37.79.605    PARTICIPATING PROVIDERS

(1) The third party administrator must offer to federally qualified health centers (FQHCs), rural health clinics (RHCs), Title X family planning providers, Indian health services providers, tribal health providers, urban Indian centers, migrant health centers, and county public health departments terms and conditions that are at least as favorable as those offered to other providers.

(2) The department and the third party administrator will deny payment to a provider who is currently suspended or terminated by the Medicaid or the Medicare program in any state.

(3) Participating providers shall be licensed or certified in Montana or in the case of out-of-state providers, in the state in which they practice.

(4) Physicians, advanced practice registered nurses, and physician assistants shall either have admitting privileges to at least one general or critical shortage area hospital or shall have a mechanism in place to ensure hospitalization when appropriate.

(5) In addition to the cost sharing provisions outlined in ARM 37.79.501, participating providers may bill the enrollee, parent, or guardian for services provided to a HMK coverage group enrollee, which are not covered benefits.

(6) A third party administrator may not prohibit a participating provider from:

(a) discussing a treatment option with an enrollee, parent, or guardian; or

(b) advocating on behalf of an enrollee within the utilization review or grievance processes established by the third party administrator.

History: 53-4-1004, 53-4-1009, 53-4-1105, MCA; IMP, 53-4-1003, 53-4-1004, 53-4-1009, 53-4-1104, 53-4-1105, MCA; NEW, 2000 MAR p. 1221, Eff. 5/12/00; AMD, 2004 MAR p. 1027, Eff. 2/13/04; AMD, 2008 MAR p. 49, Eff. 1/18/08; AMD, 2009 MAR p. 1673, Eff. 10/1/09.