37.86.3007    OUTPATIENT HOSPITAL SERVICES, PROSPECTIVE PAYMENT METHODOLOGY, CLINICAL DIAGNOSTIC LABORATORY SERVICES

(1) Clinical diagnostic laboratory services, including automated multichannel test panels (commonly referred to as "ATPs") and lab panels, will be reimbursed on a fee basis as follows with the exception of hospitals reimbursed under ARM 37.86.3005 and specific lab codes which are paid under ARM 37.86.3020:

(a) The fee for a clinical diagnostic laboratory service is the applicable percentage of the Medicare fee schedule as follows:

(i) 60% of the prevailing Medicare fee schedule for a birthing center or where a hospital laboratory acts as an independent laboratory, i.e., performs tests for persons who are nonhospital patients;

(ii) 62% of the prevailing Medicare fee schedule for a hospital designated as a sole community hospital as defined in ARM 37.86.2901; or

(iii) 60% of the prevailing Medicare fee schedule for a hospital that is not designated as a sole community hospital as defined in ARM 37.86.2901.

(b) For clinical diagnostic laboratory services where no Medicare fee has been assigned, but a Medicaid fee has been assigned, the fee is the amount set in ARM 37.85.212; or

(c) if there is no Medicare or Medicaid fee, the service will be reimbursed at hospital specific outpatient cost to charge ratio as in ARM 37.86.2803. Birthing centers will be reimbursed the statewide outpatient cost to charge ratio.

(2) For purposes of this rule, clinical diagnostic laboratory services include the laboratory tests listed in codes defined in the HCPCS and listed in the Clinical Diagnostic Fee Schedule (CLAB) published January 1, 2018.

(3) Specimen collection will be reimbursed separately for drawing a blood sample through venipuncture or for collecting a urine sample by catheterization. Specimen collection will be reimbursed as specified in the department's outpatient fee schedule as adopted in ARM 37.86.3025, whether or not the specimens are referred to physicians or other laboratories for testing. No more than one collection fee may be allowed for each patient visit, regardless of the number of specimens drawn. 

 

History: 53-2-201, 53-6-113, MCA; IMP, 53-2-201, 53-6-101, 53-6-111, 53-6-113, MCA; NEW, 2001 MAR p. 27, Eff. 1/12/01; AMD, 2002 MAR p. 1991, Eff. 8/1/02; AMD, 2003 MAR p. 1652, Eff. 8/1/03; AMD, 2005 MAR p. 265, Eff. 2/11/05; AMD, 2006 MAR p. 2849, Eff. 11/10/06; AMD, 2006 MAR p. 3078, Eff. 1/1/07; AMD, 2017 MAR p. 2287, Eff. 1/1/18; AMD, 2018 MAR p. 2057, Eff. 10/20/18.