Administrative Rules of Montana
Department 37 - PUBLIC HEALTH AND HUMAN SERVICES
Chapter 37.86 - MEDICAID PRIMARY CARE SERVICES
Subchapter 37.86.29 - Inpatient Hospital Services
Rule 37.86.2947 - OUT-OF-STATE HOSPITAL AND CENTERS OF EXCELLENCE REIMBURSEMENT

Universal Citation: MT Admin Rules 37.86.2947

Current through Register Vol. 18, September 20, 2024

(1) Inpatient hospital services provided in border hospitals will be reimbursed under the APR-DRG prospective payment system described in ARM 37.86.2905, 37.86.2907, 37.86.2912, 37.86.2916, 37.86.2918, and 37.86.2920.

(2) Medicaid reimbursement for inpatient services shall not be made to hospitals located more than 100 miles outside the borders of Montana or Centers of Excellence unless the provider has obtained authorization from the department or its designated review organization prior to providing services or prior to admission. All inpatient services provided in an emergent situation must be authorized as described in ARM 37.86.2801(4)(d).

(a) Should prior authorization not be obtained, reimbursement will be 50% of the amount as calculated in ARM 37.86.2905, 37.86.2907, 37.86.2912, 37.86.2916, 37.86.2918, and 37.86.2920 for services determined to be medically necessary.

(3) A Center of Excellence is an out-of-state or border acute care medical hospital as defined in ARM 37.86.2901 that:

(a) provides through its main hospital or on-site affiliate all specialty and subspecialty medical care; and
(i) has a medical school affiliation; or

(b) provides a specialized medical service not available elsewhere; and
(i) has a medical school affiliation; and

(ii) conducts bench to bedside research.

53-2-201, 53-6-113, MCA; IMP, 53-2-201, 53-6-101, 53-6-111, 53-6-113, MCA;

Disclaimer: These regulations may not be the most recent version. Montana may have more current or accurate information. We make no warranties or guarantees about the accuracy, completeness, or adequacy of the information contained on this site or the information linked to on the state site. Please check official sources.
This site is protected by reCAPTCHA and the Google Privacy Policy and Terms of Service apply.