Reimbursement
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Governs reimbursement rules, billing, prior authorization, and payment requirements for the Montana SDMI Home and Community-Based Services (HCBS) waiver; affects providers, contracted case management teams, and Medicaid members participating in the SDMI HCBS waiver.
No material clinical or coverage changes in this revision.
Payment and Coverage Criteria
Payment and coverage criteria
Payment for SDMI HCBS services is contingent on program, provider, and member eligibility and authorization criteria.
ALL of the following
ALL of the following
- Member must be financially eligible for Medicaid during the month in which the service is rendered.
ALL of the following
- Provider must be eligible for Medicaid participation on the day the service is rendered and must agree to accept the member and bill Medicaid.
ALL of the following
- The service must be covered by Medicaid.
- The member must not have exceeded limitations for a specific service without prior authorization from the Community Program Officer.
ALL of the following
- Services must be prescribed in the member's Person-Centered Recovery Plan.
- The contracted case management team (CMT) must authorize the service.
ALL of the following
- A clean claim must be received by Conduent within 365 days of the date of service.
ALL of the following
- No payment is available for days a member is hospitalized or in a nursing facility unless retainer days are authorized by the CMT; payment is available on the date of admission and the date of discharge.
ANY of the following
- Provider reimbursement rate is the lesser of the provider's usual and customary charge or the department's Medicaid fee schedule as provided in ARM 37.85.105(5)(b).
- SDMI HCBS is the payor of last resort and will not reimburse services that are or should be paid by another source as provided in ARM 37.85.407.
- The department may authorize CMT to issue pass-through payments to non‑Medicaid providers for specified services (community transition; environmental accessibility adaptations; health and wellness; homemaker chore; specialized medical equipment and supplies).
Claim Modifiers and Fee Schedule
| UA | Required modifier for HCBS claims; must be the first modifier |
| TE | Modifier to identify nurse supervision; used with UA (UA first) |
Prior Authorization and Provider Responsibilities
CMT prior authorization required for SDMI HCBS services
All SDMI HCBS services, except case management, require approval from the department's contracted case management teams (CMT). The prior authorization number must be noted on the CMS-1500 or 837-P for all submitted charges; see SDMI HCBS 415 for instructions to create or change prior authorizations.
- Obtain CMT approval before providing any SDMI HCBS service other than case management.
- Document the CMT prior authorization number on the claim (CMS-1500 or 837-P).
- Follow the Prior Authorization Policy (SDMI HCBS 415) to create or modify authorizations.
Key Definitions and Billing Modifiers
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