(1) "Ambulatory payment classification (APC)" means Medicare's ambulatory payment classification assignment groups of CPT or HCPCS codes.
(2) "Bad debt" means inpatient and outpatient hospital services provided in which full payment is not received from the patient or from a third party payor, for which the provider expected payment and the persons are unable or unwilling to pay their bill. Bad debts may be for services provided to patients who have no health insurance or patients who are underinsured and are net of payments made toward these services. For the purpose of uncompensated care, bad debt is measured on the basis of revenue forgone, at full established rates, and bad debt does not include either provider discounts or Medicare bad debt.
(3) "Birthing center" means a facility that provides comprehensive obstetrical care for women in which births are planned to occur away from the mother's usual residence following normal, uncomplicated, low risk pregnancy and is either:
(a) a licensed outpatient center for primary care with medical resources as defined at 50-5-101, MCA; or
(b) a private office of a physician or certified nurse mid-wife that is accredited by a national organization as an alternative to a homebirth or a hospital birth.
(4) "Charity care" means inpatient and outpatient hospital services in which hospital policies determine the patient is unable to pay and did not expect to receive full reimbursement. Charity care results from a provider's policy to provide health care services free of charge (or where only partial payment is expected) to individuals who meet certain financial criteria. For the purpose of uncompensated care, charity care is measured on the basis of revenue forgone, at full established rates. Charity care does not include contractual write-offs.
(5) "Conversion factor" means an adjustment equal to Medicare's highest urban rate for Montana as published at 67 Federal Register (FR) 43616 (June 28, 2002).
(6) "Diagnostic service" means an examination or procedure performed on an outpatient or on materials derived from an outpatient to obtain information to aid in the assessment or identification of a medical condition.
(7) "Full-day partial hospitalization program" means a partial hospitalization program providing services at least six hours per day, five days per week.
(8) "Half-day partial hospitalization program" means a partial hospitalization program providing services for at least four but less than six hours per day, at least four days per week.
(9) "Healthcare common procedures coding system (HCPCS)" means the national uniform coding method maintained by the Centers for Medicare and Medicaid Services (CMS) that incorporates the American Medical Association (AMA) Physicians Current Procedural Terminology (CPT) and the three HCPCS unique coding levels, I, II, and III.
(10) "ICD-9-CM" means the International Classification of Diseases, Ninth Revision based on the official version of the United Nations World Health Organization's Ninth Revision.
(11) "Imaging service" means diagnostic and therapeutic radiology, nuclear medicine, CT scan procedures, magnetic resonance imaging services, ultra-sound, and other imaging procedures.
(12) "Outpatient" means a person who:
(a) has not been admitted by a hospital or birthing center as an inpatient;
(b) is expected by the hospital or birthing center to receive services in the hospital for less than 24 hours;
(c) is registered on the hospital or birthing center records as an outpatient; and
(d) receives outpatient services from the hospital or birthing center, other than supplies or drugs alone, for nonemergency medical conditions.
(13) "Outpatient hospital services" means preventive, diagnostic, therapeutic, rehabilitative, or palliative services provided to an outpatient by or under the direction of a physician, dentist, or other practitioner as permitted by federal law, by an institution that:
(a) is licensed or formally approved as a hospital by the officially designated authority in the state where the institution is located; and
(b) except as otherwise permitted by federal law, meets the requirements for participation in Medicare as a hospital.
(14) "Outpatient prospective payment system (OPPS)" means Medicare's outpatient prospective payment system mandated by the Balanced Budget Refinement Act of 1999 (BBRA) and the Medicare, Medicaid, SCHIP Benefits Improvement and Protection Act (BIPA) of 2000.
(15) "Partial hospitalization services" means an active treatment program that offers therapeutically intensive, coordinated, structured clinical services provided only to individuals who are determined to have a serious emotional disturbance or severe disabling mental illness. Partial hospitalization services are time-limited and provided within either an acute level program or a sub-acute level program. Partial hospitalization services include day, evening, night, and weekend treatment programs that employ an integrated, comprehensive, and complementary schedule of recognized treatment or therapeutic activities.
(a) Acute level partial hospitalization is provided by programs which:
(i) are operated by a hospital as described in 50-5-101, MCA and are colocated with that hospital such that in an emergency a patient of the acute partial hospitalization program can be transported to the hospital's inpatient psychiatric unit within 15 minutes;
(ii) serve primarily individuals being discharged from inpatient psychiatric treatment or inpatient psychiatric residential treatment; and
(iii) provide psychotherapy services consisting of at least individual, family, and group sessions at a frequency designed to stabilize patients sufficiently to allow discharge to a less intensive level of care at the earliest appropriate opportunity, on average, after 15 or fewer treatment days.
(b) Acute level partial hospitalization is reimbursed according to ARM 37.86.3022.
(c) Sub-acute level partial (SAP) hospitalization is provided by programs which:
(i) operate under the license of a general hospital with a distinct psychiatric unit or an inpatient psychiatric hospital for individuals under 21;
(ii) operate in a self-contained facility and offer integrated mental health services appropriate to the individual's needs as identified in an individualized treatment plan;
(iii) provide psychotherapy services consisting of at least three group sessions per week and five individual and/or family sessions per month;
(iv) encourage and support parent and family involvement;
(v) provide services in a supervised environment by a well-integrated, multi-disciplinary team of professionals which includes but is not limited to program therapists, behavioral specialists, teachers, and ancillary staff;
(A) a program therapist must be a licensed mental health professional who is site based;
(B) a program therapist must have an active caseload that does not exceed ten program clients;
(C) a behavioral specialist must be site based and have a bachelor's degree in a behavioral science field or commensurate experience working with children with serious emotional disturbance. There must be one behavioral specialist for each five youth in the SAP program; and
(D) all staff responsible for implementing the treatment plan must have a minimum of 24 hours orientation training and 12 additional hours of continuing education each year relating to serious emotional disturbance in children and its treatment. Training must include specific instruction on recognizing the effects of medication.
(vi) provide education services through one of the following:
(A) full collaboration with a school district;
(B) certified education staff within the program; or
(C) interagency agreements with education agencies.
(vii) provide crisis intervention and management, including response outside of the program setting;
(viii) provide psychiatric evaluation, consultation, and medication management on a regular basis. Psychiatric consultation to the program treatment staff is provided at least twice each month and includes at least one face-to-face evaluation with each youth each month;
(ix) serve children or youth with a serious emotional disturbance being discharged from inpatient psychiatric treatment or residential treatment or who would be admitted to such treatment in the absence of partial hospitalization; and
(x) are designed to stabilize patients sufficiently to allow discharge to a less intensive level of care, on average, after 60 or fewer treatment days.
(d) Sub-acute level partial hospitalization is reimbursed at the rate specified in the department's Medicaid Mental Health Fee Schedule.
(16) "Provider-based entity" means a provider that is either created by, or acquired by, a main provider for purposes of furnishing health care services under the name, ownership, and administrative and financial control of the main provider as in 42 CFR 413.65. Both professional and facility (hospital outpatient department) providers are included together under this definition.
(17) "Qualified rate adjustment (QRA)" payment means an additional payment to a county owned, operated or partially county funded rural hospital in Montana as provided in ARM 37.86.3005, when the hospital's most recently reported costs are greater than the reimbursement received from Montana Medicaid for outpatient care.
(18) "Uncompensated care" means hospital services provided in which no payment is received from the patient or from a third party payer. Uncompensated care includes charity care and bad debts.
(19) For purposes of provider based entity billing, a professional is a physician, podiatrist, mid-level, licensed clinical social worker, licensed professional counselor, or a licensed psychologist.