(1) Providers must bill for services using the procedure codes and modifiers set forth, and according to the definitions contained, in the Centers for Medicare and Medicaid Services' (CMS) Healthcare Common Procedure Coding System (HCPCS). Information regarding billing codes, modifiers, and HCPCS is available upon request from the Health Resources Division at the address stated in ARM 37.86.101(3).

(2) Reimbursement for physician services, except as otherwise provided in this rule, is the lower of:

(a) the provider's usual and customary charges (billed charges);

(b) the department's fee schedule maintained in accordance with the methodologies described in ARM 37.85.212; or

(3) Reimbursement for services of a psychiatrist, except as otherwise provided in this rule, is the lower of:

(a) the provider's usual and customary charges (billed charges); or

(b) to address problems of access to mental health services, subject to funding, up to 125% of the reimbursement for physicians provided in accordance with the methodologies described in ARM 37.85.212.

(4) Reimbursement to physicians for physician-administered drugs which are billed under HCPCS "J" and "Q" codes is either according to a fee schedule established by the department and updated at least annually based upon the Montana estimated acquisition cost or maximum allowable cost, as defined in ARM 37.86.1101 or the provider's usual and customary charge, whichever is lower. No dispensing fee is paid to physicians.

(a) The maximum allowable cost limitation shall not apply in those cases where the physician certifies in their own handwriting that in their medical judgment a specific brand name drug is medically necessary for a particular patient. Acceptable certification statements are "brand necessary" or "brand required". A check-off box on a form or a rubber stamp is not acceptable.

(5) Reimbursement and claim completion instructions for Medicaid designated provider based entities are found in ARM 37.86.3031, 37.86.3033, 37.86.3035, and 37.86.3037.