37.88.101    MEDICAID MENTAL HEALTH SERVICES FOR ADULTS, AUTHORIZATION REQUIREMENTS

(1) Mental health services for a Medicaid adult under the Montana Medicaid program will be reimbursed only if the client is 18 or more years of age and has been determined to have a severe disabling mental illness.

(2) In addition to the requirements contained in rule, the department has developed and published the Behavioral Health and Developmental Disabilities (BHDD) Division Medicaid Services Provider Manual for Substance Use Disorder and Adult Mental Health, dated July 1, 2023, which it adopts and incorporates by reference. The purpose of the manual is to implement requirements for utilization management and services. A copy of the manual may be obtained from the department by a request in writing to the Department of Public Health and Human Services, Behavioral Health and Developmental Disabilities (BHDD) Division, 100 N. Park, Ste. 300, P.O. Box 202905, Helena, MT 59620-2905 or at: https://dphhs.mt.gov/bhdd/BHDDMedicaidServicesProviderManual.

(3) Medicaid reimbursement for mental health services will be the lowest of:

(a) the provider′s actual (submitted) charge for the service; or

(b) the rate established in the department′s fee schedule. Reimbursement fees are as provided in ARM 37.85.105 and 37.85.106.

(4) The department may review the medical necessity of services or items at any time either before or after payment in accordance with the provisions of ARM 37.85.410. If the department determines that services or items were not medically necessary or otherwise not in compliance with applicable requirements, the department may deny payment or may recover any overpayment in accordance with applicable requirements.

(5) The department or its designee may require providers to report outcome data or measures regarding mental health services, as determined in consultation with providers and consumers.

 

History: 53-2-201, 53-6-113, MCA; IMP, 53-2-201, 53-6-101, 53-6-111, 53-6-113, MCA; NEW, 1999 MAR p. 1301, Eff. 7/1/99; TRANS, from SRS, 2000 MAR p. 195; EMERG, AMD, 2002 MAR p. 1328, Eff. 4/26/02; EMERG, AMD, 2002 MAR p. 3423, Eff. 12/13/02; EMERG, AMD, 2003 MAR p. 1087, Eff. 5/23/03; AMD, 2004 MAR p. 84, Eff. 1/1/04; AMD, 2004 MAR p. 1625, Eff. 6/4/04; AMD, 2005 MAR p. 1787, Eff. 9/23/05; AMD, 2007 MAR p. 1197, Eff. 8/24/07; AMD, 2009 MAR p. 266, Eff. 2/27/09; AMD, 2009 MAR p. 1489, Eff. 8/28/09; AMD, 2015 MAR p. 2283, Eff. 12/25/15; AMD, 2018 MAR p. 725, Eff. 5/1/18; AMD, 2018 MAR p. 2409, Eff. 1/1/19; AMD, 2019 MAR p. 1061, Eff. 7/6/19; AMD, 2019 MAR p. 1640, Eff. 10/1/19; AMD, 2020 MAR p. 1161, Eff. 7/1/20; AMD, 2020 MAR p. 1740, Eff. 10/1/20; AMD, 2021 MAR p. 331, Eff. 3/27/21; AMD, 2022 MAR p. 1889, Eff. 9/24/22; AMD, 2023 MAR p. 1890, Eff. 12/23/23; AMD, 2024 MAR p. 729, Eff. 4/13/24.