37.86.101    PHYSICIAN SERVICES, DEFINITIONS

(1) "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.

(2) "Physician services" means those services provided by individuals licensed under the State Medical Practice Act to practice medicine or osteopathy which, as defined by state law, are within the scope of their practice.

(3) "Usual and customary" means those charges that the billing physician would charge for a particular service in a majority of cases, including Medicaid and non-Medicaid patients.

(4) The department hereby adopts and incorporates by reference the definitions found in the introduction to Physicians Current Procedural Terminology, fourth edition (CPT4), published by the American Medical Association of Chicago, Illinois. These materials set forth meanings of terms commonly used by the Montana Medicaid program in implementation of the program's physician fee schedule. A copy of the definitions herein incorporated may be obtained through the Department of Public Health and Human Services, Health Resources Division, 1400 Broadway, P.O. Box 202951, Helena, MT 59620-2951.

(5) Payment-to-charge ratio means the percent determined by dividing the previous state fiscal year's total Medicaid reimbursement for RBRVS provider covered services as defined in ARM 37.85.212 by the previous state fiscal year's total Medicaid charges for RBRVS provider covered services. The effective date and payment-to-charge ratio are as provided in ARM 37.85.105(2).

History: 53-6-113, MCA; IMP, 53-6-101, 53-6-113, MCA; NEW, 1980 MAR p. 1747, Eff. 6/27/80; AMD, 1988 MAR p. 1255, Eff. 7/1/88; AMD, 1991 MAR p. 1030, Eff. 7/1/91; AMD, 1994 MAR p. 313, Eff. 2/11/94; TRANS, from SRS, 2000 MAR p. 481; AMD, 2012 MAR p. 2625, Eff. 1/1/13; AMD, 2014 MAR p. 1407, Eff. 7/1/14; AMD, 2014 MAR p. 2171, Eff. 10/1/14; AMD, 2015 MAR p. 145, Eff. 2/13/15; AMD, 2015 MAR p. 2092, Eff. 11/26/15; AMD, 2017 MAR p. 1522, Eff. 9/9/17.