(1) The Montana Medicaid program will cover and reimburse under the RHC or FQHC programs only those services that are RHC services or FQHC services as defined in ARM 37.86.4401 and subject to the provisions of this subchapter.
(2) The Montana Medicaid program will not reimburse an RHC or FQHC for RHC or FQHC services that are services covered by a health maintenance organization for an enrolled recipient, as provided in ARM Title 37, chapter 86, subchapter 50, except as provided in ARM 37.86.4414.
(3) RHC services are covered by Montana Medicaid when provided in accordance with these rules to a recipient at the clinic, the recipient's residence or other medical facility. RHC services are not covered by Montana Medicaid when provided to a hospital patient.
(4) FQHC services are covered by Montana Medicaid when provided in accordance with these rules to a recipient in an outpatient setting only, which may include the recipient's place of residence. The recipient's place of residence may include a skilled nursing facility or a nursing facility. FQHC services are not covered by Montana Medicaid when provided to a hospital patient.
(5) The Montana Medicaid program will cover and reimburse RHC or FQHC services only if the services are provided in accordance with the same requirements that would apply if the service were provided by an individual or entity other than an RHC or an FQHC, except as specifically provided otherwise in this subchapter. These requirements include but are not limited to the following:
(a) The health professional providing the RHC or FQHC service must meet the same requirements that would apply if the health professional were to enroll directly in the Montana Medicaid program in the category of service to be provided. Such requirements include but are not limited to applicable licensure, certification and registration requirements, and applicable restrictions upon the form of entity or category of individual provider that may provide particular services. The health professional is not required to enroll separately as a Medicaid provider.
(b) The RHC or FQHC services are subject to any applicable limitations on the amount, scope, or duration of services covered by the Medicaid program, e.g., scope of practice restrictions under state licensure law, coverage exclusions, e.g., noncoverage of physical therapy maintenance services, limits on the number of hours, visits, or other units of service covered in a particular period or on the frequency of services covered, limits on the type of items or services covered within a particular category, medical necessity requirements, including specific medical necessity criteria applicable to a particular item or service, and early and periodic screening, diagnostic and treatment services (EPSDT) program requirements and restrictions.
(c) In addition to general record requirements under ARM 37.85.414, RHCs and FQHCs must comply with any additional particular record or documentation requirements applicable to the particular category or type of service, e.g., requirements for documentation of compliance with supervision and protocol requirements, requirements for written documentation of prescription or referral, requirements for written care plans and prerequisites for receipt of a particular item or service by a particular recipient.
(d) Providers must bill for RHC or FQHC services using the revenue codes specified in the department's RHC/FQHC services provider manual. The department must provide 30 days prior written notice to providers of any changes in revenue codes.
(e) RHCs and FQHCs must comply with requirements for Medicaid program authorization prior to provision of services or prior to payment, as applicable to the particular category of services being provided.
(f) Reimbursement will be made to RHCs and FQHCs for RHC and FQHC services as provided in ARM 37.86.4412 through 37.86.4414 and 37.86.4420, rather than as provided in the rules applicable to the particular category of services. This rule shall not be construed to provide that reimbursement of services provided by health professionals will be made under ARM 37.86.4412 through 37.86.4414 and 37.86.4420 when the services are not provided as an RHC or FQHC service and when the health professional is separately enrolled in and providing services under a particular Medicaid service category, subject to the rules applicable to the particular service category.
(6) A provider must notify the department, in writing, of an increase or decrease in the scope of service offered by the RHC or FQHC to Medicaid recipients. Upon the request of a provider, the department will determine if a change qualifies as an increase or decrease in the scope of service, and if so, the amount and effective date of any rate increase or decrease.
(a) As a condition of approval, the department may require the provider to submit documentation and information necessary to demonstrate compliance with requirements applicable to the category of service and/or documentation and information necessary to determine the increase or decrease in the reimbursement rate due to an increase or decrease in the scope of service including any increase or decrease in the costs of the service and any increase or decrease in the number of visits.
(b) Medicaid coverage and reimbursement of an additional category of service will not be available to a provider unless department approval was requested prior to provision of the services and unless the services comply with all applicable requirements.
(c) Any increase in the rate of reimbursement due to an increase or decrease in the scope of service shall be from the date of notification by the provider to the department. Any decrease in the rate of reimbursement due to an increase or decrease in the scope of service shall be from the date the department was notified by the provider or the date the department determines the increase or decrease in the scope of services occurred, whichever is first.
(d) The department shall complete the determination within 60 days of the written request or within 60 days of receipt of any required documentation and information, whichever is later.
(7) If clinic or center services are provided in more than one location, each location is independently considered for approval as an RHC or FQHC Medicaid provider, unless prior approval was granted by the department, to operate both locations under one provider number. To be considered for operation under one provider number, both sites must share medical staff, office staff or administrative staff. The provider must notify the department of this change in status as provided in (6).