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Ambulatory Surgical Center Services Manual

Ambulatory Surgical Center Services Manual

Ambulatory Surgical Center Services Manual

Printing the manual material found at this website for long-term use is not advisable. Department Policy material is updated periodically and it is the responsibility of the users to check and make sure that the policy they are researching or applying has the correct effective date for their circumstances.

If you experience any difficulty opening a section or link from this page, please email the webmaster.

How to Search this manual:

This edition has three search options.

  1. Search the whole manual. Open the Complete Manual pane.  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.
  2. Search by Chapter. Open any Chapter tab (for example the "Billing Procedures" tab).  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 where denials discussed in just that chapter.
  3. Site SearchSearch 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.

 


Ambulatory Surgical Center Services Manual

Updated 08/08/2017

This manual was updated 08/08/2017

Update Log

Update Log

 

Publication History

This publication supersedes all previous Physician-Related Services handbooks. Published by the Montana Department of Public Health & Human Services, January 2005.

 Updated January 2011, December 2011, March 2012, October 2016, and April 2017, and August 2017.

CPT codes, descriptions and other data only are copyright 2014 American Medical Association (or such other date of publication of CPT). All Rights reserved. Applicable FARS/DFARS Apply.

Update Log

08/08/2017
Ambulatory Surgical Center Services Manual converted to an HTML format and adapted to 508 Accessibility Standards.

08/08/2016
Ambulatory Surgical Center, August 2016: In Summary, the Cost Share section of the Billing Procedure Chapter was removed and replaced with a referral to the Cost Share section of the General Manual. The Cover Page was changed to reflect the current manual edition date.

12/31/2015
Ambulatory Surgical Center, January 2016: HELP Plan-Related Updates and Others

09/23/2015
Ambulatory Surgical Center, August 2015: Entire Manual

08/22/2011
Ambulatory Surgical Center, June 2011: Key Contacts and Websites, Passport, and Other

 

End of Update Log Chapter

Table of Contents

Key Contacts and Websites

Introduction

Introduction

 

Thank you for your willingness to serve members of the Montana Medicaid program and other medical assistance programs administered by the Department of Public Health and Human Services.

Manual Organization

This manual provides information specifically for ambulatory surgical center services. Other essential information for providers is contained in the separate General Information for Providers manual. Providers are responsible for reviewing both manuals.

A table of contents and an index allow you to quickly find answers to most questions. The margins contain important notes with extra space for writing notes. There is a list of contacts on the Contact Us page on the Provider Information website. There is also space on the inside of the front cover to record your NPI/API for quick reference when calling Provider Relations.

Manual Maintenance

Manuals must be kept current. Changes to manuals are provided through provider notices and replacement pages. When replacing a page in a paper manual, file the old pages and notices in the back of the manual for use with claims that originated under the old policy.

Rule References

Providers must be familiar with all current rules and regulations governing the Montana Medicaid program. Provider manuals are to assist providers in billing Medicaid; they do not contain all Medicaid rules and regulations. Rule citations in the text are a reference tool; they are not a summary of the entire rule. In the event that a manual conflicts with a rule, the rule prevails. Links to rules are available on the Provider Information website. Paper copies of rules are available through the Secretary of State’s office. See the Contact Us link on the Provider Information website. In addition to the general Medicaid rules outlined in the General Information for Providers manual, the following rules and regulations are also applicable to the ambulatory surgical center program:

Providers are responsible for knowing and following Medicaid rules and regulations.

  • Code of Federal Regulations (CFR)
    • 42 CFR 416
  • Montana Codes Annotated (MCA)
    • MCA 50-5-101
  • Administrative Rules of Montana (ARM)
    • ARM 37.86.1401–37.86.1406 Ambulatory Surgical Centers

Claims Review (MCA 53-6-111 and ARM 37.85.406)

The Department is committed to paying Medicaid providers’ claims as quickly as possible. Medicaid claims are electronically processed and usually are not reviewed by medical experts prior to payment to determine if the services provided were appropriately billed. Although the computerized system can detect and deny some erroneous claims, there are many erroneous claims which it cannot detect. For this reason, payment of a claim does not mean that the service was correctly billed or the payment made to the provider was correct. Periodic retrospective reviews are performed which may lead to the discovery of incorrect billing or incorrect payment. If a claim is paid and the Department later discovers that the service was incorrectly billed or paid or the claim was erroneous in some other way, the Department is required by federal regulation to recover any overpayment, regardless of whether the incorrect payment was the result of Department or provider error or other cause.

Getting Questions Answered

The provider manuals are designed to answer most questions; however, questions may arise that require a call to a specific group (such as a program officer, Provider Relations, or a prior authorization unit). See the Contact Us link in the left menu on the Provider Information website.

Medicaid manuals, manual replacement pages, provider notices, fee schedules, forms, and more are available on the Provider Information website.

 

End of Introduction Chapter

Covered Services

Covered Services

 

General Coverage Principles

Medicaid covers almost all ambulatory surgical center services when they are medically necessary. This chapter provides covered services information that applies specifically to ambulatory surgical center services. Like all healthcare services received by Medicaid members, these services must also meet the general requirements listed in the Provider Requirements chapter of the General Information for Providers manual.

Ambulatory Surgical Center Services (ARM 37.86.1402)
Covered surgical procedures can only be rendered by a licensed ambulatory surgical center. Clinic services must be provided by a clinic that is licensed as an outpatient facility by the appropriate licensing entity of the state where the facility is located and meet the requirements for participation in Medicare. Clinic services must be provide by or under the direction of a licensed physician or, where appropriate, a licensed dentist.

All of the following are conditions for coverage of listed ambulatory surgical center procedures:

  • Covered surgical procedures are limited to those procedures that do not generally exceed a total of 90 minutes operating time and a total of 4 hours recovery or convalescent time.
  • If the covered surgical procedure requires anesthesia, the anesthesia must be local or regional anesthesia, or general anesthesia of 90 minutes or less duration.
  • Covered surgical procedures may not be of a type that generally result in extensive blood loss; require a major or prolonged invasion of body cavities; directly involve major blood vessels; are generally emergent or life threatening in nature; or can safely be performed in a physician’s or dentist’s office.

Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) Services (ARM 37.86.2201–2235)
The EPSDT Well-Child program covers all medically-necessary services for children age 20 and under. Providers are encouraged to use a series of screening and diagnostic procedures designed to detect diseases, disabilities, and abnormalities in the early stages.

Some services are covered for children that are not covered for adults, such as the following:

  • Nutritionist services
  • Respiratory therapy
  • Therapeutic family and group home care
  • Substance dependency inpatient and day treatment services
  • School-based services

All prior authorization and Passport approval requirements must be followed. For more information about the recommended well-child screen and other components of EPSDT, see the EPSDT Well-Child chapter in the General Information for Providers manual.

Coverage of Specific Services (ARM 37.86.1405)

Medicaid follows Medicare’s rules for coverage of most services. The following are coverage rules for specific ambulatory surgical center services.

Clinic Services, Covered Procedures (ARM 37.86.1405)
Ambulatory surgical center (ASC) services:

  • Are services that will be covered by Medicaid if provided in an outpatient ASC setting incident to provisions of physician or dental services to the member where the services and supplies are furnished in the ASC on a physician’s or dentist’s order by ASC personnel under the supervision of ASC medical staff.
  • Are limited as provided by ARM 37.86.1402(1)–(5) with the term clinic taken to mean ASC.
  • Clinic services covered by the Medicaid program include physician services covered in ARM 37.86.101, ARM 37.86.104, and ARM 37.86.105.
  • Clinic services covered by the Medicaid program include mid-level practitioner services covered in ARM 37.86.201, ARM 37.86.202, and ARM 37.86.205.

Use the fee schedule for your provider type to verify coverage for specific services.

 

End of Covered Services Chapter

Passport

Passport

What is Passport to Health? (ARM 37.86.5101–5120)

Passport to Health is the primary care case management (PCCM) program for Montana Medicaid and Healthy Montana Kids (HMK) Plus members. The Passport to Health program provides case management-related services that include locating, coordinating, and monitoring primary healthcare services. To achieve this, the Passport program works with the state’s other care coordination programs:

  • Nurse First Advice Line
  • Team Care
  • Health Improvement Program (HIP)

Medicaid and HMK Plus members who are eligible for Passport must enroll in the program (about 70% of Montana Medicaid and HMK Plus members are eligible). Each member has a designated Passport provider such as a physician, mid-level practitioner, or primary care clinic.

Passport members may change their Passport provider up to once per month, but the change will not be effective until the following month at the earliest, depending on the date the choice is made (ARM 37.86.5103–5104).

Additional Passport information is found in the Passport to Health manual, available on the Passport to Health link in the left menu and applicable provider type pages on the Provider Information website.

 

End of Passport to Health Chapter

Prior Authorization

Prior Authorization

 

Prior authorization refers to a list of services that require approval from the Medicaid program prior to the service being rendered. If a service requires prior authorization, the requirement exists for all Medicaid members.

When prior authorization is granted, the provider is issued a prior authorization number that must be on the claim.

Medicaid does not pay for services when prior authorization requirements are not met.

See the Prior Authorization Information link in the left menu on the Provider Information website.

 

End of Prior Authorization Chapter

Coordination of Benefits

Coordination of Benefits

 

For Coordination of Benefits, providers should refer to the section on Third Party Liability in the Member Eligibility and Responsibilities chapter in the General Information for Providers manual.

 

End of Coordination of Benefits Chapter

Billing Procedures

Billing Procedures

 

Claim Forms

Services provided by the healthcare professionals covered in this manual must be billed either electronically or on a CMS-1500 claim form. CMS-1500 forms are available from various publishing companies; they are not available from the Department or Provider Relations.

Member Cost Sharing (ARM 37.85.204 and ARM 37.85.402)

See the General Information for Providers manual for additional information on member cost sharing.

 

End of Billing Procedures Chapter

Remittance Advice and Adjustments

Remittance Advices and Adjustments

 

See the General Information for Providers manual for information on remittance advices and adjustments.

 

End of Remittance Advices and Adjustments Chapter

How Payment Is Calculated

How Payment Is Calculated

 

Overview

Although providers do not need the information in this chapter to submit claims to Montana Medicaid, the information allows providers to understand how payment is calculated and to predict approximate payment for particular claims.

Ambulatory Surgical Centers

Effective for dates of service on or after April 1, 2008, Montana Medicaid implemented a prospective ambulatory surgical center payment system in line with the Centers for Medicare and Medicaid Services (CMS) ambulatory surgical center methodology.

This payment system prospectively determines amounts to be paid for covered surgical and ancillary services identified by codes and modifiers established under the CMS Healthcare Common Procedure Coding System (HCPCS). This payment system also indicates which costs are packaged and which surgical procedures are excluded.

Montana Medicaid rates follow the CMS quarterly ambulatory surgical center payment updates. Lists of payable HCPCS codes and their corresponding payment rates are available on the Montana Medicaid ASC fee schedules. CMS also publishes quarterly addendums indicating covered surgical and ancillary services and non-covered surgical services.

Whenever CMS proposes to revise the payment rate for ambulatory surgical centers, CMS publishes a notice in the Federal Register describing the revision. The notice also explains the basis on which the rates were established. After reviewing public comments, CMS publishes a notice establishing the rates authorized by this section. In setting these rates, CMS may adopt reasonable classifications of facilities and may establish different rates for different types of surgical procedures.

Providers should review the Montana Medicaid ASC fee schedules on the Montana Healthcare Programs website.

Other Issues

Outpatient Services
When Medicaid pays an ambulatory surgical center for outpatient services, the separate claim for the physician’s services must show the ambulatory surgical center as the place of service (POS). This POS code (24) results in the physician receiving the facility fee listed in the physician fee schedule.

Modifiers

  • Review the guidelines for using modifiers in the CPT book, HCPCS book, and other helpful resources (e.g., CPT Assistant, APC Answer Letter).
  • Always read the complete description for each modifier; some modifiers are described in the CPT book, while others are described in the HCPCS book.
  • Medicaid accepts most of the same modifiers as Medicare, but not all.
  • The Medicaid claims processing system recognizes three pricing modifiers and one informational modifier per claim line on the CMS-1500. 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-1500.

How Payment Is Calculated on TPL Claims
When a member has coverage from both Medicaid and another insurance company, the other insurance company is often referred to as third party liability or TPL. In these cases, the other insurance is the primary payer, and Medicaid makes a payment as the secondary payer. Medicaid will make a payment only when the TPL payment is less than the Medicaid allowed amount.

How Payment Is Calculated on Medicare Crossover Claims
When a member has coverage from both Medicare and Medicaid, Medicare is the primary payer. Medicaid will pay the coinsurance and deductible, less any TPL or incurment, on ambulatory surgical center (ASC) claims for these dually-eligible individuals.

Payment Examples for Dually-Eligible Members
A provider submits an ASC claim for a member who has Medicare and Medicaid coverage. The Medicare coinsurance and deductible are $65 and $185. This total ($250) becomes the Medicaid allowed amount. Medicaid will pay the total as long as no TPL or incurment amounts are applicable.

A provider submits an ASC claim for a member who has Medicare, Medicaid, and TPL. The Medicare coinsurance and deductible are $65 and $185. This $250 total becomes the Medicaid allowed amount. The other insurance company paid $225. This amount is subtracted from the Medicaid allowed amount leaving $25. Medicaid pays $25 for this claim. If the TPL payment had been $250 or more, this claim would have paid at $0.

A provider submits an ASC claim for a member who has Medicare, Medicaid, and a Medicaid Incurment. The Medicare coinsurance and deductible are $65 and $185. This total ($250) becomes the Medicaid allowed amount. The member owes $150 for his Medicaid incurment, so this amount is subtracted from the $250. Medicaid will pay the provider $100 for this claim.

 

End of How Payment Is Calculated Chapter

Definitions and Acronyms

Definitions and Acronyms

 

See the Definitions and Acronyms link in the menu on the Provider Information website for additional definitions and acronyms.

Ambulatory Surgical Center Services

Services that are provided in a licensed, freestanding ambulatory surgical center. Surgical center services do not include physician services, anesthesiologist services, ambulance services, or major prosthetic appliances such as intraocular lenses.

Clinic Services

Preventive, diagnostic, therapeutic, rehabilitative or palliative items or services provided under the direction of a physician by an outpatient facility that is not part of a hospital, but is organized and operated to provide medical care to outpatients independent of a hospital. Clinic services may be provided in surgical centers and public health departments. Clinic services do not include mental health center services as defined in ARM 37.88.901.

 

End of Definitions and Acronyms Chapter

Index

Index

Previous editions of this manual contained an index.

This edition has three search options.

1.Search the whole manual. Open the Complete Manual pane.  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.

2.Search by Chapter. Open any Chapter tab (for example the "Billing Procedures" tab).  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 where denials discussed in just that chapter.

3.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.

 

End of Index Chapter

End of Ambulatory Surgical Center Services Manual

Complete Ambulatory Surgical Center Services Manual

Ambulatory Surgical Center Services Manual

 

To print this manual, right click your mouse and choose "print".  Printing the manual material found at this website for long-term use is not advisable. Department Policy material is updated periodically and it is the responsibility of the users to check and make sure that the policy they are researching or applying has the correct effective date for their circumstances.

Update Log

 

Publication History

This publication supersedes all previous Physician-Related Services handbooks. Published by the Montana Department of Public Health & Human Services, January 2005.

 Updated January 2011, December 2011, March 2012, October 2016, and April 2017 and August 2017.

CPT codes, descriptions and other data only are copyright 2014 American Medical Association (or such other date of publication of CPT). All Rights reserved. Applicable FARS/DFARS Apply.

Update Log

08/08/2017
Ambulatory Surgical Center Services Manual converted to an HTML format and adapted to 508 Accessibility Standards.

08/08/2016
Ambulatory Surgical Center, August 2016: In Summary, the Cost Share section of the Billing Procedure Chapter was removed and replaced with a referral to the Cost Share section of the General Manual. The Cover Page was changed to reflect the current manual edition date.

12/31/2015
Ambulatory Surgical Center, January 2016: HELP Plan-Related Updates and Others

09/23/2015
Ambulatory Surgical Center, August 2015: Entire Manual

08/22/2011
Ambulatory Surgical Center, June 2011: Key Contacts and Websites, Passport, and Other

 

End of Update Log Chapter

 

Table of Contents

 

Key Contacts and Websites

Introduction

Manual Organization

Manual Maintenance

Rule References

Claims Review (MCA 53-6-111 and ARM 37.85.406)

Getting Questions Answered

Covered Services

General Coverage Principles

Coverage of Specific Services (ARM 37.86.1405)

Passport

What is Passport to Health (ARM 37.86.5101-5120)

Prior Authorization

Coordination of Benefits

Billing Procedures

Claim Forms

Member Cost Sharing (ARM 37.85.204 and ARM 37.85.402)

Remittance Advices and Adjustments

How Payment Is Calculated

Overview

Ambulatory Surgical Centers

Other Issues

Definitions and Acronyms

Index

 

End of Table of Contents Chapter

 

Key Contacts and Websites

 

See the Contact Us link in the menu on the Montana Healthcare Programs Provider Information website for a list of key contacts and websites.

 

End of Key Contacts and Websites Chapter

 

Introduction

 

Thank you for your willingness to serve members of the Montana Medicaid program and other medical assistance programs administered by the Department of Public Health and Human Services.

Manual Organization

This manual provides information specifically for ambulatory surgical center services. Other essential information for providers is contained in the separate General Information for Providers manual. Providers are responsible for reviewing both manuals.

A table of contents and an index allow you to quickly find answers to most questions. The margins contain important notes with extra space for writing notes. There is a list of contacts on the Contact Us page on the Provider Information website. There is also space on the inside of the front cover to record your NPI/API for quick reference when calling Provider Relations.

Manual Maintenance

Manuals must be kept current. Changes to manuals are provided through provider notices and replacement pages. When replacing a page in a paper manual, file the old pages and notices in the back of the manual for use with claims that originated under the old policy.

Rule References

Providers must be familiar with all current rules and regulations governing the Montana Medicaid program. Provider manuals are to assist providers in billing Medicaid; they do not contain all Medicaid rules and regulations. Rule citations in the text are a reference tool; they are not a summary of the entire rule. In the event that a manual conflicts with a rule, the rule prevails. Links to rules are available on the Provider Information website. Paper copies of rules are available through the Secretary of State’s office. See the Contact Us link on the Provider Information website. In addition to the general Medicaid rules outlined in the General Information for Providers manual, the following rules and regulations are also applicable to the ambulatory surgical center program:

Providers are responsible for knowing and following Medicaid rules and regulations.

  • Code of Federal Regulations (CFR)
    • 42 CFR 416
  • Montana Codes Annotated (MCA)
    • MCA 50-5-101
  • Administrative Rules of Montana (ARM)
    • ARM 37.86.1401–37.86.1406 Ambulatory Surgical Centers

Claims Review (MCA 53-6-111 and ARM 37.85.406)

The Department is committed to paying Medicaid providers’ claims as quickly as possible. Medicaid claims are electronically processed and usually are not reviewed by medical experts prior to payment to determine if the services provided were appropriately billed. Although the computerized system can detect and deny some erroneous claims, there are many erroneous claims which it cannot detect. For this reason, payment of a claim does not mean that the service was correctly billed or the payment made to the provider was correct. Periodic retrospective reviews are performed which may lead to the discovery of incorrect billing or incorrect payment. If a claim is paid and the Department later discovers that the service was incorrectly billed or paid or the claim was erroneous in some other way, the Department is required by federal regulation to recover any overpayment, regardless of whether the incorrect payment was the result of Department or provider error or other cause.

Getting Questions Answered

The provider manuals are designed to answer most questions; however, questions may arise that require a call to a specific group (such as a program officer, Provider Relations, or a prior authorization unit). See the Contact Us link in the left menu on the Provider Information website.

Medicaid manuals, manual replacement pages, provider notices, fee schedules, forms, and more are available on the Provider Information website.

 

End of Introduction Chapter

 

Covered Services

 

General Coverage Principles

Medicaid covers almost all ambulatory surgical center services when they are medically necessary. This chapter provides covered services information that applies specifically to ambulatory surgical center services. Like all healthcare services received by Medicaid members, these services must also meet the general requirements listed in the Provider Requirements chapter of the General Information for Providers manual.

Ambulatory Surgical Center Services (ARM 37.86.1402)
Covered surgical procedures can only be rendered by a licensed ambulatory surgical center. Clinic services must be provided by a clinic that is licensed as an outpatient facility by the appropriate licensing entity of the state where the facility is located and meet the requirements for participation in Medicare. Clinic services must be provide by or under the direction of a licensed physician or, where appropriate, a licensed dentist.

All of the following are conditions for coverage of listed ambulatory surgical center procedures:

  • Covered surgical procedures are limited to those procedures that do not generally exceed a total of 90 minutes operating time and a total of 4 hours recovery or convalescent time.
  • If the covered surgical procedure requires anesthesia, the anesthesia must be local or regional anesthesia, or general anesthesia of 90 minutes or less duration.
  • Covered surgical procedures may not be of a type that generally result in extensive blood loss; require a major or prolonged invasion of body cavities; directly involve major blood vessels; are generally emergent or life threatening in nature; or can safely be performed in a physician’s or dentist’s office.

Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) Services (ARM 37.86.2201–2235)
The EPSDT Well-Child program covers all medically-necessary services for children age 20 and under. Providers are encouraged to use a series of screening and diagnostic procedures designed to detect diseases, disabilities, and abnormalities in the early stages.

Some services are covered for children that are not covered for adults, such as the following:

  • Nutritionist services
  • Respiratory therapy
  • Therapeutic family and group home care
  • Substance dependency inpatient and day treatment services
  • School-based services

All prior authorization and Passport approval requirements must be followed. For more information about the recommended well-child screen and other components of EPSDT, see the EPSDT Well-Child chapter in the General Information for Providers manual.

Coverage of Specific Services (ARM 37.86.1405)

Medicaid follows Medicare’s rules for coverage of most services. The following are coverage rules for specific ambulatory surgical center services.

Clinic Services, Covered Procedures (ARM 37.86.1405)
Ambulatory surgical center (ASC) services:

  • Are services that will be covered by Medicaid if provided in an outpatient ASC setting incident to provisions of physician or dental services to the member where the services and supplies are furnished in the ASC on a physician’s or dentist’s order by ASC personnel under the supervision of ASC medical staff.
  • Are limited as provided by ARM 37.86.1402(1)–(5) with the term clinic taken to mean ASC.
  • Clinic services covered by the Medicaid program include physician services covered in ARM 37.86.101, ARM 37.86.104, and ARM 37.86.105.
  • Clinic services covered by the Medicaid program include mid-level practitioner services covered in ARM 37.86.201, ARM 37.86.202, and ARM 37.86.205.

Use the fee schedule for your provider type to verify coverage for specific services.

 

End of Covered Services Chapter

 

Passport

What is Passport to Health? (ARM 37.86.5101–5120)

Passport to Health is the primary care case management (PCCM) program for Montana Medicaid and Healthy Montana Kids (HMK) Plus members. The Passport to Health program provides case management-related services that include locating, coordinating, and monitoring primary healthcare services. To achieve this, the Passport program works with the state’s other care coordination programs:

  • Nurse First Advice Line
  • Team Care
  • Health Improvement Program (HIP)

Medicaid and HMK Plus members who are eligible for Passport must enroll in the program (about 70% of Montana Medicaid and HMK Plus members are eligible). Each member has a designated Passport provider such as a physician, mid-level practitioner, or primary care clinic.

Passport members may change their Passport provider up to once per month, but the change will not be effective until the following month at the earliest, depending on the date the choice is made (ARM 37.86.5103–5104).

Additional Passport information is found in the Passport to Health manual, available on the Passport to Health link in the left menu and applicable provider type pages on the Provider Information website.

 

End of Passport Chapter

 

Prior Authorization

 

Prior authorization refers to a list of services that require approval from the Medicaid program prior to the service being rendered. If a service requires prior authorization, the requirement exists for all Medicaid members.

When prior authorization is granted, the provider is issued a prior authorization number that must be on the claim.

Medicaid does not pay for services when prior authorization requirements are not met.

See the Prior Authorization Information link in the left menu on the Provider Information website.

 

End of Prior Authorization Chapter

 

Coordination of Benefits

 

For Coordination of Benefits, providers should refer to the section on Third Party Liability in the Member Eligibility and Responsibilities chapter in the General Information for Providers manual.

 

End of Coordination of Benefits Chapter

 

Billing Procedures

 

Claim Forms

Services provided by the healthcare professionals covered in this manual must be billed either electronically or on a CMS-1500 claim form. CMS-1500 forms are available from various publishing companies; they are not available from the Department or Provider Relations.

Member Cost Sharing (ARM 37.85.204 and ARM 37.85.402)

See the General Information for Providers manual for additional information on member cost sharing.

 

End of Billing Procedures Chapter

 

Remittance Advices and Adjustments

 

See the General Information for Providers manual for information on remittance advices and adjustments.

 

End of Remittance Advices and Adjustments Chapter

 

How Payment Is Calculated

 

Overview

Although providers do not need the information in this chapter to submit claims to Montana Medicaid, the information allows providers to understand how payment is calculated and to predict approximate payment for particular claims.

Ambulatory Surgical Centers

Effective for dates of service on or after April 1, 2008, Montana Medicaid implemented a prospective ambulatory surgical center payment system in line with the Centers for Medicare and Medicaid Services (CMS) ambulatory surgical center methodology.

This payment system prospectively determines amounts to be paid for covered surgical and ancillary services identified by codes and modifiers established under the CMS Healthcare Common Procedure Coding System (HCPCS). This payment system also indicates which costs are packaged and which surgical procedures are excluded.

Montana Medicaid rates follow the CMS quarterly ambulatory surgical center payment updates. Lists of payable HCPCS codes and their corresponding payment rates are available on the Montana Medicaid ASC fee schedules. CMS also publishes quarterly addendums indicating covered surgical and ancillary services and non-covered surgical services.

Whenever CMS proposes to revise the payment rate for ambulatory surgical centers, CMS publishes a notice in the Federal Register describing the revision. The notice also explains the basis on which the rates were established. After reviewing public comments, CMS publishes a notice establishing the rates authorized by this section. In setting these rates, CMS may adopt reasonable classifications of facilities and may establish different rates for different types of surgical procedures.

Providers should review the Montana Medicaid ASC fee schedules on the Montana Healthcare Programs website.

Other Issues

Outpatient Services
When Medicaid pays an ambulatory surgical center for outpatient services, the separate claim for the physician’s services must show the ambulatory surgical center as the place of service (POS). This POS code (24) results in the physician receiving the facility fee listed in the physician fee schedule.

Modifiers

  • Review the guidelines for using modifiers in the CPT book, HCPCS book, and other helpful resources (e.g., CPT Assistant, APC Answer Letter).
  • Always read the complete description for each modifier; some modifiers are described in the CPT book, while others are described in the HCPCS book.
  • Medicaid accepts most of the same modifiers as Medicare, but not all.
  • The Medicaid claims processing system recognizes three pricing modifiers and one informational modifier per claim line on the CMS-1500. 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-1500.

How Payment Is Calculated on TPL Claims
When a member has coverage from both Medicaid and another insurance company, the other insurance company is often referred to as third party liability or TPL. In these cases, the other insurance is the primary payer, and Medicaid makes a payment as the secondary payer. Medicaid will make a payment only when the TPL payment is less than the Medicaid allowed amount.

How Payment Is Calculated on Medicare Crossover Claims
When a member has coverage from both Medicare and Medicaid, Medicare is the primary payer. Medicaid will pay the coinsurance and deductible, less any TPL or incurment, on ambulatory surgical center (ASC) claims for these dually-eligible individuals.

Payment Examples for Dually-Eligible Members
A provider submits an ASC claim for a member who has Medicare and Medicaid coverage. The Medicare coinsurance and deductible are $65 and $185. This total ($250) becomes the Medicaid allowed amount. Medicaid will pay the total as long as no TPL or incurment amounts are applicable.

A provider submits an ASC claim for a member who has Medicare, Medicaid, and TPL. The Medicare coinsurance and deductible are $65 and $185. This $250 total becomes the Medicaid allowed amount. The other insurance company paid $225. This amount is subtracted from the Medicaid allowed amount leaving $25. Medicaid pays $25 for this claim. If the TPL payment had been $250 or more, this claim would have paid at $0.

A provider submits an ASC claim for a member who has Medicare, Medicaid, and a Medicaid Incurment. The Medicare coinsurance and deductible are $65 and $185. This total ($250) becomes the Medicaid allowed amount. The member owes $150 for his Medicaid incurment, so this amount is subtracted from the $250. Medicaid will pay the provider $100 for this claim.

 

End of How Payment Is Calculated Chapter

 

Definitions and Acronyms

 

See the Definitions and Acronyms link in the menu on the Provider Information website for additional definitions and acronyms.

Ambulatory Surgical Center Services

Services that are provided in a licensed, freestanding ambulatory surgical center. Surgical center services do not include physician services, anesthesiologist services, ambulance services, or major prosthetic appliances such as intraocular lenses.

Clinic Services

Preventive, diagnostic, therapeutic, rehabilitative or palliative items or services provided under the direction of a physician by an outpatient facility that is not part of a hospital, but is organized and operated to provide medical care to outpatients independent of a hospital. Clinic services may be provided in surgical centers and public health departments. Clinic services do not include mental health center services as defined in ARM 37.88.901.

 

End of Definitions and Acronyms Chapter

 

Index

Previous editions of this manual contained an index.

This edition has three search options.

1.Search the whole manual. Open the Complete Manual pane.  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.

2.Search by Chapter. Open any Chapter tab (for example the "Billing Procedures" tab).  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 where denials discussed in just that chapter.

3.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.

 

End of Index Chapter

End of Ambulatory Surgical Center Services Manual