37.87.1216    PSYCHIATRIC RESIDENTIAL TREATMENT FACILITY SERVICES, BENEFIT LIMITS, CERTIFICATION OF NEED, UTILIZATION REVIEW AND INSPECTIONS OF CARE REQUIREMENTS

(1) Prior to admission and as frequently as the department deems necessary, the department or its agents may evaluate the medical necessity and quality of services for each Medicaid member.

(a) In addition to the other requirements of these rules, the provider must provide to the department or its agent upon request any records related to services or items provided to a Medicaid member.

(b) The department may contract with and designate public or private agencies or entities, or a combination of public and private agencies and entities, to perform utilization review, inspections of care, and other functions under this rule as an agent of the department.

(2) The department or its agents may conduct periodic inspections of care in PRTFs participating in the Medicaid program.

(3) A provider must submit a certificate of need as described in the Children's Mental Health Bureau Medicaid Services Manual, adopted and incorporated by reference in ARM 37.87.903.

(4) An authorization by the department or its utilization review agent under this rule is not a final or conclusive determination of medical necessity and does not prevent the department or its agents from evaluating or determining the medical necessity of services or items at any time.

History: 53-2-201, 53-6-113, MCA; IMP, 53-2-201, 53-6-101, 53-6-111, MCA; NEW, 2008 MAR p. 2360, Eff. 1/1/09; AMD, 2013 MAR p. 270, Eff. 3/1/13; AMD, 2015 MAR p. 2147, Eff. 12/11/15.