53-6-197. Abortion coverage. (1) Coverage under the Montana medicaid program for physician services for abortion is allowed only if the abortion is performed by a physician and only if:

(a) the life of the mother will be endangered if the fetus is carried to term;

(b) the pregnancy is the result of an act of rape or incest; or

(c) the abortion is medically necessary.

(2) To receive medicaid reimbursement for physician services for an abortion described in subsection (1)(a), a physician shall certify that the woman suffers from a physical disorder, physical injury, or physical illness, including a life-endangering physical condition caused by or arising from the pregnancy, that would place the woman in danger of death unless an abortion is performed.

(3) To receive medicaid reimbursement for physician services for an abortion described in subsection (1)(c), a physician shall certify that, although the woman is not in danger of death unless an abortion is performed, the woman suffers from:

(a) a physical condition that would be significantly aggravated by the pregnancy; or

(b) a severe mental illness or intellectual disability that would be significantly aggravated by the pregnancy.

(4) Prior authorization is required for physician services for abortion. If prior authorization is not obtained because of an emergency, a claim for payment must undergo post-service, prepayment review. Prior authorization is not required for treatments for incomplete abortion, miscarriage, or septic abortion.

(5) The following supporting documentation must be submitted for an abortion described in subsection (1)(a) or (1)(c), either with the prior authorization request or with any claim for payment for which prior authorization was not received:

(a) the woman's medical history, including:

(i) age, current medications, medical conditions, and allergies;

(ii) number of pregnancies and number of live births;

(iii) last menstrual period and the status and results of any pregnancy test;

(iv) chronic illnesses and surgeries;

(v) behavioral health issues;

(vi) smoking and substance abuse; and

(vii) obstetric history;

(b) a brief review of systems to identify symptoms the woman may be experiencing;

(c) the results of a physical examination, including vital signs, heart, lungs, abdomen, extremities, and, if imaging is not available, estimate of gestational age;

(d) if available, results of laboratory tests, including rh factor, hemoglobin, and human chorionic gonadotropin;

(e) if available, imaging to estimate gestational age;

(f) documentation that:

(i) the diagnosis of the condition leading to a determination that an abortion is necessary was made by a medical professional qualified by education, training, and experience to make the diagnosis; and

(ii) the woman is receiving care for the condition;

(g) the reason for the abortion procedure;

(h) for medication or chemical abortions, documentation confirming review of contraindications, adequate patient education, and compliance with the requirements of the medicaid physician-related services manual;

(i) the treatment plan; and

(j) the woman's signed informed consent for the proposed abortion procedure.

(6) As used in this section, the following terms apply:

(a) "Abortion" has the meaning provided in 50-20-104.

(b) "Physician" has the meaning provided in 37-3-102.