Definitions
Below are definitions and acronyms that pertain to Autism services.
Adaptive Behavior Composite
A composite of the four domains measured in the Vineland. These Domains are Communication, Daily Living, Socialization and Motor Skills as defined by the Vineland. After age seven Motor Skills are no longer included in the Adaptive Behavior Composite.
Autism Spectrum Disorder (ASD)
ASD as defined in the Fifth Edition of the Diagnostic and Statistical Manual (DSM) of Mental Disorders of the American Psychiatric Association and as reimbursed under the ICD-10 diagnostic code F84.0.
Behavior Analyst Certification Board (the board)
The national board that certifies Board Certified Behavior Analysts, Assistant Behavior Analysts and Registered Behavior Technicians. It is accredited by the National Commission for Certifying Agencies (NCAA).
Board Certified Assistant Behavior Analyst (BCaBA)
An assistant behavior analyst currently certified by the board and licensed in accordance with Senate Bill 193 of the 65th Legislature upon administrative implementation of that act.
Board Certified Behavior Analyst (BCBA)
A behavior analyst currently certified by the board and licensed in accordance with Senate Bill 193 of the 65th Legislature upon administrative implementation of that act.
Board Certified Behavior Analyst – Doctoral (BCBA-D)
A behavior analyst currently certified by the board and licensed in accordance with Senate Bill 193 of the 65th Legislature upon administrative implementation of that act with doctoral training in behavior analysis.
Board Certified Behavior Analyst Student
A student enrolled in an accredited BCBA master’s or doctorate education program and currently enrolled in at least 3 credits of coursework and/or practicum approved by the board.
Clinical Setting
A setting in which the treatment plan can be developed where the member does not reside or is not a part of his/her typical day. A provider’s office or any other space rented or owned by a provider is considered a clinical setting.
Community Setting
A setting that is integrated in the community, accessible to people not receiving services, and readily provides for socialization, errand running, shopping, attending religious services, leisure and other non-clinical activities.
Core ASD Features
Persistent impairment resulting in deficiencies in social communication, deficiencies in social interaction, and restrictive and repetitive behaviors.
Eligibility and Utilization Contractor
The department contractor selected through the Request for Proposal (RFP) process who conducts diagnostic and comprehensive evaluations to determine eligibility and completes 6 month medical necessity reviews.
Evidence-Based Practice
A practice listed on the National Autism Center’s National Standards Project list of Established Interventions for ASD or the National Professional Development Center on ASD list of evidence-based practices to treat ASD.
Family Support Specialist with an Autism Endorsement (FSS-AE)
A Family Support Specialist with a current autism endorsement issued by the department.
Guardian
The parents of a minor child with parental rights under law or a person who has legally appropriate guardianship.
High Intensity
The level of need that necessitates a treatment plan, implementation guidance, and intensive treatment services.
Home
The primary residence in which the member lives.
Implementation Guidance
Services directed at educating and coaching the guardian to implement the initial treatment plan, and educating and coaching the guardian to implement modifications for the treatment plan. Services include modeling interventions with the member and giving direction to the implementation of the plan in the home or other community settings that are a part of the member's typical day.
Intensive Treatment
Intensive treatment is the delivery of face-to face services implementing the treatment plan including developmental and behavioral techniques, data collection to measure progress, and generalization of acquired skills. Services should generally be delivered by an RBT. As may be necessary a BCBA or intermediate professional may also provide intensive treatment services reimbursed at the RBT rate. The RBT must work under the supervision of a BCBA who bills for the work and assumes responsibility for services delivered. The BCBA must directly observe a portion of an RBT’s service delivery, as required by the board. The rate for this service includes direct supervision completed by the BCBA. The member and guardian (or adult authorized in writing by the guardian) must be present for the entire duration of services.
Intermediate Professional
A BCaBA, Family Support Specialist with an Autism Endorsement (FSS-AE) issued on or after July 1, 2014, or student currently enrolled in an accredited BCBA master’s or doctorate education program.
Low Intensity
The level of need that only necessitates a treatment plan and implementation guidance services.
Member
A person enrolled in Montana Medicaid who for purposes of the program of ASD services authorized through this sub-chapter are eligible to receive those services.
Modeling
The intermediate professional or BCBA correctly demonstrating an evidence-based practice from the treatment plan with the member and an imitation of the evidence-based practice by the guardian.
Month
A calendar month.
Registered Behavior Technician (RBT)
A behavior technician currently registered with the board.
Related Conditions
A condition that is severe, chronic, and persistent; and requires treatment or services similar to those required for persons with ASD; and is not attributable to mental illness or emotional disturbance; and manifests in each of the core ASD features.
Treatment Modality
The particular evidence-based practice(s) used for treatment of a specific member.
Treatment Plan
An individualized evidence-based written document that describes the protocol to be implemented to provide ASD services to a member. It is developed by a BCBA or intermediate professional based on assessment(s) and direct observation. The treatment plan is agreed upon, signed and dated by the member’s guardian and BCBA.
Vineland
The Vineland Adaptive Behavior Scales Second Edition published in 2005, or newer edition, which is a tool that measures the social and personal skills of a member. It is used to assess a member’s typical performance of day to day activities across the domains of communication, daily living skills, socialization, motor skills and adaptive behavior.
Week
Sunday – Saturday calendar week.
End of Definitions Chapter
Autism 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 Ambulance Services manuals. Published by the Department of Health and Human Services, August 2016.
Updated August 2017.
CPT codes, descriptions and other data only are copyright 1999 American Medical Association (or such other date of publication of CPT). All Rights Reserved. Applicable FARS/DFARS Apply.
Update Log
08/01/2017
Autism Services Manual converted to an HTML format and adapted to 508 Accessibility Standards.
End of Update Log Chapter
Table of Contents
Key Contacts
Key Websites
Introduction
Manual Organization and Maintenance
Rule References
Claim Reviews
Definitions
Eligibility
Covered Services
General Coverage Principles
Services within Scope of Practice
Services Provided by Board Certified Behavior Analysts and Intermediate Professionals
Non-covered Services
Coverage of Specific Services
Program Coverage
Treatment Plans
Implementation Guidance
Intensive Treatment
Prior Authorization
Billing Procedures
Cost Sharing
Members with other Insurance
How Payment is Calculated
Overview
The RBRVS Fee Schedule
Fee Calculation
Basis of Relative Values
Composition of Relative Values
Site of Service Differential
Conversion Factor
Other Modifiers
Status Codes
How Payment is Calculated on TPL Claims
End of Table of Contents Chapter
Key Contacts
Hours for Key Contacts are 8:00 a.m. to 5:00 p.m. Monday through Friday (Mountain Time), unless otherwise stated. The phone numbers designated “In state” will not work outside Montana.
Provider Relations
For questions about eligibility, payments, denials, general claims questions, Medicaid or PASSPORT provider enrollment, address or phone number changes, or to request provider manuals or fee schedules:
(800) 624-3958 In state
(406) 442-1837 Out of state and Helena
Send written inquiries to:
Montana Provider Relations Unit
P.O. Box 4936
Helena, MT 59604
Claims
Send paper claims to:
Claims Processing Unit
P. O. Box 8000
Helena, MT 59604
Client Eligibility
For client eligibility, see the Client Eligibility and Responsibilities chapter in the General Information For Providers manual.
Third Party Liability
For questions about private insurance, Medicare or other third-party liability:
(800) 624-3958 In state
(406) 443-1365 Out of state and Helena
(406) 442-0357 Fax
Send written inquiries to:
Third Party Liability Unit
P. O. Box 5838
Helena, MT 59604
Provider Policy Questions
For policy questions, contact the appropriate division of the Department of Public Health and Human Services; see the Introduction chapter in the General Information For Providers manual.
Technical Services Center
Providers who have questions or changes regarding electronic funds transfer should call the number below and ask for the Direct Deposit Manager (406) 444-9500.
EDI Gateway
For questions regarding electronic claims sub- missions:
(800) 987-6719 Phone
(850) 385-1705 Fax
EDI Gateway Services
2324 Killearn Center Blvd.
Tallahassee, FL 32309
Secretary of State of Montana
The Secretary of State's office publishes the most current version of the Administrative Rules of Montana (ARM):
(406) 444-2055 Phone
Secretary of State of Montana
P.O. Box 202801
Helena, MT 59620-2801
End of Key Contacts Chapter
Key Web Sites
Autism State Plan Services
CMS Approved Montana State Plan - https://www.medicaid.gov/State-resource-center/Medicaid-State-Plan-Amendments/Downloads/MT/MT-15-0029.pdf
Information Available:
- Medicaid Information
- Medicaid news
- Provider manuals
- Notices and manual replacement pages
- Fee schedules
- Remittance advice notices
- Forms
- Provider enrollment
- Frequently asked questions (FAQs)
- Upcoming events
- Electronic billing information
- Newsletters
- Key contacts
Information Available:
The Behavior Analyst Certification Board (BACB) provides credentialing standards for:
- Board Certified Behavior Analyst - Doctoral (BCBA-D)
- Board Certified Behavior Analyst (BCBA)
- Board Certified Assistant Behavior Analyst (BCaBA)
- Registered Behavior Technician (RBT)
Information Available:
EDI Gateway is Montana’s HIPAA clearinghouse. Visit this web- site for more information on:
- Provider Services
- EDI Support
- Enrollment
- Manuals
- Software
- Companion Guides
Information Available:
- EDI implementation guides
- HIPAA implementation guides and other tools
- EDI education
End of Key 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 and Maintenance
Manuals must be kept current.
Notification of manual updates are provided through the weekly web postings under “Recent Website Posts” on the home page of the provider website and under Provider Notices on the provider type page of the provider website. Older versions of the manual may be found through the Archive page on the Provider website. 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.
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 always prevails. Paper copies of rules are available through the Secretary of State's office. The following rules are specific to Autism state plan services: ARM XX.XX.XX through ARM XX.XX.XX. Claims Review (MCA 53-6-111, 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 billed appropriately. Although the computerized system can detect and deny some erroneous claims, there are many erroneous claims which it cannot detect. Therefore, payment of a claim does not mean the service was correctly billed or the payment made to the provider was correct. If a claim is paid and the Department later discovers that the service was incorrectly billed or paid or the claim was erroneous in another way, the Department is required by Federal regulation to recover any overpayment, regardless of whether the incorrect payment was the result of the Department or provider error or other cause.
End of Introduction Chapter
Definitions
Below are definitions and acronyms that pertain to Autism services.
Adaptive Behavior Composite
A composite of the four domains measured in the Vineland. These Domains are Communication, Daily Living, Socialization and Motor Skills as defined by the Vineland. After age seven Motor Skills are no longer included in the Adaptive Behavior Composite.
Autism Spectrum Disorder (ASD)
ASD as defined in the Fifth Edition of the Diagnostic and Statistical Manual (DSM) of Mental Disorders of the American Psychiatric Association and as reimbursed under the ICD-10 diagnostic code F84.0.
Behavior Analyst Certification Board (the board)
The national board that certifies Board Certified Behavior Analysts, Assistant Behavior Analysts and Registered Behavior Technicians. It is accredited by the National Commission for Certifying Agencies (NCAA).
Board Certified Assistant Behavior Analyst (BCaBA)
An assistant behavior analyst currently certified by the board and licensed in accordance with Senate Bill 193 of the 65th Legislature upon administrative implementation of that act.
Board Certified Behavior Analyst (BCBA)
A behavior analyst currently certified by the board and licensed in accordance with Senate Bill 193 of the 65th Legislature upon administrative implementation of that act.
Board Certified Behavior Analyst – Doctoral (BCBA-D)
A behavior analystcurrently certified by the board and licensed in accordance with Senate Bill 193 of the 65th Legislature upon administrative implementation of that act with doctoral training in behavior analysis.
Board Certified Behavior Analyst Student
A student enrolled in an accredited BCBA master’s or doctorate education program and currently enrolled in at least 3 credits of coursework and/or practicum approved by the board.
Clinical Setting
A setting in which the treatment plan can be developed where the member does not reside or is not a part of his/her typical day. A provider’s office or any other space rented or owned by a provider is considered a clinical setting.
Community Setting
A setting that is integrated in the community, accessible to people not receiving services, and readily provides for socialization, errand running, shopping, attending religious services, leisure and other non-clinical activities.
Core ASD Features
Persistent impairment resulting in deficiencies in social communication, deficiencies in social interaction, and restrictive and repetitive behaviors.
Eligibility and Utilization Contractor
The department contractor selected through the Request for Proposal (RFP) process who conducts diagnostic and comprehensive evaluations to determine eligibility and completes 6 month medical necessity reviews.
Evidence-Based Practice
A practice listed on the National Autism Center’s National Standards Project list of Established Interventions for ASD or the National Professional Development Center on ASD list of evidence-based practices to treat ASD.
Family Support Specialist with an Autism Endorsement (FSS-AE)
A Family Support Specialist with a current autism endorsement issued by the department.
Guardian
The parents of a minor child with parental rights under law or a person who has legally appropriate guardianship.
High Intensity
The level of need that necessitates a treatment plan, implementation guidance, and intensive treatment services.
Home
The primary residence in which the member lives.
Implementation Guidance
Services directed at educating and coaching the guardian to implement the initial treatment plan, and educating and coaching the guardian to implement modifications for the treatment plan. Services include modeling interventions with the member and giving direction to the implementation of the plan in the home or other community settings that are a part of the member's typical day.
Intensive Treatment
Intensive treatment is the delivery of face-to face services implementing the treatment plan including developmental and behavioral techniques, data collection to measure progress, and generalization of acquired skills. Services should generally be delivered by an RBT. As may be necessary a BCBA or intermediate professional may also provide intensive treatment services reimbursed at the RBT rate. The RBT must work under the supervision of a BCBA who bills for the work and assumes responsibility for services delivered. The BCBA must directly observe a portion of an RBT’s service delivery, as required by the board. The rate for this service includes direct supervision completed by the BCBA. The member and guardian (or adult authorized in writing by the guardian) must be present for the entire duration of services. .
Intermediate Professional
A BCaBA, Family Support Specialist with an Autism Endorsement (FSS-AE) issued on or after July 1, 2014, or student currently enrolled in an accredited BCBA master’s or doctorate education program.
Low Intensity
The level of need that only necessitates a treatment plan and implementation guidance services.
Member
A person enrolled in Montana Medicaid who for purposes of the program of ASD services authorized through this sub-chapter are eligible to receive those services.
Modeling
The intermediate professional or BCBA correctly demonstrating an evidence-based practice from the treatment plan with the member and an imitation of the evidence-based practice by the guardian.
Month
A calendar month.
Registered Behavior Technician (RBT)
A behavior technician currently registered with the board.
Related Conditions
A condition that is severe, chronic, and persistent; and requires treatment or services similar to those required for persons with ASD; and is not attributable to mental illness or emotional disturbance; and manifests in each of the core ASD features.
Treatment Modality
The particular evidence-based practice(s) used for treatment of a specific member.
Treatment Plan
An individualized evidence-based written document that describes the protocol to be implemented to provide ASD services to a member. It is developed by a BCBA or intermediate professional based on assessment(s) and direct observation. The treatment plan is agreed upon, signed and dated by the member’s guardian and BCBA.
Vineland
The Vineland Adaptive Behavior Scales Second Edition published in 2005, or newer edition, which is a tool that measures the social and personal skills of a member. It is used to assess a member’s typical performance of day to day activities across the domains of communication, daily living skills, socialization, motor skills and adaptive behavior.
Week
Sunday – Saturday calendar week.
End of Definitions Chapter
Eligibility
Autism treatment services, in accordance with EPSDT, are provided to Medicaid members 20 years of age or younger. These services are recommended by a physician or other licensed practitioner pursuant to 42 CFR 440.130(c).
In order to receive ASD services, a Medicaid member who has initially been diagnosed with ASD by a physician or psychiatrist within the last 3 years may be referred by a physician, psychiatrist, or other licensed practitioner for a comprehensive evaluation to determine if the member is eligible and in need of ASD services. A Medicaid member who has not initially been diagnosed with ASD by a physician or psychiatrist within the last 3 years may be referred by a physician, psychiatrist, physician assistant, advanced practice registered nurse, or licensed clinical psychologist for a comprehensive evaluation, including a diagnostic assessment, to determine if the person is eligible and in need of ASD services.
The comprehensive evaluation is conducted by an independent state contractor to determine if a Medicaid member qualifies for ASD services and the level of care (Low Intensity or High Intensity). Medical necessity reviews will be conducted every six months. Medicaid members must meet all the criteria in order to continue to receive ASD services.
End of Eligibility Chapter
Covered Services
General Coverage Principles
This chapter provides covered service information that applies specifically to services performed by Board Certified Behavior Analysts (BCBA, BCBA-D), Registered Behavior Technicians (RBT), Board Certified Assistant Behavior Analysts (BCaBA), Family Support Specialists (FSS-AE), and students enrolled in an accredited BCBA master’s or doctorate education program. Like all healthcare services received by Medicaid members, services rendered by these providers must also meet the general requirements listed in the Provider Requirements chapter of the General Information for Providers manual.
Services within Scope of Practice (ARM 37.85.401)
Services are covered only when they are within the scope of the provider’s license. As a condition of participation in the Montana Medicaid program, all providers must comply with all applicable state and federal statutes, rules, and regulations.
Services Provided by Board Certified Behavior Analysts Intermediate Professionals and Registered Behavior Technicians (ARM ……)
Board Certified Behavior Analysts must maintain current certification and be enrolled as a Montana Medicaid provider in order to provide ASD services to Montana Medicaid members. Intermediate professionals, including BCaBAs, FSS-AEs, and BCBA students, as well as RBTs may perform services but must be billed to Medicaid under the supervising BCBA's NPI. BCBA providers cannot bill for services they did not provide, except for services provided by a RBT, BCaBA, FSS-AE, or BCBA student.
Non-Covered Services
The following Children's Mental Health Bureau services may not be provided concurrently for a Medicaid member that is receiving Autism State Plan services due to the duplicative nature of the services:
• Community Based Psychiatric Rehabilitation and Support
• Home Support Services
• Psychiatric Residential Treatment Facility
• Therapeutic Group Home
• Therapeutic Foster Care
• Acute Hospital
Coverage of Specific Services
After a comprehensive evaluation is completed by the state contractor, covered services may include the following:
• Treatment Plan development and continued review
• Implementation Guidance
• Intensive Treatment
The BCBA may not bill for more than one of the covered services provided to the same member during the same time period.
End of Covered Services Chapter
Program Coverage
Treatment Plans
All individuals eligible for ASD services will require a behavioral assessment and treatment plan development. This service requires prior authorization prior to performing the service. The treatment plan must include the following:
• Developmentally appropriate functional goals
• Treatment outcomes
• Methods of implementation
• Treatment modality, frequency, intensity, duration, and setting(s)
• Modifications as needed.
The treatment plan must be:
• Developed by a BCBA or intermediate professional after a face-to-face assessment
• Updated every 6 months with data submitted for medical necessity review
• Agreed upon, signed, and dated by the member's guardian and the BCBA
• Completed in a clinical or home setting
Description: Behavior Identification Assessment
Provider: BCBA or intermediate professional
Maximum Allowed: 1 unit every 6 months
One treatment plan service will be authorized every 6 months.
Implementation Guidance
Services include the BCBA or intermediate professional who wrote the treatment plan educating and coaching the guardian on how to implement the treatment plan in the home or the community environment where the member typically spends his or her time. Services include modeling interventions with the member. These services cannot be provided in a clinical setting. Up to 50% of service time may be delivered while the member is attending school or daycare. These services require prior authorization prior to performing the service.
Description: Behavior Treatment with Protocol Modification first 30 minutes of patient face-to-face time
Provider: BCBA or intermediate professional
Maximum Allowed: 1 unit
Description: Behavior Treatment with Protocol Modification each additional 30 minutes of patient face-to-face time
Provider: BCBA or intermediate professional
Maximum Allowed: 16 units
Services are limited to 70 units every 6 months. Additional units may be authorized if all of the following criteria are met:
-
Additional modification to the treatment plan is needed to address an increase in functional limitation deficits.
-
There is documentation of the amount of hours requested and specifically how they will be used to address the functional limitation deficit increase.
-
All implementation guidance has been exhausted.
-
The guardian requests additional services.
Intensive Treatment
Intensive treatment is the delivery of face-to face services implementing the treatment plan including developmental and behavioral techniques, data collection to measure progress, and generalization of acquired skills. Services should general be delivered by an RBT. As may be necessary a BCBA or intermediate professional may also provide intensive treatment services reimbursed at the RBT rate. The RBT must work under the supervision of a BCBA who bills for the work and assumes responsibility for services delivered. The BCBA must directly observe a portion of an RBT’s service delivery, as required by the board. The rate for this service includes direct supervision completed by the BCBA. The member and guardian (or adult authorized in writing by the guardian) must be present for the entire duration of services.
These services must be provided in a home or other setting that is part of the member's typical day. Up to 50% of service time may be delivered while the member is attending school or daycare. These services require prior authorization prior to performing the service.
Description: Behavior Treatment by Protocol first 30 minutes
Provider: Registered Behavioral Technician
Maximum Allowed: 1 unit
Description: Behavior Treatment by Protocol first 30 minutes
Provider: Registered Behavioral Technician
Maximum Allowed: 16 units
These services are limited to 40 units per week unless all of the following criteria are met:
-
The member has been consistently receiving intensive treatment at least 15 hours per week over the past 6 months or more.
-
There is a specific behavioral issue that can be addressed with the delivery of additional intensive treatment over the course of no more than 90 days.
-
The member's guardian(s) have been educated and are participating in the implementation of the features of the treatment plan for which they are responsible.
End of Program Coverage Chapter
Prior Authorization
ASD services require prior authorization prior to any service being performed. The Eligibility and Utilization Contractor enters care spans and service authorizations into the MMIS system.
For general information about Prior Authorization, see the General Information for Providers manual.
End of Prior Authorization Chapter
Billing Procedures
Services provided by healthcare professionals covered in this manual must be either electronically billed or on a CMS claim form. CMS claim forms are available from various publishing companies and are not available from the Department or Provider Relations.
Cost Sharing
Members receiving ASD services are exempt from cost sharing.
Members with Other Insurance
If a member is also covered by Medicare, has other insurance, or some other third party is responsible for the cost of the member's healthcare, see the Coordination of Benefits chapter in this manual.
Other Resources
On July 7, 2014, CMS released an Informational Bulletin to provide information on the options available under the federal Medicaid program for furnishing services to eligible individuals with ASD. The Bulletin discusses requirements related to services for individuals eligible for the Medicaid benefit for children (also known as Early and Periodic Screening, Diagnostic and Treatment (EPSDT)).
Using the Medicaid Fee Schedule
When billing Medicaid, it is important to use the Department's fee schedule for your provider type in conjunction with the detailed coding descriptions listed in the CPT and HCPCS coding books. Current fee schedules are available on the Provider Information website.
The BCBA assumes full professional responsibility for all services provided by an intermediate professional or registered behavior technician. All services are billed under the BCBA's provider NPI. Providers bill using standard Current Procedural Terminology (CPT) procedure codes and are reimbursed according to the Department's RBRVS system.
End of Billing Procedures Chapter
How Payment is Calculated
Overview
Though providers do not need the information in this chapter in order to submit claims to the Department, the information allows providers to understand how payment is calculated and to predict approximate payment for particular claims.
The RBRVS Fee Schedule
Most services by provider types covered in this manual are reimbursed for using the Department’s RBRVS fee schedule. RBRVS stands for Resource-Based Relative Value Scale. The fee schedule includes CPT codes and HCPCS codes. Within the CPT coding structure, only anesthesia services and clinical lab services are not reimbursed for using the RBRVS fee schedule.
RBRVS was developed for the Medicare program. Medicare does a major update annually, with smaller updates performed quarterly. Montana Medicaid’s RBRVS-based fee schedule is based largely on the Medicare model, with a few differences as described below. By adapting the Medicare model to the needs of the Montana Medicaid program, the Department was able to take advantage of the research performed by the federal government and national associations of physicians and other healthcare professionals. RBRVS-based payment methods are widely used across the U.S. by Medicaid programs, workers’ compensation plans and commercial insurers.
Fee Calculation
Each fee is the product of a relative value times a conversion factor.
Basis of Relative Values
For almost all services, Medicaid uses the same relative values as Medicare in Montana. Nationally, Medicare adjusts the relative values for differences in practice costs between localities, but Montana is considered a single locality. For less than 1% of codes, relative values are not available from Medicare. For these codes, the Department has set the relative values.
When Medicaid payment differs from the fee schedule, consider the following:
- The Department pays the lower of the established Medicaid fee or the provider’s charge
- Modifiers. (See Other Modifiers in this chapter.)
- Provider type (See Professional Differentials in this chapter.)
- Place of service (See Site of Service Differential in this chapter.)
- Date of service (Fees for services may change over time.)
- Also check for cost sharing and Medicare or TPL payments shown on the remittance advice.
Composition of Relative Values
For each code, the relative value is the sum of a relative value for the work effort (including time, stress, and difficulty), the associated transitional practice expense, and the associated malpractice expense.
Site of Service Differential
The Medicare program has calculated two sets of relative values for each code: one reflects the practitioner’s practice cost of performing the service in an office and one reflects the practitioner’s practice cost of performing the service in a facility.
Medicaid typically pays a lower fee if the service is provided in a facility because Medicaid typically also pays the facility.
Conversion Factor
The Department sets the conversion factor for the state fiscal year (July through June) and it is listed on the fee schedule.
Other Modifiers
Under the RBRVS fee schedule, certain other modifiers also affect payment. Modifiers affecting reimbursement are listed in the table on the next page.
Status Codes
The Medicare physician fee schedule includes status codes that show how each services is reimbursed. Medicaid also uses status codes. The table below com- pares Medicare and Medicaid RBRVS status codes.
Medicare and Medicaid RBRVS Status Values
Medicare Status: A Active code paid using RVUs
Medicaid Status: A Active code paid using RVUs set by Medicare
Medicare Status: B Bundled code
Medicaid Status: B Bundled code
Medicare Status: C Carrier determines coverage and payment
Medicaid Status: C Medicaid determines coverage and payment.
Medicare Status: D Deleted code
Medicaid Status: D Discontinued code
Medicare Status: E Excluded from fee schedule by regulation
Medicaid Status: [Medicaid reviews each code and usually assigns A, K or X status]
Medicare Status: F Deleted/discontinued code; no grace period
Medicaid Status: F [Assigned to D status]
Medicare Status: G Use another code; grace period allowed
Medicaid Status: G Use another code; grace period set code-by-code
Medicare Status: H Modifier deleted
Medicaid Status: [Assigned to D status]
Medicare Status: I Use another code; no grace period
Medicaid Status: [Assigned to G status]
Medicare Status:
Medicaid Status: J Anesthesia code
Medicare Status:
Medicaid Status: K Active code paid using RVUs set by Medicaid
Medicare Status:
Medicaid Status: L Not paid via RBRVS. See lab fee schedule.
Medicare Status:
Medicaid Status: M Not paid via RBRVS. See non-RBRVS fee schedule.
Medicare Status: N Excluded from fee schedule by policy
Medicaid Status: [Medicaid reviews each code and usually assigns A, K or X status]
Medicare Status: P Bundled or excluded
Medicaid Status: [Medicaid reviews each code and usually assigns B or X status]
Medicare Status: R Restricted coverage
Medicaid Status: [Medicaid reviews each code and usually assigns A or K status]
Medicare Status: T Injections
Medicaid Status: [Medicaid reviews each code and usually assigns A status]
Medicare Status: X Excluded from fee schedule by statute
Medicaid Status: X Not covered
Medicare publishes RVUs for codes that have Medicare status values of R and sometimes publishes RVUs for codes with status values of E, N or X. Medicare uses the label “injections” for status T but now uses the code for other situations (e.g., pulse oximetry) where Medicare pays for the service only if no other service is performed on the same day.
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 (TPL). In these cases, the other insurance is the primary payer (as described in the Coordination of Benefits chapter of this manual), and Medicaid makes a payment as the secondary payer. The Medicaid reimbursement amount is reduced by the TPL payment.
End of How Payment is Calculated Chapter
Index
In place of an index, this manual 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 Autism Services Manual