37.86.1004    REIMBURSEMENT METHODOLOGY FOR RESOURCE BASED RELATIVE VALUE FOR DENTISTS (RVD)

(1) For procedures listed in the relative values for dentists scale, reimbursement rates shall be determined using the following methodology:

(a) The fee for a covered service shall be the amount determined by multiplying the relative value unit specified in the relative values for dentists scale by the conversion factor specified in (1)(c). The department adopts and incorporates by reference the Relative Values for Dentists (RVDs) as provided in ARM 37.85.105(3).

(b) The conversion factor and provider fees for dentists, dental hygienists, and denturists procedures are calculated as follows:

(i) The total units of each procedure code paid in a prior period is multiplied by the RVU as published in (1)(a) to equal the RVD for each procedure code. Typically, the prior period used is the prior state fiscal year.

(ii) The sum of all RVDs calculated in (1)(b)(i) equals the total units of dental service.

(iii) The Montana Legislature's appropriation for dental service during the appropriation period is divided by the total units of dental service calculated in (1)(b)(ii). The resulting dollar value is equal to one unit of dental value and is the dental conversion factor.

(iv) The RVU as published in (1)(a) for each dental procedure is multiplied by the dental conversion factor calculated in (1)(b)(iii) to calculate the Medicaid reimbursement for the procedure. When this calculation is made for all covered procedures the Montana Medicaid Dental, Dental Hygienist, and Denturist Fee Schedules are generated.

(v) A policy adjuster may be applied to some fees calculated in (1)(b)(iv) for certain categories of services or to the conversion factor to increase or decrease the fees paid by Medicaid.

(c) The conversion factor used to determine the Medicaid payment amount for services provided to eligible individuals is provided in ARM 37.85.105(3).

History: 53-2-201, 53-6-113, MCA; IMP, 53-6-101, MCA; NEW, 2001 MAR p. 1117, Eff. 6/22/01; AMD, 2002 MAR p. 1780, Eff. 6/28/02; EMERG, AMD, 2002 MAR p. 2665, Eff. 9/27/02; AMD, 2003 MAR p. 1314, Eff. 7/1/03; AMD, 2005 MAR p. 1073, Eff. 7/1/05; AMD, 2007 MAR p. 1824, Eff. 11/9/07; AMD, 2008 MAR p. 1156, Eff. 7/1/08; AMD, 2009 MAR p. 1017, Eff. 7/1/09; AMD, 2011 MAR p. 1384, Eff. 7/29/11; AMD, 2013 MAR p. 1111, Eff. 7/1/13.