Mont. Admin. r. 37.86.1807 - PROSTHETIC DEVICES, DURABLE MEDICAL EQUIPMENT, AND MEDICAL SUPPLIES, FEE SCHEDULE
(1) Providers must
bill for prosthetic devices, durable medical equipment, medical supplies and
related maintenance, repair and services using the procedure codes and
modifiers set forth and according to the definitions contained in the Centers
for Medicare and Medicaid Services' (CMS) Healthcare Common Procedure Coding
System (HCPCS). Information regarding billing codes, modifiers and HCPCS is
available upon request from the Department of Public Health and Human Services,
Health Resources Division, 1401 East Lockey, P.O. Box 202951, Helena, MT
59620-2951.
(2) Prosthetic devices,
durable medical equipment, and medical supplies will be reimbursed in
accordance with the department's Durable Medical Equipment, Prosthetics,
Orthotics, and Supplies (DMEPOS) Fee Schedule, as provided in ARM
37.85.105(3),
which is adopted and incorporated by reference.
(3) The department's DMEPOS Fee Schedule for
items other than those billed under generic or miscellaneous codes as described
in (1) will include fees set and maintained according to the following
methodology:
(a) 100% of the Medicare region
D allowable fee;
(b) 100% of the
Medicaid allowable fee established by the department if there is no Medicare
region D allowable fee established; or
(c) Except as provided in (4), for all items
for which no Medicare or Medicaid allowable fee is available, the department's
fee schedule amount will be 75% of the provider's usual and customary charge.
(i) For purposes of (3)(c) and (4), the
amount of the provider's usual and customary charge may not exceed the
reasonable charge usually and customarily charged by the provider to all
payers.
(A) The charge will be considered
reasonable if less than or equal to the manufacturer's suggested list price.
(B) For items without a
manufacturer's suggested list price, the charge will be considered reasonable
if the provider's acquisition cost from the manufacturer is at least 50% of the
charge amount.
(C) For items that
are custom fabricated at the place of service, the amount charged will be
considered reasonable if it does not exceed the average charge of all Medicaid
providers by more than 20%.
(D) For
rental items, the reasonable monthly charge may not exceed a percentage of the
reasonable purchase charge, as specified in ARM
37.86.1806(3).
(ii) Items having no product retail list
price, such as items customized by the provider, will be reimbursed at 75% of
the provider's usual and customary charge as defined in (3)(b)(i).
(4) The department's
DMEPOS Fee Schedule, referred to in ARM 37.86.1807(2), for items billed under
generic or miscellaneous codes as described in (1) will be 75% of the
provider's usual and customary charge as defined in (3)(b)(i).
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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