This regulation establishes Medicaid reimbursement rates and authorization requirements for mental health services provided to youth in Montana. It sets out how fees are calculated (lower of actual charge or fee schedule), specifies prior authorization and continued stay review requirements, and allows limited outpatient therapy sessions without a serious emotional disturbance diagnosis. Providers must comply with the Children's Mental Health Medicaid Services Provider Manual and are subject to medical necessity review before or after payment.
View official source37.87.901 MEDICAID MENTAL HEALTH SERVICES FOR YOUTH, REIMBURSEMENT (1) Medicaid reimbursement for mental health services will be the lowest of: (a) the provider's actual (submitted) charge for the service; or (b) the rate established in the department's fee schedule. Reimbursement fees are as provided in ARM 37.85.105 (6). (2) For services for which Medicare does not specify Relative Value Unit (RVU) as provided in ARM 37.85.212 , the department determines the Medicaid fee for children's mental health services as follows: (a) if there is use resulting in Medicaid reimbursements totaling at least $10,000 in a state fiscal year (SFY), and a minimum of four separate providers have billed the code, then the Medicaid fee is determined by multiplying the average charges by the payment-to-charge ratio; or (b) if there is use resulting in Medicaid reimbursements totaling less than $10,000 in an SFY and fewer than four separate providers have billed the code in an SFY, the Medicaid fee will be determined by: (i) reviewing similar procedure codes within the same service scope and adjusting the rate to be equal to a comparable procedure code or the average of similar procedure codes if there is more than one; or (ii) reviewing similar procedure codes within the same service scope and adjusting the rate to be equal to a comparable procedure code or the average of similar codes plus 10% when severity is higher or increased resources are needed for the service. If the code is determined to have a lower severity component or fewer resources are required than when compared to the similar procedure code or average of similar procedure codes, the rate will equal the comparable procedure code or average of similar procedure codes less 10%. Authorizing statute(s): 53-2-201 , 53-6-113 , MCA Implementing statute(s): 53-2-201 , 53-6-101 , 53-6-111 , MCA History: NEW, 2010 MAR p. 1512, Eff. 7/1/10; AMD, 2011 MAR p. 49, Eff. 1/15/11; AMD, 2011 MAR p. 1708, Eff. 8/26/11; AMD, 2012 MAR p. 1273, Eff. 7/1/12; AMD, 2013 MAR p. 164, Eff. 2/1/13; AMD, 2013 MAR p. 1111, Eff. 7/1/13; AMD, 2014 MAR p. 1407, Eff. 7/1/14; AMD, 2015 MAR p. 1500, Eff. 10/1/15. 37.87.903 MEDICAID MENTAL HEALTH SERVICES FOR YOUTH, AUTHORIZATION REQUIREMENTS (1) The department will not reimburse providers for two services that duplicate one another on the same day. (2) The department will reimburse providers of Medicaid mental health youth services if they meet the prior authorization or continued stay review requirements specified in the Children's Mental Health Medicaid Services Provider Manual, referenced in (7). (3) Youth are not required to have a serious emotional disturbance to receive the following outpatient therapy services: (a) the first 24 sessions of individual, family, or both outpatient therapies per state fiscal year. Group outpatient therapy is not included in the 24-session limit; and (b) group outpatient therapy. (4) The department may waive a requirement for prior authorization or continued authorization when the provider submits documentation that: (a) there was a clinical reason why the request for prior authorization or continued authorization could not be made at the required time, and the provider submitted a subsequent authorization request within ten business days; or (b) a timely request for prior authorization or continued authorization was not possible because of an equipment failure or malfunction of the department or its designee that prevented the transmittal of the request at the required time and the provider submitted a subsequent authorization request within ten business days. (5) In computing any time period specified in this subchapter, every day is counted, including Saturdays, Sundays, and legal holidays. If the last day falls on a weekend or holiday, the deadline is the next business day. (6) If the department finds exceptional circumstances that reasonably justify a provider's failure to timely request prior authorization or continued authorization, it may extend the deadline for meeting the requirement. (7) In addition to the requirements contained in rule, the department has developed and published a provider manual entitled Children's Mental Health Medicaid Services Provider Manual (manual), dated May 12, 2023, for the purpose of implementing requirements for utilization management. The department adopts and incorporates by reference the Children's Mental Health Medicaid Services Provider Manual, dated May 12, 2023. A copy of the manual may be obtained at https://dphhs.mt.gov/bhdd/cmb/Manuals . (8) The department may review the medical necessity of services or items at any time either before or after payment in accordance with the provisions of ARM 37.85.410 . If the department determines that services or items were not medically necessary or were otherwise not in compliance with applicable requirements, the department may deny payment or may recover any overpayment in accordance with applicable requirements. (9) The department or its designee may require providers to report outcome data or measures regarding mental health services, as determined in consultation with providers and interested persons. Authorizing statute(s): 53-2-201 , 53-6-113 , MCA Implementing statute(s): 53-2-201 , 53-6-101 , 53-6-111 , MCA History: NEW, 2009 MAR p. 266, Eff. 2/27/09; AMD, 2010 MAR p. 1512, Eff. 7/1/10; AMD, 2011 MAR p. 49, Eff. 1/15/11; AMD, 2011 MAR p. 1154, Eff. 6/24/11; AMD, 2011 MAR p. 1708, Eff. 8/26/11; AMD, 2012 MAR p. 2086, Eff. 10/12/12; AMD, 2013 MAR p. 164, Eff. 2/1/13; AMD, 2013 MAR p. 2153, Eff. 11/15/13; AMD, 2014 MAR p. 2147, Eff. 9/19/14; AMD, 2015 MAR p. 1500, Eff. 10/1/15; AMD, 2016 MAR p. 1393, Eff. 8/6/16; AMD, 2018 MAR p. 458, Eff. 3/1/18; AMD, 2018 MAR p. 1116, Eff. 7/1/18; AMD, 2020 MAR p. 691, Eff. 4/18/20; AMD, 2020 MAR p. 2435, Eff. 1/1/21; AMD, 2022 MAR p. 159, Eff. 1/29/22; AMD, 2024 MAR p. 611, Eff. 3/23/24.