Administrative Rules of Montana
Department 37 - PUBLIC HEALTH AND HUMAN SERVICES
Chapter 37.86 - MEDICAID PRIMARY CARE SERVICES
Subchapter 37.86.14 - Ambulatory Surgical Centers
Rule 37.86.1406 - CLINIC SERVICES, REIMBURSEMENT

(a) 100% of the Medicare allowable amount. For purposes of determining the Medicare allowable amount for ASC services to Medicaid members under this rule, the department adopts and incorporates by reference the methodology at 42 CFR part 416, subpart F, and the schedule listing the allowable amounts for ASC services in the Medicare Claims Processing Manual. The cited authorities are federal regulations and manuals specifying the methods and rules used to determine reasonable cost for purposes of the Medicare program. The Medicare Claims Processing Manual can be found on the Centers for Medicare and Medicaid website at www.cms.gov. The Code of Federal Regulations can be found at www.gpo.gov.

(b) For ASC services where no Medicare fee has been assigned, the fees will be set at the average Medicaid payment-to-charge ratio for all ASC services that have a Medicaid fee.

(c) Except as provided in (1)(d), the payment specified in (1)(a) or (1)(b) is an all inclusive bundled payment per procedure or service which shall be deemed to cover all outpatient services provided to the patient, including but not limited to nursing, pharmacy, laboratory, imaging services, other diagnostic services, supplies and equipment and other ASC services. For purposes of ASC surgery services, a visit shall be deemed to include all ASC services related or incident to the ambulatory surgery visit that are provided the day before or the day of the ambulatory surgery event.

(d) Physician services are separately billable according to the applicable Medicaid rules governing billing for physician services.

(e) When multiple procedures are performed at the same time on the same patient, the first procedure listed shall be paid as provided at (1)(a) or (1)(b) as appropriate. Subsequent procedures shall be paid at 50% of the amount provided at (1)(a) or (1)(b) as appropriate.