This publication supersedes all versions of previous general information provider handbooks. This publication is to be used conjunction with provider type manuals. Published by the Montana Department of Public Health & Human Services, February 2002.
Updated September 2002, October 2003, September 2004, November 2004, April 2005, April 2008, February 2012, April 2012, June 2014, July 2014, September 2014, November 2014, August 2015, November 2015, January 2016, July 2016, August 2016, February 2017, and July 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.
General Information for Providers Manual converted to an HTML format and adapted to 508 Accessibility Standards.
In summary, the Telemedicine Chapter was added as a new chapter. And the Medically Needy section of the Member Responsibilities Chapter page 6.5 was updated.
The Introduction contains updated links in the HELP section.
Cost Share was updated in the Billings Procedure.
A duplicate word was removed in the RA chapter.
The Cover Page was changed to reflect the current date of the new General Manual revision.
General Information For Providers, July 2016
Table of Contents was amended by changing the title of “Basic Medicaid Waiver” to “Waiver for Additional Services and Populations (formerly Basic Medicaid Waiver)”.
Index was amended by changing the title of “Basic Medicaid Waiver” to “Waiver for Additional Services and Populations (formerly Basic Medicaid Waiver)”.
Page 1.3 changed the title “Basic Medicaid Waiver for Additional Services and Populations” to “Waiver for Additional Services and Populations (formerly Basic Medicaid Waiver)”
General Information for Providers, January 2016: Introduction Regarding HELP Plan Information
General Information for Providers, January 2016: Introduction Regarding HELP Plan Information
General Information for Providers, January 2016: HELP Plan-Related Updates and Others
General Information for Providers, November 2015: Billing Procedures, Revenue Codes 25X and 27X
General Information for Providers, August 2015: Entire Manual
General Information for Providers, November 2014: Billing Procedures
General Information for Providers, September 2014: Billing Procedures
General Information for Providers, July 2014: Member Eligibility and Responsibilities
General Information for Providers, June 2014: General Information for Providers
If information is found on the website, it has been removed from the manual, and a link to the source is provided.
General Information for Providers, April 2012: Medicaid Covered Services and Client Eligibility
The Medicaid program plays an essential role in providing health insurance for Montanans. Before the enactment of Medicare and Medicaid, healthcare for the elderly and the indigent was provided through a patchwork of programs sponsored by governments, charities, and community hospitals.
Today, Medicare is a federal program that provides insurance for persons aged 65 and over and for people with severe disabilities, regardless of income. Medicaid provides healthcare coverage to specific populations, especially low-income families with children, pregnant women, disabled people, and the elderly. Medicaid is administered by state governments under broad federal guidelines. Recent healthcare laws have greatly increased the number of people who qualify for Medicaid. See the Montana Medicaid Program: Report to the 2017 Legislature.
Providers must be familiar with current rules and regulations governing the Montana Medicaid program. The provider manuals are meant 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 online on the provider type pages on the Provider Information website or at http://www.sos.mt.gov/ARM/index.asp.
Providers can order the Administrative Rules of Montana, including individual titles, online or by mail, through the Secretary of State website. Select the How to Order option in the Additional Resources section.
The General Information for Providers manual provides answers to general Medicaid questions about provider enrollment, member eligibility, and surveillance and utilization review.
This manual is designed to work with Medicaid provider type manuals, which contain program information on covered services, prior authorization, and billing for specific services.
It is divided by chapters, and a table of contents and index allow providers to find answers to most questions. The margins contain important information and space for writing notes. For eligibility and coordination of benefit information, see the Member Eligibility and Responsibilities chapter in this manual. Provider-specific information is in provider type manuals. Contact Provider Relations at 1-800-624-3958 with questions.
Changes and updates to manuals are provided through provider notices and replacement pages, which are posted on the Provider Information website. When replacing a page in a paper manual, file the old page in back of the manual for use with claims that originated under the old policy.
Providers are responsible for knowing and following current Medicaid rules and regulations. Manuals, replacement pages, and provider notices are provided as a guide and do not create any contractual liability on the part of the Department to any provider.
Replacement pages are designed for front-to-back printing. The heading at the top indicates the date of the changes (e.g., Replacement Page, August 2015).
Additional information is available through the Provider Information website.
Providers can stay informed with the latest Medicaid news and events, download provider manuals/replacement pages, provider notices, fee schedules, newsletters, and forms. Other resources are also available. See the menu for links.
The monthly Montana Healthcare Programs online newsletter, the Claim Jumper, covers Medicaid program changes and includes a list of documents posted to the Provider Information website during that time frame.
Provider Training Opportunities
Montana Healthcare Programs offers a variety of training opportunities that are announced on the Provider Information website and in the Claim Jumper newsletter. Recorded training sessions are available on the Training page of the website.
Medicaid works with various contractors who represent Medicaid through the services they provide. While it is not necessary for providers to know contractor duties, the information below is provided as informational.
- Conduent State Healthcare, LLC. Answers provider inquiries and enrolls providers in Medicaid and Passport to Health; processes claims for Medicaid, MHSP, HMK, pharmacy, dental, and eyeglasses, and HELP claims listed in the HELP Plan section.
- Mountain-Pacific Quality Health. Provides prior authorization for many Medicaid services.
- Magellan Medicaid Administration (dba First Health Services). Provides prior authorization, utilization review, and continued stay review for some mental health services.
Standard Medicaid Benefits
All Medicaid members are eligible for Standard Medicaid services if medically necessary. Covered services include, but are not limited to, audiology services, clinic services, community health centers services, dental services, doctor visits, hospital services, immunizations, Indian Health Services, laboratory services, mental health services, Nurse First services, nursing facility, occupational therapy, pharmacy, public health clinic services, substance dependency services, tobacco cessation, transportation, vision services, well-child checkups, and x-rays.
Waiver for Additional Services and Populations (formerly Basic Medicaid Waiver)
This waiver includes individuals age 18 or older, with Severe Disabling Mental Illnesses (SDMI) who qualify for or are enrolled in the state-financed Mental Health Services Plan (MHSP), but are otherwise ineligible for Medicaid benefits and either have:
- Income 0–138% of the federal poverty level (FPL) and are eligible for or enrolled in Medicare; or
- Income 139–150% of the FPL regardless of Medicare status (they can be covered or not covered by Medicare and be eligible).
Members covered under this waiver receive Standard Medicaid benefits. To apply or for more information, contact the Addictive and Mental Disorders Division at 1-406-444-2878 or visit the AMDD website.
HELP Plan Benefits
The Montana Health and Economic Livelihood Partnership (HELP) Plan provides health coverage to adults ages 19–64 with incomes up to 138% of the FPL; who are not enrolled or eligible for Medicare; who are not incarcerated; and who are U.S. citizens or documented, qualified aliens who are Montana residents.
Most services will be administered through Blue Cross and Blue Shield of Montana (BCBSMT), a third party administrator, and some services will be administered through Conduent.
Services for the HELP Plan Processed by BCBSMT Most medical and behavior health services will be processed by BCBSMT, including:
- Behavioral Health (Mental Health and Substance Use Disorder)
- Convalescent Home (excludes Custodial Care)
- Durable Medical Equipment/Supplies
- Early and Periodic Screening, Diagnostic, and Treatment (EPSDT)
- Lab and X-Ray (Medical)
- Medical Vision and Exams
- Rehabilitative and Habilitative
Services for the HELP Plan Processed by Conduent
- Diabetes Prevention Program
- Federally Qualified Health Center
- Hearing Aids
- Home Infusion
- Indian Health Services/Tribal Health
- Rural Health Clinic
• HELP Plan Provider Services 1 (877) 296-8206 (BCBSMT)
• BCBSMT website http://www.bcbsmt.com/mthelpplan
• HELP Plan Provider Services 1 (800) 624-3958 (Conduent)
• Provider Information website http://medicaidprovider.mt.gov
• HELP Plan Information website http://dphhs.mt.gov/healthcare
In addition to Medicaid, the Department of Public Health and Human Services (DPHHS, the Department) offers other programs. In addition to those listed below, other subsidized health insurance plans may be available from programs funded by the federal government or private organizations.
Chemical Dependency Bureau State Paid Substance Dependency/Abuse Treatment Programs
For individuals who are ineligible for Medicaid and whose family income is within program standards. For more information on these programs, call 406-444-3964 or visit http://dphhs.mt.gov/amdd/SubstanceAbuse.
Children’s Mental Health Bureau Non-Medicaid Services
Funding sources for short-term use, not entitlement programs. Planning efforts toward family reunification are the primary objective, with transition planning essential for youth in out-of-home care. For information, call 406-444-4545, or refer to the Non-Medicaid Services Provider Manual at http://dphhs.mt.gov/dsd/CMB/Manuals.
Children’s Special Health Services (CSHS)
A program that assists children with special healthcare needs who are not eligible for Medicaid by paying medical costs, finding resources, and conducting clinics. For more information, call 406-444-3622 (local) or 800-762-9891 (toll-free in Montana) or visit http://dphhs.mt.gov/publichealth/cshs.
Health Insurance Premium Payment (HIPP)
A program that allows Medicaid funds to be used to pay for private health insurance coverage when it is cost effective to do so. Visit http://dphhs.mt.gov/MontanaHealthcarePrograms/HIPP.
Healthy Montana Kids (HMK)
HMK offers low-cost or free health insurance for low-income children younger than 19. Children must be uninsured U.S. citizens or qualified aliens, Montana residents who are not eligible for Medicaid. Visit http://www.dphhs.mt.gov/HMK.
Mental Health Services Plan (MHSP)
A program for adults who are ineligible for Medicaid and whose family income is within program standards. Visit http://dphhs.mt.gov/amdd/Mentalhealthservices.
If a member loses Medicaid, family planning services may be paid by Plan First, which is a separate Medicaid program that covers family planning services for eligible women. Some of the services covered include office visits, contraceptive supplies, laboratory services, and testing and treatment of sexually transmitted diseases (STDs). Visit http://www.dphhs.mt.gov/MontanaHealthcarePrograms/PlanFirst.aspx.
End of Introduction Chapter
To be eligible for enrollment, a provider must:
- Provide proof of licensure, certification, accreditation, or registration according to Montana state laws and regulations.
- Provide a completed W-9.
- Meet the conditions in this chapter and in program instructions regulating the specific type of provider, program, and/or service.
Providers must complete a Montana Healthcare Programs Provider Enrollment Form, which is a contract between the provider and the Department. Healthcare providers must have a National Provider Identifier (NPI) or atypical provider identifier (API), which should be used in all correspondence with Medicaid. Providers must enroll for each type of service they provide. For example, a
pharmacy that also sells durable medical equipment (DME) must enroll for the pharmacy and again for DME.
To enroll online as a Montana Medicaid provider, visit the Montana Access to Health (MATH) web portal directly at https://mtaccesstohealth.acs-shc.com or the Montana Healthcare Programs Provider Information website and click the MATH Web Portal link near the top left, or contact Provider Relations at 1-800-624-3958.
Medicaid payment is made only to enrolled providers.
Each newly enrolled provider is sent an enrollment letter confirming enrollment. The letter includes instructions for obtaining additional information from the Provider Information website.
Letters to atypical providers include their API.
Medicaid-related forms are available on the Provider Information website. However, providers must order CMS-1500, UB-04, and dental claim forms from an authorized vendor.
Out-of-state providers can avoid denials and late payments by renewing Medicaid enrollment early.
For continued Medicaid participation, providers must maintain a valid license or certificate. For Montana providers, licensure or certification is automatically verified and enrollment renewed each year. If licensure or certification cannot be confirmed, the provider is contacted. Out-of-state providers are notified when Medicaid enrollment is about to expire. To renew enrollment, providers should mail or fax a copy of their license or certificate to Provider Relations. See the Contact Us link on the Provider Information website.
Changes in Enrollment
Changes in address, telephone/fax, name, ownership, legal status, tax ID, or licensure must be submitted in writing to Provider Relations. Faxes are not accepted because the provider’s original signature and NPI (healthcare providers) or API (atypical providers) are required. For change of address, providers can use the form on the website; for a physical address change, providers must include a completed W-9 form.
To avoid payment delays, notify Provider Relations of an address change in advance.
Change of Ownership
When ownership changes, the new owner must re-enroll in Montana Medicaid. For income tax reporting purposes, the provider must notify Provider Relations at least 30 days in advance about any changes to a tax identification number. Early notification helps avoid payment delays and claim denials.
Providers who submit claims electronically experience fewer errors and quicker payment. For more information on electronic claims submission options, see the Electronic Claims section in the Billing Procedures chapter in this manual.
Terminating Medicaid Enrollment
Medicaid enrollment may be terminated by writing to Provider Relations; however, some provider types have additional requirements. Providers should include their NPI (healthcare providers) or API (atypical providers) and the termination date in the letter. The Department may also terminate a provider’s enrollment under the following circumstances:
- Breaches of the provider agreement.
- Demonstrated inability to perform under the terms of the provider agreement.
- Failure to abide by applicable Montana and U.S. laws.
- Failure to abide by the regulations and policies of the U.S. Department of Health and Human Services or the Montana Medicaid program.
Authorized Signature (ARM 37.85.406)
All correspondence and claim forms submitted to Medicaid must have an NPI (healthcare providers) or API (atypical providers) and an authorized signature. The signature may belong to the provider, billing clerk, or office personnel, and may be handwritten, typed, stamped, or computer-generated. When a signature is from someone other than the provider, that person must have written authority to bind and represent the provider for this purpose. Changes in enrollment information require the provider’s original signature.
- Providers have the right to end participation in Medicaid in writing at any time; however, some provider types have additional requirements.
- Providers may bill Medicaid members for cost sharing (ARM 37.85.204).
- Providers may bill a member for the copayments specified in ARM 37.83.826 and may bill certain members for amounts above the Medicare deductibles and coinsurance as allowed in ARM 37.83.825.
- Providers may bill Medicaid members for services not covered by Medicaid if the provider and member have agreed in writing prior to providing services.
- When the provider does not accept the member as a Medicaid member, a specific custom agreement is required stating that the member agrees to be financially responsible for the services received.
- A provider may bill a member for non-covered services if the provider has informed the member in advance of providing the services that Medicaid will not cover the services and that the member will be required to pay privately for the services, and if the member has agreed to pay privately for the services. Non-covered services are services that may not be reimbursed for the particular member by the Montana Medicaid program under any circumstances and covered services are services that may be reimbursed by the Montana Medicaid program for the particular member if all applicable requirements, including medical necessity, are met (ARM 37.85.406).
- Providers have the right to choose Medicaid members, subject to the conditions in Accepting Medicaid Members later in this chapter.
- Providers have the right to request administrative reviews and fair hearings for a Department action that adversely affects the provider’s rights or the member’s eligibility (ARM 37.85.411).
Administrative Reviews and Fair Hearings (ARM 37.5.310)
A provider may request an administrative review if he/she believes the Department has made a decision that fails to comply with applicable laws, regulations, rules, or policies.
To request an administrative review, state in writing the objections to the Department’s decision and include substantiating documentation for consideration in the review. The request must be addressed to the division that issued the decision and delivered (or mailed) to the Department. The Department must receive the request within 30 days from the date the Department’s contested determination was mailed. Providers may request extensions in writing within this 30 days. See the Contact Us link on the Provider Information website.
If the provider is not satisfied with the administrative review results, a fair hearing may be requested. Fair hearing requests must contain concise reasons the provider believes the Department’s administrative review determination fails to comply with applicable laws, regulations, rules, or policies. This document must be signed and received by the Fair Hearings Office within 30 days from the date the Department mailed the administrative review determination. A copy must be delivered or mailed to the division that issued the determination within 3 working days of filing the request.
Provider Participation (ARM 37.85.401)
By enrolling in the Montana Medicaid program, providers must comply with all applicable state and federal statutes, rules, and regulations, including but not limited to, federal regulations and statutes found in Title 42 of the Code of Federal Regulations and the United States Code governing the Medicaid program and all applicable Montana statutes and rules governing licensure and certification.
Accepting Medicaid Members (ARM 37.85.406)
Institutional providers, eyeglass providers, and non-emergency transportation providers may not limit the number of Medicaid members they will serve. Institutional providers include nursing facilities, skilled care nursing facilities, intermediate care facilities, hospitals, institutions for mental disease, inpatient psychiatric hospitals, and residential treatment facilities.
Other providers may limit the number of Medicaid members. They may also stop serving private-pay members who become eligible for Medicaid. Any such decisions must follow these principles:
- No member should be abandoned in a way that would violate professional ethics.
- Members may not be refused service because of race, color, national origin, age, or disability.
- Members enrolled in Medicaid must be advised in advance if they are being accepted only on a private-pay basis.
- In service settings where the patient is admitted or accepted as a Medicaid member by a provider, facility, institution, or other entity that arranges provision of services by other or ancillary providers, all other or ancillary providers will be deemed to have accepted the individual as a Medicaid member and may not bill the patient for the services unless, prior to provision of services, the particular provider informed the patient of their refusal to accept Medicaid and the member agreed to pay privately for the services. See ARM 37.85.406(11)(d) for details.
- Most providers may begin Medicaid coverage for retroactively eligible members at the current date or from the date retroactive eligibility was effective. See the Retroactive Eligibility section in the Member Eligibility and Responsibilities chapter of this manual for details.
- When a provider bills Medicaid for services rendered to a patient, the provider has accepted the patient as a Medicaid member.
- Once a patient has been accepted as a Medicaid member, the provider may not accept Medicaid payment for some covered services but refuse to accept Medicaid payment for other covered services.
Non-Discrimination (ARM 37.85.402)
Providers may not discriminate illegally in the provision of service to eligible Medicaid members or in employment of persons on the grounds of race, creed, religion, color, sex, national origin, political ideas, marital status, age, or disability. Providers shall comply with the Civil Rights Act of 1964 (42 USC 2000d, et seq.), the Age Discrimination Act of 1975 (42 USC 6101, et seq.), the Americans With Disabilities Act of 1990 (42 USC 12101, et seq.), section 504 of the Rehabilitation Act of 1973 (29 USC 794), and the applicable provisions of Title 49, MCA, as amended and all regulations and rules implementing the statutes.
Providers are entitled to Medicaid payment for diagnostic, therapeutic, rehabilitative or palliative services when the following conditions are met:
- Provider must be enrolled in Medicaid. (ARM 37.85.402)
- Services must be performed by practitioners licensed and operating within the scope of their practice as defined by law. (ARM 37.85.401)
- Member must be enrolled in Medicaid and be nonrestricted. See Member Eligibility and Responsibilities for restrictions. (ARM 37.85.415 and ARM 37.85.205)
- Service must be medically necessary. The Department may review medical necessity at any time before or after payment. (ARM 37.85.410)
- Service must be covered by Medicaid and not be considered cosmetic, experimental, or investigational. (ARM 37.82.102, ARM 37.85.207, and ARM 37.86.104)
- Medicaid and/or third party payers must be billed according to rules and instructions as described in the Billing Procedures chapter, current provider notices and manual replacement pages, and according to ARM 37.85.406 (Billing, reimbursement, claims processing and payment) and ARM 37.85.407 (third party liability).
- Charges must be usual and customary. (ARM 37.85.212 and ARM 37.85.406)
- Reimbursement to providers from Medicaid and all other payers may not exceed the total Medicaid fee. For example, if payment to the provider from all responsible parties ($75.00) is greater than the Medicaid fee ($70.00), Medicaid will pay at $0. (ARM 37.85.406)
- Claims must meet timely filing requirements. See the Billing Procedures chapter in this manual for timely filing requirements. (ARM 37.85.406)
Medicaid Payment Is Payment in Full (ARM 37.85.406)
Providers must accept Medicaid payment as payment in full for any covered service, except applicable cost sharing that should be charged to the member.
Payment Return (ARM 37.85.406)
If Medicaid pays a claim, and then discovers that the provider was not entitled to the payment for any reason, the provider must return the payment.
- Providers are required to fully disclose ownership and control information when requested by the Department. (ARM 37.85.402)
- Providers are required to make all medical records available to the Department. (ARM 37.85.410 and ARM 37.85.414)
- All services must be made a part of the medical record. (ARM 37.85.414)
- Providers must treat Medicaid members and private-pay members equally in terms of scope, quality, duration, and method of delivery of services unless specifically limited by regulations. (ARM 37.85.402)
- Providers may not deny services to a member because the member is unable to pay cost sharing fees. (ARM 37.85.402)
Confidentiality (ARM 37.85.414)
All Medicaid member and applicant information and related medical records are confidential. Providers are responsible for maintaining confidentiality of healthcare information subject to applicable laws.
Record Keeping (ARM 37.85.414)
Providers must maintain all Medicaid-related medical and financial records for 6 years and 3 months following the date of service. The provider must furnish these records to the Department or its designee upon request. The Department or its designee may audit any Medicaid-related records and services at any time. Such records may include but are not limited to:
- Original prescriptions
- Certification of medical necessity
- Treatment plans
- Medical records and service reports including but not limited to:
- Patient’s name and date of birth
- Date and time of service
- Name/title of person providing service (other than billing practitioner)
- Chief complaint or reason for each visit
- Pertinent medical history
- Pertinent findings on examination
- Medication, equipment, and/or supplies prescribed or provided
- Description and length of treatment
- Recommendations for additional treatments, procedures, or consultations
- X-rays, tests, and results
- Dental photographs/teeth models
- Plan of treatment and/or care, and outcome
- Specific claims and payments received for services
- Each medical record entry must be signed and dated by the person ordering or providing the service.
- Prior authorization information
- Claims, billings, and records of Medicaid payments and amounts received from other payers for services provided to Medicaid members
- Records/original invoices for items prescribed, ordered, or furnished
- Any other related medical or financial data
Compliance with Applicable Laws, Regulations, and Policies
All providers must follow all applicable rules of the Department and all applicable state and federal laws, regulations, and policies. 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.
The following are references for some of the rules that apply to Montana Medicaid. The provider manual for each individual program contains rule references specific to that program.
- Title XIX Social Security Act 1901 et seq.
- 42 U.S.C. 1396 et seq.
- Code of Federal Regulations (CFR)
- CFR Title 42 – Public Health
- Montana Codes Annotated (MCA)
- MCA Title 53 – Social Services and Institutions
- Administrative Rules of Montana (ARM)
- ARM Title 37 – Public Health and Human Services
Links to rules are available on the provider type pages of the Provider Information website. Paper copies of rules are available through the Secretary of State’s office.
Provider Sanctions (ARM 37.85.501–507 and ARM 37.85.513)
The Department may withhold a provider’s payment or suspend or terminate Medicaid enrollment if the provider has failed to abide by terms of the Medicaid contract, federal and state laws, regulations, and policies.
Providers are responsible for keeping informed about applicable laws, regulations, and policies.
Below is a list of non-Medicaid Department of Public Health and Human Services (DPHHS) programs.
End of Provider Requirements Chapter
The Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) Services program is the federally sponsored, comprehensive healthcare benefits package for Medicaid-enrolled children through age 20. It helps families get early identification and treatment of medical, dental, vision, mental health, and developmental problems for their children. All Medicaid families are encouraged to use these services. See ARM 37.86.2201–2235.
EPSDT well-child checkups include:
- Assessment of physical, emotional, and developmental history
- Unclothed physical exams
- Assessment of mental/behavioral health
- Assessment of nutritional status
- Assessment of overall health, including referrals
- Laboratory tests
- Health education (also called anticipatory guidance)
- Family planning services and adolescent maternity care
- Appropriate immunizations
- Eye exams
- Hearing services
- Oral health
EPSDT includes a medical screen (sometimes called a well-child checkup), vision screen, dental screen, and hearing screen for all Medicaid-enrolled children. Montana Medicaid has adopted the Bright Futures/American Academy of Pediatrics Recommendations for Preventive Pediatric Health Care. This schedule can be found at https://brightfutures.aap.org. Click on the Clinical Practice Tab, and choose the Get to Know the Bright Futures Guidelines and Core Tools option.
These screens help identify and take care of health problems early in a child’s growth. Each screen includes a comprehensive health and developmental history; a comprehensive, unclothed physical exam; age-appropriate immunizations and laboratory tests (including blood lead levels); and health education. The screens are provided at specific periods throughout a child’s growth.
When a Medicaid-eligible child requires medically necessary services that are safe and effective, those services may be covered under Medicaid even if they are not covered for adults. Healthcare, diagnostic services, treatments, and other measures that would correct or improve defects or physical or mental illnesses or conditions are available based on medical necessity. If these services are not a covered service of Montana Medicaid, prior authorization is required. For more information on prior authorization, see the Prior Authorization chapter of this manual, your provider type manual, and the Prior Authorization Information page on the Provider Information website.
Who Can Provide EPSDT Screenings?
- Advanced Registered Nurse Practitioners (ARNP)
- Physician assistants
- Registered nurse under guidance of a physician or ARNP may perform the screenings but not diagnose or treat.
- Providers must be Montana Medicaid-enrolled to receive payment from Medicaid.
The Well-Child Screen
The foundation of EPSDT is the well-child screen. These screens should begin as early as possible in a child’s life or as soon as the child is enrolled in Medicaid. The well-child screens are based on a periodicity schedule established by medical, dental, and other healthcare experts, including the American Academy of Pediatrics. The Well-Child Screen Recommendations are found on the Bright Futures website, https://brightfutures.aap.org.
Every infant should have a newborn evaluation after birth. If a child comes under care for the first time at any point on the schedule, or if any items are not accomplished at the suggested age, the schedule should be brought up-to-date at the earliest possible time. If a well-child screen shows that a child is at risk based on the child’s environment, history, or test results, the provider should perform required or recommended tests even though they may not be indicated for the child’s age. Developmental, psychosocial, and chronic disease issues for children and adolescents may require frequent counseling and treatment visits separate from preventive care visits.
A comprehensive history, obtained from the parent or other responsible adult who is familiar with the child’s history should be done during the initial visit. Once it is done, it only needs to be updated at subsequent visits. The history should include the following:
- Developmental history to determine whether the child’s individual developmental processes fall within a normal range of achievement compared to other children of his/her age and cultural background.
- Discussion of the child’s development, as well as techniques to enhance the child’s development, with the parents.
- Nutritional history and status. Questions about dietary practices identify unusual eating habits, such as pica, or extended use of bottle feedings, or diets that are deficient or excessive in one or more nutrients.
- Complete dental history.
Appropriate Developmental Surveillance. Providers should administer an age-appropriate developmental screen at each well-child visit. Any concerns raised during the surveillance should be promptly addressed with standardized developmental screening tests. See the recommended algorithm provided by Bright Futures at http://pediatrics.aappublications.org/content/118/1/405.full.
Appropriate Developmental Screening. Providers should administer an ageappropriate developmental screen at age 9, 18, and 30 months. Results should be considered in combination with other information gained through the history, physical examination, observation, and reports of behavior. If developmental problems are identified, appropriate follow-up and/or referral to proper resources should be made.
Speech and language screens identify delays in development. The most important readiness period for speech is 9 to 24 months. Parents should be urged to talk to their children early and frequently. Refer the child for speech and language evaluation as indicated.
Parents of children with developmental disabilities should be encouraged to contact Parents Let’s Unite for Kids (PLUK).
PLUK is an organization designed to provide support, training, and assistance to children with disabilities and their parents. Call, write, or visit the PLUK website, http://www.pluk.org/.
516 North 32nd Street
Billings, MT 59101-6003
(406) 255-0540 Phone
(800) 222-7585 Toll Free
(406) 255-0523 Fax
Depression Screening. Signs and symptoms of emotional disturbances represent deviations from or limitations in healthy development. These problems usually will not warrant a psychiatric referral but can be handled by the provider. He/she should discuss problems with parents and give advice. If a psychiatric referral is warranted, the provider should refer the child to an appropriate provider. Recommended screening using the Patient Health Questionnaire (PHQ-2) or other tools found on the Bright Futures website.
Alcohol and Drug Use Screen. The provider should screen for risky behaviors (e.g., substance abuse, unprotected sexual activity, tobacco use, firearm possession). In most instances, indications of such behavior will not warrant a referral but can be handled by the provider, who should discuss the problems with the member and the parents and give advice. If a referral is warranted, the provider should refer to an appropriate provider. Recommended screening tool can be found on the Bright Futures website.
Providers should assess the nutritional status at each well-child screen. Children with nutritional problems may be referred to a licensed nutritionist or dietician for further assessment or counseling.
Unclothed Physical Inspection
At each visit, a complete physical examination is essential. Infants should be totally unclothed and older children undressed and suitably draped.
A vision screen appropriate to the age of the child should be conducted at each well-child screen. If the child is uncooperative, rescreen within six months.
A hearing screen appropriate to the age of the child should be conducted at each well-child screen. All newborns should be screened.
Autism screenings are recommended at age 18 and 24 months, and a recommended tool is provided on the Bright Futures website.
Critical Congenital Heart Defect Screen
Screening using pulse oximetry should be performed in newborns, after 24 hours old and before discharge.
Providers who conduct well-child screens must use their medical judgment in determining applicability of performing specific laboratory tests. Appropriate tests should be performed on children determined at risk through screening and assessment.
Hematocrit and Hemoglobin. Hematocrit or hemoglobin tests should be done for at-risk (premature and low birth weight) infants at ages newborn and 2 months. For children who are not at risk, follow the recommended schedule.
Blood Lead Level. All children in Medicaid are at risk of lead poisoning. To ensure their good health, the federal government requires that all Medicaid-enrolled children be tested for lead poisoning. Testing is recommended at 12 and 24 months of age. Children up to age 6 years who have not been checked for lead poisoning before should also be tested.
A blood lead level test should be performed on all children at 12 and 24 months of age.
All Medicaid children at other ages should be screened. Complete a verbal risk assessment for all Medicaid children up to age 6 years at each EPSDT screening:
- Does your child live in Butte, Walkerville, or East Helena, which are designated high-risk areas?
- Does your child live near a lead smelter, battery recycling plant, or other industry (operating or closed) likely to release lead?
- Does your child live in or regularly visit a house built before 1960, which contains lead paint?
- Does your child live near a heavily traveled major highway where soil and dust may be contaminated with lead?
- Does your child live in a home where the plumbing consists of lead pipes or copper with lead solder joints?
- Does your child frequently come in contact with an adult who works with lead, such as construction, welding, pottery, reloading ammunition (making own bullets), etc.?
- Is the child given any home or folk remedies? If yes, discuss.
If the answer to all questions is no, a child is considered at low risk for high doses of lead exposure. Children at low risk for lead exposure should receive a blood test at 12 and 24 months.
If the answer to any question is yes, a child is considered at high risk for high doses of lead exposure and a blood lead level test must be obtained immediately regardless of the child’s age.
Tuberculin Screening. Tuberculin testing should be done on individuals in high-risk populations or if historical findings, physical examination, or other risk factors so indicate.
Dyslipidemia Screening. Screening should be considered based on risk factors and family history at 24 months, 4, 6, 8, 12, 13, 14, 15, 16, and 17 years, and is indicated at or around 10 and 20 years of age.
STI/HIV Screening. All adolescent members should be screened for sexually transmitted infections (STIs) and HIV based on risk assessment starting at age 11 and reassessed annually with at least one assessment occurring between the ages of 16–18 years old.
Cervical Dysplasia Screening. Adolescents are not routinely screened for cervical dysplasia until age 21. See the 2010 AAP statement for indications at https://www.aap.org/en-us/Pages/Default.aspx.
The immunization status of each child should be reviewed at each well-child screen. This includes interviewing parents or caretakers, reviewing immunization records, and reviewing risk factors.
The Recommended Childhood Immunization schedule is available on the AMA website and the Centers for Disease Control and Prevention website.
The child’s provider should perform annual dental screens, and results should be included in the child’s initial/interval history. Annual dental screens include an oral inspection, fluoride varnish (as available) and making a referral to a dentist for any of the following reasons:
- When the first tooth erupts, and every six months thereafter.
- If a child with a first tooth has not obtained a complete dental examination by a dentist in the past 12 months.
- If an oral inspection reveals cavities or infection, or if the child is developing a handicapping malocclusion or significant abnormality.
Discussion and Counseling/Anticipatory Guidance
Providers should discuss examination results, address assessed risks, and answer any questions in accordance with parents’ level of understanding. Age-appropriate discussion and counseling should be an integral part of each visit. Allow sufficient time for unhurried discussions.
At each screening visit, provide age-appropriate anticipatory guidance concerning such topics as the following:
- Auto safety: Car seats, seat belts, air bags, positioning young or lightweight children in the backseat.
- Recreational safety: Helmets and protective padding, playground equipment.
- Home hazards: Poisons, accidents, weapons, matches/lighters, staying at home alone, use of detectors for smoke, radon gas, and carbon monoxide.
- Exposure to sun and secondhand smoke.
- Adequate sleep, exercise, and nutrition, including eating habits and eating disorders.
- Peer pressure.
- General health: Immunizations, patterns of respiratory infections, skin eruptions, care of teeth.
- Problems such as whining, stealing, setting fires, etc. as indicated by parental concern.
- Behavior and development: Sleep patterns, temper, attempts at independence (normal and unpleasant behavior), curiosity, speech and language, sex education and development, sexual activities, attention span, toilet training, alcohol and tobacco use, substance abuse.
- Interpersonal relations: Attitude of father; attitude of mother; place of child in family; jealousy; selfishness, sharing, taking turns; fear of strangers; discipline, obedience; manners, courtesy; peer companionship/relations; attention getting; preschool, kindergarten and school readiness and performance; use of money; assumption of responsibility; need for affection and praise; competitive athletics.
End of EPSDT Well-Child Chapter
Telemedicine is the use of interactive audio-video equipment to link practitioners and patients located at different sites. The Montana Medicaid Program reimburses providers for medically necessary telemedicine services furnished to eligible members.
Telemedicine is not itself a unique service but a means of providing selected services approved by Montana Medicaid. Telemedicine involves two collaborating providers, an originating provider and a distance provider. The provider where the member is located is the originating provider or originating site. In most cases, the distant provider is a clinician who acts as a consultant to the originating provider. However, in some cases the distant provider may be the only provider involved in the service.
Providers must be enrolled as Montana Medicaid providers and be licensed in the State of Montana in order to:
- Treat a Montana Medicaid member; and
- Submit claims for payment to Montana Medicaid
When to Use Telemedicine
Montana Medicaid considers the primary purposes of telemedicine are to bring providers to people living in rural areas, and to allow members access to care that is not available within their community. Providers should weigh these advantages against quality of care and member safety considerations. Members may choose which is more convenient for them when providers make telemedicine available.
Telemedicine should not be selected when face-to-face services are medically necessary. Members should establish relationships with primary care providers who are available on a face-to-face basis.
Telemedicine can be provided in member’s residence; the distance provider is responsible for the confidentiality requirements. Member’s residences do not qualify for originating provider reimbursement.
Telemedicine Confidentiality Requirements
All Medicaid providers using telemedicine to deliver Medicaid services must employ existing quality-of-care protocols and member confidentiality guidelines when providing telemedicine services. Health benefits provided through telemedicine must meet the same standard of care as in-person care. Record keeping should comply with Medicaid requirements in Administrative Rules of Montana (ARM) 37.85.414.
Transmissions must be performed on dedicated secure lines or must utilize an acceptable method of encryption adequate to protect the confidentiality and integrity of the transmission. Transmissions must employ acceptable authentication and identification procedures by both the sender and receiver.
General Billing Instructions
Providers may only bill procedure codes for which they are already eligible to bill. Services not otherwise covered by Montana Medicaid are not covered when delivered via telemedicine. The use of telecommunication equipment does not change prior authorization or any other Medicaid requirements established for the services being provided.
The availability of services through telemedicine in no way alters the scope of practice of any health care provider; or authorizes the delivery of health care services in a setting or manner not otherwise authorized by law.
Telemedicine reimbursement does not include:
- Consultations provided by telephone (interactive audio); or
- Facsimile machine transmissions.
- Crisis hotlines
The originating and distant providers may not be within the same facility or community. The same provider may not be the pay to for both the originating and distance provider.
If a rendering provider’s number is required on the claim for a face-to-face visit, it is required on a telemedicine claim.
Originating Provider Requirements
The originating site provider must have secure and appropriate equipment to ensure confidentiality, including camera(s), lighting, transmission and other needed electronics.
Originating providers bill using procedure code Q3014 (telemedicine originating site fee) for the use of a room and telecommunication equipment. The telehealth place of service code 02 does not apply to originating site facilities billing a facility fee.
The following provider types may bill procedure code Q3014:
- Outpatient Hospital;
- Critical Access Hospital*;
- Federally Qualified Health Center*;
- Rural Health Center*;
- Indian Health Service*;
- Licensed Clinical Social Worker;
- Licensed Professional Counselor;
- Mental Health Center:
- Chemical Dependency Clinic;
- Public Health Clinic; or
- Family Planning Clinic.
*Reimbursement for Q3014 is a set fee and is paid outside of both the cost to charge ratio and the all-inclusive rate.
Originating provider claims must include a specific diagnosis code to indicate why a member is being seen by the distance provider. The originating site must request the diagnosis code(s) from the distance site prior to billing the telemedicine appointment.
The originating provider may also, as appropriate; bill for clinical services provided on-site the same day that a telemedicine originating site service is provided. This originating site may not bill for assisting the distant provider with an examination, this includes any services that would be normally included in a face-to-face visit.
Distance Provider Requirements
Distance providers should submit claims for telehealth services using the appropriate CPT or HCPCS code for the professional service along with the GT modifier (interactive communication). Effective January 1, 2017, providers must also use the telehealth place of service of 02 for claims submitted on a CMS-1500 claim. By coding with the GT modifier and the 02 place of service, the provider is certifying that the service was a face-to-face visit provided via interactive audio-video telemedicine.
Any out of state distance providers must be licensed in the State of Montana and enrolled in Montana Medicaid in order to provide telemedicine services to Montana Medicaid members. Providers must contact the Montana Department of Labor and Industry to find out details on licensing requirements for their applicable professional licensure.
End of Telemedicine Chapter
Member Eligibility and Responsibilities
Medicaid ID Cards
Each Medicaid member is issued his/her own permanent Montana Access to Health Medicaid ID card (including QMB only members), Healthy Montana Kids Plus (HMK Plus) card.
Members must never throw away the card, even if their Medicaid eligibility ends.
The ID card lists the member’s name, member number, and date of birth. The member number may be used for checking eligibility and for billing Medicaid.
Since eligibility information is not on the card, providers must verify eligibility before providing services. See the Verifying Member Eligibility section below.
Providers should verify eligibility before providing services.
Verifying Member Eligibility
Member eligibility may change monthly. Providers should verify eligibility at each visit using any of the methods described in the following table.
The list below shows information returned to the provider in response to an eligibility inquiry:
- Member’s Medicaid ID number. Used when billing Medicaid.
- Eligibility Status. Medicaid eligibility status for the requested dates:
- Standard Medicaid. Member is eligible for all Medicaid covered services.
- QMB. Member is a qualified Medicare beneficiary. See the section titled When a Member Has Other Coverage in this chapter.
- Team Care. TC indicator means member is enrolled in the Team Care program. All services must be provided or approved by the designated Passport provider.
- Designated Provider. The member’s primary care provider’s name and phone number are shown for members who are enrolled in Passport to Health or Team Care. In either case, all services must be provided or approved by the designated provider. See the Passport to Health provider manual.
- TPL. If the member has other insurance coverage (TPL), the name of the other insurance carrier is shown.
- Medicare ID Number. A Medicare identification number for members who are eligible for both Medicaid and Medicare.
Member without Card
Since eligibility information is not on the card, it is necessary for providers to verify eligibility before providing services whether or not the member presents a card. Confirm eligibility using one of the methods shown in the Verifying Member Eligibility table. If eligibility is not available, the provider may contact the member’s local Office of Public Assistance (OPA).
Care rendered to newborns can be billed under the newborn’s original Medicaid ID number assigned by the mother’s local OPA until a permanent ID number becomes available. The hospital or the parents may apply for the child’s Social Security number. Parents are responsible for notifying their local OPA when they have received the child’s new Social Security number.
Inmates in Public Institutions (ARM 37.82.1321)
Medicaid does not cover members who are inmates in a public institution.
Presumptive eligibility is available to hospitals and their affiliated facilities that participate with Montana Medicaid.
Personnel must be trained and certified to make presumptive eligibility determinations for short-term, temporary coverage for the following coverage groups:
- Adults between the ages of 18 and 26 who were in Foster Care and receiving Medicaid at age 18
- Healthy Montana Kids Plus
- Healthy Montana Kids
- Parent/Caretaker Relative Medicaid
- Pregnant women (ambulatory prenatal care)
- Women between the ages of 19 and 64 who have been screened and diagnosed with breast or cervical cancer.
To encourage prenatal care, uninsured pregnant women may receive presumptive eligibility for Medicaid.
Presumptive eligibility may be for only part of a month and does not cover inpatient hospital services, but does include other applicable Medicaid services.
For more information about presumptive eligibility training or certification, see the Presumptive Eligibility page of the Provider Information website.
When a member is determined retroactively eligible for Medicaid, the member should give the provider a Notice of Retroactive Eligibility (160-M). The provider has 12 months from the date retroactive eligibility was determined to bill for those services.
Retroactive Medicaid eligibility does not allow a provider to bypass prior authorization requirements. See specific provider manuals for requirements.
When a member becomes retroactively eligible for Medicaid, the provider may:
- Accept the member as a Medicaid member from the current date.
- Accept the member as a Medicaid member from the date retroactive eligibility was effective.
- Require the member to continue as a private-pay member.
Institutional providers (nursing facilities, skilled care nursing facilities, intermediate care facilities for the mentally retarded, institutions for mental disease, inpatient psychiatric hospitals, and residential treatment facilities) must accept retroactively eligible member from the date eligibility was effective. Non-emergency transportation and eyeglass providers cannot accept retroactive eligibility. For more information on billing Medicaid for retroactive eligibility services, see the Billing Procedures chapter in this manual.
Coverage for the Medically Needy
This coverage is for members who have an income level that is higher than the SSI-eligible Medicaid program standards. However, when a member has high medical expenses relative to income he/she can become eligible for Medicaid by incuring medical expenses and/or making a cash payment equal to the spend down amount on a monthly basis. The spend down amount is based on the member's countable income. When the member chooses to use the Medical Expense option to meet their spend down, he/she is responsible to pay for medical services before Medicaid eligibility begins and Medicaid pays for remaining covered services.
Providers should verify if medically needy members are covered by Medicaid on the date of service to determine whether to bill the member or Medicaid.
Because eligibility does not cover an entire month, when the medical expense option is used the member’s eligibility information may show eligibility for only part of the month and the provider may receive a One Day Authorization Notice. The One Day Authorization Notice , sent by the local OPA, states the date eligibility began and the portion of the bill the member must pay. If the provider has not received a One Day Authorization Notice , he/she should verify eligibility for the date of service by any method described in this chapter or by contacting the member’s local OPA. Since this eligibility may be determined retroactively, the provider may receive the One Day Authorization Notice weeks or months after services have been provided.
Members may choose the cash option process where they can pay a monthly premium to Medicaid equal to the spend down amount, instead of making payments to providers, and have Medicaid coverage for the entire month. This method results in quicker payment, simplifies the eligibility process, and eliminates spend down notices. Providers may encourage but not require members to use the cash option.
It is important to note that after a client submits their payment to Medicaid, the Department requires time to process the payment. Once the payment is processed, the system will provide the Medicaid coverage. The client may choose to submit their payment to Medicaid after medical services have been provided. In that situation, the client's Medicaid eligibility information will not be available at the time the service is provided and any claims submitted at that time will be denied. Once the spend down has been paid and processed, active eligibility will display and claims can be submitted.
Nurse First programs provide disease management and nurse triage services for Medicaid members throughout the state.
Nurse First Advice Line, 1-800-330-7847. A toll-free, confidential telephone number members may call 24/7/365 for advice from a registered nurse about injuries, diseases, healthcare, or medications. The nurses do not diagnose or provide treatment. Most Medicaid members are eligible to use the Nurse First Advice Line, except members in a nursing home/institution or members with both Medicare Part A and B and Medicaid coverage. The program is voluntary though participation is strongly encouraged.
Health Improvement Program (HIP). A service provided under the Passport to Health program for members who have one or more chronic health conditions. Care management focuses on helping members improve their health outcomes through education, help with social services, and coordination with the member’s medical providers.
Montana Breast and Cervical Cancer Treatment Program
This program provides Standard Medicaid coverage for women who have been screened through the Montana Breast and Cervical Health Program (MBCHP) and diagnosed with breast and/or cervical cancer or a pre-cancerous condition. All other policies and procedures in this chapter apply. For information regarding screening through the MBCHP program, call 1-888-803-9343.
When a Member Has Other Coverage
Medicaid members often have coverage through Medicare, workers’ compensation, employment-based coverage, individually purchased coverage, etc. Coordination of benefits is the process of determining which source of coverage is the primary payer in a particular situation. In general, providers should bill other carriers before billing Medicaid, but there are some exceptions. (See the section titled Exceptions to Billing Third Party First in this chapter.) Medicare is processed differently than other sources of coverage.
Identifying Additional Coverage
The member’s Medicaid eligibility verification may identify other payers such as Medicare or other third party payers. If a member has Medicare, the Medicare ID number is provided. If a member has additional coverage, the carrier is shown. Some examples of third party payers include:
- Private health insurance
- Employment-related health insurance
- Workers’ compensation insurance*
- Health insurance from an absent parent
- Automobile insurance*
- Court judgments and settlements*
- Long-term care insurance
*These third party payers (and others) may not be listed on the member’s eligibility verification.
Providers should use the same procedures for locating third party sources for Medicaid members as for their non-Medicaid members. Providers cannot refuse service because of a third party payer or potential third party payer.
When a Member Has Medicare
Medicare claims are processed and paid differently than other non-Medicaid claims. The other sources of coverage are called third party liability or TPL, but Medicare is not.
Medicare Part A Claims
Medicare Part A carriers and Medicaid use electronic exchange of institutional claims covering Part A services. Providers must submit these claims first to Medicare. After Medicare processes the claim, an Explanation of Medicare Benefits (EOMB) is sent to the provider. The provider then reviews the EOMB and submits the claim to Medicaid.
Medicare Part B Crossover Claims
The Department has an agreement with the Medicare Part B carrier for Montana (Noridian) and the Durable Medical Equipment Regional Carrier (DMERC) under which the carriers provide the Department with claims for members who have both Medicare and Medicaid coverage. Providers must tell Medicare that they want their claims sent to Medicaid automatically, and must have their Medicare provider number on file with Medicaid.
When members have both Medicare and Medicaid covered claims, and have made arrangements with both Medicare and Medicaid, Part B services need not be submitted to Medicaid. When a crossover claim is submitted only to Medicare, Medicare will process the claim, submit it to Medicaid, and send the provider an explanation of Medicare benefits (EOMB). Providers must check the EOMB for the statement indicating that the claim has been referred to Medicaid for further processing. It is the provider’s responsibility to follow up on crossover claims and make sure they are correctly billed to Medicaid within the timely filing limit. (See the Billing Procedures chapter in this manual.)
Providers should submit Medicare crossover claims to Medicaid only when:
- The referral to Medicaid statement is missing. In this case, submit a claim and a copy of the Medicare EOMB to Medicaid for processing.
- The referral to Medicaid statement is present, but there is no response from Medicaid within 45 days of receiving the Medicare EOMB. Submit a claim and a copy of the Medicare EOMB to Medicaid for processing.
- Medicare denies the claim. The provider may submit the claim to Medicaid with the EOMB and denial explanation (as long as the claim has not automatically crossed over from Medicare).
When submitting electronic claims with paper attachments, see the Billing Electronically with Paper Attachments section of the Billing Procedures chapter.
When submitting a claim with the Medicare EOMB, use Medicaid billing instructions and codes. Medicare’s instructions, codes, and modifiers may not be the same as Medicaid’s. The claim must also include the Medicaid provider number and Medicaid member ID number. It is the provider’s responsibility to follow up on crossover claims and make sure they are correctly billed to Medicaid within the timely filing limit.
When a Member Has TPL (ARM 37.85.407)
When a Medicaid member has additional medical coverage (other than Medicare) it is often referred to as third party liability or TPL. In most cases, providers must bill other insurance carriers before billing Medicaid.
Providers are required to notify their members that any funds the member receives from third party payers (when the services were billed to Medicaid) must be turned over to the Department. These words printed on the member’s statement fulfill this obligation: When services are covered by Medicaid and another source, any payment the member receives from the other source must be turned over to Medicaid.
Exceptions to Billing Third Party First
In a few cases, providers may bill Medicaid first:
- When a Medicaid member is also covered by Indian Health Service (IHS) or the Crime Victim Compensation Program, providers must bill Medicaid first. These are not considered a third party liability.
- When a member has Medicaid eligibility and MHSP eligibility for the same month, Medicaid must be billed first.
- ICD prenatal and ICD preventive pediatric diagnosis conditions may be billed to Medicaid first. In these cases, Medicaid will “pay and chase” or recover payment itself from the third party payer.
- The following services may also be billed to Medicaid first:
- Nursing facility (as billed on nursing home claims)
- Hearing aids and batteries
- Home and community-based services (waiver)
- Oxygen in a nursing facility
- Personal assistance/Community First Choice
- Transportation (other than ambulance)
- If the third party has only potential liability, the provider may bill Medicaid first. Do not indicate the potential third party on the claim. Instead, notify the Department by sending the claim and notification to Third Party Liability, P.O. Box 5838, Helena, MT 59604.
Requesting an Exemption
Providers may request to bill Medicaid first under certain circumstances. In each of these cases, the claim and required information should be sent directly to the Third Party Liability unit.
- When a provider is unable to obtain a valid assignment of benefits, the provider should submit the claim with documentation that he/she attempted to obtain assignment and certification that the attempt was unsuccessful.
- When the provider has billed the third party insurance and has received a non-specific denial (e.g., no member name, date of service, amount billed), submit the claim with a copy of the denial and a letter of explanation.
- When the Child Support Enforcement Division has required an absent parent to have insurance on a child, the claim can be submitted to Medicaid then the following requirements are met:
- The third party carrier has been billed, and 30 days or more have passed since the date of service.
- The claim is accompanied by a certification that the claim was billed to the third party carrier, and payment or denial has not been received.
- If another insurance has been billed, and 90 days have passed with no response, submit the claim with a note explaining that the insurance company has been billed (or a copy of the letter sent to the insurance company). Include the date the claim was submitted to the insurance company and certification that there has been no response.
When the Third Party Pays or Denies a Service
When a third party payer is involved (excluding Medicare) and the other payer:
- Pays the claim, indicate the amount paid when submitting the claim to Medicaid for processing.
- Allows the claim, and the allowed amount went toward the member’s deductible, include the insurance explanation of benefits (EOB) when billing Medicaid.
- Denies the claim, submit the claim and a copy of the denial (including the reason explanation) to Medicaid.
- Denies a line on the claim, bill the denied line on a separate claim and submit to Medicaid. Include the EOB from the other payer and an explanation of the reason for denial (e.g., definition of denial codes).
When the Third Party Does Not Respond
If another insurance has been billed, and 90 days have passed with no response, bill Medicaid as follows:
- Submit the claim and a note explaining that the insurance company has been billed, or submit a copy of the letter sent to the insurance company.
- Include the date the claim was submitted to the insurance company.
- Send this information to the Third Party Liability Unit.
Coordination Between Medicare and Medicaid
Coordination of benefits between Medicare and Medicaid is generally accomplished through electronic crossover of claims. It is important to always bill Medicare prior to Medicaid for healthcare services. After Medicare processes the claim, it will automatically cross over to Medicaid. If a claim does not cross automatically to Medicaid from Medicare, the provider should not submit the claim to Medicaid until Medicare has processed. Medicaid payment is subsequent to Medicare and will only pay up to the Medicaid fee after considering the payment from Medicare. See the How Payment Is Calculated chapter in the provider type manuals to learn how Medicaid payments are calculated.
- Qualified Medicare Beneficiary (QMB). For QMBs, Medicaid pays their Medicare A and B premiums and some or all of the Medicare coinsurance and deductibles (up to the Medicaid fee). QMB members may or may not also be eligible for Medicaid benefits.
- QMB Only. Medicaid will make payments only toward the Medicare coinsurance and deductible.
- QMB and Medicaid. Covered services include the same services as for Medicaid only members. If a service is covered by Medicare but not by Medicaid, Medicaid will pay all or part of the Medicare coinsurance and deductible. If a service is covered by Medicaid but not by Medicare, then Medicaid will be the primary payer for that service.
- Specified Low-Income Medicare Beneficiary (SLMB). Medicaid pays the Medicare Part B premium only.
- SLMB Only. Members do not receive Medicaid cards, are not eligible for other Medicaid benefits, and must pay their own Medicare coinsurance and deductibles.
- SLMB and Medicaid. For services Medicare covers, Medicaid will pay the lower of the Medicare coinsurance and deductible or the Medicaid fee less Medicare payments for Medicaid covered services. If a service is covered by Medicare but not by Medicaid, Medicaid will not pay coinsurance, deductible, or any other cost of the service. For services Medicare does not cover but Medicaid covers, Medicaid will be the primary payer for that service.
- Qualifying Individual (QI). Medicaid pays the Medicare Part B premium only. Members should not have a dual eligibility when qualifying under the QI program. In other words, members cannot have QI and Medicaid at the same time. When a QI recipient becomes Medicaid-eligible, the QI benefit is canceled and replaced by the Medicaid eligibility.
Medicaid Benefits for Dually Eligible Members
Type of Dual Eligible: QMB only
Medicare Premium Paid by: Medicaid
Medicare Coinsurance and Deductible Paid by: Medicaid*
Type of Dual Eligible: QMB/Medicaid
Medicare Premium Paid by: Medicaid
Medicare Coinsurance and Deductible Paid by: Medicaid*
Type of Dual Eligible: Other dual eligibles
Medicare Premium Paid by: Member
Medicare Coinsurance and Deductible Paid by: Medicaid*
Type of Dual Eligible: Specified Low-Income Medicare Beneficiary
Medicare Premium Paid by: Medicaid
Medicare Coinsurance and Deductible Paid by: Member
*See the How Payment Is Made chapter in your provider type manual to learn how Medicaid calculates payment for Medicare coinsurance and deductibles.
Members with Other Sources of Coverage
Medicaid members may also have coverage through workers’ compensation, employment-based coverage, individually purchased coverage, etc. Other parties also may be responsible for healthcare costs. Examples of these situations include communal living arrangements, child support, or auto accident insurance. These other sources of coverage have no effect on what services Medicaid covers. However, other coverage does affect the payment procedures. (See the How Payment Is Calculated chapter in your provider type manual.)
The Health Insurance Premium Payment (HIPP) Program
Some Medicaid members have access to private insurance coverage, typically through a job, but do not enroll because they cannot afford the premiums. In these cases, Medicaid may pay the premiums, at which time the private insurance plan becomes the primary insurer. The member also remains eligible for Medicaid. When Medicaid members have access to private insurance coverage, they may apply for the HIPP program.
Indian Health Service (IHS)
The Indian Health Service (IHS) provides federal health services to American Indians and Alaska Natives. IHS is a secondary payer to Medicaid. For more information, see the Subsidized Health Insurance Programs in Montana table at the end of this chapter.
The Crime Victim Compensation Program is designed to help victims of crime heal. This program may provide funding for medical expenses, mental health counseling, lost wages support, funerals, and attorney fees. Crime Victim Compensation is a secondary payer to Medicaid. For more information, see the Subsidized Health Insurance Programs in Montana table later in this chapter.
When Members Are Uninsured
Several state and federal programs are available to help the uninsured; see the Subsidized Health Insurance Programs in Montana table at the end of this chapter.
Medicaid members are required to:
- Know and understand what Standard Medicaid benefits include.
- Notify providers that they have Medicaid coverage.
- Present a valid Montana Access to Health (MATH) or Healthy Montana Kids (HMK) Plus card at each visit.
- Pay Medicaid cost sharing amounts; see the Billing Procedures chapter in this manual.
- Notify providers of any other coverage, such as Medicare or private insurance.
- Notify providers of any change in coverage.
- Forward any money received from other insurance payers to the provider.
- Inform their local office of public assistance about any changes in address, income, etc.
Medicaid members may see any Medicaid-enrolled provider as long as Passport to Health and prior authorization guidelines are followed, and as long as they are not enrolled in Team Care.
Member eligibility provisions also apply to Department of Public Health and Human Services programs other than Medicaid. The information covered in this chapter applies to members enrolled in the Mental Health Services Plan (MHSP) and Healthy Montana Kids (HMK) dental services and eyeglasses only.
Chemical Dependency Bureau State Paid Substance Dependency/Abuse Treatment Program (CDB-SPSDATP)
Members in this program are not issued a Montana Access to Health card. Members should apply for services directly from the state-approved programs. For a list of these programs, call 406-444-9408. Services require prior authorization and authorization for continued stay review.
Healthy Montana Kids (HMK)
Few children are eligible for both Medicaid and HMK simultaneously. If a patient presents both cards, check the dates of Medicaid eligibility and the child’s HMK enrollment. If both cards are valid, treat the patient as an HMK patient. Services not covered by HMK may be covered by Medicaid.
If a member presents an HMK card for dental services, the provider should refer to the HMK dental services manual for information about coverage and billing. If a member presents an HMK card for eyeglasses, the card is valid only with the HMK program’s designated supplier. (See the HMK section of the Optometric and Eyeglass Services manual.) If a member presents an HMK card for any other service, see the HMK provider manual published by Blue Cross and Blue Shield of Montana. Call 1-800-447-7828 for more information.
Mental Health Services Plan (MHSP)
MHSP members will present a hard white plastic card. Their MHSP card makes them eligible only for those services covered by MHSP, which are described in the mental health and prescription drug manuals. Medicaid members do not need an MHSP card to receive mental health services.
If a member loses Medicaid, he/she may get family planning services paid by Plan First, which is a separate Medicaid program that covers family planning services for eligible women. Some of the services covered include office visits, contraceptive supplies, laboratory services, and testing and treatment of STDs. Visit http://dphhs.mt.gov/MontanaHealthcarePrograms/PlanFirst.
Subsidized Health Insurance Programs in Montana
Providers may refer member to the following programs.
Program: Children’s Special Health Services
Administered by: Montana DPHHS
Target Populations: Children with special healthcare needs.
For Information on Eligibility:
Program: Crime Victim Compensation Program
Administered by: Montana Department of Justice
Target Populations: Crime victims and their dependents and relatives.
For Information on Eligibility:
Program: Indian Health Service
Administered by: Billings Area Indian Health Service
Target Populations: All enrolled members of federally recognized tribes.
For Information on Eligibility:
Administered by: Montana DPHHS
Target Populations: Low-income children and their family members, and disabled individuals.
For Information on Eligibility:
Local Office of Public Assistance
Administered by: Centers for Medicare and Medicaid Services
Target Populations: People who are age 65 and over, have a disability, or have end-stage renal disease.
For Information on Eligibility:
U.S. Social Security Administration office
Program: Mental Health Services Plan (MHSP)
Administered by: Montana DPHHS
Target Populations: Individuals with a qualifying mental health diagnosis who are ineligible for Medicaid.
For Information on Eligibility:
Community Mental Health Center
Program: Workers’ Compensation
Administered by: State Fund and independent workers’ compensation insurers
Target Populations: People with injuries or illnesses related to their work.
For Information on Eligibility:
406-444-6543 Workers Compensation
Note: Eligibility rules are complex; members and providers should check with the program administrator for specifics.
End of Member Eligibility and Responsibilities Chapter
Surveillance and Utilization Review
Surveillance and Utilization Review (42 CFR 456)
The Department’s Surveillance and Utilization Review Section (SURS) performs federally mandated retrospective reviews of paid claims (42 CFR 456). SURS is required to safeguard against unnecessary and inappropriate use of Medicaid services and against excess payments. If the Department pays a claim, but subsequently discovers that the provider was not entitled to payment for any reasons, the Department is entitled to recover the resulting overpayment (ARM 37.85.406).
SURS monitors compliance with state and federal rules, laws, and policies in several ways:
- New Provider Audits. SURS reviews the billing data of newly enrolled providers and may also review documentation.
- Provider Self-Audits. A self-audit is an opportunity for the provider to perform an audit and self-disclose errors to SURS. Providers may access the website for Office of Inspector General (OIG) provider self-disclosure protocol resources at http://oig.hhs.gov/compliance/self-disclosure-info/index.asp.
- Individual Audits. An individual audit is conducted by the Program Integrity Auditor in charge of reviewing the provider type being audited.
- Team Audits. Team audits are conducted by a team of Program Integrity Auditors whose individual expertise contributes to the review of the issue being audited.
- Data Mining Audits. An audit conducted by data mining which reviews the appropriateness of the data submitted on the claim, such as dates of service, procedure code, units, etc.
- Statistical Sampling. When a provider is audited, claims data is gathered for the audit time frame. If a provider has a large number of claims for which records collection and submission for a complete review would be burdensome to the provider, a statistical sample of the claims may be reviewed at the option of the Department. SURS uses a program called RAT-STATS to pull a random subset (sample) of the total claims under review (universe). The audit is then completed on the sample of claims. The determination made on the sample is then extrapolated to the entire universe. If a provider disagrees with the final determination, a 100% review of claims may be requested by the provider. More information about the statistical sampling process can be found in ARM 37.85.416.
During an audit, SURS personnel send a spreadsheet to the provider with paid claims data. The provider is required to send supporting documentation for the items listed on the spreadsheet. A SURS Program Integrity Auditor reviews the documentation and/or data submitted by the provider.
If SURS determines an overpayment that exceeds $5,000, the audit is presented to the Medicaid Review Committee for review and approval. With the approval of the committee, an overpayment letter will be sent to the provider.
If SURS determines an overpayment that is less than $5,000, the case is reviewed by the associated program bureau chief, program officer, SURS supervisor, and Program Compliance bureau chief. Their approval will initiate an overpayment letter to the provider.
The overpayment letter specifies the amount of the overpayment, the date the funds are due, how to appeal the Department’s decision, and the appropriate contact person.
- The SURS unit encourages providers to call with any questions or concerns regarding the audit of paid claims.
- The Department is entitled to recover payment made to providers when a claim was paid incorrectly for any reason. (MCA 53-6-111, ARM 37.85.406)
- The Department may charge interest on recovered funds. (MCA 53-6-111)
- When an inappropriate payment has been identified, the Department may recover the overpayment by any legal means, including withholding of provider payments on subsequent claims. (MCA 53-6-111)
- The Department may sanction a provider, including suspension or termination of Medicaid enrollment, if the provider has failed to abide by terms of the Medicaid contract, federal and state laws, regulations and/or policies. (MCA 53-6-111, ARM 37.85.501–502, ARM 37.85.513)
- Prior authorization does not guarantee payment; a claim may be denied or money paid to providers may be recovered if the claim is found to be inappropriate. (MCA 53-6-111, ARM 37.85.406, ARM 37.85.410)
- The provider must upon request provide to the Department or its designated review organization without charge any records related to services or items provided to a member. The provider shall submit a true and accurate copy of each record of the service or item being reviewed as it existed within 90 days after the date on which the claim was submitted to Medicaid. (ARM 37.85.410, ARM 37.85.414)
The following suggestions may help reduce billing errors but are not inclusive of all possible errors and recoupment scenarios.
- Be familiar with the Medicaid provider manuals, fee schedules, and provider notices that are in effect for the claim dates of service. Read the Claim Jumper provider newsletter. These are available on the Provider Information website.
- Comply with applicable state and federal regulations, including but not limited to the Administrative Rules of Montana. (ARM 37.85.401)
- Use CPT, HCPCS, and ICD coding books that are in effect for the claim dates of service, and refer to the long descriptions. Relying on short descriptions can result in inappropriate billing. Additional coding resources such as those noted in CPT are also recommended.
- All providers of services must maintain complete records which fully demonstrate the extent, nature, and medical necessity of services and items provided to Montana Medicaid members. Information regarding the minimum requirements for records are found in ARM 37.85.414. In addition to complying with these minimum requirements, providers must also comply with any specific record keeping requirements applicable to the type of services the provider furnishes. See the Record Keeping section in the Provider Requirements chapter in this manual.
- When reimbursement is based on the length of time spent providing the service, the records must specify the time spent or the time treatment began and ended for each procedure. (ARM 37.85.414)
- Attend classes on coding offered by certified coding specialists.
- Avoid billing for the same service/supply twice. Contact Provider Relations for the status of submitted claims.
- Use specific codes rather than miscellaneous codes. For example, Code 99213 is more specific (problem-focused visit) than Code 99499 (unlisted evaluation and management service).
- Verify that the item/service meets criteria for payment by the Department. (See current fee schedule, provider manuals, and Administrative Rules of Montana.)
- Bill only under your own provider number.
- Bill only for services you provided.
- Bill for the appropriate level of service provided. For example, the CPT coding book contains detailed descriptions and examples of what differentiates a level 1 office visit (Code 99201) from a level 5 office visit (Code 99205).
- Services covered within “global periods” for certain CPT procedures are not paid separately and should not be billed separately. Most surgical and obstetric procedures and some medical procedures include routine care before and after the procedure. Medicaid fee schedules show the global period for each CPT service.
- Pay close attention to modifiers used with CPT and HCPCS codes on both CMS-1500 bills and UB-04 bills. Modifiers are becoming more prevalent in healthcare billing, and they often affect payment calculations.
- Choose the least costly alternative. For example, if a member is able to operate a standard wheelchair, then a motorized wheelchair should not be prescribed or provided.
- For repeat members, use an established patient code (e.g., Code 99213) instead of a first time patient code (e.g., Code 99203).
- Use the correct units measurement on CMS-1500 and UB-04 bills. In general, Medicaid follows the definitions in the CPT and HCPCS coding books. Unless otherwise specified, one unit equals one visit or one procedure. For specific codes, however, one unit may be 15 minutes, a percentage of body surface area, or another quantity. Always check the long text of the code description.
End of Surveillance and Utilization Review Chapter
Services provided by the healthcare professionals covered in this manual may be billed electronically or on paper claim forms, which are available from various publishing companies; they are not available from the Department or Provider Relations.
Timely Filing Limits (ARM 37.85.406)
Providers must submit clean claims to Medicaid within:
- Twelve months from whichever is later:
- the date of service
- the date retroactive eligibility or disability is determined
- Six months from the date on the Medicare explanation of benefits approving the service.
- Six months from the date on an adjustment notice from a third party payer who has previously processed the claim for the same service, and the adjustment notice is dated after the periods described above.
For claims involving Medicare or TPL, if the 12-month time limit has passed, providers must submit clean claims to Medicaid within:
- Medicare Crossover Claims. Six months from the date on the Medicare explanation of benefits, if the Medicare claim was timely filed and the member eligible for Medicare at the time the Medicare claim was filed.
- Claims Involving Other Third Party Payers (excluding Medicare). Six months from the date on an adjustment notice from a third party payer who has previously processed the claim for the same service, and the adjustment notice is dated after the periods described above.
Clean claims are claims that can be processed without additional information or action from the provider. The submission date is defined as the date that the claim was received by the Department or the claims processing contractor. All problems with claims must be resolved within this 12-month period.
Tips to Avoid Timely Filing Denials
- Correct and resubmit denied claims promptly. (See the Remittance Advices and Adjustments chapter in this manual.)
- If a claim submitted to Medicaid does not appear on the remittance advice within 45 days, contact Provider Relations for claim status.
- If another insurer has been billed and 90 days have passed with no response, a provider can bill Medicaid. (See the Member Eligibility and Responsibilities chapter in this manual for more information.)
- To meet timely filing requirements for Medicare/Medicaid crossover claims, see the Member Eligibility and Responsibilities chapter in this manual and, if applicable, the Coordination of Benefits chapter in your provider type manual.
When to Bill Medicaid Members (ARM 37.85.406)
In most circumstances, providers may not bill Medicaid members for services covered under Medicaid. The main exception is that providers may collect cost sharing from members.