(1) These requirements are in addition to those rule provisions generally applicable to Medicaid providers.

(2) Medicaid coverage of mid-level practitioner services is available according to the requirements and procedures specified for physicians under ARM 37.86.101, 37.86.104, and 37.86.105.

(3) Mid-level practitioner services must be medically necessary as defined in ARM 37.82.102 and 37.85.410.

(4) Coverage of mid-level practitioner services is limited to the provision of services by the following providers:

(a) mid-level practitioners who are considered to have an independent employment status;

(b) hospitals employing or contracting with certified registered nurse anesthetists if:

(i) the Secretary of Health and Human Services has not granted the hospital authorization for continuation of cost pass-through under section 9320 of the Omnibus Budget Reconciliation Act of 1986, as amended by section 608(c) of the Family Support Act of 1988 (Public Law 100-485);

(ii) the hospital obtains from the department or its fiscal agent a provider number for certified registered nurse anesthetist services; and

(iii) the hospital bills for services on form HCFA-1500.

(c) physicians, ambulatory surgical centers, diagnostic centers or public health departments, employing or contracting with mid-level practitioners if:

(i) the physician or the provider entity obtains from the department or its fiscal agent a provider number for the mid-level practitioner; and

(ii) the physician or the provider entity bills for services on form HCFA-1500.

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

(a) usual and customary charges; or

(b) 90% of the reimbursement for physicians provided in accordance with the methodologies described in ARM 37.85.212 and 37.86.105.

(6) Reimbursement for immunizations, family planning services, administration of injectables, radiology, laboratory and pathology, cardiography and echocardiography services and for clients under 21 years of age is the lower of:

(a) usual and customary charges; or

(b) 100% of the reimbursement for physicians provided in accordance with the methodologies described in ARM 37.85.212 and 37.86.105.

(7) A mid-level practitioner shall submit all claims for services personally provided by the mid-level practitioner, using the mid-level practitioner's own Medicaid provider number and any appropriate modifiers, unless another provider is authorized to bill for services provided by the mid-level practitioner by administrative rule or state law.

(8) Reimbursement for drugs which are billed under HCPCS "J" and "Q" codes is the lower of:

(a) the usual and customary charge; or

(b) 100% of reimbursement for physicians in accordance with ARM 37.86.105.

(9) The following services are not covered by Medicaid as mid-level practitioner services:

(a) educational visits and educational materials (including group settings);

(b) mileage and travel expenses;

(c) no show or cancelled appointments;

(d) preparation of special medical or insurance reports;

(e) consultations with other mid-level practitioners;

(f) delivery services not provided in a licensed health care facility unless provided in an emergency situation; and

(g) drug dispensing fees.

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