Medicaid provider general handbook

From your keyboard press the Ctrl and F keys at the same time. A search box will appear. Type in a descriptive or key word for example "Denials". The search box will show all locations where denials discussed in the manual. Search by Chapter. Open any Chapter tab for example the "Billing Procedures" tab. The search box will show where denials discussed in just that chapter. Site Search. Search the manual as well as other documents related to a particular search term on the Montana Healthcare Programs Site Specific Search page.

Prior manuals may be located through the provider website archives. Complete General Information for Providers Manual.

General Information for Providers Manual To print this manual, right click your mouse and choose "print". Update Log Publication History This publication supersedes all versions of previous general information provider handbooks.

Term "Medicaid" replaced with "Montana Healthcare Programs" throughout the manual. Terms "client" and "patient" replaced with "member". Rule References Providers must be familiar with current rules and regulations governing the Montana Healthcare Programs program. Manual Organization The General Information for Providers manual provides answers to general Montana Healthcare Programs questions about provider enrollment, member eligibility, and surveillance and utilization review.

Manual Maintenance Manuals must be kept current. Website Information Additional information is available through the Provider Information website. Provider Training Opportunities Montana Healthcare Programs offers a variety of training opportunities that are announced on the Provider Information website and in the Claim Jumper newsletter. Contract Services Montana Healthcare Programs works with various contractors who represent Montana Healthcare Programs through the services they provide.

Mountain-Pacific Quality Health. Provides prior authorization for many Montana Healthcare Programs services. Provides prior authorization, utilization review, and continued stay review for some mental health services.

End of Introduction Chapter Provider Requirements Provider Enrollment To be eligible for enrollment, a provider must: Provide proof of licensure, certification, accreditation, or registration according to Montana state laws and regulations. Provide a completed W Montana Healthcare Programs payment is made only to enrolled providers.

Letters to atypical providers include their API. Demonstrated inability to perform under the terms of the provider agreement. Failure to abide by applicable Montana and U. Failure to abide by the regulations and policies of the U.

Authorized Signature ARM Provider Rights Providers have the right to end participation in Montana Healthcare Programs in writing at any time; however, some provider types have additional requirements. Providers may bill Montana Healthcare Programs members for services not covered by Montana Healthcare Programs if the provider and member have agreed in writing prior to providing services. When the provider does not accept the member as a Montana Healthcare Programs member, a specific custom agreement is required stating that the member agrees to be financially responsible for the services received.

A provider may bill a member for non-covered services if the provider has informed the member in advance of providing the services that Montana Healthcare Programs will not cover the services and that the member will be required to pay privately for the services, and if the member has agreed to pay privately for the services. Non-covered services are services that may not be reimbursed for the particular member by the Montana Healthcare Programs program under any circumstances and covered services are services that may be reimbursed by the Montana Healthcare Programs program for the particular member if all applicable requirements, including medical necessity, are met ARM Providers have the right to choose Montana Healthcare Programs members, subject to the conditions in Accepting Montana Healthcare Programs Members later in this chapter.

Provider Participation ARM Any such decisions must follow these principles: No member should be abandoned in a way that would violate professional ethics. Members may not be refused service because of race, color, national origin, age, or disability.

Members enrolled in Montana Healthcare Programs must be advised in advance if they are being accepted only on a private-pay basis. In service settings where the member is admitted or accepted as a Montana Healthcare Programs member by a provider, facility, institution, or other entity that arranges provision of services by other or ancillary providers, all other or ancillary providers will be deemed to have accepted the individual as a Montana Healthcare Programs member and may not bill the member for the services unless, prior to provision of services, the particular provider informed the member of their refusal to accept Montana Healthcare Programs and the member agreed to pay privately for the services.

Most providers may begin Montana Healthcare Programs coverage for retroactively eligible members at the current date or from the date retroactive eligibility was effective.

See the Retroactive Eligibility section in the Member Eligibility and Responsibilities chapter of this manual for details. When a provider bills Montana Healthcare Programs for services rendered to a member, the provider has accepted the member as a Montana Healthcare Programs member. Once a member has been accepted as a Montana Healthcare Programs member, the provider may not accept Montana Healthcare Programs payment for some covered services but refuse to accept Montana Healthcare Programs payment for other covered services.

Providers are entitled to Montana Healthcare Programs payment for diagnostic, therapeutic, rehabilitative or palliative services when the following conditions are met: Provider must be enrolled in Montana Healthcare Programs.

ARM See Member Eligibility and Responsibilities for restrictions. The Department may review medical necessity at any time before or after payment.

Charges must be usual and customary. See the Billing Procedures chapter in this manual for timely filing requirements. Disclosure Providers are required to fully disclose ownership and control information when requested by the Department. Provider Sanctions ARM Nutritional history and status. Questions about dietary practices identify unusual eating habits, such as pica, or extended use of bottle feedings, or diets that are deficient or excessive in one or more nutrients.

Complete dental history. Does your child live near a lead smelter, battery recycling plant, or other industry operating or closed likely to release lead? Does your child live in or regularly visit a house built before , which contains lead paint? Does your child live near a heavily traveled major highway where soil and dust may be contaminated with lead?

Does your child live in a home where the plumbing consists of lead pipes or copper with lead solder joints? Does your child frequently come in contact with an adult who works with lead, such as construction, welding, pottery, reloading ammunition making own bullets , etc.?

Is the child given any home or folk remedies? If yes, discuss. Annual dental screens include an oral inspection, fluoride varnish as available and making a referral to a dentist for any of the following reasons: When the first tooth erupts, and every six months thereafter. If a child with a first tooth has not obtained a complete dental examination by a dentist in the past 12 months.

If an oral inspection reveals cavities or infection, or if the child is developing a handicapping malocclusion or significant abnormality. At each screening visit, provide age-appropriate anticipatory guidance concerning such topics as the following: Auto safety: Car seats, seat belts, air bags, positioning young or lightweight children in the backseat.

Recreational safety: Helmets and protective padding, playground equipment. Exposure to sun and secondhand smoke. Adequate sleep, exercise, and nutrition, including eating habits and eating disorders.

Peer pressure. General health: Immunizations, patterns of respiratory infections, skin eruptions, care of teeth. Problems such as whining, stealing, setting fires, etc. Behavior and development: Sleep patterns, temper, attempts at independence normal and unpleasant behavior , curiosity, speech and language, sex education and development, sexual activities, attention span, toilet training, alcohol and tobacco use, substance abuse. End of Prior Authorization Chapter Telemedicine Program Overview Telemedicine is the use of interactive audio-video equipment to link practitioners and members located at different sites.

Providers must be enrolled as Montana Healthcare Programs providers and be licensed in the State of Montana in order to: Treat a Montana Healthcare Programs member; and Submit claims for payment to Montana Healthcare Programs When to Use Telemedicine Montana Healthcare Programs considers the primary purposes of telemedicine are to bring providers to people living in rural areas, and to allow members access to care that is not available within their community.

Telemedicine Confidentiality Requirements All Montana Healthcare Programs providers using telemedicine to deliver Montana Healthcare Programs services must employ existing quality-of-care protocols and member confidentiality guidelines when providing telemedicine services. General Billing Instructions Providers may only bill procedure codes for which they are already eligible to bill. Telemedicine reimbursement does not include: Consultations provided by telephone interactive audio ; or Facsimile machine transmissions.

Crisis hotlines The originating and distant providers may not be within the same facility or community. Originating Provider Requirements The originating site provider must have secure and appropriate equipment to ensure confidentiality, including camera s , lighting, transmission and other needed electronics.

Verifying Member Eligibility Member eligibility may change monthly. Contact: Provider Relations P. Monday—Friday Information Available: Verify presumptive eligibility Special Instructions: To become a provider who determines presumptive eligibility, call Subsidized Health Insurance Programs in Montana Providers may refer member to the following programs.

For Information on Eligibility: www. For Information on Eligibility: U. Social Security Administration office www. For Information on Eligibility: Workers Compensation Note: Eligibility rules are complex; members and providers should check with the program administrator for specifics. Update Log. Table of Contents.

Key Contacts and Key Websites. Introduction The Montana Healthcare Programs program plays an essential role in providing health insurance for Montanans. End of Introduction Chapter. Provider Requirements. Provider Requirements Provider Enrollment To be eligible for enrollment, a provider must: Provide proof of licensure, certification, accreditation, or registration according to Montana state laws and regulations. Prior Authorization.

End of Prior Authorization Chapter. Telemedicine Program Overview Telemedicine is the use of interactive audio-video equipment to link practitioners and members located at different sites. End of Telemedicine Chapter. Member Eligibility and Responsibilities.

Surveillance and Utilization Review. SURS reviews the billing data of newly enrolled providers and may also review documentation. Provider Self-Audits. A self-audit is an opportunity for the provider to perform an audit and self-disclose errors to SURS. Individual Audits. An individual audit is conducted by the Program Integrity Compliance Specialist in charge of reviewing the provider type being audited.

Team Audits. Team audits are conducted by a team of Program Integrity Compliance Specialists whose individual expertise contributes to the review of the issue being audited. Data Mining Audits. An audit conducted by data mining which reviews the appropriateness of the data submitted on the claim, such as dates of service, procedure code, units, etc.

Statistical Sampling. When a provider is audited, claims data is gathered for the audit time frame. If a provider has a large number of claims for which records collection and submission for a complete review would be burdensome to the provider, a statistical sample of the claims may be reviewed at the option of the Department.

The audit is then completed on the sample of claims. The determination made on the sample is then extrapolated to the entire universe. More information about the statistical sampling process can be found in ARM Key Points The SURS unit encourages providers to call with any questions or concerns regarding the audit of paid claims. The Department is entitled to recover payment made to providers when a claim was paid incorrectly for any reason.

MCA When an inappropriate payment has been identified, the Department may recover the overpayment by any legal means, including withholding of provider payments on subsequent claims. The provider shall submit a true and accurate copy of each record of the service or item being reviewed as it existed within 90 days after the date on which the claim was submitted to Montana Healthcare Programs.

Be familiar with the Montana Healthcare Programs provider manuals, fee schedules, and provider notices that are in effect for the claim dates of service. Read the Claim Jumper provider newsletter. These are available on the Provider Information website. Comply with applicable state and federal regulations, including but not limited to the Administrative Rules of Montana. Relying on short descriptions can result in inappropriate billing. Additional coding resources such as those noted in CPT are also recommended.

All providers of services must maintain complete records which fully demonstrate the extent, nature, and medical necessity of services and items provided to Montana Healthcare Programs members. Information regarding the minimum requirements for records are found in ARM In addition to complying with these minimum requirements, providers must also comply with any specific record keeping requirements applicable to the type of services the provider furnishes.

See the Record Keeping section in the Provider Requirements chapter in this manual. When reimbursement is based on the length of time spent providing the service, the records must specify the time spent or the time treatment began and ended for each procedure.

Contact Provider Relations for the status of submitted claims. Use specific codes rather than miscellaneous codes. For example, Code is more specific problem-focused visit than Code unlisted evaluation and management service. See current fee schedule, provider manuals, and Administrative Rules of Montana. Bill only under your own provider number. Bill only for services you provided. Bill for the appropriate level of service provided.

For example, the CPT coding book contains detailed descriptions and examples of what differentiates a level 1 office visit Code from a level 5 office visit Code Most surgical and obstetric procedures and some medical procedures include routine care before and after the procedure. Modifiers are becoming more prevalent in healthcare billing, and they often affect payment calculations.

Choose the least costly alternative. For example, if a member is able to operate a standard wheelchair, then a motorized wheelchair should not be prescribed or provided. For repeat members, use an established patient code e. Unless otherwise specified, one unit equals one visit or one procedure. For specific codes, however, one unit may be 15 minutes, a percentage of body surface area, or another quantity.

Always check the long text of the code description. End of Surveillance and Utilization Review Chapter. Billing Procedures. Billing Procedures Claim Forms Services provided by the healthcare professionals covered in this manual may be billed electronically or on paper claim forms, which are available from various publishing companies; they are not available from the Department or Provider Relations.

Six months from the date on an adjustment notice from a third party payer who has previously processed the claim for the same service, and the adjustment notice is dated after the periods described above.

Six months from the date on the Medicare explanation of benefits, if the Medicare claim was timely filed and the member eligible for Medicare at the time the Medicare claim was filed. See the Remittance Advices and Adjustments chapter in this manual. If a claim submitted to does not appear on the remittance advice within 45 days, contact Provider Relations for claim status.

If another insurer has been billed and 90 days have passed with no response, a provider can bill Montana Healthcare Programs. See the Member Eligibility and Responsibilities chapter in this manual for more information. More specifically, providers cannot bill members directly: For the difference between charges and the amount Montana Healthcare Programs paid.

For a covered service provided to a Montana Healthcare Program-enrolled member who was accepted as a Montana Healthcare Programs member by the provider, even if the claim was denied. When a third party payer does not respond. When a member fails to arrive for a scheduled appointment. Montana Healthcare Programs may not be billed for no-show appointments either. When services are free to the member, such as in a public health clinic. Montana Healthcare Programs may not be billed for those services either.

Exceptions are outlined in ARM Under certain circumstances, providers may need a signed agreement to bill a member. Billing for Retroactively Eligible Members When a member becomes retroactively eligible for Montana Healthcare Programs , the provider may: Accept the member as a Montana Healthcare Programs member from the current date. Accept the member as a Montana Healthcare Programs member from the date retroactive eligibility was effective. Require the member to continue as a private-pay member.

Always refer to the long descriptions in coding books. Coding Tips Standard use of medical coding conventions is required when billing Montana Healthcare Programs. Always read the complete description and guidelines in the coding books. Attend classes on coding offered by certified coding specialists. Use specific codes rather than unlisted codes. Evaluation and management services have 3 to 5 levels. See your CPT manual for instructions on determining appropriate levels of service.

CPT codes that are billed based on the amount of time spent with the member must be billed with the code that is closest to but not over the time spent. If these codes are omitted, hospitals may be underpaid. Take care to use the correct units measurement. Coding Resources Please note that the Department does not endorse the products of any particular publisher. Updated each January. Contact: Available through various publishers and bookstores.

Various newsletters and other coding resources are available in the commercial marketplace. Multiple Services on Same Date Outpatient hospital providers must submit a single claim for all services provided to the same member on the same day.

Span Bills Outpatient hospital providers may include services for more than one day on a single claim, so long as the service is paid by fee schedule e. Reporting Service Dates All line items must have a valid date of service. Montana Healthcare Programs accepts most of the same modifiers as Medicare, but not all.

The Montana Healthcare Programs claims processing system recognizes three pricing modifiers and one informational modifier per claim line on the CMS Providers are asked to place any modifiers that affect pricing in the first two modifier fields.

Discontinued or reduced service modifiers must be listed before other pricing modifiers on the CMS For a list of modifiers that change pricing, see the How Payment Is Calculated chapter in this manual. Billing Tips for Specific Services Prior authorization is required for some services.

The following drugs may generate additional payment: Vaccines, antigens, and immunizations Chemotherapeutic agents and the supported and adjunctive drugs used with them Immunosuppressive drugs Orphan drugs Radiopharmaceuticals Certain other drugs, such as those provided in an emergency department for heart attacks NDC Requirements The Federal Deficit Reduction Act of mandates that all State Montana Healthcare Programs require the submission of National Drug Codes NDCs on claims submitted with certain procedure codes for physician-administered drugs.

Enter the digit NDC numeric code in the format, without the hyphens. Any unused spaces for the entire quantity are left blank. Partial Hospitalization Partial hospitalization services must be billed with the national code for partial hospitalization, the appropriate modifier, and the prior authorization code.

Montana Healthcare Programs covers elective sterilization for men and women when all of the following requirements are met: Member must complete and sign the Informed Consent to Sterilization MA form at least 30 days, but not more than days, prior to the sterilization procedure. This form is the only form Montana Healthcare Programs accepts for elective sterilizations.

If this form is not properly completed, payment will be denied. The day waiting period may be waived for either of the following: Premature Delivery. The Informed Consent to Sterilization must be completed and signed by the member at least 30 days prior to the estimated delivery date and at least 72 hours prior to the sterilization.

Emergency Abdominal Surgery. The Informed Consent to Sterilization form must be completed and signed by the member at least 72 hours prior to the sterilization procedure. Member must be at least 21 years of age when signing the form. Member must not have been declared mentally incompetent by a federal, state, or local court, unless the member has been declared competent to specifically consent to sterilization.

Member must not be confined under civil or criminal status in a correctional or rehabilitative facility, including a psychiatric hospital or other correctional facility for the treatment of the mentally ill. The member must be made aware of available alternatives of birth control and family planning. The member must understand the sterilization procedure being considered is irreversible. The member must be made aware of the discomforts and risks which may accompany the sterilization procedure being considered.

The member must be informed of the benefits and advantages of the sterilization procedure. An interpreter must be present and sign for members who are blind or deaf, or do not understand the language to assure the person has been informed. Informed consent for sterilization may not be obtained under the following circumstances: If the member is in labor or childbirth.

If the member is seeking or obtaining an abortion. For medically necessary sterilizations, including hysterectomies, oophorectomies, salpingectomies, and orchiectomies, one of the following must be attached to the claim, or payment will be denied: A completed Montana Healthcare Programs Hysterectomy Acknowledgement form MA for each provider submitting a claim.

When no prior sterility Section B or life-threatening emergency Section C exists, the member or representative, if any and physician must sign and date Section A of this form prior to the procedure. See 42 CFR Also, for Section A, signatures dated after the surgery date require manual review of medical records by the Department. The Department must verify that the member and representative, if any was informed orally and in writing, prior to the surgery, that the procedure would render the member permanently incapable of reproducing.

The member does not need to sign this form when Sections B or C are used. For members who have become retroactively eligible for Montana Healthcare Programs , the physician must certify in writing that the surgery was performed for medical reasons and must document one of the following: The individual was informed prior to the hysterectomy that the operation would render the member permanently incapable of reproducing.

The reason for the hysterectomy was a life-threatening emergency. The member was already sterile at the time of the hysterectomy and the reason for prior sterility. Submitting Electronic Claims Providers who submit claims electronically experience fewer errors and quicker payment. This free software provided by Conduent allows for the creation of basic claim submissions.

Please note that this software is not compatible with Windows 10 and has limited support as it is free software. Please note that the clearinghouse must be enrolled to submit claims to Montana Healthcare Programs. A secure website that allows providers to verify eligibility, check claim status, and view medical claims history. Valid X12N files can be uploaded through this website. MoveIt DMZ. This secure transfer protocol is for providers and clearinghouses that submit large volumes of files in excess of 20 per day or are regularly submitting files larger than 2 MB.

This utilizes SFTP and an intermediate storage area for the exchange of files. Billing Electronically With Paper Attachments When submitting claims that require additional supporting documentation, the Attachment Control Number field must be populated with an identifier. Identifier formats can be designed by software vendors or clearinghouses, but the preferred method is the provider's Montana Healthcare Programs ID number followed by the member's ID number and the date of service, each separated by a dash: When submitting claims that require additional supporting documentation, the Attachment Control Number field must be populated with an identifier.

Identifier formats can be designed by software vendors or clearinghouses, but the preferred method is the provider's Montana Healthcare Programs ID number followed by the member's ID number and the date of service, each separated by a dash: The supporting documentation must be submitted with a Paperwork Attachment Cover Sheet. Claim Inquiries Contact Provider Relations for general claim questions and questions regarding payments, denials, member eligibility.

The Most Common Billing Errors and How to Avoid Them Paper claims are often returned to the provider before they can be processed, and many other claims, both paper and electronic, are denied.

Verify the correct NPI and Taxonomy are on the claim. Reasons for Return or Denial: Authorized signature missing How to Prevent Returned or Denied Claims: Each claim must have an authorized signature belonging to the provider, billing clerk, or office personnel. The signature may be typed, stamped, hand-written, or computer-generated. Use dark ink and center the information in the form locator. Information must not be obscured by lines. Reasons for Return or Denial: Member ID number not on file, or member was not eligible on date of service How to Prevent Returned or Denied Claims: Before providing services to the member, verify member eligibility by using one of the methods described in the Member Eligibility and Responsibilities chapter of this manual.

Montana Healthcare Programs eligibility may change monthly. Reasons for Return or Denial: Procedure requires Passport provider referral — No Passport provider number on claim How to Prevent Returned or Denied Claims: A Passport provider number must be on the claim form when a referral is required.

Passport approval is different from prior authorization. See the Passport to Health provider manual. Reasons for Return or Denial: Prior authorization number is missing How to Prevent Returned or Denied Claims: Prior authorization is required for certain services, and the prior authorization number must be on the claim form.

Prior authorization is different from Passport. See the Prior Authorization chapter in this manual. Reasons for Return or Denial: Prior authorization does not match current information How to Prevent Returned or Denied Claims: Claims must be billed and services performed during the prior authorization span.

The claim will be denied if it is not billed according to the spans on the authorization. Reasons for Return or Denial: Duplicate claim How to Prevent Returned or Denied Claims: Check all remittance advices for previously submitted claims before resubmitting. When making changes to previously paid claims, submit an adjustment form rather than a new claim form.

See Remittance Advices and Adjustments in this manual. Reasons for Return or Denial: Claim past day filing limit How to Prevent Returned or Denied Claims: The Claims Processing unit must receive all clean claims and adjustments within the timely filing limits described in this chapter. To ensure timely processing, claims and adjustments must be mailed to Claims Processing. Reasons for Return or Denial: Provider is not eligible during dates of services, enrollment has lapsed due to licensing requirements, or provider number terminated How to Prevent Returned or Denied Claims: Out-of-state providers must update licensure for Montana Healthcare Programs enrollment early to avoid denials.

If enrollment has lapsed due to expired licensure, claims submitted with a date of service after the expiration date will be denied until the provider updates his or her enrollment.

New providers cannot bill for services provided before Montana Healthcare Programs enrollment begins. If a provider is terminated from the Montana Healthcare Programs program, claims submitted with a date of service after the termination date will be denied.

Check the appropriate Montana Healthcare Programs fee schedule to verify the procedure code is valid for your provider type.

End of Billing Procedures Chapter. Remittance Advices and Adjustments. Remittance Advices and Adjustments The Remittance Advice The remittance advice is the best tool providers have to determine the status of a claim. The remittance is divided into the following sections: Remittance Advice Notice This section is on the first page of the remittance advice.

Remittance advices are available for only 90 days on the web portal. Credit Balance Claims Credit balances occur when claim adjustments reduce original payments causing the provider to owe money to the Department.

Credit balances can be resolved in two ways: By working off the credit balance. Remaining credit balances can be deducted from future claims. These claims will continue to appear on consecutive remittance advices until the credit has been paid. This method is required for providers who no longer submit claims to Montana Healthcare Programs. Please attach a note stating that the check is to pay off a credit balance and include your provider number. Send the check to the attention of the Third Party Liability unit.

Rebilling and Adjustments Rebillings and adjustments are important steps in correcting any billing problems providers may experience. Providers may rebill Montana Healthcare Programs when a claim is denied.

Check the reason and remark codes, make the appropriate corrections and resubmit the claim. Do not attempt to adjust denied claims. Provider Handbook. General Information. General Billing Instructions.

General Information and Requirements for Providers. Remittance Advice Analysis. Provider Types and Specialties. TPR Carrier Codes. DHW Dental Services. Idaho Behavioral Health Plan. Idaho Medicaid Policy. Idaho Smiles. QIO - Telligen Website. Provider Guidelines. Adult Residential Care. Agency Professional. Ambulatory Health Care Facility. Ambulatory Surgical Centers.

Audiology Services. Behavioral Health and Social Services. Dietary and Nutritional Services. Eye and Vision Services. Home Health and Hospice Services. Laboratory Services. Licensed Midwife. Long-Term Care Facility. Nursing and Custodial Care Facilities. Nursing Services. Using the Manual. Printing the Manual. Although MDHHS will continue to issue paper policy bulletins as necessary, paper manuals are not provided. The online version of the Manual is updated quarterly to incorporate any policies transmitted via policy bulletins since the last Manual update.

You will receive the current published version of the manual that is available at that time. You may submit the request by mail, f ax, or e-mail to one of the following:. Providers using the CD will need to retain all bulletins received throughout the year to use in addition to the CD. To view and utilize the link and search functions of the Manual, you will need to have Adobe Acrobat version 6. If you do not have this software, or a lower version, you can click on the Adobe Acrobat Reader Icon below to download the software free of charge.

To acquaint yourself with this manual, begin with the Medicaid Provider Manual Overview. The Overview describes how information is organized and how to navigate through the document.