37.86.205    MID-LEVEL PRACTITIONER SERVICES, REQUIREMENTS AND REIMBURSEMENT

(1) These requirements are in addition to those rule provisions generally applicable to Medicaid providers.

(2) Medicaid coverage of mid-level practitioner services is available according to the requirements and procedures specified for physicians under ARM 37.86.101, 37.86.104, and 37.86.105.

(3) Mid-level practitioner services must be medically necessary as defined in ARM 37.82.102 and 37.85.410.

(4) Coverage of mid-level practitioner services is limited to the provision of services by the following providers:

(a) mid-level practitioners who are considered to have an independent employment status;

(b) hospitals employing or contracting with certified registered nurse anesthetists if:

(i) the Secretary of Health and Human Services has not granted the hospital authorization for continuation of cost pass-through under section 9320 of the Omnibus Budget Reconciliation Act of 1986, as amended by section 608(c) of the Family Support Act of 1988 (Public Law 100-485);

(ii) the hospital obtains from the department or its fiscal agent a provider number for certified registered nurse anesthetist services; and

(iii) the hospital bills for services on form CMS 1500 or CMS 837P electronic transaction.

(c) physicians, ambulatory surgical centers, diagnostic centers or public health departments, employing or contracting with mid-level practitioners if:

(i) the physician or the provider entity obtains from the department or its fiscal agent a provider number for the mid-level practitioner; and

(ii) the physician or the provider entity bills for services on form CMS 1500 or CMS 837P electronic transaction.

(5) Reimbursement for services, except as otherwise provided in this rule, is the lower of:

(a) usual and customary charges; or

(b) a provider rate of reimbursement which is a percentage of the reimbursement for physicians provided in accordance with the methodologies described in ARM 37.85.212 and 37.86.105. The effective date and percentage is as provided in ARM 37.85.105(2).

(6) Reimbursement for immunizations, drugs which are billed under associated HCPCS codes, family planning services, administration of injectables, radiology, laboratory and pathology, cardiography and echocardiography services, and for clients under 21 years of age is the lower of:

(a) usual and customary charges; or

(b) 100% of the reimbursement for physicians provided in accordance with the methodologies described in ARM 37.85.212 and 37.86.105.

(7) The following services are not covered by Medicaid as mid-level practitioner services:

(a) educational visits and educational materials (including group settings);

(b) mileage and travel expenses;

(c) no show or cancelled appointments;

(d) preparation of special medical or insurance reports;

(e) consultations with other mid-level practitioners;

(f) delivery services not provided in a licensed health care facility unless provided in an emergency situation; and

(g) drug dispensing fees.

(8) Claims for child delivery must have one of the following line procedure code modifiers or the line will be denied:

(a) CG-cesarean section/induction prior to 39 weeks;

(b) GK–spontaneous vaginal delivery prior to 39 weeks (noninduced);

(c) KX–vaginal delivery at or after 39 weeks (induced or not induced); or

(d) SC–cesarean section at or after 39 weeks.

(9) The maternity policy adjustor is not applied to early elective delivery.

(10) Gestational age must be determined and documented in medical records. The department accepts the following American Congress of Obstetricians and Gynecologists guidelines for determining gestational age:

(a) fetal heart tones documented for 20 weeks by nonelectronic fetoscope or 30 weeks by Doppler;

(b) a positive serum or urine pregnancy test by a reliable laboratory at least 36 weeks prior to delivery;

(c) an ultrasound prior to 20 weeks gestation that confirms the gestational age of at least 39 weeks at delivery; or

(d) when pregnancy care was not initiated within 20 weeks gestation, the gestational age may be documented from the first day of the last menstrual period (LMP).

 

History: 53-2-201, 53-6-113, MCA; IMP, 53-6-101, MCA; NEW, 1987 MAR p. 1688, Eff. 10/1/87; AMD, 1988 MAR p. 1255, Eff. 7/1/88; AMD, 1989 MAR p. 1848, Eff. 11/10/89; AMD, 1990 MAR p. 540, Eff. 3/16/90; AMD, 1990 MAR p. 2299, Eff. 12/28/90; AMD, 1990 MAR p. 2305, Eff. 12/28/90; AMD, 1991 MAR p. 1044, Eff. 6/28/91; AMD, 1994 MAR p. 313, Eff. 2/11/94; AMD, 1995 MAR p. 1580, Eff. 8/11/95; AMD, 1997 MAR p. 1269, Eff. 7/22/97; AMD, 1998 MAR p. 676, Eff. 3/13/98; TRANS, from SRS, 2000 MAR p. 481; AMD, 2002 MAR p. 1775, Eff. 6/28/02; AMD, 2006 MAR p. 3078, Eff. 1/1/07; AMD, 2009 MAR p. 1012, Eff. 7/1/09; AMD, 2012 MAR p. 2625, Eff. 1/1/13; AMD, 2013 MAR p. 1111, Eff. 7/1/13; AMD, 2014 MAR p. 2171, Eff. 10/1/14; AMD, 2017 MAR p. 1522, Eff. 9/9/17; AMD, 2018 MAR p. 458, Eff. 3/1/18.