(1) Providers must bill for services using the procedure codes and modifiers set forth, and according to the definitions contained, in the Health Care Financing Administration's Common Procedure Coding System (HCPCS). Information regarding billing codes, modifiers and HCPCS is available upon request from the Department of Public Health and Human Services, Health Resources Division, 1400 Broadway, P.O. Box 202951, Helena, MT 59620-2951.

(2) Subject to the requirements of this rule, the Montana Medicaid program pays the following for therapy services:

(a) For patients who are eligible for Medicaid, the lower of:

(i) the provider's usual and customary charge for the service;

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

(iii) for items or services where no RBRVS or Medicare fee is available, the fee schedule amount 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 44% of the average charge billed by all providers in the aggregate.

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