Administrative Rules of Montana
Department 37 - PUBLIC HEALTH AND HUMAN SERVICES
Chapter 37.86 - MEDICAID PRIMARY CARE SERVICES
Subchapter 37.86.30 - Outpatient Hospital Services
Rule 37.86.3001 - OUTPATIENT HOSPITAL SERVICES, DEFINITIONS

(1) "Ambulatory payment classification (APC)" means Medicare's ambulatory payment classification assignment groups of CPT or HCPCS codes.

(2) "Bad debt" means inpatient and outpatient hospital services provided in which full payment is not received from the patient or from a third party payor, for which the provider expected payment and the persons are unable or unwilling to pay their bill. Bad debts may be for services provided to patients who have no health insurance or patients who are underinsured and are net of payments made toward these services. For the purpose of uncompensated care, bad debt is measured on the basis of revenue forgone, at full established rates, and bad debt does not include either provider discounts or Medicare bad debt.

(3) "Birthing center" means a facility that provides comprehensive obstetrical care for women in which births are planned to occur away from the mother's usual residence following normal, uncomplicated, low risk pregnancy and is either:

(4) "Charity care" means inpatient and outpatient hospital services in which hospital policies determine the patient is unable to pay and did not expect to receive full reimbursement. Charity care results from a provider's policy to provide health care services free of charge (or where only partial payment is expected) to individuals who meet certain financial criteria. For the purpose of uncompensated care, charity care is measured on the basis of revenue forgone, at full established rates. Charity care does not include contractual write-offs.

(5) "Conversion factor" means a base rate initially calculated by CMS and used to translate APC relative weights into dollar payment rates.

(6) "Diagnostic service" means an examination or procedure performed on an outpatient or on materials derived from an outpatient to obtain information to aid in the assessment or identification of a medical condition.

(7) "Disproportionate share hospital-specific uncompensated care" means the costs of inpatient and outpatient hospital services provided to clients who have no health insurance or source of third-party coverage. (8) "Full-day partial hospitalization program" means a partial hospitalization program providing services at least six hours per day, five days per week.

(9) "Early elective delivery" means either a nonmedically necessary labor induction or cesarean section that is performed prior to 39 weeks and 0/7 days gestation.

(10) "Half-day partial hospitalization program" means a partial hospitalization program providing services for at least four but less than six hours per day, at least four days per week.

(11) "Healthcare common procedures coding system (HCPCS)" means the national uniform coding method maintained by the Centers for Medicare and Medicaid Services (CMS) that incorporates the American Medical Association (AMA) Physicians Current Procedural Terminology (CPT) and the three HCPCS unique coding levels, I, II, and III.

(12) "ICD-9-CM" means the International Classification of Diseases, Ninth Revision based on the official version of the United Nations World Health Organization's Ninth Revision, effective for dates of service or discharge date prior to and including September 30, 2015.

(13) "ICD-10-CM" means the International Classification of Diseases, Tenth Revision based on the official version of the World Health Organization's Tenth Revision for diagnosis coding, effective for dates of service or discharge date October 1, 2015 and thereafter.

(14) "Imaging service" means diagnostic and therapeutic radiology, nuclear medicine, CT scan procedures, magnetic resonance imaging services, ultra-sound, and other imaging procedures.

(15) "Lactation services" means support through breastfeeding education and consultations with certified lactation providers to increase the health of both mother and baby.

(16) "Outpatient" means a person who:

(17) "Outpatient hospital reimbursement adjustor (HRA)" means a payment to a Montana PPS hospital or critical access hospital as specified in ARM 37.86.3015.

(18) "Outpatient hospital services" means preventive, diagnostic, therapeutic, rehabilitative, or palliative services provided to an outpatient by or under the direction of a physician, dentist, or other practitioner as permitted by federal law, by an institution that:

(19) "Outpatient hospital utilization fee" means the utilization fee collected by the Department of Revenue as provided in 15-66-102, MCA.

(20) "Outpatient prospective payment system (OPPS)" means Medicare's outpatient prospective payment system mandated by the Balanced Budget Refinement Act of 1999 (BBRA) and the Medicare, Medicaid, SCHIP Benefits Improvement and Protection Act (BIPA) of 2000.

(21) "Outpatient revenue" means the gross revenue from a hospital's charges for services provided on an outpatient basis. Charges for professional services provided as part of an outpatient treatment are not included.

(22) "Partial hospitalization services" means an active treatment program that offers therapeutically intensive, coordinated, structured clinical services provided only to individuals who are determined to have a serious emotional disturbance or severe disabling mental illness. Partial hospitalization services are time-limited and provided within either an acute level program or a subacute level program. Partial hospitalization services include day, evening, night, and weekend treatment programs that employ an integrated, comprehensive, and complementary schedule of recognized treatment or therapeutic activities.

(23) "Prospective payment system (PPS) hospital" means a hospital reimbursed pursuant to the diagnosis related group (DRG) system. DRG hospitals are classified as such by the Centers for Medicare and Medicaid Services (CMS) in accordance with 42 CFR part 412.

(24) "Provider-based entity" means a provider that is either created by, or acquired by, a main provider for purposes of furnishing health care services under the name, ownership, and administrative and financial control of the main provider as in 42 CFR 413.65.

(25) "Uncompensated care" means hospital services provided in which no payment is received from the patient or from a third party payer. Uncompensated care includes charity care and bad debts.

(26) "Upper payment limit" means the federal limit placed on fee-for-service reimbursement of Medicaid providers.

(27) "340B drug pricing program" means a drug pricing program established under section 340B of the Veterans Health Care Act which offers outpatient pharmaceuticals at substantially reduced prices to qualified entities.