(1) Subject to the requirements of this rule, the department will pay the lowest of the following for optometric services:

(a) the provider's usual and customary charge for the service or item;

(b) the reimbursement provided in accordance with the methodologies described in ARM 37.85.212; or

(c) the amount specified for the particular service or item in the department's fee schedule.

(2) For items or services where no RBRVS or Medicare is available, the fee schedule amount in (1)(c) will be calculated using the following methodology:

(a) Establishing a fee for a service that has been billed at least 50 times by all providers in the aggregate during the previous 12-month period. The department will set each fee at the payment-to-charge ratio in accordance with ARM 37.85.105(2)(d).

(b) For supplies or equipment, reimbursement will be set at 75% of the manufacturer's suggested retail price. For items without a manufacturer's suggested retail price, the charge will be considered reasonable if the provider's acquisition charge from the manufacturer is at least 50% of the charge amount. For items that are custom-fabricated at the place of service, the amount charged will be considered reasonable if it does not exceed the average charge of all Medicaid providers by more than 20%.

(c) For services where utilization cannot meet the methodology outlined in (a), the fee shall be set at the same rate as a service similar in scope.

(3) To address problems of access to optometric services, a provider rate of reimbursement adjustment is provided in ARM 37.85.105(2)(h).