(1) The interim rate for services provided to "youth" as the term is defined at ARM 37.87.102 for PRTF providers located in the state of Montana is composed of:

(a) the psychiatric service rate provided in the department's Medicaid Mental Health and Mental Health Services Plan, Individuals Under 18 Years of Age Fee Schedule adopted in ARM 37.87.901;

(b) a direct care wage add-on through a contract with the department or in the psychiatric service rate in (1)(a), as applicable; and

(c) a facility-specific ancillary add-on rate for ancillary costs, not already included in the base psychiatric service rate in (1)(a).

(2) Medicaid services included in the ancillary add-on rate in (1)(c) may be provided in and by the PRTF by individuals employed by or under contract with the PRTF who have appropriate credentials or by outside providers. Services provided outside the PRTF are not separately reimbursable and must be reimbursed by the PRTF. At a minimum, covered ancillary services include the following services:

(a) ambulatory surgical center;

(b) audiologist;

(c) care coordination per the limits in (3);

(d) chiropractor;

(e) dentist, denturist, and orthodontist;

(f) durable medical equipment;

(g) emergency room services not related to the youth's psychiatric condition;

(h) eyeglasses;

(i) federally qualified health center;

(j) hearing provider and hearing aides;

(k) Indian health services for enrolled tribal members;

(l) lab and pharmacy services not related to the youth's psychiatric condition;

(m) licensed addiction counselor;

(n) medical transportation and ambulance services;

(o) MRI, or other diagnostic services;

(p) nutritionist;

(q) optometrist and ophthalmologist;

(r) outpatient hospital services not related to the youth's psychiatric condition;

(s) pharmacy for post-discharge medication;

(t) physical and speech therapist;

(u) physician, psychiatrist, and mid-level practitioner;

(v) podiatrist;

(w) public health clinic;

(x) respiratory therapist;

(y) rural health clinic;

(z) any other Medicaid service approved by the department to address the youth's plan of care needs in the facility.

(3) If a PRTF contracts for care coordination the following limits apply:

(a) up to 16 units per month to attend multidisciplinary treatment team meetings to monitor the youth's progress; and

(b) up to 32 units within 30 days of the youth's discharge. Of these 32 units, up to 16 units may be used for attending treatment team and discharge planning meetings and up to 16 units may be used for making referrals and related activities for needed services upon discharge; and

(c) only one care coordinator will be reimbursed per youth.

(4) Reimbursement for in-house practitioner services in (2) only includes the professional component of the service.

(5) The ancillary add-on rate in (1)(c) will be adjusted retrospectively when:

(a) allowable ancillary costs are reported using auditable data, standardized forms, instructions, definitions, and timelines supplied by the department; and

(b) ancillary costs in the facility-specific aggregate for all discharges, for Montana Medicaid paid youth, in a state fiscal year exceed or are less than the reimbursement that the facility received as an interim rate:

(i) the department will reimburse the facility for costs exceeding 100% of the aggregate; and

(ii) the facility will reimburse the department for costs less than 100% of the aggregate.

(6) The psychiatric service rate in (1)(a) is a bundled per diem rate, and includes:

(a) services, therapies, and items related to the youth's psychiatric condition;

(b) services provided by licensed psychologists, licensed clinical social workers, and licensed professional counselors; and

(c) lab and pharmacy services related to the youth's psychiatric condition, with the exception noted in (2)(s) pharmacy for post discharge medication.

(7) Covered ancillary services provided by the PRTF will be cost-settled using the existing Medicaid reimbursement rate according to the applicable Medicaid fee schedule. Covered ancillary services provided by outside providers will be cost-settled using the amount the PRTF reimbursed the outside providers. This amount may not exceed the outside provider's usual and customary charge. Whenever possible, outside ancillary service providers will be reimbursed the Medicaid rate.

(8) Third party liability billing requirements apply for PRTF and ancillary services reimbursed by the Medicaid program. Medicaid prior authorization requirements for ancillary services in (2) do not apply when the youth is in a PRTF.

(9) Reimbursement for the following personal transportation may be included in the PRTF cost report, per the reimbursement rate on the current "Montana Medicaid Personal and Commercial Transportation Fee Schedule":

(a) When the personal transportation is provided by the PRTF for a youth to a medical appointment off site and the mileage exceeds 15 miles per month per specific youth. Documentation must be maintained regarding the youth's name, outside provider name, appointment date and time, and mileage; and

(b) When a youth's parent, guardian, or other family member is reimbursed mileage to drive to and from the PRTF to attend family therapy sessions. Reimbursement for transporting a youth to and from their home for a therapeutic home visit is not an allowable expense unless family therapy is provided prior to the youth's home visit and upon their return to the PRTF. Meals and/or lodging are not covered for a round trip that can reasonably be made in one day. If a round trip cannot be reasonably made in one day, meals and lodging may be reimbursed according to the fee schedule in (9), and the following documentation maintained:

(i) youth name;

(ii) date of family therapy session;

(iii) parent, guardian, or family member name;

(iv) community the parent, guardian, or family member is driving from;

(v) total mileage; and

(vi) total number of meals.

(10) If the youth's condition requires admission to a hospital, the youth must be discharged from the PRTF for the hospital to be reimbursed.

(11) If a youth receiving in-patient care in a PRTF has an unusually expensive medical condition that requires a higher ancillary rate, prior to the cost settlement process, the PRTF may request interim reimbursement for the ancillary care. The department at its discretion may grant the youth specific request if the PRTF:

(a) submits a request in writing to the department with documentation of the expenses; and

(b) interim payments must be requested within 90 days of the date of service and will be taken into consideration during the ancillary cost settlement process described in (3). Payment of these claims will be made by the department within 90 days from the date all requirements for payment are met.

(12) Care coordination services will be reimbursed to the PRTF at the prevailing Medicaid rate for Healthcare Common Procedure Coding System (HCPCS) code T1016 (Targeted Case Management) when:

(a) the parent or guardian is given the choice of eligible providers;

(b) services are not contingent on youth receiving other services from the agency providing care coordination;

(c ) services are adequately documented in a narrative form and maintained in the care coordinator's records to justify the number of units billed to the PRTF; and

(d) care coordination activities are included on the youth's PRTF's treatment plan. A separate care coordination assessment and care plan are not required.

(13) Reimbursement will be made to in-state and out-of-state PRTF providers for reserving a bed while the youth is temporarily absent for a therapeutic home visit if:

(a) the youth's plan of care documents the medical need for therapeutic home visits as part of a therapeutic plan to transition the youth to a less restrictive level of care;

(b) the youth is temporarily absent on a therapeutic home visit;

(c) the provider clearly documents staff contact and youth achievements or regressions during and following the therapeutic home visit;

(d) the youth is absent from the provider's facility for no more than three patient days per therapeutic home visit, unless additional days are authorized by the department; and

(e) the out-of-state PRTF pays for transportation for youth on a therapeutic home visit from an out-of-state PRTF.

(14) No more than 14 patient days per youth in each state fiscal year will be allowed for therapeutic home visits.

(15) Providers must bill for PRTF services using the revenue codes designated by the department.

(16) Notice of the youth's admission and discharge dates must be submitted to the department or its designee the day of admission or discharge. A $100 fine may be imposed against the facility for each instance where the department does not receive timely notification.