37.79.602    PROVISION OF BENEFITS

(1) The department may impose the following requirements in the provision of benefits:

(a) the use of certain types of providers to the extent allowed by law;

(b) prior authorization for benefits other than emergency services;

(c) directing an enrollee to the appropriate level of care for receipt of covered benefits; and

(d) denial of payment to a provider for benefits provided to an enrollee if the participation requirements in this rule are not met by the enrollee or the enrollee's parent, or guardian.

(2) An enrollee must use the HMK coverage group's TPA participating providers unless:

(a) the department authorizes a nonparticipating provider to provide a service; or

(b) the enrollee receives emergency services or emergency room screen.

(3) The TPA and participating providers must provide covered benefits as listed in this subchapter to enrollees in the same manner as those benefits are provided to any child who is not enrolled in the HMK Plan.

(4) The department will deny payment to any entity located outside of the United States (U.S.) for any items or services provided to an enrollee.

History: 53-4-1004, 53-4-1009, 53-4-1105, MCA; IMP, 53-4-1003, 53-4-1004, 53-4-1009, 53-4-1104, 53-4-1105, MCA; NEW, 2000 MAR p. 1221, Eff. 5/12/00; AMD, 2004 MAR p. 330, Eff. 2/13/04; AMD, 2008 MAR p. 48, Eff. 1/18/08; AMD, 2009 MAR p. 1673, Eff. 10/1/09; AMD, 2013 MAR p. 214, Eff. 2/15/13.