10) The maternity policy adjustor is not applied to early elective delivery.

(11) Gestational age must be determined and documented in medical records. The department accepts the following American Congress of Obstetricians and Gynecologists guidelines for determining gestational age: