If we have an error, can we submit a corrected claim at the same time that we send the claim credit?
Yes. However, make it clear that you would like the corrected claim submitted after the claim credit is processed. In Box 8 of the Adjustment form, indicate "See Corrected Claim."
When adjusting a claim, do you need a copy of the original bill?
No. You do not have to send a copy of the claim. However, if you prefer, you may send a copy of the corrected claim. There is an exception for UB billers: If you are combining an inpatient and outpatient claim, send an updated, corrected claim.
What happens if we get paid for members who are not ours?
If this happens, call Provider Relations at 1.800.624.3958, and we will complete the appropriate adjustments.
If we are sending an adjustment to add a TPL payment, do we send the EOB?
No. Put the information in the correct box in Section B of the Individual Adjustment Request form. The Individual Adjustment Request form is available on the Forms page.
Should our office test submitting claims with our clearinghouse?
Yes, if you are using a new clearinghouse, it is important to ensure claims will be accepted by Montana Health Care Programs following all billing requirements.
We received an error report (277CA) from our clearinghouse or Montana Provider Relations saying our NPI and/or taxonomy is not on file. What could be the cause?
There could be several reasons for this:
- We do not have you enrolled with your NPI number. Make sure you have enrolled with Xerox State Healthcare, LLC (Xerox) and have received the acknowledgement letter that your individual or group NPI and taxonomy have been approved to bill claims.
- The claims processing system completes several checks of the NPI being billed to ensure that it is valid. Listed are the most common edits questions that would prevent your claims from processing.
Is it a valid NPI number?
Is the taxonomy code correct? The taxonomy code billed on your claims has to match the taxonomy you had indicated during enrollment and is on your provider file established at that time.
Is the billing provider's ZIP+4 correct? If it is different from what IS on file, the claims will not process.
For schools billing CSCT, is the correct team number being billed and is it in the correct location on the claim?
Again, if any of these do not match, a report will be generated and the claims will not process.
Why do we need a taxonomy code?
Taxonomy is required as one of several data elements to match the enrollment in MMIS. If an entity has more than one enrollment under an NPI, the taxonomy is the first match the claims processing system makes to determine the line of business.
Which provider types require a rendering/attending NPI and taxonomy?
Podiatry clinics, physical therapist clinics, speech therapist clinics, occupational therapist clinics, dental clinics, physician clinics, dedicated emergency departments, general groups or clinics, family planning clinics, provider based clinics, rural health clinics (RHCs), federally qualified health centers (FQHCs), and hospitals require a rendering/attending NPI and taxonomy. If rendering/attending provider NPI and taxonomy are not sent or the rendering/attending provider information sent is the same as the billing provider information, your claims will deny.
For providers billing professional claims (CMS-1500, 837P, or 2012 ADA dental claim form), the rendering/attending provider taxonomy is not required if the rendering/attending and billing provider are the same. Do not include a rendering NPI.
If you are a provider type that does not require a rendering/attending NPI and taxonomy, your claims will deny if the rendering/attending NPI and taxonomy on the claim are different than the billing NPI and taxonomy on the claim.
If you are an ambulance provider, durable medical equipment provider, or ambulatory surgical center who are billing only for your services and not the physician's, leave the rendering/attending provider fields blank.
If you are an RHC or FQHC, you can now bill professional services administered in a hospital setting on a CMS-1500. Enter the RHC or FQHC NPI and taxonomy as the billing provider and the physician's NPI and taxonomy as the rendering/attending provider. Any claims that denied because of this recent system change are re-billed.
Providers enrolled as individuals cannot be the billing provider for other individuals. Only providers enrolled as a clinic or with a clinic specialty can bill for someone else's services.
What if we have more than one rendering provider on a professional claim?
The Montana Health Care Programs claims processing system can process only one rendering provider per professional claim. If a provider enters more than one rendering provider on a paper professional claim, the system will choose the rendering that appears on the first line and complete adjudication using that rendering number. Additional rendering providers billed on the claim will not be processed. Professional claims submitted electronically with multiple rendering providers will be split into separate claims.
I have two NPIs, one for myself and one for my clinic. Which one do I use when I am billing for services I rendered?
If you own the clinic and the clinic's regular practice is to bill with the clinic as the billing provider, continue to use the clinic NPI and taxonomy as the billing provider and your individual NPI and taxonomy as the rendering/attending provider.
We were told to use the clinic’s taxonomy. Do we use the one from Montana Provider Relations or do we get another one from NPPES?
Providers are not bound to use the taxonomy given to them by NPPES.
Billing providers use the taxonomy with which they enrolled in Montana Health Care Programs
Clinic enrollment, providers choose either the taxonomy that matches what they received from NPPES or the one that best fits their practice.
The list of taxonomies used by Montana Health Care Programs are on the Provider Information website on the appropriate provider type page.
I decided to add another person to my practice and I want to bill and get paid for all services. What do I do?
Obtain an NPI for the clinic from NPPES and enroll with Montana Health Care Programs as a clinic. Then submit your claims with the clinic NPI and taxonomy as the billing provider and the NPI and taxonomy of the provider who rendered the service as the rendering/attending provider. Individual providers cannot bill for services rendered by another provider.
I decided to add another person to my practice, but we want to bill our own services. How do we do this?
Each provider uses his/her own NPI and taxonomy as the billing provider.
We have several claims that have been denied because of NPI issues. What do we do with them?
Refer to the NPI claims instructions on the Provider Information website to determine the reason your claims are denying, then correct and resubmit them within the 365-day timely filing limit.
If you have questions, contact Provider Relations at 1.800.624.3958 or 406.442.1837, by fax at 406.442.4402, firstname.lastname@example.org, or through the Ask Provider Relations function on the Montana Access to Health (MATH) web portal at https://mtaccesstohealth.acs-shc.com/. Most inquiries will be responded to within 3 days.
What number do we use for a clinic that is part of a provider-based entity?
Facilities that are CMS-designated provider-based entities may choose to enroll as a clinic with a clinic taxonomy or they may choose to use the hospital NPI and appropriate taxonomy as the billing provider. The professional portion of the provider-based service billed on a CMS-1500/837P use the NPI and the appropriate taxonomy for which they enrolled.
The NPI and taxonomy of the professional performing the provider-based service is entered as the rendering provider on the CMS-1500/837P and the billing provider is the enrolled organization whether they chose the clinic NPI or they chose to use the hospital NPI with the corresponding taxonomy.
They use the NPI with which they enrolled. The facility portion of the provider-based service billed on a UB-04/837I uses the hospital NPI and the appropriate taxonomy for an acute care hospital. The NPI and taxonomy of the professional performing the provider-based service is entered as the attending provider on the UB-04/837I.
What about crossover claims? Do we include our taxonomy code on claims we are sending to Medicare?
Yes, Medicare will transmit the taxonomy codes on claims submitted by you to Medicare. If your claim rejects, does not reach the claims processing system, or denies because of a taxonomy related issue, you can contact our Call Center to confirm the NPI and taxonomy code on the file we are receiving from Medicare, or you can directly bill Montana Health Care Programs for these crossovers electronically or through your clearinghouse. If you have to bill Medicare with a group NPI, you must be enrolled into Montana Medicaid to ensure that your claims will crossover automatically.
How do mental health centers bill?
Mental health centers enroll for each type of provider and service – such as case management, therapeutic group home, and therapeutic family care/foster care – for which they now bill. Centers enroll each of the service types using their clinic NPI and choosing the provider type and taxonomy for each.
For example, enroll for case management by choosing case management- mental health in the Provider Type drop-down box and enter the center's NPI.
When the mental health center bills for these services, they will bill with the center's NPI and the taxonomy for the type of service being provided.
Services currently being billed using the community mental health center provider number will be billed using the mental health center NPI and taxonomy.
The mental health center enrolls for practitioner services using the mental health center NPI and the appropriate taxonomy for the practitioner enrolling.
For crossovers, Medicare requires the mental health center to bill using the facility/group NPI and taxonomy as billing and each individual as a rendering/attending provider. Claims billed with the mental health center NPI and taxonomy of an individual practitioner (e.g., social worker, licensed professional counselor) can then cross over, granted that the rendering provider is enrolled into Montana Medicaid.
What does HIPAA mean?
HIPAA is the acronym for the Health Care Portability and Accountability Act. In October 2003, it was mandated that all electronic health care transactions be submitted in a standard format, regardless of the payer to which they were submitted. These standard formats have been reviewed and updated to meet changes which have taken place in health care since 2003; the new required format is Version 5, Release 1, Sub-Release 0, also known as 005010.
What qualifier do we use to reflect taxonomy on the professional claim?
Use the qualifier PXC for electronic claims and the qualifier ZZ on paper professional claim.
When we file claims electronically, how long are we required to keep EOBs?
Keep EOBs for 6 years and 3 months.
Do you ever send the actual claim back?
Yes. If one of the basic required information is missing (provider number, bill date, signature), we will return the entire paper claim to the provider with a letter stating what problems were found.
Do you only process clinic claims one week, and then hospital claims the next week?
No. All claims that are received at Xerox are processed each week, regardless of claim type.
How long does it take to get payment?
It can take anywhere from one to 4 weeks, depending on the backlog of claims and whether your claim is paper or sent electronically.
Do you pay for claims under $5?
If only one claim is submitted for payment, and the payment is under $5, then we will wait until the next time a claim is submitted and add those claims together for a payment of more than $5. However, twice a year, we reduce the payment threshold to $.01 to release all small checks.
Is the 160-M sent to Provider Relations or to Claims?
For electronic claims, the 160-M can either be faxed to 406.442.4402 with the appropriate Paperwork Attachment Cover Sheet or mailed with the same cover sheet to Claims, P.O. Box 8000, Helena, MT 59604. For paper claims, providers can either attach the paperwork to the claim or submit the paperwork separately with a Paperwork Attachment Cover Sheet as described above. Instructions can be found at the bottom of the cover sheet.
Do all diagnosis codes get keyed?
Yes, up to 4 diagnosis codes per claim on a paper CMS-1500 and up to 18 on a paper UB-04. For electronic claims, all diagnosis codes are accepted on the transaction, but only four are used in processing the 837P and eighteen for the 837I are used for processing.
What if there is a child who comes in for immunizations, and there are more immunizations than spaces for diagnosis?
You can make the diagnosis pointer point to whichever diagnosis you would like for child immunizations. The diagnosis does not have to match the procedure in this case only. Although 12 diagnosis codes are allowed on the CMS-1500, we currently accept 4.
What do we do if Montana Provider Relations says a claim was paid, but we are unable to find it on the remittance advice statement?
If you call Provider Relations at 1.800.624.3958, they can give you the date of the statement. If you are still unable to find it, a PR representative can pull your statement for that time and send it to you. There is a $1 per page charge for this service. Montana Provider Relations can also fax your remittance advice or burn it to a CD free of charge.
If a provider has performed a sterilization, and the member gets retroactive eligibility, can the provider bill Medicaid without the sterilization form?
No. You cannot bill Medicaid without the correct form. If the provider suspects that the member may become eligible for Medicaid, the provider has the member sign the form 30 days prior to the sterilization. However, for a medically necessary sterilization, the provider can send the claim and supporting documentation, including operative notes and the physician’s statement to the Department for review.
A member became retroactively eligible during his hospital stay. He was in the hospital on 05/30/11, but he was eligible for Medicaid on 06/01/11. Medicare requires dates of service from 05/30/11. How can the provider bill this?
The provider will have to prorate the stay for Medicaid eligibility both on the Medicare EOB and on the Medicaid claim.
What is the receipt date for electronic claims? Is the date received the same as the date sent?
The receipt date is the date the claim is actually uploaded onto the mainframe. This is usually the day after it is received, except for weekends and holidays.
How do we submit a claim for a recently born child without an ID?
Our system cannot pay a claim without an ID. You cannot submit the claim until you get an ID number from the local Office of Public Assistance (OPA). The OPA may assign an original ID number or use the newborn’s Social Security number. Members or providers can call the member’s local Office of Public Assistance.
What is the difference between enrolling as an individual and enrolling as an organization?
Only providers who are enrolled as an organization can bill for the services of other providers. Providers enrolled as individuals cannot bill for services rendered by another provider. Only providers enrolled as a clinic or with a clinic specialty can bill as a billing provider with another provider as the rendering/attending.
We have submitted all the required paperwork but still have not been notified that our enrollment is complete. How long do we wait before contacting Montana Provider Relations?
If you have not received your welcome letter 3 weeks after you have submitted all of your completed and signed paperwork, contact Montana Provider Relations at 1.800.624.3958 or 406.442.1837.
How do we know which taxonomy code to use for enrollment?
The confirmation letter or e-mail you received from NPPES will contain the taxonomy you use for enrollment. Taxonomy codes are listed on the website under the appropriate provider type. For billing purposes, use the taxonomy code noted in your welcome letter sent by Montana Provider Relations.
We were told to use clinic taxonomy. Do we use the one from Montana Provider Relations or do we get another one from NPPES?
Providers are not bound to use the taxonomy given to them by NPPES. For billing, providers use the taxonomy with which they enrolled in Montana Healthcare Programs. For clinic enrollment, providers choose from the drop-down list either the taxonomy that matches what they received from NPPES or the one that best fits their practice.
Where do we find ZIP+4 extensions?
You can find this information by typing in your address on the U.S. Postal Service website, http://zip4.usps.com/zip4/welcome.jsp.
How do we fill out the tax reporting information?
The tax reporting information is needed for generating 1099 tax information. Use the tax-reporting information from your W-9 to complete the tax-reporting section of the enrollment.
Are we required to fill out the ownership/control information?
Yes. CMS requires that ownership information be collected for all health care providers who provide services that are publicly funded so states can qualify for federal funds.
Refer to CFR 42 455.100–106. There is no distinction between for-profit and not for profit. Enrollments will be denied if ownership information is not provided.
How do we know if we are a provider-based facility?
Provider-based status means a relationship exists between a hospital as the main provider and one of the following as defined by rule:
A provider-based entity is a health care provider “that is either created by, or acquired by, a main provider for the purpose of furnishing health care services of a different type from those of the main provider under the name, ownership, administrative and financial control of the main provider.”
A department of a provider is a “facility or organization or a physician office that is either created by, or acquired by, a main provider for the purpose of furnishing health care services of the same type as those furnished by the main provider under the name, ownership, financial and administrative control of the main provider.”
A department cannot be licensed to provide health care services in its own right or be qualified on its own to participate in Medicare. The definition does not include a rural health clinic (RHC) or a federally qualified health center (FQHC) except in limited circumstances.
A remote location of a hospital is defined as “a facility or organization that is either created by, or acquired by, a hospital that is a main provider for purposes of furnishing inpatient hospital services under the name, ownership, and financial and administrative control of the main provider.” The remote location is not licensed in its own right or separately certified as a Medicare provider.
A satellite facility is a hospital unit or part of a hospital unit that provides inpatient services in a building also used by another hospital or in one or more buildings on the same campus as buildings used by another hospital. Campus” is defined as the area immediately adjacent to the main buildings and other areas and buildings not strictly contiguous but that are located within 250 yards of the main buildings.
All providers who are provider-based facilities are required to send the CMS letter received designating them as a provider-based facility.
Why are we required to sign up for electronic funds transfer (also referred to as direct deposit)?
Electronic funds transfer (EFT) makes funds available to you more quickly than paper checks. The electronic payment option allows Montana Health Care Programs providers to receive their payments on Monday of the payment week. If you feel you have extenuating circumstances that prohibit you from receiving payment via EFT, request a waiver by including a signed letter explaining why paper checks are required.
How will we know if our enrollment is complete?
Once your enrollment is complete, you receive a welcome letter from Montana Provider Relations informing you that your enrollment is active. The welcome letter contains your NPI for health care providers or your Atypical Provider Identifier (API) for atypical providers.
What provider number do we use when verifying eligibility?
Utilize your NPI or your new Montana Health Care Programs provider number.
If a member is entering a nursing home, can he/she transfer assets in order to qualify for Medicaid?
Can he/she gift a home to a child or is he/she required to sell it? Nursing home residents cannot have given away assets within the 60 months prior to applying for Medicaid as a nursing home resident. If they have given away assets or sold them for less than fair market value, an asset transfer penalty (ineligibility period) may be assigned to the person. The penalty will run from the date the person otherwise qualified for and had applied for Medicaid as a nursing home resident. There are exceptions to this rule; direct questions to the local Office of Public Assistance (OPA).
Do infants automatically get coverage too?
If the mother is eligible for and receiving non-medically needy Medicaid at the time of birth, then the baby is eligible for the Medicaid Newborn program. This provides coverage for up to one year for the infant, as long as the baby continues to live in Montana.
Can a provider sign the Medicaid application if the applicant is not capable?
Yes, if the applicant is not able to complete the application, another party, including a provider, may assist. However, the provider cannot apply on a member’s behalf if the member is not willing to apply for Medicaid.
How does eligibility information come from the local Office of Public Assistance (OPA) to Montana Provider Relations? How long does this take?
OPA workers enter member information into the eligibility system. This is uploaded and passed to Montana Provider Relations every night. Nursing home spans take longer because of the additional check to verify the initial span. If you have specific questions, call Montana Provider Relations at 1.800.624.3958 or 406.442.1837 for assistance.
Can you tell me a little bit about incurment amounts and how it applies to providers?
Incurments apply to members who do not meet Medicaid financial eligibility until they spend down (incur) some of their income on medical services. On a certain day, they may be eligible for everything except a specific provider or portion of a specific provider’s services with which they meet their incurment. Ideally, if this happens, you, as a provider will get a form (160-M) from the OPA notifying you to bill Medicaid for some or all services provided to the member on the date the incurment was met. The date the incurment is met will be the day prior to the start date of Medicaid eligibility appearing on the eligibility verification systems.
How far back can medical bills go and still be counted for incurment?
Paid and unpaid bills may be applied toward the incurment for up to 3 months after the month in which they are incurred. Current payments made on outstanding bills that were incurred more than 3 months prior to the benefit month may be applied toward the incurment if the bills have not already been applied to an incurment in the past, and the provider has not written off the bill.
What is the difference between QMB, QMB only, and Medicare/Medicaid?
Qualified Medicare Beneficiary (QMB) only members receive a Medicaid hard card. Under this program, Medicaid pays the member’s Medicare Part A and Part B premiums and Medicaid’s portion of the Medicare coinsurance and deductibles up to the qualified amount. Members are covered only for Medicare allowed services.
QMB Medicaid members are eligible for Medicare, Medicaid, and QMB. A member who has QMB and Medicaid receives a Medicaid card. Under this program, Medicaid pays the member’s Medicare part A and B premiums and Medicaid’s portion of the Medicare coinsurance and deductibles up to the qualified amount. Members are covered for Medicare allowed services, as well as services that only Medicaid allows. If however, Medicare denies a service for medical necessity, Medicaid will also deny for the same reason. Members are responsible to make Medicaid cost shares for services only paid for by Medicaid.
Medicare/Medicaid – For members that are dually eligible, Medicaid pays for services allowed by Medicaid according to a lower-of pricing formula as well as those allowed by Medicare.
What does SLMB stand for?
SLMB stands for Specified Low-Income Medicare Beneficiary. For members who are SLMB only, Medicaid pays the Medicare premium only. Medicaid does not provide reimbursement for coinsurance, deductible or medical services.
If a member has SLMB only, who is responsible for the Medicare coinsurance and deductibles?
The member is responsible for the coinsurance and deductible.
What is the difference between HMK and HMK Plus?
Healthy Montana Kids Plus (HMK Plus) was formerly Children’s Medicaid. HMK Plus is health care coverage for low-income children and youth up to age 19 in Montana who are at or below 133% of the federal poverty level (FPL) guidelines. To be eligible for HMK Plus, applicants must meet income limits. HMK was formerly the Children’s Health Insurance Plan (CHIP). It is a free or low-cost health coverage plan also run through the HMK program of DPHHS. The plan provides health coverage to eligible Montana children and teenagers up to age 19 with income between 133%–250% FPL. A child qualifies for HMK based on family size and income. There are no pre-existing condition limitations. A small copayment not to exceed $215 per family per year may apply.
Where can applicants receive an application for Medicaid?
You can get an application from any local Office of Public Assistance or online at https://app.mt.gov/mtc/apply/index.html.
Where can applicants receive an application for Healthy Montana Kids?
Applications for HMK are available online or through the mail.
- Online at http://www.dphhs.mt.gov/hmk/
- By mail. Call 1-877-KIDS-NOW (1-877-543-7669), and an application will be sent.
- In Montana communities at several locations, including but not limited to:
- County Offices of Public Assistance Health departments
- Health care facilities
- WIC offices
- Head Start facilities
- Indian Health Service (IHS)
Who do we call to report provider or member fraud or abuse?
To report provider fraud or elder abuse, call the Medicaid Provider Fraud Hotline at 800.376.1115.
Reporting Medicaid Provider Fraud and/or Elder Abuse
Montana Department of Justice, Investigations Bureau, Medicaid Fraud Control Unit (MFCU) Section
The Medicaid Fraud Control Section is responsible for investigating any crime that occurs in a health care facility, including theft, drug diversion, sexual assault and homicide. The section also investigates elder exploitation, elder abuse and fraud by providers within the Medicaid system. This may include investigations into doctors, dentists, durable medical equipment companies, mental health providers and other Medicaid providers.
To report member waste, fraud and/or abuse, call the Member Fraud Hotline 800.201.6308.
Reporting Medicaid Member Waste, Fraud and/or Abuse
DPHHS, Quality Assurance Division, Program Compliance Bureau
Member fraud can include one or more of the following:
Submitted a false application for Medicaid
Provided false or misleading information about income, assets, family members, or resources
Shared a Medicaid card with another individual
Sold or bought a Medicaid card
Diverted for resale or other reasons prescription drugs, medical supplies, or other benefits
Participated in doctor or pharmacy shopping
Obtained Medicaid benefits that they were not entitled to through other fraudulent means
Paying cash for controlled substances
If we call a claim up in the MATH web portal, and it has denied for invalid diagnosis code, is it possible to go further to find out why?
No. The claim status on the web portal is an ANSI X12 276 transaction. The 276 does not allow for reason and remark code display. Review your remittance advice for denial reasons.
When we use MATH, the only information we can receive is our own. How do we find out how many units have been used for a service that has limits, such as prior authorized limits, or limits for mental health service plan?
Call Montana Provider Relations at 1.800.624.3958 or 406.442.1837. They can look up prior authorization limits.
Can we bill the member for a code that Medicaid does not cover?
If it is a non-covered service, the provider must inform the member, in advance, that the service being rendered is not covered. Have the member sign a statement specific to the service to be rendered, and that the member understands he/she is responsible for payment. The provider can bill the member if these steps have been followed.
If a non-covered service is provided at the same time as another, covered service, can Medicaid be billed for the covered service if private pay is established for the non-covered service?
Yes. You can bill Medicaid for the covered service.
If a member is not eligible, but we do not know he is not eligible until after the treatment because he does not provide a card, can we charge him?
A provider can use one of several methods to check Medicaid eligibility—the Montana Access to Health web portal, FaxBack, Automated Voice Response, or the Xerox Provider Relations line. These methods are described in provider manuals and notices. If a provider cannot verify Medicaid eligibility, the provider can accept the member as a private-pay member until eligibility is verified. If the provider later verifies Medicaid eligibility for a member accepted as private-pay, the provider can opt to bill Medicaid (within timely filing rules) or to continue the private-pay arrangement with the member.
What can an emergency department (ED) do with a member who continues to present to the ED with non-emergent symptoms? If the provider determines he/she has Medicaid, can the provider arrange for private payment?
The Emergency Medical Treatment and Active Labor Act (EMTALA) prohibit a delay in providing the required screening or stabilization treatment in order to inquire about payment methods or insurance status. It is acceptable to ask what insurance the member has and to ask to make a copy of the card as long as in doing so you do not delay giving the screening/ stabilization. You might follow a script, that states to the members that seeing them for the medical screening examination and stabilization treatment (if an emergency does indeed exist) does not in any way imply that you have accepted their method of payment (whether it be private insurance, Medicaid or Medicare). Payment will be discussed after completion of the medical screening exam and at that time it could be decided that the member will be required to pay privately. EMTALA prohibits making the “private pay arrangement” prior to initiating the medical screening examination. As soon as it is initiated, payment conversations can take place.
On our form for the member to sign determining their insurance, can we add a line that states the member will be responsible if Medicaid does not cover the service or if the member is not eligible?
For a non-covered service, you cannot have a blanket form; it has to be specific as to which service is not covered and what the member will be expected to pay. You could create a blanket form stating that if the member is not eligible for Medicaid that he/she will be responsible for the bill, as long as you apply this policy for all payment types. This is the case even if you do not have a form signed by the member.
Can we bill for no-shows for Montana Health Care Programs members?
You cannot bill Montana Health Care Programs or the Montana Health Care Programs member for no shows.
Is it okay to post a sign in our office that after 3 no-shows we will not accept the member anymore?
Yes, as long as you treat private pay and Montana Health Care Programs members the same. If you are the member’s Passport Provider, follow the process for disenrolling a Passport member outlined in your Passport Provider Handbook.
Sometimes we bill someone as private pay and then when the claims go to collections, the member tells us they have Medicaid. What are our options at this point?
If you had established private pay with that member, then you can continue that process and turn them over to collection. You may bill Medicaid if within timely filling (see your provider manual).
Where on the CMS-1500 form is the Passport referral number placed?
On an electronic claim: Loop 2300, reference segment, data element 02, with the qualifier 9F in Loop 2300, reference segment, data element 01. On a paper claim: Box 17A.
Which services do not need Passport referrals?
The Physician-Related Services Manual lists services that do not need Passport referrals. Also, see the "Medicaid Covered Services" chapter in the General Information for Providers manual.
Do we speak to the Passport primary care provider (PCP) to get a Passport referral?
Office staff can relay the referral, but the PCP provides and documents the referral.
Is it the member’s responsibility to get a referral before visiting a provider who is not the member’s PCP?
No. If a member visits a provider who is not the member’s PCP, the non-PCP provider gets a referral from the PCP.
How are Passport providers assigned?
The Passport member either chooses the PCP or is assigned to a PCP by Medicaid if the member does not select. Assignment is made as described in the Passport to Health Provider Handbook. When assigned, the member is notified of the Passport provider assignment. When checking Medicaid eligibility, a provider who is not the member’s PCP also checks the identity of the Passport provider and contacts the Passport provider for a referral.
Our Passport number has changed. Which Passport number do we give if a provider calls for a Passport referral for a visit that occurred on a date our old Passport number was effective?
Provide the Passport number that was effective on the date of service. However, if you did not make the referral, you are not obligated to provide a referral after the fact.
We have a member that we referred to a specialist, and that specialist referred the member to another specialist, but we have no record.
Once a Passport provider gives a referral, the provider who requested the referral cannot refer the member to a third provider. The Passport provider refers the member to the third provider.
What if my Passport number is being used without me giving a referral?
If a Passport provider suspects that his/her Passport number is being used without a referral, the provider is encouraged to contact Provider Relations at 1.800.624.3958 or 406.442.1837.
If the Passport provider sends a written referral, does that qualify, or is the provider still required to call?
A written referral that includes the Passport number is sufficient. No phone call is required.
Are all Medicaid members Passport-eligible except those residing in nursing homes?
Approximately 70% of Medicaid enrolled individuals are eligible for Passport. Members not eligible for Passport include those who: live in a nursing home or other institution; are covered by both Medicare and Medicaid (dual-eligible); are enrolled as medically needy; are covered by Medicaid for less than 3 months; are eligible under subsidized adoption; have only retroactive Medicaid eligibility; receive Home- and Community-Based Waiver services. Exemptions from Passport may be granted for other situations on a case-by-case basis.
Can we use a Passport referral received by the hospital for the physician on call?
The Passport PCP will outline the purpose of the referral when giving a referral to a facility. The referral to the facility cannot be assumed to be a referral for all services.
Is there a mechanism to change the Passport provider when a member moves?
When a member moves, the member can select a new Passport PCP on the website or by calling the Member Help Line, 800.362.8312. Until the member selects a new PCP, the member will remain with the current PCP in the Passport system.
Is the Passport approval number the same as the provider’s Medicaid ID number?
No. The Passport number is a 7-digit number and is not the provider’s Medicaid (NPI or API) number.
Why are members allowed to change Passport providers monthly?
Passport allows members to change Passport providers every month if they desire, through the State’s agreement with the Federal government. Each month, less than 4% of Medicaid members change providers. Less than 2% change providers more than 3 times a year.
What do we do when members come with no referral?
It is the provider’s responsibility to get a Passport referral. After confirming that the member is Medicaid eligible, contact the Passport provider for a referral. If you are unable to get a Passport referral at that time, you may still provide services and pursue Passport approval after services are rendered, or you may ask the member to sign a private pay agreement. If you pursue a private pay agreement, the agreement will clearly state that the member will be responsible for the bill, not that they may be responsible. If you accept the member as private pay and the member pays you, you may still try to get Passport approval after the service and then refund the member’s money.
If Passport referral was denied by a PCP because the PCP has not seen the member, what can we do?
Options are to encourage the member to see the member’s Passport PCP, ask the member to sign a private pay agreement, or refuse to see the member. The Passport provider has the right to not give a referral.
If a Passport provider will not give a referral, can the member go to Medicaid to get a referral?
Medicaid does not override a Passport provider’s decision.
Can a provider disenroll a member, or is the member the only one who can make this change?
A provider may disenroll a member based on the 4 approved disenrollment reasons detailed in the Passport provider agreement. A provider gives a member 30-days’ notice by sending a letter to the member and to Passport.
How are members auto-assigned to a provider?
Members are auto-assigned a provider if they do not choose one. In auto-assigning a member, the Passport program seeks to preserve existing provider-member relationships. Members are assigned based on the following criteria, in this order:
Prior Passport enrollment
Most recent claims history
Family (Child/Adult) history
American Indians assigned to IHS/Tribal Health if one is within 50 miles of address
Random within the geographic area
Do claims have to be sent to the other payer if the provider knows the insurance is going to deny?
Yes, we may not know that the claim will be denied. You can get a blanket denial to attach to your claims that we will accept for 2 years.
What about when a member has Medicare/Medicaid coverage and the service is denied by Medicare for not being medically necessary?
Medicaid follows Medicare's determination of medical necessity. Therefore, if the Medicare EOB indicates the service was denied for medical necessity, Medicaid would also deny the service.
What about those cases where Medicaid shows a TPL, but the provider cannot get any information from either the member or the other carrier?
Request assistance from the Montana Healthcare Programs TPL Unit. They will contact the insurance company to verify coverage and update the member’s records as appropriate.
If you give us a denial, and we have to resubmit a particular line and it is Medicare/Medicaid, when we resubmit that line, do we resubmit the Medicare EOB?
Yes, we need the Medicare EOB every time.
What happens if the message says the claim crossed over, but the member ID was not correct? If we send it on paper, will it get paid, or will it be denied?
If the member ID number was incorrect, either submit the claim electronically with the Medicare data in the appropriate loops and segments or send the paper claim with the corrected member ID to Xerox with the appropriate Medicare EOB.
What if the TPL does not pay? What documentation needs to be submitted to Medicaid?
Submit the TPL explanation of benefits, ensuring the header information and the verbiage identifying the reason for denial are present.
What if the TPL does not respond after being billed? What documentation is submitted to Medicaid?
If the TPL has not paid within 90 days, submit documentation showing when you filed the claim with the private insurance company. Xerox will pay the claim and chase the TPL for you.
When a member is currently on workers’ compensation, and he/she comes in for a complaint unrelated to the workers’ compensation, is a denial required, and do we submit that bill in hard copy?
A denial is not required but some indication that the claim is not related to the workers’ compensation injury is required. For electronic claims, documentation that the service is unrelated to workers’ compensation is sent as a paperwork attachment with the PWK indicator in the appropriate loop and segment. If the relationship cannot be adequately determined, the claim will be denied and the provider will be asked to send a hard copy. The provider indicates on the claim form the injury is not workers’ compensation-related (Field 19 on CMS 1500; Field 64 on the UB-04). These claims are submitted directly to TPL, P.O. Box 5838, Helena, MT 59604.
There are some members who have cancer policies. What do we do when the member is not being seen for cancer-related illness?
Get a blanket denial from the TPL Unit. Fax a Blanket Denial Request for TPL form, which is available on the Forms page of the Provider Information website, to 406.442.0357 or call 406.443.1365 or 1.800.624.3958. When you send your Medicaid claim for processing, the TPL Unit will verify that the blanket denial letter is accurate for that service before overriding the TPL insurance. For a blanket denial request, send a copy of the EOB from the other payer reflecting the denial from the other insurance as non-covered.
Can we get an override form for services not customarily covered by an insurance company, so that we do not have to send the claim to the TPL first and have it denied before Medicaid can pay?
Yes. Fax a Blanket Denial Request for TPL form, available on the Forms page of the Provider Information website along with a copy of an EOB indicating the insurance company does not pay for the service, to 406.442.0357 or call 406.443.1365 or 1.800.624.3958. When you send your Medicaid claim for processing, the claims processing unit will verify that the blanket denial letter is accurate for that service before overriding the TPL insurance. For a blanket denial request, send a copy of the EOB from the other payer reflecting the denial from the other insurance as non-covered.
If we have an EOB from private insurance listing a paid amount, do we attach the EOB to the claim?
No. You only record the actual payment from the TPL. If the claim was denied by the TPL, then you would attach a TPL EOB along with the explanation or reason code for why it denied, or if the allowed amount went toward the member’s deductible.
Is it true that UB providers (including RHCs, FQHCs, and home health) do not have to include a Medicare EOB?
Yes. The Medicare payment needs to be in form locator 54. The coinsurance and deductibles go in form locator 39–41, with the appropriate value code. On the electronic claims transaction, the coinsurance and deductible are reported in Loop 2430, CAS segment.
What happens when the insurance company sends the payment for a claim to the member rather than the provider? Can we bill the member the entire amount?
No. You can only bill the member for the amount listed on the insurance company’s EOB.
Which fields on the UB-04 are used to indicate Medicare coinsurance and deductible if form locator (FL) 39 is used by the provider for something else?
The provider may also use FL 40–41 to report that information.
We are not a Medicare provider. What can we do when a claim that we sent to Medicaid denied because there was no Medicare EOB?
Medicare has a legal obligation to process these claims as the primary insurance. This obligation is not waived because of a provider’s enrollment status with Medicare. Montana Medicaid is required to deny the claim because Medicare is the liable third party. The only exception to this rule is for provider types not permitted to enroll as Medicare providers. Blanket denials may be used to process claims of dual eligible recipients for these provider types.
With Medicare, when you adjust a claim you are not able to adjust only one line, you have to adjust the whole claim. Then the deductible amount changes and then you have to complete a Medicaid adjustment form. Is there a simpler way?
No, but you can send an adjustment with the new Medicare EOB that indicates on the face that Medicare information has changed. We will review the coinsurance and deductible. Adjustments do not come to us electronically from Medicare.
What is considered proof of billing the private insurance for pay and chase to begin?
If you send a signed letter indicating the date you billed and which insurance company, we accept that as proof of billing.
How do we bill for a member who is eligible for Medicare Part D but is not enrolled in a prescription drug plan yet?
The Limited Income Newly Eligible Transition (LI NET) Program, administered by Humana, is designed to eliminate any gaps in coverage for low-income individuals transitioning to Medicare Part D drug coverage. The 4-step LI NET billing process can be found at the LI NET pharmacy website, http://www.humana.com/pharmacists/pharmacy_resources/information.aspx, or by calling 1.800.783.1307.
What drugs will Medicaid pay for a member eligible for Medicare Part D?
Due to changes in federal law, Medicaid will no longer pay for benzodiazepines for dual eligible members (those with both Medicare and Medicaid coverage). Benzodiazepines will be covered by the dual eligible member's Medicare Part D prescription drug plan (PDP). In addition, most barbiturates will also be covered under Medicare Part D. Medicaid may cover the barbiturate if it is not used for chronic mental illness, epilepsy, or cancer. Montana Medicaid will use SmartPA® to prevent Medicaid payment for benzodiazepines and to review diagnoses for barbiturates. See the related provider notice for and the Prescription Drug Services manual on the Pharmacy page of the website more information.
If a provider has a problem with a particular member not showing up for appointments, does the provider have to give a reason for refusing to see the member anymore?
No. The provider can tell the member over the phone that he/she is severing the relationship. The provider follows up in writing to keep as documentation in the member’s file. Do not treat Medicaid members differently than private pay members. However, if the provider is the member’s Passport Provider, follow the process for disenrolling a Passport member outlined in the Passport Provider Handbook.
Do you consider urgent care facilities the same as an emergency room?
No. They are not considered emergency.
If we have a visitor from another state, do we have to enroll as a provider for that state?
No. Enrolling as a Medicaid provider is voluntary, so you can make the choice whether to enroll with that state’s Medicaid program or arrange for the member to be private pay.
What do you consider a new member? If a member leaves for 3 to 4 years then comes back, would he be a new or established member?
A new patient is one who has not received any professional services from a physician or another physician of the same specialty who belongs to the same group practice within the past three years. Refer to the Evaluation and Management guidelines section of the CPT.
We work in a public health clinic, and we get claims returned saying that the member has MHSP, and since we are not a mental health provider, we cannot give them shots. Why is this not covered?
Because the Mental Health Services Plan (MHSP) is 100% state funded, these members can only get mental health related services. They are not Medicaid members; they are MHSP members.
What happens when a member is ordered to get a walker?
The member wants the deluxe walker, but Medicaid will only pay for standard walker. Both walkers have the same procedure code. Could we bill the member for the difference between the deluxe walker that is not covered and the standard walker that is? If the member wants the deluxe walker, but only requires the standard walker then the deluxe walker is considered a non-covered service. The member pays for the full amount of the non-covered service. Document that this is a non-covered service.
If I receive payment for a service, but the payment is later recovered by SURS, can we bill the Montana Health Care Programs member for that service?
If the provider made an error that resulted in overpayment or Montana Health Care Programs made an error in processing, the provider cannot bill the member.
Where can we find the Administrative Rules of Montana?
They can be found at http://www.sos.mt.gov/ARM/index.asp. Most of the Medicaid rules are in Section 37.
What is the Provider Information website address?
The address is http://medicaidprovider.mt.gov/. If you access the website using a previously saved bookmark or favorite, you will be notified that the website has changed and directed to the home page.
Where can we find Montana Code Annotated?
You can access the MCA from the link on each provider type page: http://leg.mt.gov/bills/mca_toc/index.htm
How do we get a new fee schedule?
Fee schedules are available on the Provider Information website by following the Resources by Provider Type link and accessing your specific provider type page. If you cannot locate a fee schedule, contact Provider Relations.