(1) Reimbursement for the out-of-state Psychiatric Residential Treatment Facility (PRTF) is established in the department's Medicaid fee schedule, as adopted in ARM 37.85.105.

(2) The bundled per diem rate for out-of-state PRTFs services coverage includes the following services:

(a) all services, therapies, and items related to treating the condition of the youth;

(b) all services provided by licensed physicians, psychiatrists, midlevel practitioners, psychologists, clinical social workers, and professional counselors;

(c) psychological testing;

(d) lab and pharmacy services; and

(e) supportive services necessary for daily living and safety.

(3) The Montana Medicaid Program will reimburse enrolled providers directly for the following services which are not included in the out-of-state per diem rate:

(a) up to 80 units of targeted case management services, as defined in ARM 37.86.3301, per PRTF stay; and

(b) a clinical intake assessment by a licensed mental health center, with an endorsement to provide adult services for transition age youth 17 to 18, to determine whether they have a severe and disabling mental illness and if they qualify for adult mental health services.

(4) The Montana Medicaid Program will reimburse state plan ancillary services in addition to the out-of-state bundled per diem rate when these ancillary services are provided by a different provider under arrangement with the PRTF. The ancillary services provided must be:

(a) directed by the PRTF physician;

(b) stated in the treatment plan of the youth; and

(c) documented in the medical records for the youth.