Current through Register Vol. 18, September 20, 2024
(1) Reimbursement for inpatient hospital
services is set forth in ARM
37.86.2806,
37.86.2905,
37.86.2907,
37.86.2912,
37.86.2916,
37.86.2918,
37.86.2920,
37.86.2924,
37.86.2925,
37.86.2928,
37.86.2943, and
37.86.2947. Reimbursement for
outpatient hospital services is set forth in ARM
37.86.3005,
37.86.3006,
37.86.3007,
37.86.3009,
37.86.3014,
37.86.3016,
37.86.3018,
37.86.3020,
37.86.3022,
37.86.3025,
37.86.3037, and
37.86.3109. Cost of hospital
services will be determined for inpatient and outpatient care separately.
Administratively necessary days are not a benefit of the Montana Medicaid
program.
(2) The department may
require providers of inpatient or outpatient hospital services to obtain
authorization from the department or its designated review organization either
prior to provision of services, prior to admission, or prior to
payment.
(3) Medicaid reimbursement
shall not be made or shall be reduced unless the provider has obtained
authorization from the department or its designated review organization prior
to providing any of the following services:
(a) inpatient psychiatric services provided
in an acute care psychiatric hospital, acute care general hospital or a
distinct part psychiatric unit of an acute care general hospital, and
outpatient partial hospitalization as required by ARM
37.88.101:
(i) if prior authorization is not obtained,
the claim will be denied;
(ii)
Medicare crossover claims do not need prior authorization; and
(iii) third party liability claims must be
prior authorized.
(b)
services related to transplantations covered under ARM
37.86.4701 and
37.86.4705:
(i) if prior authorization is not obtained,
the claim will be denied;
(ii)
Medicare crossover claims must be prior authorized; and
(iii) third party liability claims must be
prior authorized.
(c)
any other services for specific diagnosis or procedures that require all
Medicaid providers to obtain prior authorization:
(i) if prior authorization is not obtained,
the claim will be denied;
(ii)
Medicare crossover claims must be prior authorized; and
(iii) third party liability claims must be
prior authorized.
(d)
inpatient services in facilities designated as a Center of Excellence and all
out-of-state facilities:
(i) if prior
authorization is not obtained, reimbursement of the inpatient claim will be 50%
of the amount calculated in (1); except in claims subject to (3)(a), (b), and
(c) will be denied;
(ii) Medicare
inpatient crossover claims do not need prior authorization except claims
subject to (3)(b) and (c); and
(iii) inpatient third party liability claims
must be prior authorized:
(A) if prior
authorization is not obtained, reimbursement of the inpatient third party
liability claim will be 50% of the amount calculated in (1); except claims
subject to (3)(a), (b), and (c) will be denied.
(4) Upon request, the department
may grant retroactive authorization for the provision of the hospital's
services when:
(a) the person to whom
services were provided was determined by the department to be retroactively
eligible for Montana Medicaid benefits including hospital benefits;
(b) the hospital can document that at the
time of admission it did not know, or have any basis to assume, that the client
was Montana Medicaid eligible;
(c)
the hospital can document that the admission was medically necessary for
purposes of emergency stabilization or stabilization for transfer;
(d) interim claims in a PPS hospital equal to
or greater than 30 days of continuous inpatient services at the same facility;
or
(e) the hospital is
retroactively enrolled as a Montana Medicaid provider, and the enrollment
includes the dates of service for which authorization is requested provided the
hospital's retroactive enrollment is completed allowing time for the hospital
to obtain prior authorization and to submit a clean claim within timely filing
deadlines in accordance with ARM
37.85.406.
(5) For purposes of (4)(a), (b), and (c) the
hospital must call for authorization within three working days (Monday through
Friday) of the admission or the date it gained knowledge of the client's
Medicaid eligibility and must meet the requirements for timely filing as
specified in ARM 37.85.406:
(a) the basis for
the request must be documented in the client's hospital record; and
(b) providers seeking retroactive
authorization for adult mental health claims must submit their requests in
writing.
(6) The
department or its designated review organization may approve a request for
prior authorization when the service is medically necessary under any of the
following conditions:
(a) the client travels
to another state because the department finds the required inpatient services
are not available in Montana, or it is determined by the department that it is
general practice for clients in a particular locality to use inpatient
resources in a border hospital, or an in-state qualified provider who could
normally render the inpatient service but does not think they can adequately
treat the client;
(b) there is a
medical emergency and the recipient's health would be endangered if the client
were required to travel to Montana to obtain the medical services;
(c) the client, or the client's
representative, can demonstrate to the satisfaction of the department that
medical services represent the least costly service and all other viable
alternatives have been exhausted per medical standards of care; or
(d) the client is a child residing in another
state for whom Montana makes adoption assistance or foster care maintenance
payments.
(7) Medicaid
reimbursement for early elective delivery and nonmedically necessary cesarean
sections will not be made unless the hospital submitting the claim meets the
following requirements:
(a) Effective July 1,
2014, a hospital submitting claims for deliveries must have a hard stop policy
regarding early elective deliveries and nonmedically necessary cesarean
sections that complies with the requirements in ARM
37.86.2902(9).
(b) Effective October 1, 2014, hospital
claims for inductions and cesarean sections must meet the following coding
requirements:
(i) current ICD inpatient
procedure codes must be used on all inpatient hospital claims; and
(ii) claims for inductions or cesarean
sections must have one of the following condition codes:
(A) Condition Code 81&-cesarean section
or induction performed at less than 30 weeks for medical necessity;
(B) Condition Code 82-cesarean section or
induction performed at less than 39 weeks gestation elective; or
(C) Condition Code 83-cesarean section or
induction performed at 39 weeks gestation or greater.
(iii) The department will begin accepting
these coding changes as of July 1, 2014.
(c) Beginning October 1, 2014, the department
will reduce reimbursement to hospitals that perform early elective inductions
or cesarean sections prior to 39 weeks and 0/7 days gestation, or nonmedically
necessary cesarean sections at any gestation:
(i) a 33% reduction in PPS reimbursement;
or
(ii) cost-based hospital interim
reimbursement will be reduced 33% and the total claim payment will not be
eligible for final reimbursement through cost settlement as provided in ARM
37.86.2806.
(8) All hospitals must use current ICD
procedure codes for inpatient claims and current CPT codes for outpatient
claims, including Medicare crossover claims.
2-4-201,
53-2-201,
53-6-113,
MCA; IMP,
2-4-201,
53-2-201,
53-6-101,
53-6-111,
53-6-113,
53-6-141,
MCA;
