Mont. Admin. r. 37.86.2005 - OPTOMETRIC SERVICES, REIMBURSEMENT
(1)
Subject to the requirements of this rule, the department will pay the lowest of
the following for optometric services:
(a)
the provider's usual and customary charge for the service or item;
(b) the reimbursement provided in accordance
with the methodologies described in ARM
37.85.212;
or
(c) the amount specified for
the particular service or item in the department's fee schedule.
(2) For items or services where no
RBRVS or Medicare is available, the fee schedule amount in (1)(c) will be
calculated using the following methodology:
(a) Establishing a fee for a service that has
been billed at least 50 times by all providers in the aggregate during the
previous 12-month period. The department will set each fee at the
payment-to-charge ratio in accordance with ARM
37.85.105(2)(d).
(b) For supplies or equipment, reimbursement
will be set at 75% of the manufacturer's suggested retail price. For items
without a manufacturer's suggested retail price, the charge will be considered
reasonable if the provider's acquisition charge from the manufacturer is at
least 50% of the charge amount. 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%.
(c) For services where
utilization cannot meet the methodology outlined in (a), the fee shall be set
at the same rate as a service similar in scope.
(3) To address problems of access to
optometric services, a provider rate of reimbursement adjustment is provided in
ARM
37.85.105(2)(h).
Notes
AUTH: 53-6-113, MCA; IMP: 53-6-101, 53-6-113, MCA
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