(1) Mental health services for a Medicaid adult under the Montana Medicaid program will be reimbursed only if the client is 18 or more years of age and has been determined to have a severe disabling mental illness as defined in ARM 37.86.3503.

(2) Adult intensive outpatient therapy services may be medically necessary for a person with safety and security needs who has demonstrated the ability and likelihood of benefit from continued outpatient therapy. The person must meet the requirements of (2)(a) or (b). The person must also meet the requirements of (2)(c). The person has:

(a) a DSM diagnosis with a severity specifier of moderate or severe bipolar I disorder, bipolar II disorder, or major depressive disorder; or

(b) a DSM diagnosis borderline personality disorder;

(c) ongoing difficulties in functioning because of mental illness for a period of at least six months or for an obviously predictable period over six months, as indicated by:

(i) dysregulation of emotion, cognition, behavior, and interpersonal relationships;

(ii) resulting in recurrent suicidal, parasuicidal, serious self-damaging impulsive behaviors, or serious danger to others;

(iii) a history of treatment at a higher level of care, and

(iv) evidence that lower levels of care are inadequate to meet the needs of the client.

(3) The department may review the medical necessity of services or items at any time either before or after payment in accordance with the provisions of ARM 37.85.410. If the department determines that services or items were not medically necessary or otherwise in compliance with applicable requirements, the department may deny payment or may recover any overpayment in accordance with applicable requirements.

(4) The department or its designee may require providers to report outcome data or measures regarding mental health services, as determined in consultation with providers and consumers.