Administrative Rules of Montana
Department 37 - PUBLIC HEALTH AND HUMAN SERVICES
Chapter 37.86 - MEDICAID PRIMARY CARE SERVICES
Subchapter 37.86.50 - Health Maintenance Organizations (HMO)
Rule 37.86.5013 - HEALTH MAINTENANCE ORGANIZATIONS: REIMBURSEMENT OF PROVIDERS

(1) An HMO must reimburse a federally qualified health center or a rural health clinic which is a participating provider either the same payment per enrollee or service made to other primary care providers or the facility specific medicaid interim rate for each enrollee visit.

(2) An HMO need not reimburse, except as otherwise provided in this rule, claims for medically necessary services provided by non-participating providers if the same service is covered by the HMO under its contract with the department.

(3) An HMO must reimburse medically necessary family planning services as defined in ARM 37.86.5007(3) provided by a nonparticipating family planning provider to an enrollee who sought the services without referral.

(4) An HMO must reimburse immunizations and blood lead testing provided by a public health clinic to an enrollee.

(5) An HMO must reimburse nonparticipating providers for services for urgent conditions, emergencies or emergency room screenings provided to an enrollee.

(6) An HMO, owned, controlled or sponsored by or affiliated with a religious organization, must reimburse a covered service received by an enrollee that the HMO does not make available due to the service constituting a violation of the religious tenets of the organization, to which the HMO is related.

(7) An HMO is not responsible for reimbursement of the disproportionate share payments for inpatient hospital services provided to an enrollee.

(8) An HMO must reimburse services for an urgent condition, emergency or emergency room screens in an amount that is not less than the department's medicaid rates for those services.