Mont. Admin. R. 37.86.4413 - RURAL HEALTH CLINICS AND FEDERALLY QUALIFIED HEALTH CENTERS, ESTABLISHMENT OF INTERIM PAYMENT FOR NEW RHC OR FQHC
(1) The interim Medicaid prospective payment
system (PPS) base per-visit rate for a newly qualified RHC or FQHC or an FQHC
shifting from non-state government operated to privately operated shall be
equal to 100% of the average PPS rate for other RHCs or FQHCs located in the
same or adjacent area with a similar caseload. In the event that there is no
such RHC or FQHC, payment shall be made in accordance with the methodology
provided in (2) .
(2) If there is
no RHC or FQHC located in the same or adjacent area with a similar caseload,
the interim PPS rate shall be equal to the RHC's or FQHC's total projected
allowable costs divided by the RHC's or FQHC's total projected allowable
visits. The provider must submit to the department or its agent an estimate of
budgeted costs and visits for the RHC or FQHC for the reporting period in the
form and detail required by the department and such other information as the
department may require to establish a rate. The projected allowable cost and
allowable visit information is subject to a reasonableness review by the
department.
(3) At the end of the
RHC's or FQHC's first two complete fiscal years, the department will establish
the facility specific baseline PPS rate.
(4) The department must receive the RHC's or
FQHC's as-filed Medicare cost reports for the first two complete fiscal years
no later than six months after the end of the RHC's or FQHC's first two
complete fiscal years, or otherwise the request is deemed untimely.
(a) The department may request additional
information from the RHC or FQHC, and the facility is required to submit the
requested information within 30 days of the department's request. If the
requested information is not received within that timeframe, the request is
deemed untimely. The request for additional information will include a notice
that failure to submit the materials within the requested 30 calendar days will
result in suspension of payments for Medicaid services billed to the department
until such time as the supplemental materials are received by the
department.
(b) If the department
has not received the materials in (4)(a) thirty days prior to the expiration of
the six month deadline, the department shall send a notice to the RHC or FQHC
and inform it that failure to submit the materials in a timely manner will
result in suspension of payments for Medicaid services billed to the department
until such time as the materials are received by the department.
(5) Upon receiving the RHC's or
FQHC's as-filed Medicare cost reports and any additional information requested
pursuant to (4)(a), the department will establish the RHC's and FQHC's baseline
PPS rate by calculating the total allowable cost of RHC or FQHC services for
the first two complete fiscal years divided by the total allowable visits for
the first two complete fiscal years. The baseline PPS rate may be adjusted to
take into account any increase or decrease in the scope of service as provided
in ARM
37.86.4412.
(6) The department will provide
written notification of the calculated baseline PPS rate to the RHC or FQHC
within 90 days of receiving all information related to the request.
(7) The department shall reimburse the RHC or
FQHC the baseline PPS rate for requests submitted within the timeframe
specified in (4)(a) and (b) effective the date of the RHC or FQHC
enrollment.
(8) If an RHC or FQHC
fails to timely submit the materials in (4)(a), or if applicable (2)(b), the
department shall suspend all payments to the RHC or FQHC for Medicaid services
billed to the department until such time as the supplemental materials are
received. Once all required materials are received the effective date of the
baseline PPS rate is the effective date of the RHC or FQHC
enrollment.
(9) Reimbursement after
the baseline PPS rate is only modified through the processes outlined in ARM
37.86.4406,
[NEW RULE I, NEW RULE II, NEW RULE III], and 37.86.4412.
Notes
AUTH: 53-2-201, 53-6-113, MCA; IMP: 53-2-201, 53-6-101, 53-6-111, 53-6-113, MCA
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