(1) Except as provided in (4), the department pays the lowest of the following for ambulance services:

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

(b) the amount listed in the department's Ambulance Fee Schedule.

(2) The department adopts and incorporates by reference the Montana Medicaid Fee Schedule, Ambulance as provided in ARM 37.85.105(3) and ARM 37.85.105(2) for drugs.

(3) For items and services for which no fee has been set in the department's fee schedule referred to in (2), reimbursement will be set by the following method:

(a) if Medicare sets a fee, the Medicare fees are applicable as the Medicaid fee; or

(b) if Medicare does not set a fee, the Medicaid fees are set by evaluating the fees of services similar in scope to the new code.

(4) For supplies or equipment, where there is no Medicare or Medicaid set fee, the provider's usual and customary charge in (1)(a) will be considered reasonable if set at 75% of the manufacturer's suggested retail price. For items without a manufacturer's suggested retail price, the charge will be considered reasonable if the provider's acquisition cost from the manufacturer is at least 50% of the charge amount.

(5) The department may reimburse providers for ambulance services to transport patients to and from out-of-state facilities at negotiated fees where the department or its designee in its discretion determines that the in-state reimbursement rates are inadequate to assure that the person will receive medically necessary services.