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School-Based Services Manual

School-Based Services Manual

School-Based Services Manual

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School-Based Services Manual

Updated 11/02//2017

This manual was updated 11/02/2017

Update Log

Update Log

 

Publication History

This publication supersedes all previous School-Based Services handbooks. Published by the Montana Department of Public Health & Human Services, August 2003.

Updated October 2003, December 2003, January 2004, April 2004, August 2004, April 2005, May 2005, August 2005, January 2006, April 2006, February 2007, April 2008, June 2011, April 2012, March 2013, May 2013, October 2017, and November 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

11/02/2017
Code changes were made in the Billing Procedures Chapter.

10/20/2017
School-Based Services Manual converted to an HTML format and adapted to 508 Accessibility Standards.

07/10/2013
School-Based Services, May 2013: Entire Manual
These replacement pages includes a terminology change (client to member); however, unless a paragraphs also included content changes, it is not marked as a change.

04/27/2012
School-Based Services, April 2012: Covered Services

06/09/2011
School-Based Services, June 2011: Covered Services

09/16/2008
School-Based Services, April 2008: Key Contacts, Covered Services, Billing Procedures, and Claim Instructions

02/14/2007
School-Based Services, February 2007: Revised Physician Order Information, New Private Duty Nursing Request Form

04/25/2006
School-Based Services, April 2006: Coordination of Benefits Information

01/17/2006
School-Based Services, January 2006: Documentation Requirements, Restricted CSCT Services, Private-Duty Nursing Review Requirements, and School-Based Services Codes

10/06/2005
School-Based Services, August 2005: Covered Services and Billing Information for CSCT and Therapy  

05/12/2005
School-Based Services, May 2005: Key Contacts and Place of Service

04/11/2005
School-Based Services, April 2005: Key Contacts

08/30/2004
School-Based Services, August 2004: Audiology Services Defined  

04/26/2004
School-Based Services, April 2004: Key Contacts and Websites, Covered Services, COB, Billing Procedures, Claim Forms, RAs and Adjustments, Forms and Definitions

01/14/2004
School-Based Services, January 2004: Covered Services Error Correction

12/23/2003
School-Based Services, December 2003:CSCT Changes

 

End of Update Log Chapter

Table of Contents

Table of Contents

 

Key Contacts

Key Websites

Introduction

Manual Organization

Manual Maintenance

Rule References

Getting Questions Answered

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

Program Overview

Covered Services

General Coverage Principles

Services for Children (ARM 37.86.2201–2221)
Services within Scope of Practice (ARM 37.85.401)
Provider Requirements
IEP Requirements
Member Qualifications
School Qualifications
Physician Order/Referral
Documentation Requirements
Noncovered Services (ARM 37.85.207 and 37.86.3002)
Importance of Fee Schedules

Coverage of Specific Services

Assessment to Initiate an IEP
Comprehensive School and Community Treatment (CSCT)
Therapy Services
Private Duty Nursing Services
School Psychologists and Mental Health Services
Personal Care Paraprofessional Services
Special Needs Transportation
Audiology
Orientation and Mobility Specialist Services
Authorization Requirements Summary

Other Programs

Children’s Mental Health Services Plan (CMHSP)
Healthy Montana Kids (HMK)

Passport to Health Program

What Is Passport to Health? (ARM 37.86.5101–5120, 37.86.5303, and 37.86.5201–5206)

Passport to Health Primary Care Case Management (ARM 37.86.5101–5120)
Team Care (ARM 37.86.5303)
Nurse First Advice Line
Health Improvement Program (ARM 37.86.5201–5206)

Other Programs

Prior Authorization

What Is Prior Authorization (ARM 37.86.5101–5120)

Getting Questions Answered

Other Programs

Coordination of Benefits

When Members Have Other Coverage

Identifying Other Sources of Coverage

When a Member Has Medicare

Medicare Part B Crossover Claims
When Medicare Pays or Denies a Service
When Medicaid Does Not Respond to Crossover Claims

Submitting Medicare Claims to Medicaid

When a Member Has TPL (ARM 37.85.407)

CSCT Services
Billing for Medicaid Covered Services When No IEP Exists
Billing for Medicaid Covered Services under an IEP
Exceptions to Billing Third Party First
Requesting an Exemption
When the Third Party Pays or Denies a Service
When the Third Party Does Not Respond

Billing Procedures

Claim Forms

Timely Filing Limits (ARM 37.85.406)

Tips to Avoid Timely Filing Denials

When Providers Cannot Bill Medicaid Members (ARM 37.85.406)

Member Cost Sharing (ARM 37.85.204 and 37.85.402)

Billing for Members with Other Insurance

Billing for Retroactively Eligible Members

Service Fees

Coding Tips

Using Modifiers
Multiple Services on the Same Date
Time and Units
Place of Service

Billing for Specific Services

Assessment to Initiate an IEP
Therapy Services
Private Duty Nursing Services
School Psychologists and Mental Health Services
Personal Care Paraprofessional Services
Special Needs Transportation
Audiology

Submitting Electronic Claims

Billing Electronically with Paper Attachments

Submitting Paper Claims

Claim Inquiries

The Most Common Billing Errors and How to Avoid Them

Other Programs

Submitting a Claim

CMS-1500 Agreement

Avoiding Claim Errors

Other Programs

Remittance Advices and Adjustments

The Remittance Advice

Sample Remittance Notice

Credit Balances

Rebilling and Adjustments

How Long Do I Have to Rebill or Adjust a Claim?
Rebilling Medicaid
Adjustments
Mass Adjustments

Payment and the RA

How Payment Is Calculated

Overview

Payment for School-Based Services

Speech, Occupational and Physical Therapy Services
Private Duty Nursing
School Psychologist
Personal Care Paraprofessionals
CSCT Program
How Payment Is Calculated on TPL Claims
How Payment Is Calculated on Medicare Crossover Claims

Appendix A: Forms

Individual Adjustment

Audit Preparation Checklist

Private Duty Nursing Services Request

Paperwork Attachment Cover Sheet

Appendix B: Personal Care Paraprofessional Services Documentation

Personal Care Paraprofessional Services Provided in Schools – Child Profile

Purpose

Procedure

Instructions

Task/Hour Guide Instructions

Purpose

Specific Tasks

Task/Hour Guide

Definitions and Acronyms

Index

 

End of Table of Contents Chapter

Key Contacts

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.

Chemical Dependency

For coverage information and other details regarding chemical dependency treatment, write or call:

(406) 444-3964 Phone

Send written inquiries to:

Chemical Dependency Bureau
Addictive and Mental Disorders Division
DPHHS
P.O. Box 202905
Helena, MT 59620-2905

Claims

Send paper claims and adjustment requests to:

Claims Processing Unit
P.O. Box 8000
Helena, MT 59604

CSCT Program

For more information on the Comprehensive School and Community Treatment (CSCT) program, contact Childrens Mental Health Program specialist.

(406) 444-4545 Phone
(406) 444-4913 Fax

Send written inquiries to:

CSCT Specialist
Childrens Mental Health
DPHHS
P.O. Box 4210
Helena, MT 59620-4210

Direct Deposit Arrangements

Providers who would like to receive their electronic remittance advices and electronic funds transfer should fax their information to Provider Relations:

(406) 442-4402 Fax

EDI Technical Help Desk

For questions regarding electronic claims submission:
Send e-mail inquiries to: MTPRHelpdesk@conduent.com

(800) 987-6719 In/Out of state
(406) 442-1837 Helena
(406) 442-4402 Fax


Montana EDI
P.O. Box 4936
Helena, MT 59604

Healthy Montana Kids (HMK)

(877) 543-7669 Phone (toll-free)
(877) 418-4533 Fax (toll-free)
(406) 444-6971 Phone (Helena)
(406) 444-4533 Fax (Helena)
Send email inquires to: hmk@mt.gov

HMK Program Officer
P.O. Box 202951
Helena, MT 59620-2951

Member Eligibility

There are several methods for verifying member eligibility. For details on each, see Verifying Member Eligibility in the Member Eligibility and Responsibilities chapter of the General Information for Providers manual.

FaxBack
(800) 714-0075 (24 hours)
Voice Response System
(800) 714-0060 (24 hours)
Montana Access to Health Web Portal - http://mtaccesstohealth.acs-shc.com/
Medifax EDI
(800) 444-4336, X 2072 (24 hours)

Member Help Line

Members who have general Medicaid or Passport
questions may call the Help Line:

(800) 362-8312 Phone

Send written inquiries to:

Passport to Health
P.O. Box 254
Helena, MT 59624-0254

Nurse First

For questions regarding the Nurse First Advice Line, contact:

(406) 444-4540 Phone
(406) 444-1861 Fax

Nurse First Program Officer
Managed Care Bureau
DPHHS
P.O. Box 202951
Helena, MT 59620-2951

Prior Authorization

The following are some of the Department’s prior authorization contractors. Providers are expected to refer to their specific provider manual for prior authorization instructions.

Mountain-Pacific Quality Health
For prior authorization for school-based private duty nursing services:

(406) 443-4020 X150 Helena
(800) 262-1545 X150 Outside Helena
(406) 443-4585 Fax

Send written inquiries to:

Medicaid Utilization Review
Mountain-Pacific Quality Health
Helena, MT 59602

For questions regarding prior authorization for medical necessity therapy reviews:

(406) 457-5887 Local
(877) 443-4021 X5887 Toll-free
(877) 443-2580 Fax local/long distance

Send written inquiries to:

Mountain Pacific Quality Health
3404 Cooney Drive
Helena, MT 59602

Magellan Medicaid Administration
For questions regarding prior authorization and continued stay review for selected mental health services.

(800) 770-3084 Phone
(800) 639-8982 Fax
(800) 247-3844 Fax

Magellan Medicaid Administration
4300 Cox Road
Glen Allen, VA 23060

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. For inquiries related to licensure/endorsement, contact the Quality Assurance Division, Licensing Bureau:

(406) 444-2676 Phone
(406) 444-1742 Fax

Send written inquiries to:

Quality Assurance Division
Licensing Bureau
2401 Colonial Drive, Third Floor
Helena, MT 59602-2693

Provider Relations

For general claims questions, questions about eligibility, Passport to Health, payments, and denials:

(800) 624-3958 In/Out of state
(406) 442-1837 Helena
(406) 442-4402 Fax

Send e-mail inquiries to MTPRHelpdesk@conduent.com

Send written inquiries to:

Provider Relations Unit
P.O. Box 4936
Helena, MT 59604

Secretary of State

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
P.O. Box 202801
Helena, MT 59620-2801

Surveillance/Utilization Review

To report suspected provider fraud/abuse:

(406) 444-4586
(800) 376-1115

To report suspected member fraud/abuse:

(800) 201-6308

Send written inquiries to:

Fraud and Abuse
SURS
2401 Colonial Drive
P.O. Box 202953
Helena, MT 59620-2953

Team Care Program

For questions regarding Team Care:

(406) 444-9673 Phone
(406) 444-1861 Fax

Team Care Program Officer
Managed Care Bureau
DPHHS
P.O. Box 202951
Helena, MT 59620-2951

Third Party Liability

For questions about private insurance, Medicare, or other third-party liability:

(800) 624-3958 In/Out of state
(406) 442-1837 In/Out of state

Send written inquiries to:

Third Party Liability Unit
P.O. Box 5838
Helena, MT 59604

 

End of Key Contacts Chapter

Key Websites

Key Websites

 

EDI Gateway - www.acs-gcro.com

Information Available:

EDI Gateway is Montana’s HIPAA clearinghouse. Visit this website for more information on:

  • EDI enrollment
  • EDI support
  • FAQs
  • Manuals
  • Provider services
  • Related links
  • Software

 

HMK Website - www.hmk.mt.gov

 Information Available:

  • Information on Healthy Montana Kids (HMK)

 

Montana Access to Health Web Portal - mtaccesstohealth.acs-shc.com

 

Provider Information Website - medicaidprovider.mt.gov

 

Information Available:

  • FAQs
  • Fee schedules
  • HIPAA update
  • Key contacts
  • Links to other websites
  • Medicaid forms
  • Medicaid news
  • Newsletters
  • Notices and manual replacement pages
  • Passport to Health information
  • Provider enrollment
  • Provider manuals
  • Remittance advice notices
  • Training resources
  • Upcoming events

 

Washington Publishing Company - www.wpc-edi.com

A fee is charged for documents; however, code lists are viewable online at no charge.

Information Available:

  • HIPAA guides
  • HIPAA tools

 

 

End of Key Websites Chapter

Introduction

Introduction

 

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

Manual Organization

This manual provides information specifically for the School-Based Services Program.

Most chapters have a section titled Other Programs that includes information about other Department programs such as the Mental Health Services Plan (MHSP) and Healthy Montana Kids (HMK). Other essential information for providers is contained in the separate General Information for Providers manual. Each provider is asked to review both the general manual and the specific manual for his/her provider type.
 

A table of contents and an index allow you to quickly find answers to most questions. The margins contain important notes with extra space for writing notes. There is a list of Key Contacts at the beginning of each manual. We have also included a space on the inside front cover to record your NPI for quick reference when calling Provider Relations.

Manual Maintenance

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

Providers are responsible for knowing and following current laws and regulations.

Rule References

Providers must be familiar with all current rules and regulations governing the Montana Medicaid program. Provider manuals are to assist providers in billing Medicaid; they do not contain all Medicaid rules and regulations. Rule citations in the text are a reference tool; they are not a summary of the entire rule. In the event that a manual conflicts with a rule, the rule prevails. Links to rule references are available on the Provider Information website. Paper copies of rules are available through the Secretary of State’s office. (See Key Contacts.)

The following rules and regulations are specific to the school based services program. Additional Medicaid rule references are available in the General Information for Providers manual.

  • Administrative Rules of Montana (ARM)
    • ARM 37.86.2201 EPSDT Purpose, Eligibility and Scope
    • ARM 37.86.2206–2207 EPSDT Medical and Other Services; Reimbursement
    • ARM 37.86.2217 EPSDT Private Duty Nursing
    • ARM 37.86.2230–2235 EPSDT, School-Based Health Related Services

Getting Questions Answered

The provider manuals are designed to answer most questions; however, questions may arise that require a call to a specific group (such as a program officer, Provider Relations, or a prior authorization unit). The list of Key Contacts at the front of this manual has important phone numbers and addresses pertaining to this manual. The Introduction chapter in the General Information for Providers manual also has a list of contacts for specific program policy information. Medicaid manuals, provider notices, replacement pages, fee schedules, forms, and much more are available on the Provider Information website. (See Key Websites.)

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 appropriately billed. Although the computerized system can detect and deny some erroneous claims, there are many erroneous claims it cannot detect. For this reason, payment of a claim does not mean the service was correctly billed or the payment made to the provider was correct. Periodic retrospective reviews are performed that may lead to the discovery of incorrect billing or incorrect payment. If a claim is paid and the Department later discovers the service was incorrectly billed or paid or the claim was erroneous in some other way, the Department is required by federal regulation to recover any overpayment, regardless of whether the incorrect payment was the result of Department or provider error or other cause (42 CFR 456.3).

Program Overview

Title XIX of the Social Security Act provides for a program of medical assistance to certain individuals and families with low income. This program, known as Medicaid, became law in 1965 as a jointly funded cooperative venture between the federal and state governments. Federal oversight for the Medicaid program lies with the Centers for Medicare and Medicaid Services (CMS) in the Department of Public Health and Human Services (DPHHS).

The Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) program is a special program for Medicaid beneficiaries under 21 years of age. The purpose of EPSDT is to ensure that through periodic checkups and early detection, children’s health problems are prevented and/or ameliorated. The EPSDT program allows states to provide services even if these services are not covered under the Medicaid state plan for other beneficiaries.

The Medicare Catastrophic Coverage Act, enacted in 1988, contained provisions which permit state Medicaid programs to provide reimbursement for health-related services provided as part of a child’s Individualized Education Plan (IEP). This reversed a previous policy that Medicaid could not reimburse for services provided by schools. As a result of this act, the State of Montana allows schools and cooperatives to bill for Medicaid services provided to Medicaid members pursuant to an IEP.

Medicaid reimburses health-related services provided by schools that are written into an IEP, if the services are covered under the Medicaid state plan or are covered under EPSDT. Services billed to Medicaid must be provided by qualified practitioners with credentials meeting state and federal Medicaid program requirements. Medicaid provides reimbursement for health-related services and does not reimburse for services that are educational or instructional in nature.

Medicaid can be an important source of funding for schools, particularly because the cost of providing special education can greatly exceed the federal assistance provided under the Individuals with Disabilities Education Act (IDEA). Children who qualify for IDEA are frequently eligible for Medicaid services. Although Medicaid is traditionally the “payer of last resort” for health care services, it is required to reimburse for IDEA related medically necessary services for eligible children before IDEA funds are used.

In Montana, the Department of Public Health & Human Services, Medicaid Services Bureau, administers the Medicaid School-Based Services Program. This guide contains specific technical information about program requirements associated with seeking payment for covered services rendered in a school setting. The purpose of this guide is to inform schools on the appropriate methods for claiming reimbursement for the costs of health-related services provided.

 

End of Introduction Chapter

Covered Services

Covered Services

General Coverage Principles

Medicaid covers health-related services provided to children in a school setting when all of the following are met:

  • The child qualifies for Individuals with Disabilities Education Act (IDEA).
  • The services are written into an Individual Education Plan (IEP).
  • The services are not free. Providers may not bill Medicaid for any services that are generally offered to all members without charge.
  • For CSCT services, children must have a serious emotional disturbance (SED) diagnosis as specified under ARM 37.87.303.

Refer to the IEP requirements in this chapter and the Coordination of Benefits chapter regarding billing services included/not included in a child’s IEP.

This chapter provides covered services information that applies specifically to school-based services. School-based services providers must meet the Medicaid
provider qualifications established by the state and have a provider agreement with the state. These providers must also meet the requirements specified in this manual and the General Information for Providers manual. School-based services provided to Medicaid members include the following:

  • Therapy services (physical therapy, occupational therapy, speech language pathology)
  • Audiology
  • Private duty nursing
  • School psychology and mental health services (including clinical social work and clinical professional counseling)
  • Comprehensive School and Community Treatment (CSCT)
  • Personal care (provided by paraprofessionals)
  • Other diagnostic, preventative and rehabilitative services
  • Specialized transportation
  • Orientation and Mobility Specialist services (for blind and low vision)

Services for Children (ARM 37.86.2201–2221)
The Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) Program is a comprehensive approach to health care for Medicaid members ages 20 and under. It is designed to prevent, identify, and then treat health problems before they become disabling. Under EPSDT, Medicaid eligible children may receive any medically necessary covered service, including all school-based services described in this manual. All applicable prior authorization requirements apply. (See the Prior Authorization chapter in this manual.)

Services within Scope of Practice (ARM 37.85.401)
Services provided under the School-Based Services Program are covered only when they are within the scope of the provider’s license.

Provider Requirements
Most school-based services must be provided by licensed health care providers. The exception is that activities of daily living services may be provided by personal care paraprofessionals. Medicaid does not cover services provided by a teacher or teacher’s aide; however, teachers or teacher aides may be used to assist in the development of child care planning. School-based services must be provided by only those providers listed in the table below.

Provider Requirements

Provider Type:
Private duty nursing services provided by:

  • Licensed registered nurse
  • Licensed practical nurse

Provider Requirements:
Nurses must have a valid certificate of registration issued by the Board of Nurse Examiners of the State of Montana or the Montana Board of Nursing Education and Nurse Registration.

 

Provider Type:
Mental health services provided by:

  • Credentialed school psychologist
  • Licensed psychologist
  • Licensed clinical professional counselor
  • Licensed clinical social worker

Provider Requirements:
Mental health providers must be licensed according to Montana’s state requirements. School psychologist services are provided by a professional with a Class 6 specialist license with a school psychologist endorsement.

 

Provider Type:
Therapy services provided by:

  • Licensed occupational therapist
  • Licensed physical therapist
  • Licensed speech language pathologists


Provider Requirements:
These therapists are required to meet appropriate credentialing requirements as defined by the Montana Licensing Board.

 

Provider Type:
Audiology

Provider Requirements:
Must meet credentialing requirements as defined by the Montana Licensing Board.

 

Provider Type:
Personal care paraprofessional

Provider Requirements:
No licensing requirements.

 

Provider Type:
Comprehensive School and Community Treatment (CSCT)

Provider Requirements:
Must be provided by a licensed mental health center with a CSCT endorsement.

 

Provider Type:
Orientation and Mobility Specialist

Provider Requirements:
Must have certification of the Academy for Certification of Vision Rehabilitation & Education Professionals (ACVREP) or a National Blindness Professional Certification (NOMC) from the National Blindness Professional Certification Board (NBPCB).

 

It is the responsibility of the school district to assure appropriately licensed providers perform all Medicaid covered services. Each school district must maintain documentation of each rendering practitioner’s license, certification, registration or credential to practice in Montana. Medicaid providers who have had their license suspended by a state or federal government entity may not provide school-based services. 

Services provided to Medicaid members must be documented in the member’s IEP.

IEP Requirements
Services provided to Medicaid members must be covered by Medicaid and documented in the member’s Individualized Education Plan (IEP), unless otherwise specified. School-based providers may bill Medicaid for Medicaid-covered health-related services provided to children with those services written into the IEP, even though the services may be provided to non-Medicaid children for free. However, if a child is covered by both Medicaid and private insurance, the private insurance must be billed prior to Medicaid. Exception to billing other insurance: Blue Cross and Blue Shield of Montana and HMK. Medicaid does not cover health-related services that are not included in an IEP unless all of the following requirements are met:

  • Youth is enrolled in Medicaid.
  • Services are medically necessary.
  • A fee schedule is established for health-related services (can be a sliding scale to adjust for individuals with low incomes).
  • The provider determines if each individual who receives services has insurance coverage or will be billed on a private-pay basis.
  • The provider bills all individuals and/or the insurance carrier for the medical service provided.

Member Qualifications
To qualify for Medicaid school-based services, the member must be a Medicaid member and meet all the following criteria:

  • Be Medicaid-eligible on the date of service.
  • Be between the ages 3 and 20.
  • Be entitled to school district services under the Individuals with Disabilities Education Act (IDEA).
  • Have Medicaid reimbursable services referenced in his or her Individual Educational Plan (IEP). This shows that Medicaid covered services are recommended by the school district.
  • In the case of CSCT services, the member must have an SED diagnosis and services may or may not be included in the client’s IEP.

Cooperatives, joint boards, and non-public schools that do not receive state general funds for special education can not participate in the Medicaid program as a school-based provider.

School Qualifications
Only public school districts, full-service education cooperatives and joint boards of trustees may enroll in the Montana Medicaid School-Based Services Program. To qualify, the district, cooperative or joint board must receive special education funding from the state’s Office of Public Instruction general fund for public education. School districts include elementary, high school and K–12 districts that provide public educational services. Full-service education cooperatives and joint boards include those cooperatives eligible to receive direct state aid payments from the Superintendent of Public Instruction for special education services.

Schools That Employ Medical Service Providers:

  • Schools that employ all or most of their medical service providers for whom the school submits bills can be enrolled with a single NPI for all services.
  • Schools may use this single NPI to bill for any Medicaid covered service provided by a licensed provider.
  • Schools that wish to have separate NPIs for each provider type (e.g., speech therapists, occupational therapists, and physical therapists) can request separate NPIs from the National Plan and Provider Enumeration System (NPPES).

Schools That Contract with External Medical Service Providers:

  • Schools that contract with all or most of their providers must have the provider of service bill for each service they provide with their own individual NPI.
  • Providers and schools can arrange with the Department for payments to be made to the school. If payments are assigned to the school, the school will also have the responsibility to collect third party liability payments on behalf of the service providers.

For more information on enrollment, visit the Provider Information website or contact Provider Enrollment. (See Key Contacts.)

Physician Order/Referral
Medicaid does not require physician orders or referrals for health-related services that are documented in the member’s IEP. The exception is private duty nursing services and personal care assistant services, which require a written order for private-duty nursing or physician signature for personal care assistance services. Other health-related services can be authorized by a licensed school practitioner meeting the State of Montana provider requirements to secure health-related services under an IEP.

Documentation Requirements
School-based service providers must maintain appropriate records. All case records must be current and available upon request. Records can be stored in any readily accessible format and location, and must be kept for six years and three months from the date of service. For more information on record keeping requirements, see the Surveillance/Utilization Review chapter in the General Information for Providers manual.

Medical documentation must include the following:

  • Keep legible records.
  • Date of service and the child’s name.
  • The services provided during the course of each treatment and how the child responded.
  • Except for CSCT, the services for which the school is billing Medicaid must be written into the child’s IEP.
  • If the service is based on time units, (i.e., 15 minutes per unit), the provider of service should indicate begin and end times or the amount of time spent for each service. A service must take at least 8 minutes to bill one unit of service if the procedure has “per 15 minutes” in its description.
  • Providers must sign and date each record documented on the day the medical service was rendered. Provider initials on daily records are acceptable providing their signature is included in other medical documentation within the child’s record.
  • Documentation must, at least quarterly, include notes on member progress toward their goals. This is for the support of medical necessity and reviewing of the progress to maintain the rehabilitative nature of the service.
  • The service provider must keep sufficient documentation to support the procedures billed to Medicaid. If a service is not documented, it did not happen.
  • Documentation must not be created retroactively. Providers are responsible for maintaining records at the time of service.
  • CSCT services are not required to be included in the IEP because often members that require these services do not fit the special education requirements. The clinical assessment must document the medical necessity and the clinical treatment plan must demonstrate how the CSCT services will address the medical necessity. In addition to the above requirements, CSCT documentation must also include:
    • Where services were provided;
    • Result of service and how it relates to the treatment plan and goals;
    • Progress notes for each individual therapy and other direct service;
    • Monthly overall progress notes; and
    • Individual outcomes compared to baseline measures and established benchmarks.

The Montana Medicaid School-Based Services Program is subject to both state and federal audits. As the Medicaid provider, the school certifies that the services being claimed for Medicaid reimbursement are medically necessary and furnished under the provider’s direction. Both fiscal and clinical compliance are monitored. In the event of adverse findings, the district/cooperative (not the mental health provider) will be held responsible for any paybacks to Medicaid. If school districts have included a program area for CSCT in their accounting system, then the district can book revenue received from third party insurers or parents that paid privately for CSCT services, providing audit documentation. To assist in document retention for audit purposes, see the Audit Preparation Checklist on the Montana Medicaid Provider Information website.

Noncovered Services (ARM 37.85.207)
The following is a list of services not covered by Medicaid.

  • A provider’s time while attending member care meetings, Individual Educational Plan (IEP) meetings, individual treatment plan meetings, or member-related meetings with other medical professionals or family members.
  • A provider’s time while completing IEP related paperwork or reports, writing the CSCT individualized treatment plans or documenting medical services provided
  • CSCT services provided without an individualized treatment plan for this service.
  • Services considered experimental or investigational.
  • Services that are educational or instructional in nature.
  • Services that are not medically necessary. The Department may review for medical necessity at any time before or after payment.

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

Importance of Fee Schedules
The easiest way to verify coverage for a specific service is to check the Department’s school-based services fee schedule. In addition to being listed on the fee schedule, all services provided must also meet the coverage criteria listed in the Provider Requirements chapter of the General Information for Providers manual and in this chapter. Use the fee schedule in conjunction with the more detailed coding descriptions listed in the CPT and HCPCS coding books. Take care to use the fee schedule and coding books that pertain to the date of service. Fee schedules are available on the Provider Information website. (See Key Websites.)

Coverage of Specific Services

The following are coverage rules for specific school-based services.

Assessment to Initiate an IEP
Medicaid covers medical evaluations (assessments) to develop an IEP as long as an IEP is subsequently established and health-related needs are identified.

Comprehensive School and Community Treatment (CSCT)
As of July 2012, the CSCT program moved from the Health Resources Division to the Children’s Mental Health Bureau (CMHB). Guidance related to the CSCT program can now be found in the Youth Mental Health Services manual, which can be found on the Provider Information.

Therapy Services
Therapy includes speech, occupational and physical therapy services. Services may be performed by a therapy assistant or therapy aide but must be billed to Medicaid under the school’s supervising licensed therapist’s NPI. (See the Billing Procedures chapter in this manual.)

  • Telehealth services are allowed for Speech Therapists.  no additional reimbursement other than the therapy itself for this type of service will be given.
  • Speech therapy aides require personal, direct supervision by the licensed provider in accordance with the following guidelines:
  • Speech therapy aides:
    • Aide 1 = supervised on-site a minimum of 10% of member contact time. At the discretion of the supervising speech-language pathologist, the on-site supervision requirement may be reduced to 2% after the first year of supervision.
    • Aide 2 = shall be supervised on-site 10% of member contact time.
    • Aide 3 = shall be supervised on-site 20% of member contact time. Refer to ARM 24.222.702.

The levels of supervision for occupational and physical therapy aides and assistants are as follows:

  • Direct: The licensed provider must be present in the office and immediately available to furnish assistance and direction throughout the performance of the procedure. The licensed provider must be in the direct treatment area of the member-related procedure being performed.
  • Routine: The licensed provider must provide direct contact at least daily at the site of work, with interim supervision occurring by other methods, such as telephonic, electronic or written communication.
  • General: Procedure is furnished under the licensed provider's direction and control, but the licensed provider's presence is not required during the performance of the procedure.
  • Temporary Practice Permit holders (new graduates from occupational therapy school who are waiting for their national exam results) must work under routine supervision of the licensed therapist. If the exam is failed, the Temporary Practice Permit immediately becomes void. Routine supervision requires direct contact at least daily at the site of work.
  • Occupational Therapy Assistants require general supervision, meaning the licensed provider does not have to be physically on the premises at the time of the service. However, the licensed therapist must provide face-to-face supervision at least monthly.
  • Occupational Therapy Aides require direct supervision by a licensed occupational therapist or a certified occupational therapy assistant. This means the licensed provider must be present in the office and immediately available to the aide.
  • Physical Therapy Assistants are licensed professionals and do not require any form of supervision.
  • Physical Therapy Aides require direct supervision, meaning that the licensed provider must be on the premises.
  • Physical Therapy services are allowed as Telehealth.  No additional reimbursement is available other than the therapy service itself.
  • Temporarily licensed therapists can never supervise anyone.

Services Included
Covered therapy services include the following:

  • Restorative therapy services when the particular services are reasonable and necessary to the treatment of the member’s condition and subsequent improvement of function. The amount and frequency of services provided must be indicated on the member’s IEP.
  • Assessment services to determine member medical needs and/or to establish an IEP, as long as the assessment results in health-related services documented in the IEP.

Service Requirements
For all therapies being billed, they must be included in the student’s IEP.

Services Restricted

  • Montana Medicaid does not cover therapy services that are intended to maintain a member’s current condition but only covers services to improve member functions.

Private Duty Nursing Services
Private duty nursing services are skilled nursing services provided by a registered or licensed practical nurse.

Service Requirements
Medicaid covers private duty nursing services when all of the following requirements are met:

  • When the member’s attending physician or mid-level practitioner orders these services in writing
  • When prior authorization (PA) is obtained. (See the Prior Authorization chapter in this manual for PA requirements.)

School Psychologists and Mental Health Services
Psychological services in schools are based on determining eligibility for inclusion in special education programming and not necessarily to determine a medical diagnosis outside of the guidelines of the Individuals with Disabilities Education Act.

Services Included
Psychological and mental health services include the following:

  • Individual psychological therapy.
  • Psychological tests and other assessment procedures when the assessment results in health-related services being written into the IEP.
  • Interpreting assessment results.
  • Obtaining, integrating and interpreting information about child behavior and conditions as it affects learning, if it results in an IEP. This only includes direct face-to-face service.
  • Mental health and counseling services that are documented on the member’s IEP.
  • Consultation with the child’s parent as part of the child’s treatment.

Service Requirements
Medicaid covers psychological counseling services when the following two criteria are met:

  • The member’s IEP includes a behavior management plan that documents the need for the services.
  • Service is not provided concurrently with CSCT services (unless prior authorization has been obtained).

Services Restricted
Montana Medicaid does not cover the following psychological services:

  • Testing for educational purposes
  • Psychological evaluation, if provided to a child when an IEP is not subsequently established
  • Review of educational records
  • Classroom observation
  • Scoring tests

Personal Care Paraprofessional Services
Personal care paraprofessional services are medically necessary in-school services provided to members whose health conditions cause them to be limited in performing activities of daily living. That is, these services are provided for members with functional limitations.

The school district must maintain documentation of each service provided, which may take the form of a trip log.

Services Included
These activities of daily living services include:

  • Dressing
  • Eating
  • Escorting on bus
  • Exercising (ROM)
  • Grooming
  • Toileting
  • Transferring
  • Walking

Service Requirements

  • These services must be listed on the member’s IEP.
  • Approval must be given by the member’s primary care provider prior to billing for Medicaid covered services. Billing for these services cannot be claimed until the primary care provider signs and dates the Child Profile form.  Claiming can start on the date of the signature.  This is done by use of the Child Profile Form located in Appendix B.

Services Restricted
Medicaid does not cover the following services provided by a personal care paraprofessional:

  • Skilled care services that require professional medical personnel
  • Instruction, tutoring or guidance in academics
  • Behavioral management

See the Personal Care Paraprofessional Services Documentation, which includes the child profile and service delivery record. The child profile provides detailed examples of activities of daily living.

Medicaid does not cover special transportation services on a day that the member does not receive a Medicaid covered service that is written into the IEP.

Special Needs Transportation
Special needs transportation includes transportation services for members with special needs for the purpose of obtaining non-emergency medical services that are outside of traditional transportation services provided for members without disabilities.

Services Include
Special needs transportation services are covered when all of the following criteria are met:

  • Transportation is provided to and/or from a Medicaid-covered service on the day the service was provided.
  • The Medicaid-covered service is included in the member’s IEP.
  • The member must be in need of a specialized wheelchair or subject to transport by stretcher.

Specialized transportation services are covered if one of the following conditions exists :

  • A member requires transportation in a vehicle adapted to service the needs of students with disabilities, including a specially adapted school bus.
  • A member resides in an area that does not have school bus transportation (such as those in close proximity to a school).
  • The school incurs the expense of the service regardless of the type of transportation rendered.

Services Included
Special needs transportation includes the following:

  • Transportation from the member’s place of residence to school (where the member receives health-related services covered by the Montana School-Based Services Program, provided by school), and/or return to the residence.
  • Transportation from the school to a medical provider’s office who has a contract with the school to provide health-related services covered by the Montana School-Based Services Program, and return to school.

Services Restricted
Members with special education needs who ride the regular school bus to school with other non-disabled children in most cases will not have a medical need for transportation services and will not have transportation listed in their IEP. In this case, the bus ride should not be billed to the Montana School-Based Services Program. The fact that members may receive a medical service on a given day does not necessarily mean that special transportation also would be reimbursed for that day.

Audiology
Audiology assessments are performed by individuals possessing the state of Montana credentials for performing audiology services.

Services Included
Covered audiology services include the following:

  • Assessment to determine member’s medical needs and/or to establish an IEP, as long as the assessment results in health-related services documented in the IEP.
  • Services provided must be documented in the member’s IEP.

Service Requirements
Medicaid covers audiology services when the services to be provided during a school year are written into the child’s IEP.

Services Restricted
Medicaid does not cover the following audiology services:

  • Testing for educational purposes.
  • Services provided during Child Find assessments.

Orientation and Mobility Specialist Services
Orientation and Mobility Specialist services are medically necessary in-school services provided to students to alleviate movement deficiencies resulting from a lack of vision.

Orientation and Mobility Specialists need to have a certification by the Academy for Certification of Vision Rehabilitation and Education Professionals (ACVREP) or a National Orientation & Mobility Certification (NOMC) offered by the National Blindness Professional Certification Board (NBPCB). The credential is valid for a period of 5 years and is renewable by documenting work and/or participation in professional activities.

Services Included
Orientation & Mobility Specialist service include the following:

  • Sensory integrative techniques to enhance sensory processing and promote adaptive responses to environmental demands, direct one-on-one patient contact by provider. This includes assessment type services.
  • Self-care/home management training (e.g., ADLs and compensatory training, instruction in use of assistive technology devices/adaptive equipment) direct one-on-one contact by provider.
  • See School-Based fee schedule online for the correct CPT codes to use when billing.

Authorization Requirements Summary
The following table is a summary of authorization requirements for school-based services that were described in each section above. For more information on how to obtain prior authorization and Passport provider approval, see the Prior Authorization and Passport to Health chapters in this manual.

Authorization Requirements

Service:  Therapy
Prior Authorization:  No
Passport Provider Approval:  No
Written Physician Order/Referral:  No

Service:  Private Duty Nursing
Prior Authorization:  Yes
Passport Provider Approval:  No
Written Physician Order/Referral:  Yes
 

Service:  School Psychologist and Mental Health
Prior Authorization:  No
Passport Provider Approval:  No
Written Physician Order/Referral:  No

Service:  Personal Care Paraprofessional
Prior Authorization:  No
Passport Provider Approval:  No
Written Physician Order/Referral:  Yes (Child Profile Form is signed by child’s physician.)

Service:  Specialized Transportation
Prior Authorization:  No
Passport Provider Approval:  No
Written Physician Order/Referral:  No

Service:  Audiology
Prior Authorization:  No
Passport Provider Approval:  No
Written Physician Order/Referral:  No

Service:  Orientation & Mobility
Prior Authorization:  No
Passport Provider Approval:  No
Written Physician Order/Referral:  No

Other Programs

This is how the information in this chapter applies to Department programs other than Medicaid.

Children’s Mental Health Services Plan (CMHSP)
The school-based services in this manual are not covered benefits of the Children’s Mental Health Services Plan (CMHSP) administered by the Children’s Mental Health Bureau. However, the mental health services in this chapter are covered benefits for Medicaid members. For more information on the CMHSP program, see the mental health annual available on the Provider Information website (see Key Contacts).

Healthy Montana Kids (HMK)
The school-based services in this manual are not covered benefits of Healthy Montana Kids (HMK). Additional information regarding HMK benefits is available by contacting Blue Cross and Blue Shield of Montana (BCBSMT) at 1-800-447-7828 (toll-free) or 406-447-7828 (Helena).

 

End of Covered Services Chapter

Passport to Health Program

Passport to Health Program

 

What Is Passport to Health? (ARM 37.86.5101–5120, ARM 37.86.5303, and ARM 37.86.5201–5206)

Passport to Health is the managed care program for Montana Medicaid and
Healthy Montana Kids (HMK) Plus members. The four Passport programs encourage
and support Medicaid and HM Plus members and providers in establishing a
medical home and in ensuring the appropriate use of Medicaid and HMK Plus services:

  • Passport to Health Primary Care Case Management
  • Team Care
  • Nurse First Advice Line
  • Health Improvement Program

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

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

Passport to Health Primary Care Case Management (ARM 37.86.5101–5120)
The Passport provider provides primary care case management (PCCM) services to their members. This means he/she provides or coordinates the member’s care and makes referrals to other Montana Medicaid and HMK Plus providers when necessary. Under Passport, Medicaid, and HMK Plus members choose one primary care provider (PCP) and develop an ongoing relationship that provides a medical home. The medical home is a concept that encourages a strong doctor–member relationship. An effective medical home is accessible, continuous, comprehensive, coordinated, and operates within the context of family and community.

With some exceptions, all services to Passport members must be provided or approved by the member’s Passport provider or Medicaid/HMK Plus will not reimburse for those services. The member’s Passport provider is also referred to as the PCP. (See the section titled Services That Do Not Require Passport Provider Approval in this chapter.)

Different codes are issued for Passport approval and prior authorization, and both must be recorded on the claim form, if appropriate.

Team Care (ARM 37.86.5303)
Team Care is designed to educate members to effectively access medical care. Members with a history of using services at an amount or frequency that is not medically necessary are enrolled in Team Care. Members enrolled in Team Care are also enrolled in Passport. Team Care follows the same Passport rules and guidelines for referrals, enrollment/disenrollment, prior authorization, and billing processes. However, while Passport members can change providers without cause, as often as once a month, Team Care members are locked in to one provider and one pharmacy. Providers are encouraged to make a referral to the Team Care Program Officer if they feel one of their members is appropriate for the program. A Passport provider receives an enhanced case management fee of $6 per member per month for Team Care members. When checking Medicaid or HMK Plus eligibility on the MATH web portal, a Team Care member’s provider and pharmacy will be listed. (See Key Websites.) Write all Medicaid and HMK Plus prescriptions to the designated pharmacy.

Nurse First Advice Line
The Nurse First Advice Line, 1-800-330-7847, is a 24/7, toll-free, confidential nurse triage line staffed by licensed registered nurses, and is available to all Montana Medicaid, HMK, and HMK Plus members. There is no charge to members or providers. Members are encouraged to use the Nurse First Advice Line as their first resource when they are sick or hurt. Registered nurses are available 24/7 to triage members over the phone and recommend appropriate care. Health coaches are also available to answer general health or medication questions. Nurses do not diagnose or provide treatment. The Nurse First Advice Line will fax a triage report to the Passport PCP when one of their members calls to be triaged.

Passport providers are encouraged to provide education to their members regarding the appropriate use of the emergency department (ED), including using the Nurse First Advice Line before going to the ED.

Health Improvement Program (ARM 37.86.5201–5206)
The Health Improvement Program (HIP) is for Medicaid and HMK Plus members with chronic illnesses or risks of developing serious health conditions. HIP is operated statewide through a regional network of 14 community and tribal health centers. Medicaid and HMK Plus members eligible for the Passport program are enrolled and assigned to a health center for case management. Current Passport members stay with their PCPs for primary care, but are eligible for case management services through HIP. Nurses and health coaches certified in professional chronic care will conduct health assessments; work with PCPs to develop care plans; educate members in self-management and prevention; provide pre- and post-hospital In practice, providers will most often encounter Medicaid and HMK Plus members
who are enrolled in Passport. Specific services may also require prior authorization
(PA) even if the member is a Passport enrollee. Specific PA requirements
can be found in the provider fee schedules. For more information on Passport to
Health, see the General Information for Providers manual.discharge planning; help with local resources; and remind members about scheduling needed screening and medical visits.

Medicaid uses predictive modeling software to identify chronically ill members. This software uses medical claims, pharmacy and demographic information to generate a risk score for each member. Although the software will provide a great deal of information for interventions, it will not identify members who have not received a diagnosis or generated claims. PCPs may also identify and recommend Passport members at high risk for chronic health conditions that would benefit from case management from HIP using the HIP referral form included at the health Improvement Program link on the Provider Information website. (See Key Websites.)

In practice, providers will most often encounter Medicaid and HMK Plus members who are enrolled in Passport. Specific services may also require prior authorization (PA) even if the member is a Passport enrollee. Specific PA requirements can be found in the provider fee schedules. For more information on Passport to Health, see the General Information for Providers manual.

Other Programs

Members who are enrolled in the Mental Health Services Plan (MHSP) or Healthy Montana Kids (HMK) are not enrolled in Passport, so the Passport requirements in this chapter do not apply.

For more HMK information, contact Blue Cross and Blue Shield of Montana at 1-800-447-7828 (toll-free) or 447-7828 (Helena) Additional HMK information is available on the HMK website. (See Key Websites.)

 

End of Passport to Health Program Chapter

Prior Authorization

Prior Authorization

 

What Is Prior Authorization (ARM 37.86.5101–5120)

Prior authorization (PA), Passport to Health, and Team Care are three examples of the Department’s efforts to ensure the appropriate use of Medicaid services. In most cases, providers need approval before services are provided to a particular member. Passport approval and PA are different, and some services may require both. A different code is issued for each type of approval and must be included on the claim. (See the Submitting a Claim chapter in this manual.)

If a service requires PA, the requirement exists for all Medicaid members. When PA is granted, the provider is issued a PA number which must be on the claim. See below for instructions on how to obtain PA for covered services.

Some services require PA before they are provided, such as private duty nursing services. When seeking PA, keep in mind the following:

  • Always refer to the current Medicaid fee schedule to verify if PA is required for specific services.
  • The PA Criteria for Specific Services table lists services that require PA, who to contact, and specific documentation requirements.
  • Have all required documentation included in the packet before submitting a request for PA. (See the PA Criteria for Specific Services table for documentation requirements.)
  • When PA is granted, providers will receive notification containing a PA number. This PA number must be included on the claim.

Getting Questions Answered

The Key Contacts chapter at the front of this manual provides important phone numbers and addresses. Help lines are available to get general Medicaid questions answered.

PA Criteria for Specific Services

Service:  Private duty nursing

PA Contact:

Medicaid Utilization Review Dept.
Mountain Pacific Quality Health
P.O. Box 6488
Helena, MT 59604-6488

Questions regarding this process can be answered by calling:

Helena
(406) 443-4020 X150

Outside Helena
(800) 262-1545 X50

Fax
(406) 443-4585

Requirements:

The number of units approved for private duty nursing services is based on the time required to perform a skilled nursing task.

  • A prior authorization request must be sent to the Medicaid Utilization Review Department’s peer review organization accompanied by a physician or mid-level practitioner order/referral for private duty nursing.
  • Prior authorization must be requested at the time of initial submission of the nursing plan of care and any time the plan of care is amended.
  • Providers of private duty nursing services are responsible for requesting prior authorization and obtaining renewal of prior authorization.
  • Requests for prior authorization must be obtained for the regular school year (August/September through May/June). Services provided during the summer months must be prior authorized in addition to the services provided during the regular school year. Remember, schools are responsible for obtaining the physician orders for new or amended requests for prior authorization. Prior authorization requests must be submitted to Mountain Pacific Quality Health in advance of providing the service.
  • Providers are required to send in prior authorization requests two weeks prior to the current prior authorization request end date for members receiving ongoing services.
  • Total number for units of service paid on claims must not exceed those authorized by the Medicaid Utilization Review Department. Payment will not be made for units of service in excess of those approved.
  • No retrospective prior authorization reviews will be allowed.
  • To request prior approval submit a completed Request for Private Duty Nursing Services form located on the Provider Information website under Forms. Send completed requests to the contact shown in the second column.

 

Other Programs

The Children’s Mental Health Services Plan (CMHSP) and Healthy Montana Kids (HMK) do not cover school-based services. For more information on these programs, visit the Provider Information website. (See Key Websites.)

 

End of Prior Authorization Chapter

Coordination of Benefits

Coordination of Benefits

 

When Members Have 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 must bill other carriers before billing Medicaid, but there are some exceptions. (See Exceptions to Billing Third Party First later in this chapter.) Medicare coverage is processed differently than other sources of coverage.

Identifying Other Sources of Coverage

The member’s Medicaid eligibility verification may identify other payers such as
Medicare or other third party payers. (See Member Eligibility and Responsibilities
in the General Information for Providers manual.) If a member has Medicare, the
Medicare ID number is provided. If a member has other coverage (excluding
Medicare), it will be shown under the TPL section. 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 Medicaid eligibility verification.

Providers must 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 claims involving other payers. The other sources of coverage are referred to as third party liability (TPL), but Medicare is not.

Medicare Part B Crossover Claims
Medicare Part B covers outpatient hospital care, physician care, and other services including those provided in a school setting. The Department has an agreement with Medicare Part B carrier for Montana (Noridian) and the Durable Medical Equipment Regional Carrier [DMERC]). Under this agreement, the carrier provide the Department with a magnetic tape of 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 NPI on file with Medicaid.

To avoid confusion and paperwork, submit Medicare Part B crossover claims to Medicaid only when necessary.

In these situations, providers need not submit Medicare Part B crossover claims to Medicaid. 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 Billing Procedures.)

When Medicare Pays or Denies a Service

  • When Medicare automatic crossover claims are paid or denied, they should automatically cross over to Medicaid for processing, so the provider does not need to submit the claim to Medicaid.
  • When Medicare crossover claims are billed on paper and are paid or denied, the provider must submit the claim to Medicaid with the Medicare EOMB (and the explanation of denial codes).

When submitting electronic claims with paper attachments, see the Billing Electronically with Paper Attachments section of the Billing Procedures chapter in this manual.

When Medicaid Does Not Respond to Crossover Claims
When Medicaid does not respond within 45 days of the provider receiving the Medicare EOMB, submit a claim with a copy of the Medicare EOMB to Medicaid for processing.

Submitting Medicare Claims to Medicaid

When submitting a paper claim to Medicaid, use Medicaid billing instructions and codes. Medicare’s instructions, codes, and modifiers may not be the same as Medicaid’s. The claim must include the provider’s NPI and Medicaid member ID number. The Medicare EOMB and explanation of denial codes are required only if the claim was denied.

Remember to submit Medicare crossover claims to Medicaid only when:

 

  • The referral to Medicaid statement is missing from the provider’s EOMB.
  • The provider does not hear from Medicaid within 45 days of receiving the Medicare EOMB.
  • Medicare denies the claim.

 

All Part B crossover claims submitted to Medicaid before Medicare’s 45-day response time will be returned to the provider.

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.

If a parent determines that billing their insurance would cause a financial hardship (e.g., decrease lifetime coverage or increase premiums), and refuses to let the school bill the insurance plan, the school cannot bill Medicaid for these services based on requirements of IDEA.

Providers are required to notify their members that any funds the member receives from third party payers equal to what Medicaid paid (when the services were billed to Medicaid) must be turned over to the Department. Amounts in excess of what Medicaid paid must be returned to the provider. The following words printed on the member’s statement will fulfill this requirement: “When services are covered by Medicaid and another source, any payment the member receives from the other source must be turned over to Medicaid.”

If a parent refuses to let the school bill their insurance plan, Medicaid cannot be billed either.

CSCT Services
Procedure H0036 and H2027 are Medicaid-only code and other insurances do not recognize them as a valid procedure codes. Providers of CSCT services must bill the appropriate CPT codes to other payers, as those payers require (i.e., licensed staff may provide an individual therapy to a child in CSCT, bill CPT code that best describes service provided). When billing Medicaid after TPL, submit total charges/units for that date under the H0036 code and enter the amount paid by the other insurance on the claim. Do not bill CSCT services under any other code than H0036 to Medicaid.

Billing for Medicaid Covered Services When No IEP Exists
In order to bill for Medicaid covered services that are not in the member’s IEP, the school must meet all the following requirements:

  • A fee schedule is established for health-related services (can be a sliding scale to adjust for individuals with low incomes)
  • The provider determines if each individual who receives services has insurance coverage or will be billed on a private-pay basis
  • The provider bills all individuals and/or the insurance carrier for the medical service provided

If the school bills private pay members, then they must bill as follows for the services provided:

Member Insurance Status: Medicaid only*
Billing Process: Bill Medicaid

Member Insurance Status: Private pay, no Medicaid
Billing Process: Bill family

Member Insurance Status: Private insurance/Medicaid*
Billing Process: Bill private insurance before Medicaid

Member Insurance Status: Private insurance, no Medicaid*
Billing Process: Bill private insurance

*Note: Under FERPA, schools must have written parental permission for release of information before billing Medicaid. For billing third party insurances, schools must have written permission for billing and written permission for release of information.

 

Billing for Medicaid Covered Services under an IEP
If a child is covered by both Medicaid and private insurance, and the services are provided under an IEP, providers must bill as follows:

Member Insurance Status: Medicaid only*
Billing Process: Bill Medicaid

Member Insurance Status: Private pay, no Medicaid
Billing Process: Not required to bill family

Member Insurance Status: Private insurance/Medicaid*
Billing Process: Bill private insurance before Medicaid

Member Insurance Status: Private insurance, no Medicaid
Billing Process: Not required to bill private insurance

*Note: Under FERPA, schools must have written parental permission for release of information before billing Medicaid. For billing third party insurances, schools must have written permission for billing and written permission for release of information.

 

 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 Montana Crime Victims Compensation Fund, providers must bill Medicaid before IHS or Crime Victims. These are not considered third party liability.
  • When a member has Medicaid eligibility and Children’s Mental Health Services Plan (CMHSP) eligibility for the same month, Medicaid must be billed before CMHSP.
  • When a child is covered under BCBSMT or HMK, providers may bill Medicaid first since these insurances do not cover services provided in a school setting.
  • Medicaid must be billed before IDEA funds are used.
  • Effective April 1, 2013, when a child is also covered by another insurance, and the service is provided by a school-based provider, no blanket denial form is required nor is any  information from the third party liability.

Requesting an Exemption
Providers may request to bill Medicaid first under certain circumstances. In each of these cases, the claim and required information must be sent directly to the TPL Unit. (See Key Contacts.)

  • If another insurance has been billed, and 90 days have passed with no response, include a note with the claim explaining that the insurance company has been billed, or include 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 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 directly to Medicaid in order to avoid missing the timely filing deadline.
  • When the Child Support Enforcement Division has required an absent parent to have insurance on a child, the claim can be submitted to Medicaid when 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.

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 in the “prior payments” form locator of the claim when submitting to Medicaid for processing.
  • Allows the claim, and the allowed amount went toward member’s deductible, include the insurance EOB when billing Medicaid.
  • Denies the claim, include a copy of the denial (including the denial reason codes) with the claim and submit to Medicaid. If a blanket denial is provided, the Department will accept and allow this denial for a period of no more than two years. The school must include a copy of this blanket denial with each submission for health-related services for each member. The blanket denial must be specific to the provider, member, and health related services provided to the member. Blanket denials issued to schools without a member’s name will not be accepted.
  • Denies a line on the claim, bill the denied lines together on a separate claim and submit to Medicaid. Include the explanation of benefits (EOB) from the other payer as well as an explanation of the reason for denial (e.g., definition of denial codes).

If the provider receives a payment from a third party after the Department has paid the provider, the provider must return the lower of the two payments to the Department within 60 days.

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:

  • Include a note with the claim explaining that the insurance company has been billed, or include 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. (See Key Contacts.)

 

End of Coordination of Benefits Chapter

Billing Procedures

Billing Procedures

 

Claim Forms

Services provided by the health care professionals covered in this manual must be billed either electronically on a Professional claim or on a CMS-1500 paper claim form. CMS-1500 forms 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

For claims involving Medicare or TPL, if the 12-month time limit has passed, providers must submit clean claims to Medicaid.

  • Medicare Crossover Claims: Six months from the date on the Medicare explanation of benefits approving the service (if the Medicare claim was timely filed and the member was 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. (See Key Contacts.)
  • If another insurer has been billed and 90 days have passed with no response, you can bill Medicaid. (See the Coordination of Benefits chapter in this manual for more information.)
  • To meet timely filing requirements for Medicare/Medicaid crossover claims, see the Coordination of Benefits chapter in this manual.

When Providers Cannot Bill Medicaid Members (ARM 37.85.406)

In most circumstances, providers may not bill Medicaid members for services covered under Medicaid.

More specifically, providers cannot bill members directly:

  • For the difference between charges and the amount Medicaid paid.
  • For a covered service provided to a Medicaid-enrolled member who was accepted as a Medicaid member by the provider, even if the claim was denied.
  • When the provider bills Medicaid for a covered service, and Medicaid denies the claim because of billing errors.
  • When a third-party payer does not respond.
  • When a member fails to arrive for a scheduled appointment.
  • When services are free to the member and free to non-Medicaid covered individuals.

If a provider bills Medicaid and the claim is denied because the member is not eligible, the provider may bill the member directly.

Member Cost Sharing (ARM 37.85.204 and 37.85.402)

There is no member cost sharing for school-based services.

Billing for Members with Other Insurance

If a Medicaid member is also covered by Medicare, has other insurance, or some other third party is responsible for the cost of the member’s health care, see the Coordination of Benefits chapter in this manual.

Billing for Retroactively Eligible Members

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 private-pay.

When the provider accepts the member’s retroactive eligibility, the provider has 12 months from the date retroactive eligibility was determined to bill for those services. When submitting claims for retroactively eligible members, attach a copy of the FA-455 (eligibility determination letter) to the claim if the date of service is more than 12 months earlier than the date the claim is submitted. Providers may need to contact the member’s local office of public assistance. (See the General Information for Providers manual.)

When a provider chooses to accept the member from the date retroactive eligibility was effective, and the member has made a full or partial payment for services, the provider must refund the member’s payment for the services before billing Medicaid for the services.

Service Fees

The Office of Management and Budget (OMB A-87) federal regulation specifies one government entity may not bill another government entity more than their cost. Schools should bill Medicaid their cost of providing a service, not the fee published by Medicaid for the service. The Medicaid fee schedule is to inform provider of the maximum fee Medicaid pays for each procedure.

Coding Tips

The procedure codes listed in the following table are valid procedures for schools to use for billing Medicaid.

School-Based Services Codes

Occupational Therapist


Service: Occupational therapy – individual therapeutic activities
CPT Code: 97530
Unit Measurement: 15-minute unit

Service: Occupational therapy – group therapeutic procedures
CPT Code: 97150
Unit Measurement: Per visit

Service: Occupational therapy evaluation - low 20 minutes
CPT Code: 97165
Unit Measurement: Per visit

Service: Occupational therapy evaluation - moderate - 30 minutes
CPT Code: 97166
Unit Measurement: Per visit

Service: Occupational therapy evaluation - high - 45minutes
CPT Code: 97167
Unit Measurement: Per visit

Service: Occupational therapy re-evaluation
CPT Code: 97168
Unit Measurement: Per visit

Physical Therapist


Service: Physical therapy – individual therapeutic activities
CPT Code: 97530
Unit Measurement: 15-minute unit

Service: Physical therapy – group therapeutic procedures
CPT Code: 97150
Unit Measurement: Per visit

Service: Physical therapy evaluation - low - 20 minutes
CPT Code: 97161
Unit Measurement: Per visit

Service: Physical therapy evaluation - moderate - 30 minutes
CPT Code: 97162
Unit Measurement: Per visit

Service: Physical therapy evaluation - high 45 minutes
CPT Code: 97163
Unit Measurement: Per visit

Service: Physical therapy re-evaluation
CPT Code: 97164
Unit Measurement: Per visit


Speech Therapists


Service: Evaluation of speech fluency
CPT Code: 92521
Unit Measurement: Per visit

Service: Evaluation of speech sound production
CPT Code: 92522
Unit Measurement: Per visit

Service: Evaluation of speech sound with language comprehension
CPT Code: 92523
Unit Measurement: Per visit


Private Duty Nursing


Service: Private duty nursing services provided in school
CPT Code: T1000
Unit Measurement: 15-minute unit


School Psychologist/Mental Health Services


Service: Psychological therapy – individual
CPT Code: 90832
Unit Measurement: Per 30-minute unit

Service: Psychological therapy – group
CPT Code: 90853
Unit Measurement: Per visit


CSCT Program

Service: CSCT services
CPT Code: H0036
Unit Measurement: 15-minute unit

Service: Psychoeducational Services (CSCT)
CPT Code: H2027
Unit Measurement: 15-minute unit

Personal Care Paraprofessionals


Service: Personal care services
CPT Code: T1019
Unit Measurement: 15-minute unit


Special Needs Transportation


Service: Special needs transportation
CPT Code: T2003
Unit Measurement: Per one-way trip


Audiology


Service: Audiology evaluation
CPT Code: 92557
Unit Measurement: Per visit

Service: Tympanometry
CPT Code: 92567
Unit Measurement: Per visit

Service: Evoked otoacoustic emission; limited
CPT Code: 92587
Unit Measurement: Per visit

Orientation & Mobility


Service: Sensory integrative techniques
CPT Code: 97533
Unit Measurement: 15-minute unit

Service: Self-care/home management training
CPT Code: 97535
Unit Measurement: 15-minute unit

 

Using Modifiers
School-based services providers only use modifiers for coding when the service provided to a member is not typical. The modifiers are used in addition to the CPT codes. The following modifiers may be used in schools:

  • Modifier 52 is billed with the procedure code when a service is reduced from what the customary service normally entails. For example, a service was not completed in its entirety as a result of extenuating circumstances or the well being of the individual was threatened.
  • Modifier 22 is billed with the procedure code when a service is greater than the customary service normally entails. For example, this modifier may be used when a service is more extensive than usual or there was an increased risk to the individual. Slight extension of the procedure beyond the usual time does not validate the use of this modifier.
  • Modifier 59 is billed for therapies in accordance with the Correct Coding Initiative (CCI) and to be used when codes are considered mutually exclusive or a component of one another.
  • Modifiers may also be required when providing two services in the same day that use the same code. See the section titled Multiple Services on the Same Date” for more information.

Multiple Services on the Same Date
When a provider bills Medicaid for two services that are provided on the same day that use the same CPT code and are billed under the same NPI and taxonomy, a modifier should be used to prevent the second service from being denied. The modifier GO is used for occupational therapy, and modifier GP is used for physical therapy. One of the codes needs to have modifier 59 also for the CCI edit. For example, a school bills with one NPI and taxonomy for all services. The school provided occupational therapy for a member in the morning, and physical therapy for the same member in the afternoon of October 14, 2003. The claim would be billed like this:

Image of two line items from a claim for multiple services on the same date.

Time and Units

  • A provider may bill only time spent directly with a member. Time spent traveling to provide a service and paperwork associated with the direct service cannot be included in the time spent providing a service.
  • Some CPT codes are designed to bill in units of 15 minutes (or other time increment) and others are per visit.
  • If the service provided is using a per visit code, providers should use one unit of service per visit.
  • When using codes that are based on a 15-minute time unit, providers should bill one unit of service for each 15-minute period of service provided. Units round up to the next unit after 8 minutes.

Place of Service
The only place of service code Montana Medicaid will accept is “03” (schools).

Billing for Specific Services

The following are instructions for billing for school-based services. For details on how to complete a CMS-1500 claim form, see the Submitting a Claim chapter in this manual.

School-based providers can only bill services in the amount, scope, and duration listed in the IEP. 

Assessment to Initiate an IEP
When billing for assessments (evaluations), use the CPT code for the type of service being billed. When the unit measurement is “per visit,” only one unit may be billed for the assessment/evaluation. If the evaluation is completed over the course of several days, it is considered one evaluation. Bill the date span with 1 unit of service, not multiple units of service. For example, a speech/hearing evaluation completed over a three-day period would be billed like this:

Speech/hearing evaluation sample biling

A two-hour psychological assessment (evaluation) would be billed like this (the unit measurement for this code is “per hour”):

Two Hour Psychiatric Assessment Biling Example

Therapy Services
Services may be performed by a therapy assistant or therapy aide but must be billed to Medicaid under the school’s NPI and taxonomy. Schools are responsible for assuring the proper supervision is provided for aides/assistants. (See the Covered Services chapter.) Remember to use the CCI edit modifier for all three types of therapy: speech, occupational and physical. See the Submitting a Claim chapter in this manual. Thirty minutes of individual physical therapy would be billed like this (the unit measurement for this code is “15-minute unit”):

Image of line item for therapy services.

Private Duty Nursing Services
Prior authorization is required for these services, so remember to include the prior authorization number on the claim. (See the Submitting a Claim chapter in this manual.) Private duty nursing services provided for 15 minutes would be billed like this:

Image of a single line of a claim from private duty nursing services.

Medicaid covered services provided under an IEP are exempt from the “free care rule.”

School Psychologists and Mental Health Services
A psychological therapy session of 30 minutes would be billed like this (the unit measurement for this code is per 30-minute unit):

Psychological therapy sample billing

Personal Care Paraprofessional Services
Personal care services provided to a member for 2 hours during a day would be billed like this (the unit measurement for this code is per 15-minute unit):

Image of a claim line for Personal Care services.

Special Needs Transportation
School districts must maintain documentation of each service provided, which may take the form of a trip log. Schools must bill only for services that were provided. Special transportation should be billed on a per one-way trip basis. For example, if a member was transported from his/her residence to school and received Medicaid covered health-related services that day, and then transported back to his/her residence, it would be billed like this:

Image of a claim line for Special needs transportation services.

Audiology
An audiology assessment would be billed like this (the unit measurement for this code is per visit):

Image of a claim line for audiology services.

Submitting Electronic Claims

Providers who submit claims electronically experience fewer errors and quicker payment.  Claims may be submitted using the methods below.  For detailed submission methods, see the electronic submissions manual on the Electronic Billing page of the website.

  • WINASAP 5010. This free software provided by Conduent allows for the creation of basic claim submissions.  Please note that this software is not compatible with Windows 10 and has limited support as it is free software.

o    Utilizes either a dial-up modem or submissions through the Montana Access to Health (MATH) Web Portal.

o    Requires completion of the X12N Transaction Packet to allow for claim submissions.

  • Clearinghouses/Contracted Claim Submitter.  Providers can make arrangements with a clearinghouse/contracted claim submitter for claim submission.  Please note that the clearinghouse must be enrolled to submit claims to Montana Medicaid.

o    To have an 835 file be delivered to the clearinghouse, an 835 Request form will need to be completed.

  • Montana Access to Health (MATH) Web Portal.  A secure website that allows providers to verify eligibility, check claim status, and view medical claims history.  Valid X12N files can be uploaded through this website.

o    Requires completion of the X12N Transactions Packet to allow for claim submissions.

  • MoveIt DMZ.  This secure transfer protocol is for providers and clearinghouses that submit large volumes of files (in excess of 20 per day) or are regularly submitting files larger than 2 MB.  This utilizes SFTP and an intermediate storage area for the exchange of files.

o    A request for this must be made through Conduent Provider Relations for established trading partners.

Providers should be familiar with federal rules and regulations related to electronic claims submission.

For more information on electronic claims submission options, contact Provider Relations or the EDI Technical Help Desk. (See the Key Contacts chapter.) Providers should be familiar with federal rules and regulations and Montana-specific information for sending and receiving electronic transactions. They are available on the EDI Gateway website. (See Key Websites.)

Billing Electronically with Paper Attachments

When submitting claims that require additional supporting documentation, the Attachment Control Number field must be populated with an identifier. Identifier formats can be designed by software vendors or clearinghouses, but the preferred method is the provider’s NPI followed by the member’s ID number and the date of service, each separated by a dash:

Attachment Control Number 1st box NPI, 2nd Box Member ID Number, 3rd Box Date of Service in the MMDDYYYY format

The supporting documentation must be submitted with a paperwork attachment cover sheet. See the Forms page of the Provider Information website. The number in the paper Attachment Control Number field must match the number on the cover sheet.

Submitting Paper Claims

For instructions on completing a paper claim, see the Submitting a Claim chapter in this manual. Unless otherwise stated, all paper claims must be mailed to:

Claims Processing
P.O. Box 8000
Helena, MT 59604

Claim Inquiries

Contact Provider Relations for claim questions, or questions regarding payments, denials, member eligibility.

Provider Relations will respond to the inquiry within 10 days. The response will include the status of the claim: paid (date paid), denied (date denied), or in process. Denied claims will include an explanation of the denial and steps to follow for payment (if the claim is payable).

The Most Common Billing Errors and How to Avoid Them

Paper claims are often returned to the provider before they can be processed, and many other claims (both paper and electronic) are denied.

To avoid unnecessary returns and denials, double check each claim to confirm the following items are included and accurate.

Common Billing Errors


Reasons for Return or Denial: Provider NPI missing or invalid
How to Prevent Returned or Denied Claims: The provider NPI is a 10-digit number assigned to the provider by the National Plan and Provider Enumeration System. Verify the correct provider NPI is on the claim.

Reasons for Return or Denial: Authorized signature missing
How to Prevent Returned or Denied Claims: Each claim must have an authorized signature belonging to the provider, billing clerk, or office personnel. The signature may be typed, stamped, hand-written, or computer generated.

Reasons for Return or Denial: Signature date missing
How to Prevent Returned or Denied Claims: Each claim must have a signature date.

Reasons for Return or Denial: Incorrect claim form used
How to Prevent Returned or Denied Claims: The claim must be the correct form for the provider type. Services covered in this manual require a CMS-1500 claim form (or electronic Professional claim).

Reasons for Return or Denial: Information on claim form not legible
How to Prevent Returned or Denied Claims: Information on the claim form must be legible. Use dark ink and center the information in the form locator. Information must not be obscured by lines.

Reasons for Return or Denial: Member number not on file, or member was not eligible on date of service
How to Prevent Returned or Denied Claims: Before providing services to the member, verify member eligibility by using one of the methods described in the Member Eligibility and Responsibilities chapter of the General Information for Providers manual. Medicaid eligibility may change monthly.

Reasons for Return or Denial: Prior authorization number is missing
How to Prevent Returned or Denied Claims: Prior authorization (PA) is required for certain services, and the PA number must be on the claim. See the Prior Authorization chapters in this manual.

Reasons for Return or Denial: Prior authorization does not match current information
How to Prevent Returned or Denied Claims: Claims must be billed and services performed during the prior authorization span. The claim will be denied if it is not billed according to the spans on the authorization.

Reasons for Return or Denial: Duplicate claim
How to Prevent Returned or Denied Claims: Check all remittance advices (RAs) for previously submitted claims before resubmitting. When making changes to previously paid claims, submit an adjustment form rather than a new claim (see the Remittance Advices and Adjustments chapter in this manual).

Reasons for Return or Denial: TPL on file and no credit amount on claim
How to Prevent Returned or Denied Claims: If the member has any other insurance (or Medicare), bill the other carrier before Medicaid. See the Coordination of Benefits chapter in this manual. If the member’s TPL coverage has changed, providers must notify the TPL unit (see the Key Contacts chapter) before submitting a claim.

Reasons for Return or Denial: Claim past 12-month filing limit
How to Prevent Returned or Denied Claims: The Claims Processing Unit must receive all clean claims and adjustments within the timely filing limits described in this chapter. To ensure timely processing, claims and adjustments must be mailed to Claims Processing at the address shown in the Key Contacts chapter.

Reasons for Return or Denial: Missing Medicare EOMB
How to Prevent Returned or Denied Claims: All denied Medicare crossover claims must have an Explanation of Medicare Benefits (EOMB) with denial reason codes attached, and be billed to Medicaid on paper.

Reasons for Return or Denial: Provider is not eligible during dates of services, enrollment has lapsed due to licensing requirements, or provider NPI terminated
How to Prevent Returned or Denied Claims: Out-of-state providers must update licensure for Medicaid enrollment early to avoid denials. If enrollment has lapsed due to expired licensure, claims submitted with a date of service after the expiration date will be denied until the provider updates his or her enrollment. New providers cannot bill for services provided before Medicaid enrollment begins. If a provider is terminated from the Medicaid program, claims submitted with a date of service after the termination date will be denied.

Reasons for Return or Denial: Procedure is not allowed for provider type
How to Prevent Returned or Denied Claims: Provider is not allowed to perform the service. Verify the procedure code is correct using current HCPCS and CPT billing manual. Check the appropriate Medicaid fee schedule to verify the procedure code is valid for your provider type.

 

Other Programs

The Mental Health Services Plan (MHSP) and Healthy Montana Kids (HMK) do not cover school-based services. For more information on these programs, visit the Provider Information website.

Additional information regarding HMK benefits is available on the HMK website or by contacting Blue Cross and Blue Shield of Montana (BCBSMT) at 1-800-447-7828 (toll-free) or 406-447-7828 (Helena).

 

End of Billing Procedures Chapter

Submitting a Claim

Submitting a Claim

 

The services described in this manual are billed either electronically on a Professional claim or on a CMS-1500 paper claim form. Claims submitted with all of the necessary information are referred to as “clean” and are usually paid in a timely manner (see the Billing Procedures chapter in this manual). When completing a claim, remember the following:

  • Required fields are indicated by *.
  • Fields that are required if the information is applicable to the situation or member are indicated by **.
  • Field 24h, EPSDT/Family Planning, is used as an indicator to specify additional details for certain members or services. The following are accepted codes:

EPSDT/Family Planning Indicator

Code: 1    Member/Service: EPSDT
Purpose: Overrides some benefit limits for client under age 21.

Code: 2    Member/Service: Family planning
Purpose: Overrides the Medicaid cost sharing and Passport authorization on the line.

Code: 3    Member/Service: EPSDT and family planning
Purpose: Overrides Medicaid cost sharing and Passport authorization for persons under the age of 21.

Code: 4    Member/Service: Pregnancy (any service provided to a pregnant woman)
Purpose: Overrides Medicaid cost sharing on the claim.

Code: 6    Member/Service: Nursing facility client
Purpose: Overrides the Medicare edit for oxygen services on the line.

 

  • Unless otherwise stated, all paper claims must be mailed to the following address:

Claims Processing Unit
P.O. Box 8000
Helena, MT 59604

Sample Claim

Member Information


Field: 2*
Field Title: Member's Name
Instructions: Enter patient's name as seen on member’s Montana Health Care Programs information

Field: 10d *
Field Title: Member’s ID
Instructions: Enter the member’s ID number as it appears on the member’s Montana Health Care Programs information.

Field: 1a, 9a, 11**
Field Title: Member’s ID
Instructions: If member’s ID is not located in 10d these three fields are searched for the number.

Field: 24h*
Field Title: EPSDT Family Planning
Instructions: When billing electronically, use “Y.” When billing on paper, use “1.”

Provider Information


Field: 24a shaded area
Field Title: NDC
Instructions: Enter the qualifier, N4, followed by the NDC (NDC should not have punctuation, dashes or spaces), units qualifier and units as described by the qualifier

Field: 24i  shaded**
Field Title: ID Qualifier
Instructions: ZZ for the Taxonomy qualifier.

Field: 24j shaded**
Field Title: Taxonomy Code
Instructions: Enter the Taxonomy code for the rendering provider.

Field: 24j **
Field Title: NPI, Rendering Prov
Instructions: Enter NPI Number for the rendering provider.

Field: 31*
Field Title: Signature and Date
Instructions: Enter Signature and Date.

Field: 33*
Field Title: Billing Provider Info
Instructions: Enter Physical Address with a 9 digit ZIP code and phone number.

Field: 33a*
Field Title: NPI #
Instructions: Enter NPI number for billing/pay-to provider.

Field: 33b*
Field Title: Taxonomy #
Instructions: Enter the qualifier (ZZ) and the billing provider's taxonomy code.

Billing Information


Field: 21.1 - 21.4*
Field Title: Diagnosis codes Enter at least one diagnosis.

Field: 24a*
Field Title: Date(s) of Service
Instructions: Enter the dates of service include beginning and ending date even if same.

Field: 24b*
Field Title: Place of Service
Instructions: Enter the code for place of service.

Field: 24c**
Field Title: EMG
Instructions: Emergency Indicator if applicable.

Field: 24d*
Field Title: Procedure Code
Instructions: Enter the procedure code used.  Enter modifiers if applicable.

Field: 24e*
Field Title: Diagnosis Pointer
Instructions: Enter the corresponding diagnosis pointer (1,2,3,or 4) that refers to the codes in field 21

Field: 24f*
Field Title: Charges
Instructions: Enter the total charge for this line

Field: 24g*
Field Title: Days/Units
Instructions: Enter the days or units used for the procedure.

Field: 28*
Field Title: Total Charges
Instructions: Enter total charges from all line items.

*Required Field   **Required if applicable

 

Image of a CMS 1500 Claim form. 

CMS-1500 Agreement

Your signature on the CMS-1500 constitutes your agreement to the terms presented on the back of the form. This form is subject to change by the Centers for Medicare and Medicaid Services (CMS).

CMS 1500 Instructions and disclosures

Avoiding Claim Errors

Claims are often denied or even returned to the provider before they can be processed. To avoid denials and returns, double-check each claim to confirm the following items are accurate. For more information on returned and denied claims, see the Billing Procedures chapter in this manual.

Common Claim Errors

 

Claim Error: Required field is blank
Prevention: Check the claim instructions earlier in this chapter for required fields (indicated by * or **). If a required field is blank, the claim may either be returned or denied.

Claim Error: Member ID number missing or invalid
Prevention: This is a required field (field 10d); verify that the member’s Medicaid ID number is listed as it appears on the member’s ID card.

Claim Error: Member name missing
Prevention: This is a required field (field 2); check that it is correct.

Claim Error: Provider NPI missing or invalid
Prevention: The provider NPI is a 10-digit number assigned to the provider by the National Plan and Provider Enumeration System. Verify the correct provider NPI is on the claim.

Claim Error: Prior authorization number missing
Prevention: When prior authorization (PA) is required for a service, the PA number must be listed on the claim in field 23. (See the Prior Authorization chapter in this manual.)

Claim Error: Not enough information regarding other coverage
Prevention: Fields 1a and 11d are required fields when a member has other coverage. (Refer to the examples earlier in this chapter.)

Claim Error: Authorized signature missing
Prevention: Each claim must have an authorized signature belonging to the provider, billing clerk, or office personnel. The signature may be typed, stamped, or hand-written.

Claim Error: Signature date missing
Prevention: Each claim must have a signature date. Incorrect claim form used Services covered in this manual require a CMS-1500 claim form (or electronic Professional claim).
 
Claim Error: Information on claim form not legible
Prevention: Information on the claim form must be legible. Use dark ink and center the information in the field. Information must not be obscured by lines.

Claim Error: Medicare EOMB not attached
Prevention: When Medicare is involved in payment on a claim, the Medicare EOMB must be attached to the claim or it will be denied.

 

Other Programs

This chapter also applies to claims forms completed for MHSP services and Healthy Montana Kids (HMK) eyeglass services.

 

End of Submitting a Claim Chapter

Remittance Advices and Adjustments

Remittance Advices and Adjustments

 

The Remittance Advice

The Remittance Advice (RA) is the best tool providers have to determine the status of a claim. RAs accompany payment for services rendered. The RA provides details of all transactions that have occurred during the previous RA cycle. Each line of the RA represents all or part of a claim, and explains whether the claim or service has been paid, denied, or suspended (also referred to as pending).

The pending claims section of the RA is informational only. Do not take any action on claims displayed here.

If the claim was suspended or denied, the RA also shows the reason.

To access the MATH web portal, you must first complete a Provider Enrollment Form and an Trading Partner Agreement (see the following table). To receive an electronic RA, the provider must complete a Trading Partner Agreement and register for the Montana Access to Health (MATH) web portal. You can access your electronic RA through the MATH web portal by going to the Provider Information website and selecting Log in to Montana Access to Health.

After these forms have been processed, you will receive a user ID and password that you can use to log on to the web portal. The verification process also requires a provider ID, a submitter ID, and a tax ID number. Each provider must complete an EDI Trading Partner Agreement, but if there are several providers in one location who are under one tax ID number, they can use one submitter number. These providers should enter the submitter ID in both the provider number and submitter ID fields. Otherwise, enter the provider number in the provider number field.

If a claim was denied, read the description of the EOB before taking any action on the claim.

RAs are available in PDF format. You can read, print, or download PDF files using Adobe Acrobat Reader, which is available on the Provider Information website. Due to space limitations, each RA is only available for 90 days.

Electronic RAs are available for only 90 days on the web portal.

The RA is divided into the following sections:

Sections of the Paper RA

 

Section: RA Notice
Description: The RA Notice is on the first page of the remittance advice. This section contains important messages about rate changes, revised billing procedures, and many other items that may affect providers and claims.

Section: Paid Claims
Description: This section shows claims paid during the previous cycle. It is the provider’s responsibility to verify that claims were paid correctly. If Medicaid overpays a claim and the problem is not corrected, it may result in an audit requiring the provider to return the overpayment plus interest. If a claim was paid at the wrong amount or with incorrect information, the claim must be adjusted. (See Adjustments later in this chapter.)

Section: Denied Claims
Description: This section shows claims denied during the previous cycle. If a claim has been denied, refer to the Reason/Remark column (Field 18). The Reason and Remark Code Description located at the end of the RA explains why the claim was denied. See the section titled The Most Common Billing Errors and How to Avoid Them in the Billing Procedures chapter.

Section: Pending Claims
Description: All claims that have not reached final disposition will appear in this area of the paper RA (pended claims are not available on X12N 835 transactions). The RA uses suspended and pending interchangeably. They both mean that the claim has not reached final disposition. If a claim is pending, refer to the Reason/Remark Code section (Field 18) located at the end of the RA will explain why the claim is suspended. This section is informational only. Do not take any action on claims displayed here. Processing will continue until each claim is paid or denied.

Claims shown as pending with Reason Code 133 require additional review before a decision to pay or deny is made. If a claim is being held while waiting for member eligibility information, it may be suspended for a maximum of 30 days. If Medicaid receives eligibility information within the 30-day period, the claim will continue processing. If no eligibility information is received within 30 days, the claim will be denied. When a claim is denied for lack of eligibility, the provider should verify that the correct Medicaid ID number was billed. If the ID number was incorrect, resubmit the claim with the correct ID number.

Section: Credit Balance Claims
Description: Credit balance claims are shown here until the credit has been satisfied.

Section: Gross Adjustments
Description: Any gross adjustments performed during the previous cycle are shown here.

Section: Reason and Remark Code Description
Description: This section lists the reason and remark codes that appear throughout the RA with a brief description of each.

 

Sample Remittance Notice

Image of a remittance notice with corresponding numbering.

Key Fields on the Remittance Advice


Field: 1. Provider name and address
Description: Provider’s business name and address as recorded with the Department.

Field: 2. Vendor #
Description: The 7-digit number assigned to the provider.

Field: 3. Remittance advice number
Description: The remittance advice number.

Field: 4. EFT/Check number
Description: The EFT or check number of payment

Field: 5. Date
Description: The date the RA was issued.

Field: 6. Page number
Description: The page number of the RA.

Field: 7. NPI
Description: A unique 10-digit identification number required by HIPAA for all U.S. health care providers. Providers must use their NPI to identify themselves in all HIPAA transactions.

Field: 8. Taxonomy
Description: Alphanumeric code that indicates the provider’s specialty.

Field: 9. Member ID
Description: The member’s Medicaid ID number.

Field: 10. Name
Description: The member’s name.

Field: 11. Internal control number (ICN)
Description: Each claim is assigned a unique 17-digit number (ICN). Use this number when you have any questions concerning your claim. The claim number represents the following information:

0 00111 11 123 000123
A B C D E
A = Claim medium

0 = Paper claim
2 = Electronic claim
3 = Encounter claim
4 = System generated claim (mass adjustment, nursing home turn-around
document, or point-of-sale (POS) pharmacy claim)
6 = Pharmacy

B = Julian date (e.g. April 20, 2000 was the 111th day of 2000)
C = Microfilm number

00 = Electronic claim
11 = Paper claim

D = Batch number
E = Claim number

If the first number is:

0 = Regular claim
1 = Negative side adjustment claim (Medicaid recovers payment)
2 = Positive side adjustment claim (Medicaid reprocesses)
 

Field: 12. Service dates
Description: Dates services were provided. If services were performed in a single day, the same date will appear in both columns.

Field: 13. Unit of service
Description: The units of service rendered under this procedure or NDC code.

Field: 14. Procedure/Revenue/NDC
Description: The procedure code (CPT or HCPCS), National Drug Code (NDC), or revenue code will appear in this column. If a modifier was used, it will also appear in this column.

Field: 15. Total charges
Description: The amount a provider billed for this service.

Field: 16. Allowed
Description: The Medicaid allowed amount.

Field: 17. Copayment
Description: A “Y” indicates cost sharing was deducted from the allowed amount, and an “N” indicates cost sharing was not deducted.

Field: 18. Reason and remark codes
Description: A code which explains why the specific service was denied or pended. Descriptions of these codes are listed at the end of the RA.

Field: 19. Deductions, billed amount, and paid amount
Description: Any deductions, such as cost sharing or third party liability are listed first. The amount the provider billed is next, followed by the amount of Medicaid reimbursement.

 

Credit Balances
Credit balances occur when claim adjustments reduce original payments causing the provider to owe money to the Department. These claims are considered in process and continue to appear on the RA until the credit has been satisfied.

The credit balance section is informational only. Do not post from credit balance statements.

Credit balances can be resolved in two ways:

  1. By working off the credit balance. Remaining credit balances can be deducted from future claims. These claims will continue to appear on consecutive RAs until the credit has been paid.
  2. By sending a check payable to DPHHS for the amount owed. This method is required for providers who no longer submit claims to Montana Medicaid. Attach a note stating that the check is to pay off a credit balance and include your NPI. Send the check to the attention of the Third Party Liability Unit at the address in Key Contacts.

Rebilling and Adjustments

Rebillings and adjustments are important steps in correcting any billing problems you may experience. Knowing when to use the rebilling process versus the adjustment process is important.

Medicaid does not accept any claim for resubmission or adjustment after 12 months from the date of service (see Timely Filing Limits in Billing Procedures chapter).

How Long Do I Have to Rebill or Adjust a Claim?

  • Providers may resubmit or adjust any initial claim within the timely filing limits described in the Billings Procedure chapter of this manual.
  • These time periods do not apply to overpayments that the provider must refund to the Department. After the 12-month time period, a provider may not refund overpayments to the Department by completing a claim adjustment. The provider may refund overpayments by issuing a check or asking the TPL unit to complete a gross adjustment.

Rebilling Medicaid
Rebilling is when a provider submits a claim to Medicaid that was previously submitted for payment but was either returned or denied. Claims are often returned to the provider before processing because key information such as NPI and taxonomy or authorized signature and date are missing or unreadable. For tips on preventing returned or denied claims, see the Billing Procedures and Submitting a Claim chapters.

When to Rebill Medicaid

  • Claim Denied. Providers can rebill Medicaid when a claim is denied in full, as long as the claim was denied for reasons that can be corrected. When the entire claim is denied, check the Reason and Remark Code/Description, make the appropriate corrections, and resubmit the claim (not an adjustment).

Rebill denied claims only after appropriate corrections have been made.

  • Line Denied. When an individual line is denied on a multiple-line claim, correct any errors and rebill Medicaid. Do not use an adjustment form.
  • Claim Returned. Rebill Medicaid when the claim is returned under separate cover. Occasionally, Medicaid is unable to process the claim and will return it to the provider with a letter stating that additional information is needed to process the claim. Correct the information as directed and resubmit your claim.

How to Rebill

  • Check any Reason and Remark Code listed and make your corrections on a copy of the claim, or produce a new claim with the correct information.
  • When making corrections on a copy of the claim, remember to cross out or omit all lines that have already been paid. The claim must be neat and legible for processing.
  • Enter any insurance (TPL) information on the corrected claim, or include insurance denial information, and submit to Medicaid.

Adjustments
If a provider believes that a claim has been paid incorrectly, the provider may call Provider Relations or submit a claim inquiry for review. (See the Billing Procedures chapter, Claim Inquiries.) Once an incorrect payment has been verified, the provider may submit an Individual Adjustment Request to Provider Relations. If incorrect payment was the result of a Conduent keying error, contact Provider Relations.

When adjustments are made to previously paid claims, the Department recovers the original payment and issues appropriate repayment. The result of the adjustment appears on the provider’s RA as two transactions. The original payment will appear as a credit transaction. The replacement claim reflecting the corrections will be listed as a separate transaction and may or may not appear on the same RA as the credit transaction. The replacement transaction will have nearly the same ICN number as the credit transaction, except the 12th digit will be a 2, indicating an adjustment. See Key Fields on the Remittance Advice earlier in this chapter. Adjustments are processed in the same time frame as claims.

Adjustments can only be made to paid claims.

When to request an adjustment

  • Request an adjustment when a claim was overpaid or underpaid.
  • Request an adjustment when a claim was paid but the information on the claim was incorrect (e.g., member ID, provider NPI, date of service, procedure code, diagnoses, units).

How to Request an Adjustment
To request an adjustment, use the Individual Adjustment Request form. The requirements for adjusting a claim are as follows:

  • Claims Processing must receive individual claim adjustment requests within 12 months from the date of service (see Timely Filing Limits in the Billing Procedures chapter).After this time, gross adjustments are required (see Definitions).
  • Use a separate adjustment request form for each ICN.
  • If you are correcting more than one error per ICN, use only one adjustment request form, and include each error on the form.
  • If more than one line of the claim needs to be adjusted, indicate which lines and items need to be adjusted in the Remarks section of the adjustment form.

Image of a claim adjustment form.

Completing an Adjustment Request Form

  1. Download the Individual Adjustment Request from the Provider Information website. (See Key Websites.) Complete Section A with provider and member information and the claim’s ICN number.
  2. Complete Section B with information about the claim. Fill in only the items that need to be corrected:
    1. Enter the date of service or the line number in the Date of Service or Line Number column.
    2. Enter the information from the claim that was incorrect in the Information on Statement column.
    3. Enter the correct information in the Corrected Information column.
  3. Attach copies of the RA and a corrected claim if necessary.
    1. If the original claim was billed electronically, a copy of the RA will suffice.
    2. If the RA is electronic, attach a screen print of the RA.
  4. Verify the adjustment request has been signed and dated.
  5. Send the adjustment request to Claims Processing. (See Key Contacts.)
    1. If an original payment was an underpayment by Medicaid, the adjustment will result in the provider receiving the additional payment amount allowed.
    2. If an original payment was an overpayment by Medicaid, the adjustment will result in recovery of the overpaid amount through a credit. If the result is a credit balance, it can be worked off or the provider can pay off the balance by check. (See Credit Balances earlier in this chapter.)
    3. Any questions regarding claims or adjustments must be directed to Provider Relations. (See Key Contacts.)

Completing an Individual Adjustment Request Form

Section A


Field: 1. Provider name and address
Description: Provider’s name and address (and mailing address if different).

Field: 2. Member name
Description: The member’s name is here.

Field: 3.* Internal control number (ICN)
Description: There can be only one ICN per adjustment request form. When adjusting a claim that has been previously adjusted, use the ICN of the most recent claim.

Field: 4.* Provider NPI
Description: The provider’s NPI.

Field: 5.* Member Medicaid number
Description: Member’s Medicaid ID number.

Field: 6. Date of payment
Description: Date claim was paid is found on remittance advice field 5 (see the sample RA earlier in this chapter).

Field: 7. Amount of payment
Description: The amount of payment from the remittance advice field 17 (see the sample RA earlier in this chapter.).

Section B


Field: 1. Units of service
Description: If a payment error was caused by an incorrect number of units, complete this line.

Field: 2. Procedure code/NDC/Revenue code
Description: If the procedure code, NDC, or revenue code is incorrect, complete this line.

Field: 3. Dates of service (DOS)
Description: If the date of service is incorrect, complete this line.

Field: 4. Billed amount
Description: If the billed amount is incorrect, complete this line.

Field: 5. Personal resource (nursing facility)
Description: If the member’s personal resource amount is incorrect, complete this line.

Field: 6. Insurance credit amount
Description: If the member’s insurance credit amount is incorrect, complete this line.

Field: 7. Net (Billed – TPL or Medicare paid)
Description: If the payment error was caused by a missing or incorrect insurance credit, complete this line. Net is billed amount minus the amount third party liability or Medicare paid.

Field: 8. Other/Remarks
Description: If none of the above items apply, or if you are unsure what caused the payment error, complete this line.

*Indicates a required field.

 

Mass Adjustments
Mass adjustments are done when it is necessary to reprocess multiple claims.
They generally occur when:

  • Medicaid has a change of policy or fees that is retroactive. In this case federal laws require claims affected by the changes to be mass adjusted.
  • A system error that affected claims processing is identified.

Providers are informed of mass adjustments on the first page of the RA in the RA Notice section. Mass adjustment claims shown on the RA have an ICN that begins with a 4. (See Key Fields on the Remittance Advice earlier in this chapter.)

Electronic RAs are available for only 90 days on the web portal.

Payment and the RA

Providers receive their Medicaid payment and remittance advice weekly. Payment can be via check or electronic funds transfer (EFT). Direct deposit is another name for EFT.

With EFT, the Department deposits the funds directly to the provider’s bank account. If the scheduled deposit day is a holiday, funds will be available on the next business day. This process does not affect the delivery of the remittance advice that providers currently receive with payments. RAs will continue to be mailed to providers unless they specifically request an electronic RA.

To participate in EFT, providers must complete a Direct Deposit Sign-Up Form (Standard Form 1199A). One form must be completed for each provider NPI. See the following table, Required Forms for EFT and/or Electronic RA.

Once electronic transfer testing shows payment to the provider’s account, all Medicaid payments will be made through EFT. See Direct Deposit Arrangements under Key Contacts for questions or changes regarding EFT.

Required Forms for EFT and/or Electronic RA

Form:

  • EDI Provider Enrollment Form
  • EDI Trading Partner Agreement

Purpose:

Allows providers to access their RAs on the Montana Access to Health (MATH) web portal.

Must also include:

  • EDI Provider Enrollment Form
  • EDI Trading Partner Agreement

Where to Get:

  • Provider Information website
  • Provider Relations (See Key Contacts.)

Where to Send:

Fax to number on form.

 

Form:

  • Direct Deposit Sign-Up Form (Standard Form 1199A)

Purpose:

Allows the Department to automatically deposit Medicaid payment into provider’s bank account

Where to Get:

  • Provider Information website (Forms)
  • Provider’s bank Provider Relations (See Key Contacts.)

 

 

End of Remittance Advices and Adjustments Chapter

How Payment Is Calculated

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 payment methods described do not apply to services provided under Healthy Montana Kids (HMK)/Children’s Health Insurance Program (CHIP).

Payment for School-Based Services

Federal regulations specify that one government entity may not bill another government entity more than their cost (OMB A-87). The following describes payment methods for various services that can be provided in the school setting. Payment for these services is limited to the lower of the calculated fee or the billed amount.

Speech, Occupational and Physical Therapy Services
Speech and language therapy services, occupational therapy services and physical therapy services are paid by the Resource Based Relative Value Scale (RBRVS) method of reimbursement. As noted above, only the federal portion will be paid. For more detail on the RBRVS system, see the How Payment Is Calculated chapter of the Physician-Related Services provider manual, which is available on the Provider Information website. (See Key Websites.)

Each RBRVS fee is the product of a relative value times a conversion factor. This total is always multiplied by the current Federal Matching Assistance Percentage (FMAP).

The Department publishes relative weights, the current conversion factor, and the current FMAP figure. The conversion factor is determined by the Department, and set at a level intended to achieve legislatively set budget targets.

Private Duty Nursing
The only code available for this service is T1000. Payment for this code is based on the Medicaid fee schedule, and is calculated as follows:

Fee x number of 15-minute units = payment

The current FMAP is then calculated against this total for final reimbursement

School Psychologist
Both codes available for billing school psychologist services are paid by the RBRVS method.

Each RBRVS fee is the product of a relative value times a conversion factor.  This total is always multiplied by the current FMAP for a total reimbursement.

The Department publishes relative weights, the current conversion factor, and the current FMAP figure. The conversion factor is determined by the Department, and set at a level intended to achieve legislatively set budget targets.

Personal Care Paraprofessionals
The only code available for this service is T1019. Payment for this code is based on the Medicaid fee schedule, and is calculated as follows:

Fee x number of 15 minute units = payment

The current FMAP is then calculated against this total for final reimbursement.

CSCT Program
The only code available for this service is H0036. Payment for this code is based on the Medicaid fee schedule, and is calculated as follows:

Fee x number of 15 minute units = payment

The current FMAP is then calculated against this total for final reimbursement.

All payments for CSCT services are made to the school district/cooperative. Schools may not assign payment from Medicaid directly to the mental health center provider. The purpose of this policy is to:

  • Ensure that districts are fully aware of the amount of federal Medicaid funds generated by their CSCT providers, allowing districts to determine their obligation for match.
  • Control variables are in place to account for districts revenue and expenditures.

How Payment Is Calculated on TPL Claims
When a member has coverage from both Medicaid and another insurance company, the other insurance company is 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. Medicaid will make a payment only when the TPL payment is less than the Medicaid allowed amount.

How Payment Is Calculated on Medicare Crossover Claims
When a member has coverage from both Medicare and Medicaid, Medicare is the primary payer. Medicaid will pay the coinsurance and deductible amounts for these dually eligible individuals. See the How Payment is Calculated chapter in the Physician-Related Services manual for examples on how payment is calculated on Medicare crossover claims.

 

End of How Payment is Calculated Chapter

 

Appendix A: Forms

Appendix B: Personal Care Paraprofessional Services Documentation

Appendix B: Personal Care Paraprofessional Services Documentation

 

Personal Care Paraprofessional Services Provided in Schools – Child Profile

Purpose
The Child Profile is intended to:

  • To provide an instrument for collecting and documenting essential information needed to establish the Medicaid child’s functional limitations and ability to perform activities of daily living.
  • To document information on service planning issues for personal care services.
  • To provide a worksheet for determining the daily units per week needed by the child.

Procedure
The Profile must be completed by the Individualized Education Plan (IEP) team at the initial meeting for services, at the annual review, and whenever a significant change in the child’s condition occurs causing the service need to change.

Instructions

  1. Child Name: Enter the child's full name.
  2. Child ID: Enter child's Medicaid ID number.
  3. DOB: Child’s date of birth.
  4. Date Span: The time period the child will receive personal care services, up to one year.
  5. Level of Impairment: Rate the child's impairment level according to the following scale for each task listed:

0 = Independent: No functional impairment. The child is able to conduct the activities without difficulty and has no need for assistance. Need is met with adaptive equipment or service animal.
1 = Standby/Cuing: Mild functional impairment. The child is able to conduct the activity but does require standby assist or cuing.
2 = Limited Assist: Moderate functional impairment. The child is able to conduct the activity with moderate difficulty and requires minimal assistance.
3 = Extensive Assist: Severe functional impairment. The child has considerable difficulty completing the activity and requires extensive assistance.
4 = Total Dependence: Total functional impairment. The child is completely unable to carry out any part of the activity.

An IEP team member must decide which of the five impairment levels best describes the child reviewed. An impairment in this context is a functional limitation (i.e., a limitation in the ability to carry out an activity or function). A member is considered to have an impairment with respect to a particular activity if he/she is limited, either physically or mentally, in his/her ability to carry out that activity.

The “0” and “4” rating is absolute in the sense that they indicate no functional impairment or total dependency. For example, if a child can perform any of the dressing tasks for themselves, a “4” is not appropriate. If he/she can perform the dressing task without difficulty, a “0” is appropriate.

If a child is able to conduct an activity only with difficulty, and the difficulty is such that the child frequently cannot complete some part of the activity, then the child is impaired, even if the child at other times can complete the entire activity. In addition, if the degree of difficulty is such that the child should have at least minimal assistance with that activity, then the child is impaired, even if the child can (with difficulty) conduct the activity without assistance. If the child can complete the activity but needs cuing to do so, or, because of safety considerations needs someone there while completing the task, they would require standby assistance. If the difficulty with an activity does not affect the child's conduct of the activity or does not cause any problems for the child, the child is not impaired.

Enter a Level for Each Task
The Personal Care Paraprofessional Services Profile is designed to rate a child's capacity for self-care. Determine the level for each task according to the capacity for self-care and not according to the child's access to a resource to assist with the task. In rating each item, use the child's response, your own observations of activity, and any knowledge provided about the child from other sources. To determine the severity of the child's impairment, consider the following factors:

  1. Child Perception of the Impairment: Does the child view the impairment as a major or minor problem?
  2. Congruence: Is the child's response to a particular question consistent with the child's response to other questions and, also, consistent with what you have observed?
  3. Child History: Probe for an understanding of the child's history as it relates to the current situation and of the child's attitude about the severity of the impairment. How has the impairment changed the child's lifestyle?
  4. Adaptation: If the child has adapted his physical environment or clothing to the extent that he is able to function without assistance, the degree of impairment will be lessened, but the child will still have an impairment. This includes the use of adaptive equipment.

Use the following examples for each item to help you differentiate between scores of 2 or 3.


ADL: Grooming
2 = Limited Assist: Child may set out supplies. Child may accomplish tasks an adaptive device for assistance.
3 = Extensive: Child needs to have help with shaving or shampooing, etc., because of inability to see well, to reach, or to successfully use equipment. Child needs someone to put lotion on body or to comb or brush hair.

ADL: Toileting
2 = Limited Assist: Child has instances of urinary incontinence, and needs help because of this from time to time. Fecal incontinence does not occur unless child has a specific illness episode. Child may have catheter or colostomy bag, and occasionally needs assistance with management.
3 = Extensive: Child often is unable to get to the bathroom on time to urinate. Child has occasional episodes of fecal incontinence. Child may wear diapers to manage the problem and needs some assistance with them. Child usually needs assistance with catheter or colostomy bag.

ADL: Dressing
2 = Limited Assist: Child needs occasional help with zippers, buttons, or putting on shoes and socks. Child may need help laying out and selecting clothes.
3 = Extensive: Child needs help with zippers, buttons, or shoes and socks. Child needs help getting into garments, including putting arms in sleeves, legs in pants, or pulling up pants. Child may dress totally inappropriately without help or would not finish dressing without physical assistance.

ADL: Transferring
2 = Limited Assist: Child usually can get out of bed or chair with minimal assistance.
3 = Extensive: Child needs hands-on assistance when rising to a standing position or moving into a wheelchair to prevent losing balance or falling. Child is able to help with the transfer by holding on, pivoting, and/or supporting himself.

ADL: Ambulation
2 = Limited Assist: Child walks alone without assistance for only short distances. Child can walk with minimal difficulty using an assistive device or by holding onto walls or furniture.
3 = Extensive: Child has considerable difficulty walking even with an assistive device. Child can walk only with assistance from another person. Child never walks alone outdoors without assistance. Child may use a wheelchair periodically.

ADL: Eating
2 = Limited Assist: Child may need occasional physical help. Child eats with adaptive devices but requires help with their positioning.
3 = Extensive: Child usually needs extensive hands-on assistance with eating. Child may hold eating utensils but needs continuous assistance during meals. Child would not complete meal without continual help. Spoon-feeding of most foods is required, but child can eat some finger foods.

ADL: Exercise
2 = Limited Assist: Child may need occasional assistance in completing exercise routine. Child may need occasional support or guidance.
3 = Extensive: Child needs some assistance in completing exercise routine. Child needs support or guidance.

ADL: Bus Escort
2 = Limited Assist: Child requires minimal assistance on bus en route to or from school. Child does not have family or caregiver to assist. Child receives a medical service at school on this date.
3 = Extensive: Child requires assistance on bus en route to or from school. Child does not have family or caregiver to assist. Child receives a medical service at school on this date.

 

Check the appropriate column that indicates the degree to which the child's need for help in the completion of each task is met. Check one column for each task:

M = Met: The child's needs are met. The child may be independent in this task or someone other than the Personal Care Paraprofessional is meeting the child’s need for help. Other sources for meeting the need include family or friends. No time can be authorized for any task coded with an “M”.

P = Partially Met: The child requires help with the task. Someone other than the personal care paraprofessional is providing that help part of the time, or the child may participate
in the task.

U = Unmet: The child requires help with the task and the need is currently unmet.

  1. Notes: Enter any appropriate notes.
  2. Minutes Per Day: For each task to be provided, enter the daily number of minutes needed to conduct that task.
  3. Days Per Week: For each task to be provided, enter the number of days per week the child will require assistance with the task.
  4. Total Minutes: Multiply the minutes per day times the days per week to obtain the total minutes per week for each task.

The amount of time allowed for any particular task should be determined by taking into account:

  1. The amount of assistance the child will usually need.
  2. Which specific activities need to be accomplished.
  3. Environmental/housing factors that may hinder (or facilitate) service delivery.
  4. Child’s unique circumstances.

Personal Care Paraprofessional Services Provided In Schools Child Profile - Form

Task/Hour Guide Instructions

Purpose
The purpose of this form is to record the amount of time that is spent providing Personal Care services. This form is a sample and can be recreated by district personnel to meet specific needs.

Specific Tasks
Each task has one or more activities or sub-tasks that forms the overall task. When calculating time, carefully consider which activities were provided.

  1. Dressing:
    1. Dressing member
    2. Undressing member
    3. Cuing assistance
  2. Exercise:
    1. Range of motion
  3. Grooming:
    1. Brushing teeth
    2. Laying out supplies
    3. Combing/brushing hair
    4. Applying nonprescription lotion to skin
    5. Washing hands and face
    6. Cuing assistance
  4. Toileting:
    1. Changing diapers
    2. Changing colostomy bag/emptying catheter bag
    3. Assisting on/off bed pan
    4. Assisting with use of urinal
    5. Assisting with feminine hygiene needs
    6. Assisting with clothing during toileting
    7. Assisting with toilet hygiene: includes use of toilet paper & washing hands
    8. Set-up supplies and equipment (Does NOT include preparing catheter equipment)
    9. Standby assistance
  5. Transfer:
    1. Non-ambulatory movement from one stationary position to another (transfer)
    2. Adjusting/changing member’s position in bed or chair (positioning)
  6. Ambulation (Walking):
    1. Assisting child in rising from a sitting to a standing position and/or position for use of walking apparatus
    2. Assisting with putting on and removing leg braces and prostheses for ambulation
    3. Assisting with ambulation/using steps
    4. Standby assistance with ambulation
    5. Assistance with wheelchair ambulation
      NOTE: Do not include exercise as ambulation.
  7. Eating:
    1. Spoon feeding
    2. Bottle feeding
    3. Set up of utensils/adaptive devices
    4. Assistance with using eating or drinking utensils/adaptive devices
    5. Cutting up foods
    6. Standby assistance/encouragement
      NOTE: Tube feeding is not an allowable service.
  8. Bus Escort:
    1. Accompanying a child on the bus when the child is functionally limited and receives medical service at the school on that date. Not for purposes of behavioral management.

Task/Hour Guide

 

End of Appendix B: Personal Care Paraprofessional Services Documentation Chapter

Definitions and Acronyms

Definitions and Acronyms

 

This section contains definitions, abbreviations, and acronyms used in this manual.

270/271 Transactions

The ASC X12N eligibility inquiry (270) and response (271) transactions.

276/277 Transactions

The ASC X12N claim status request (276) and response (277) transactions.

278 Transactions

The ASC X12N request for services review and response used for prior authorization.

835 Transactions

The ASC X12N payment and remittance advice (explanation of benefits) transaction.

837 Transactions

The ASC X12N professional, institutional, and dental claim transactions (each with its own separate Implementation Guide).

Accredited Standards Committee X12, Insurance Subcommittee (ASC X12N)

The ANSI-accredited standards development organization, and one of the six Designated Standards Maintenance Organizations (DSMO), that created and is tasked with maintaining the administrative and financial transactions standards adopted under HIPAA for all health plans, clearinghouses, and providers who use electronic transactions.

Administrative Rules of Montana (ARM)

The rules published by the executive departments and agencies of the state government.

Allowed Amount

The maximum amount reimbursed to a provider for a health care service as determined by Medicaid/MHSP/HMK or another payer. Other cost factors, (such as cost sharing, TPL, or incurment) are often deducted from the allowed amount before final payment. Medicaid’s allowed amount for each covered service is listed on the Department fee schedule.

Ancillary Provider

Any provider that is subordinate to the member’s primary provider, or providing services in the facility or institution that has accepted the member as a Medicaid member.

Assignment of Benefits

A voluntary decision by the member to have insurance benefits paid directly to the provider rather than to the member. The act requires the signing of a form for the purpose. The provider is not obligated to accept an assignment of benefits. However, the provider may require assignment in order to protect the provider’s revenue.

Authorization

An official approval for action taken for, or on behalf of, a Medicaid member. This approval is only valid if the member is eligible on the date of service.

Basic Medicaid

Patients with Basic Medicaid have limited Medicaid services. See the Medicaid Covered Services chapter General Information for Providers manual.

Bundled

Items or services that are deemed integral to performing a procedure or visit are not paid separately in the APC system. They are packaged (also called bundled) into the payment for the procedure or visit. Medicare developed the relative weights for surgical, medical and other types of visits so that the weights reflect the packaging rules used in the APC method. Items or services that are packaged receive a status code of “N”.

Cash Option

Cash option allows the member to pay a monthly premium to Medicaid and have Medicaid coverage for the entire month rather than a partial month.

Centers for Medicare and Medicaid Services (CMS)

Administers the Medicare program and oversees the state Medicaid programs.

Children’s Health Insurance Program (CHIP)

The Montana plan is now known as Healthy Montana Kids (HMK).

Children’s Special Health Services (CSHS)

CSHS assists children with special health care needs who are not eligible for Medicaid by paying medical costs, finding resources, and conducting clinics.

Clean Claim

A claim that can be processed without additional information from or action by the provider of the service.

Member

An individual enrolled in a Department medical assistance program.

Code of Federal Regulations (CFR)

Rules published by executive departments and agencies of the federal government.

Coinsurance

The member’s financial responsibility for a medical bill as assigned by Medicaid or Medicare (usually a percentage). Medicaid coinsurance is usually 5% of the Medicaid allowed amount, and Medicare coinsurance is usually 20% of the Medicare allowed amount.

Conversion Factor

A state specific dollar amount that converts relative values into an actual fee. This calculation allows each payer to adopt the RBRVS to its own economy.

Copayment

The member’s financial responsibility for a medical bill as assigned by Medicaid (usually a flat fee).

Cosmetic

Serving to modify or improve the appearance of a physical feature, defect, or irregularity.

Cost Sharing

The member’s financial responsibility for a medical bill assessed by a flat fee or percentage of charges.

CPT

Physicians’ Current Procedural Terminology contains procedure codes which are used by medical practitioners in billing for services rendered. The book is published by the American Medical Association.

Credit Balance Claims

Adjusted claims that reduce original payments, causing the provider to owe money to the Department. These claims are considered in process and continue to appear on the remittance advice until the credit has been satisfied.

Crossovers

Claims for members who have both Medicare and Medicaid. These claims may come electronically from Medicare or directly from the provider.

DPHHS, State Agency

The Montana Department of Public Health and Human Services (DPHHS or the Department) is the designated State Agency that administers the Medicaid program. The Department's legal authority is contained in Title 53, Chapter 6 MCA. At the federal level, the legal basis for the program is contained in Title XIX of the Social Security Act and Title 42 of the Code of Federal Regulations (CFR). The program is administered in accordance with the Administrative Rules of Montana (ARM), Title 37, Chapter 86.

Dual Eligibles

Members who are covered by Medicare and Medicaid.

Early and Periodic Screening, Diagnosis,and Treatment (EPSDT)

This program provides Medicaid-covered children with comprehensive health screenings, diagnostic services, and treatment of health problems.

Electronic Funds Transfer (EFT)

Payment of medical claims that are deposited directly to the provider’s bank account.

Emergency Services

A service is reimbursed as an emergency if one of the following criteria is met:

  • The service is billed with CPT Code 99284 or 99285
  • The member has a qualifying emergency diagnosis code. A list of emergency diagnosis codes is available on the Provider Information website.
  • The services did not meet one of the previous two requirements, but the hospital believes an emergency existed. In this case, the claim and documentation supporting the emergent nature of the service must be mailed to the emergency department review contractor.

Experimental

A noncovered item or service that researchers are studying to investigate how it affects health.

Explanation of Medicare Benefits (EOMB)

A notice sent to providers informing them of the services which have been paid by Medicare.

Fiscal Agent

Conduent State Healthcare, LLC, is the fiscal agent for the State of Montana and processes claims at the Department's direction and in accordance with ARM 37.86 et seq.

Full Medicaid

Patients with Full Medicaid have a full scope of Medicaid benefits. See the General Information for Providers manual, Medicaid Covered Services.

Gross Adjustment

A lump sum debit or credit that is not claim specific made to a provider.

HCPCS

Acronym for the Healthcare Common Procedure Coding System, and is pronounced “hickpicks.” There are two types of HCPCS codes:

  • Level 1 includes the CPT codes.
  • Level 2 includes the alphanumeric codes A–V which CMS maintains for a wide range of services from ambulance trips to hearing aids which are not addressed by CPT coding.

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.

Health Insurance Portability and Accountability Act (HIPAA)

A federal plan designed to improve efficiency of the health care system by establishing standards for transmission, storage, and handling of data.

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. DPHHS administers the program and purchases health insurance from Blue Cross and Blue Shield of Montana (BCBSMT). Benefits for dental services and eyeglasses are provided by DPHHS through the same contractor (Conduent State Healthcare, LLC) that handles Medicaid provider relations and claims processing.

International Classification of Disease (ICD)

The International Classification of Diseases contains the diagnosis codes used in coding claims and the procedure codes used in billing for services performed in a hospital setting.

Indian Health Service (IHS)

IHS provides health services to American Indians and Alaska Natives.

Individual Adjustment

A request for a correction to a specific paid claim.

Internal Control Number (ICN)

The unique number assigned to each claim transaction that is used for tracking.

Investigational

A noncovered item or service that researchers are studying to investigate how it affects health.

Mass Adjustment

Adjustments made to multiple claims at the same time. They generally occur when the Department has a change of policy or fees that is retroactive, or when a system error that affected claims processing is identified.

Medicaid/HMK Plus

A program that provides health care 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.

Medically Necessary

A term describing a requested service which is reasonably calculated to prevent, diagnose, correct, cure, alleviate or prevent worsening of conditions in the member. These conditions must be classified as one of the following: endanger life, cause suffering or pain, result in an illness or infirmity, threaten to cause or aggravate a handicap, or cause physical deformity or malfunction. There must be no other equally effective, more conservative or substantially less costly course of treatment available or suitable for the member requesting the service. For the purpose of this definition, course of treatment may include mere observation or, when appropriate, no treatment at all.

Medicare

The federal health insurance program for certain aged or disabled members.

Mental Health Services Plan (MHSP)

This plan is for individuals who have a severe and disabling mental illness (SDMI), are ineligible for Medicaid, and have a family income that does not exceed an amount established by the Department.

Mentally Incompetent

According to CFR 441.251, a mentally incompetent individual means an individual who has been declared mentally incompetent by a federal, state, or local court of competent jurisdiction for any purpose, unless the individual has been declared competent for purposes which include the ability to consent to sterilization.

Montana Access to Health (MATH) Web Portal

A secure website on which providers may view members’ medical history, verify member eligibility, submit claims to Medicaid, check the status of a claim, verify the status of a warrant, and download remittance advice reports.

Montana Breast and Cervical Cancer Treatment Program

This program provides Full 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.

Nurse First Advice Line

The Nurse First Advice Line is a toll-free, confidential number members may call any time any day for advice from a registered nurse about injuries, diseases, health care, or medications.

Passport Referral Number

This is a 7-digit number assigned to Passport providers. When a Passport provider refers a member to another provider for services, this number is given to the other provider and is required when processing the claim.

Passport to Health

A Medicaid medical home program where the member selects a primary care provider who manages the member’s health care needs.

Pay-and-Chase

Medicaid pays a claim and then recovers payment from the third party carrier that is financially responsible for all or part of the claim.

Pending Claim

These claims have been entered into the system, but have not reached final disposition. They require either additional review or are waiting for member eligibility information.

Potential Third Party Liability

Any entity that may be liable to pay all or part of the medical cost of care for a Medicaid, MHSP or HMK member.

Prior Authorization (PA)

The approval process required before certain services or supplies are paid by Medicaid. Prior authorization must be obtained before providing the service or supply.

Private-Pay

When a member chooses to pay for medical services out of his or her own pocket.

Protocols

Written plans developed by a public health clinic in collaboration with physician and nursing staff. Protocols specify nursing procedures to be followed in giving a specific exam, or providing care for particular conditions. Protocols must by updated and approved by a physician at least annually.

Provider or Provider of Service

An institution, agency, or person:

  • • Having a signed agreement with the Department to furnish medical care and goods and/or services to members; and
  • Eligible to receive payment from the Department.

Qualified Medicare Beneficiary (QMB)

QMB members are members for whom Medicaid pays their Medicare premiums and some or all of their Medicare coinsurance and deductibles.

Reason and Remark Code

A code which prints on the Medicaid remittance advice (RA) that explains why a claim was denied or suspended. The explanation of the Reason/Remark codes is found at the end of the RA (formerly called EOB code).

Referral

When providers refer members to other Medicaid providers for medically necessary services that they cannot provide.

Remittance Advice (RA)

The results of claims processing (including paid, denied, and pending claims) are listed on the RA.

Relative Value Scale (RVS)

A numerical scale designed to permit comparisons of appropriate prices for various services. The RVS is made up of the relative value units (RVUs) for all the objects in the class for which it is developed.

Relative Value Unit (RVU)

The numerical value given to each service in a relative value scale.

Resource-Based Relative Value Scale (RBRVS)

A method of determining physicians’ fees based on the time, training, skill, and other factors required to deliver various services.

Retroactive Eligibility

When a member is determined to be eligible for Medicaid effective prior to the current date.

Sanction

The penalty for noncompliance with laws, rules, and policies regarding Medicaid. A sanction may include withholding payment from a provider or terminating Medicaid enrollment.

School-Based Services

Medically necessary health-related services provided to Medicaid eligible children up to and including age 20. These services are provided in a school setting by licensed medical professionals.

Specified Low-Income Medicare Beneficiaries (SLMB)

For these members, Medicaid pays the Medicare premium only. They are not eligible for other Medicaid benefits, and must pay their own Medicare coinsurance and deductibles.

Spending Down

Members with high medical expenses relative to their income can become eligible for Medicaid by “spending down” their income to specified levels. The member is responsible to pay for services received before eligibility begins, and Medicaid pays for remaining covered services.

Team Care

A restricted services program that is part of Passport to Health. Restricted services programs are designed to assist members in making better health care decisions so that they can avoid overutilizing health services. Team Care members are joined by a team assembled to assist them in accessing health care. The team consists of the member, the PCP, a pharmacy, the Department, the Department’s quality improvement organization, and the Nurse First Advice Line. The team may also include a community-based care manager from the Department's Health Improvement Program.

Third Party Liability (TPL)

Any entity that is, or may be, liable to pay all or part of the medical cost of care for a Medicaid, MHSP or HMK member.

Timely Filing

Providers must submit clean claims (claims that can be processed without additional information or documentation from or action by the provider) 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; or
    • 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.

Usual and Customary

The fee that the provider most frequently charges the general public for a service or item.

WINASAP 5010

WINASAP 5010 is a Windows-based electronic claims entry application for Montana Medicaid. This software was developed as an alternative to submitting claims on paper. For more information, contact the EDI Technical Help Desk. (See Key Contacts.)

 

End of Definitions and Acronyms Chapter

Index

Index

Previous editions of this manual contained an index.

This edition has three search options.

1.Search the whole manual. Open the Complete Manual pane.  From your keyboard press the Ctrl and F keys at the same time.  A search box will appear.  Type in a descriptive or key word (for example "Denials". The search box will show all locations where denials discussed in the manual.

2.Search by Chapter. Open any Chapter tab (for example the "Billing Procedures" tab).  From your keyboard press the Ctrl and F keys at the same time.  A search box will appear.  Type in a descriptive or key word (for example "Denials". The search box will show where denials discussed in just that chapter.

3.Site Search.  Search the manual as well as other documents related to a particular search term on the Montana Healthcare Programs Site Specific Search page.

 

End of Index Chapter

End of School-Based Services Manual

Complete School-Based Services Manual

School-Based 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 School-Based Services handbooks. Published by the Montana Department of Public Health & Human Services, August 2003.

Updated October 2003, December 2003, January 2004, April 2004, August 2004, April 2005, May 2005, August 2005, January 2006, April 2006, February 2007, April 2008, June 2011, April 2012, March 2013, May 2013, and October 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

11/02/2017
Code changes were made in the Billing Procedures Chapter.

10/20/2017
School-Based Services Manual converted to an HTML format and adapted to 508 Accessibility Standards.

07/10/2013
School-Based Services, May 2013: Entire Manual
These replacement pages includes a terminology change (client to member); however, unless a paragraphs also included content changes, it is not marked as a change.

04/27/2012
School-Based Services, April 2012: Covered Services

06/09/2011
School-Based Services, June 2011: Covered Services

09/16/2008
School-Based Services, April 2008: Key Contacts, Covered Services, Billing Procedures, and Claim Instructions

02/14/2007
School-Based Services, February 2007: Revised Physician Order Information, New Private Duty Nursing Request Form

04/25/2006
School-Based Services, April 2006: Coordination of Benefits Information

01/17/2006
School-Based Services, January 2006: Documentation Requirements, Restricted CSCT Services, Private-Duty Nursing Review Requirements, and School-Based Services Codes

10/06/2005
School-Based Services, August 2005: Covered Services and Billing Information for CSCT and Therapy  

05/12/2005
School-Based Services, May 2005: Key Contacts and Place of Service

04/11/2005
School-Based Services, April 2005: Key Contacts

08/30/2004
School-Based Services, August 2004: Audiology Services Defined  

04/26/2004
School-Based Services, April 2004: Key Contacts and Websites, Covered Services, COB, Billing Procedures, Claim Forms, RAs and Adjustments, Forms and Definitions

01/14/2004
School-Based Services, January 2004: Covered Services Error Correction

12/23/2003
School-Based Services, December 2003:CSCT Changes

 

End of Update Log Chapter

 

Table of Contents

 

Key Contacts

Key Websites

Introduction

Manual Organization

Manual Maintenance

Rule References

Getting Questions Answered

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

Program Overview

Covered Services

General Coverage Principles

Services for Children (ARM 37.86.2201–2221)
Services within Scope of Practice (ARM 37.85.401)
Provider Requirements
IEP Requirements
Member Qualifications
School Qualifications
Physician Order/Referral
Documentation Requirements
Noncovered Services (ARM 37.85.207 and 37.86.3002)
Importance of Fee Schedules

Coverage of Specific Services

Assessment to Initiate an IEP
Comprehensive School and Community Treatment (CSCT)
Therapy Services
Private Duty Nursing Services
School Psychologists and Mental Health Services
Personal Care Paraprofessional Services
Special Needs Transportation
Audiology
Orientation and Mobility Specialist Services
Authorization Requirements Summary

Other Programs

Children’s Mental Health Services Plan (CMHSP)
Healthy Montana Kids (HMK)

Passport to Health Program

What Is Passport to Health? (ARM 37.86.5101–5120, 37.86.5303, and 37.86.5201–5206)

Passport to Health Primary Care Case Management (ARM 37.86.5101–5120)
Team Care (ARM 37.86.5303)
Nurse First Advice Line
Health Improvement Program (ARM 37.86.5201–5206)

Other Programs

Prior Authorization

What Is Prior Authorization (ARM 37.86.5101–5120)

Getting Questions Answered

Other Programs

Coordination of Benefits

When Members Have Other Coverage

Identifying Other Sources of Coverage

When a Member Has Medicare

Medicare Part B Crossover Claims
When Medicare Pays or Denies a Service
When Medicaid Does Not Respond to Crossover Claims

Submitting Medicare Claims to Medicaid

When a Member Has TPL (ARM 37.85.407)

CSCT Services
Billing for Medicaid Covered Services When No IEP Exists
Billing for Medicaid Covered Services under an IEP
Exceptions to Billing Third Party First
Requesting an Exemption
When the Third Party Pays or Denies a Service
When the Third Party Does Not Respond

 

Billing Procedures

Claim Forms

Timely Filing Limits (ARM 37.85.406)

Tips to Avoid Timely Filing Denials

When Providers Cannot Bill Medicaid Members (ARM 37.85.406)

Member Cost Sharing (ARM 37.85.204 and 37.85.402)

Billing for Members with Other Insurance

Billing for Retroactively Eligible Members

Service Fees

Coding Tips

Using Modifiers
Multiple Services on the Same Date
Time and Units
Place of Service

Billing for Specific Services

Assessment to Initiate an IEP
Therapy Services
Private Duty Nursing Services
School Psychologists and Mental Health Services
Personal Care Paraprofessional Services
Special Needs Transportation
Audiology

Submitting Electronic Claims

Billing Electronically with Paper Attachments

Submitting Paper Claims

Claim Inquiries

The Most Common Billing Errors and How to Avoid Them

Other Programs

Submitting a Claim

CMS-1500 Agreement

Avoiding Claim Errors

Other Programs

Remittance Advices and Adjustments

The Remittance Advice

Sample Remittance Notice

Credit Balances

Rebilling and Adjustments

How Long Do I Have to Rebill or Adjust a Claim?
Rebilling Medicaid
Adjustments
Mass Adjustments

Payment and the RA

How Payment Is Calculated

Overview

Payment for School-Based Services

Speech, Occupational and Physical Therapy Services
Private Duty Nursing
School Psychologist
Personal Care Paraprofessionals
CSCT Program
How Payment Is Calculated on TPL Claims
How Payment Is Calculated on Medicare Crossover Claims

Appendix A: Forms

Individual Adjustment

Audit Preparation Checklist

Private Duty Nursing Services Request

Paperwork Attachment Cover Sheet

Appendix B: Personal Care Paraprofessional Services Documentation

Personal Care Paraprofessional Services Provided in Schools – Child Profile

Purpose

Procedure

Instructions

Task/Hour Guide Instructions

Purpose

Specific Tasks

Task/Hour Guide

Definitions and Acronyms

Index

 

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.

Chemical Dependency

For coverage information and other details regarding chemical dependency treatment, write or call:

(406) 444-3964 Phone

Send written inquiries to:

Chemical Dependency Bureau
Addictive and Mental Disorders Division
DPHHS
P.O. Box 202905
Helena, MT 59620-2905

Claims

Send paper claims and adjustment requests to:

Claims Processing Unit
P.O. Box 8000
Helena, MT 59604

CSCT Program

For more information on the Comprehensive School and Community Treatment (CSCT) program, contact Childrens Mental Health Program specialist.

(406) 444-4545 Phone
(406) 444-4913 Fax

Send written inquiries to:

CSCT Specialist
​Childrens Mental Health
DPHHS
P.O. Box 4210
Helena, MT 59620-4210

Direct Deposit Arrangements

Providers who would like to receive their electronic remittance advices and electronic funds transfer should fax their information to Provider Relations:

(406) 442-4402 Fax

EDI Technical Help Desk

For questions regarding electronic claims submission, send e-mail inquiries to: MTPRHelpdesk@conduent.com

(800) 987-6719 In/Out of state
(406) 442-1837 Helena
(406) 442-4402 Fax

 

Montana EDI
P.O. Box 4936
Helena, MT 59604

 

Healthy Montana Kids (HMK)

(877) 543-7669 Phone (toll-free)
(877) 418-4533 Fax (toll-free)
(406) 444-6971 Phone (Helena)
(406) 444-4533 Fax (Helena)
Send email inquired to: hmk@mt.gov  E-Mail

HMK Program Officer
P.O. Box 202951
Helena, MT 59620-2951

Member Eligibility

There are several methods for verifying member eligibility. For details on each, see Verifying Member Eligibility in the Member Eligibility and Responsibilities chapter of the General Information for Providers manual.

FaxBack
(800) 714-0075 (24 hours)
Voice Response System
(800) 714-0060 (24 hours)
Montana Access to Health Web Portal - http://mtaccesstohealth.acs-shc.com/

Medifax EDI
(800) 444-4336, X 2072 (24 hours)

Member Help Line

Members who have general Medicaid or Passport
questions may call the Help Line:

(800) 362-8312 Phone

Send written inquiries to:

Passport to Health
P.O. Box 254
Helena, MT 59624-0254

Nurse First

For questions regarding the Nurse First Advice Line, contact:

(406) 444-4540 Phone
(406) 444-1861 Fax

Nurse First Program Officer
Managed Care Bureau
DPHHS
P.O. Box 202951
Helena, MT 59620-2951

Prior Authorization

The following are some of the Department’s prior authorization contractors. Providers are expected to refer to their specific provider manual for prior authorization instructions.

Mountain-Pacific Quality Health
For prior authorization for school-based private duty nursing services:

(406) 443-4020 X150 Helena
(800) 262-1545 X150 Outside Helena
(406) 443-4585 Fax

Send written inquiries to:

Medicaid Utilization Review
Mountain-Pacific Quality Health
Helena, MT 59602

For questions regarding prior authorization for medical necessity therapy reviews:

(406) 457-5887 Local
(877) 443-4021 X5887 Toll-free
(877) 443-2580 Fax local/long distance

Send written inquiries to:

Mountain Pacific Quality Health
3404 Cooney Drive
Helena, MT 59602

Magellan Medicaid Administration
For questions regarding prior authorization and continued stay review for selected mental health services.

(800) 770-3084 Phone
(800) 639-8982 Fax
(800) 247-3844 Fax

Magellan Medicaid Administration
4300 Cox Road
Glen Allen, VA 23060

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. For inquiries related to licensure/endorsement, contact the Quality Assurance Division, Licensing Bureau:

(406) 444-2676 Phone
(406) 444-1742 Fax

Send written inquiries to:

Quality Assurance Division
Licensing Bureau
2401 Colonial Drive, Third Floor
Helena, MT 59602-2693

Provider Relations

For general claims questions, questions about eligibility, Passport to Health, payments, and denials:

(800) 624-3958 In/Out of state
(406) 442-1837 Helena
(406) 442-4402 Fax

Send e-mail inquiries to MTPRHelpdesk@conduent.com

Send written inquiries to:

Provider Relations Unit
P.O. Box 4936
Helena, MT 59604

Secretary of State

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
P.O. Box 202801
Helena, MT 59620-2801

Surveillance/Utilization Review

To report suspected provider fraud/abuse:

(406) 444-4586
(800) 376-1115

To report suspected member fraud/abuse:

(800) 201-6308

Send written inquiries to:

Fraud and Abuse
SURS
2401 Colonial Drive
P.O. Box 202953
Helena, MT 59620-2953

Team Care Program

For questions regarding Team Care:

(406) 444-9673 Phone
(406) 444-1861 Fax

Team Care Program Officer
Managed Care Bureau
DPHHS
P.O. Box 202951
Helena, MT 59620-2951

Third Party Liability

For questions about private insurance, Medicare, or other third-party liability:

(800) 624-3958 In/Out of state
(406) 442-1837 In/Out of state

Send written inquiries to:

Third Party Liability Unit
P.O. Box 5838
Helena, MT 59604

 

End of Key Contacts Chapter

 

Key Websites

 

EDI Gateway - www.acs-gcro.com

 

Information Available:

EDI Gateway is Montana’s HIPAA clearinghouse. Visit this website for more information on:

  • EDI enrollment
  • EDI support
  • FAQs
  • Manuals
  • Provider services
  • Related links
  • Software

 

HMK Website - www.hmk.mt.gov

Information Available:

  • Information on Healthy Montana Kids (HMK)

 

Montana Access to Health Web Portal - mtaccesstohealth.acs-shc.com

 

Provider Information Website - medicaidprovider.mt.gov

 

Information Available:

  • FAQs
  • Fee schedules
  • HIPAA update
  • Key contacts
  • Links to other websites
  • Medicaid forms
  • Medicaid news
  • Newsletters
  • Notices and manual replacement pages
  • Passport to Health information
  • Provider enrollment
  • Provider manuals
  • Remittance advice notices
  • Training resources
  • Upcoming events

 

www.wpc-edi.com

 

A fee is charged for documents; however, code lists are viewable online at no charge.

Information Available:

  • HIPAA guides
  • HIPAA tools

 

 

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

This manual provides information specifically for the School-Based Services Program.

Most chapters have a section titled Other Programs that includes information about other Department programs such as the Mental Health Services Plan (MHSP) and Healthy Montana Kids (HMK). Other essential information for providers is contained in the separate General Information for Providers manual. Each provider is asked to review both the general manual and the specific manual for his/her provider type.
 

A table of contents and an index allow you to quickly find answers to most questions. The margins contain important notes with extra space for writing notes. There is a list of Key Contacts at the beginning of each manual. We have also included a space on the inside front cover to record your NPI for quick reference when calling Provider Relations.

Manual Maintenance

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

Providers are responsible for knowing and following current laws and regulations.

Rule References

Providers must be familiar with all current rules and regulations governing the Montana Medicaid program. Provider manuals are to assist providers in billing Medicaid; they do not contain all Medicaid rules and regulations. Rule citations in the text are a reference tool; they are not a summary of the entire rule. In the event that a manual conflicts with a rule, the rule prevails. Links to rule references are available on the Provider Information website. Paper copies of rules are available through the Secretary of State’s office. (See Key Contacts.)

The following rules and regulations are specific to the school based services program. Additional Medicaid rule references are available in the General Information for Providers manual.

  • Administrative Rules of Montana (ARM)
    • ARM 37.86.2201 EPSDT Purpose, Eligibility and Scope
    • ARM 37.86.2206–2207 EPSDT Medical and Other Services; Reimbursement
    • ARM 37.86.2217 EPSDT Private Duty Nursing
    • ARM 37.86.2230–2235 EPSDT, School-Based Health Related Services

Getting Questions Answered

The provider manuals are designed to answer most questions; however, questions may arise that require a call to a specific group (such as a program officer, Provider Relations, or a prior authorization unit). The list of Key Contacts at the front of this manual has important phone numbers and addresses pertaining to this manual. The Introduction chapter in the General Information for Providers manual also has a list of contacts for specific program policy information. Medicaid manuals, provider notices, replacement pages, fee schedules, forms, and much more are available on the Provider Information website. (See Key Websites.)

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 appropriately billed. Although the computerized system can detect and deny some erroneous claims, there are many erroneous claims it cannot detect. For this reason, payment of a claim does not mean the service was correctly billed or the payment made to the provider was correct. Periodic retrospective reviews are performed that may lead to the discovery of incorrect billing or incorrect payment. If a claim is paid and the Department later discovers the service was incorrectly billed or paid or the claim was erroneous in some other way, the Department is required by federal regulation to recover any overpayment, regardless of whether the incorrect payment was the result of Department or provider error or other cause (42 CFR 456.3).

Program Overview

Title XIX of the Social Security Act provides for a program of medical assistance to certain individuals and families with low income. This program, known as Medicaid, became law in 1965 as a jointly funded cooperative venture between the federal and state governments. Federal oversight for the Medicaid program lies with the Centers for Medicare and Medicaid Services (CMS) in the Department of Public Health and Human Services (DPHHS).

The Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) program is a special program for Medicaid beneficiaries under 21 years of age. The purpose of EPSDT is to ensure that through periodic checkups and early detection, children’s health problems are prevented and/or ameliorated. The EPSDT program allows states to provide services even if these services are not covered under the Medicaid state plan for other beneficiaries.

The Medicare Catastrophic Coverage Act, enacted in 1988, contained provisions which permit state Medicaid programs to provide reimbursement for health-related services provided as part of a child’s Individualized Education Plan (IEP). This reversed a previous policy that Medicaid could not reimburse for services provided by schools. As a result of this act, the State of Montana allows schools and cooperatives to bill for Medicaid services provided to Medicaid members pursuant to an IEP.

Medicaid reimburses health-related services provided by schools that are written into an IEP, if the services are covered under the Medicaid state plan or are covered under EPSDT. Services billed to Medicaid must be provided by qualified practitioners with credentials meeting state and federal Medicaid program requirements. Medicaid provides reimbursement for health-related services and does not reimburse for services that are educational or instructional in nature.

Medicaid can be an important source of funding for schools, particularly because the cost of providing special education can greatly exceed the federal assistance provided under the Individuals with Disabilities Education Act (IDEA). Children who qualify for IDEA are frequently eligible for Medicaid services. Although Medicaid is traditionally the “payer of last resort” for health care services, it is required to reimburse for IDEA related medically necessary services for eligible children before IDEA funds are used.

In Montana, the Department of Public Health & Human Services, Medicaid Services Bureau, administers the Medicaid School-Based Services Program. This guide contains specific technical information about program requirements associated with seeking payment for covered services rendered in a school setting. The purpose of this guide is to inform schools on the appropriate methods for claiming reimbursement for the costs of health-related services provided.

 

End of Introduction Chapter

 

Covered Services

General Coverage Principles

Medicaid covers health-related services provided to children in a school setting when all of the following are met:

  • The child qualifies for Individuals with Disabilities Education Act (IDEA).
  • The services are written into an Individual Education Plan (IEP).
  • The services are not free. Providers may not bill Medicaid for any services that are generally offered to all members without charge.
  • For CSCT services, children must have a serious emotional disturbance (SED) diagnosis as specified under ARM 37.87.303.

Refer to the IEP requirements in this chapter and the Coordination of Benefits chapter regarding billing services included/not included in a child’s IEP.

This chapter provides covered services information that applies specifically to school-based services. School-based services providers must meet the Medicaid
provider qualifications established by the state and have a provider agreement with the state. These providers must also meet the requirements specified in this manual and the General Information for Providers manual. School-based services provided to Medicaid members include the following:

  • Therapy services (physical therapy, occupational therapy, speech language pathology)
  • Audiology
  • Private duty nursing
  • School psychology and mental health services (including clinical social work and clinical professional counseling)
  • Comprehensive School and Community Treatment (CSCT)
  • Personal care (provided by paraprofessionals)
  • Other diagnostic, preventative and rehabilitative services
  • Specialized transportation
  • Orientation and Mobility Specialist services (for blind and low vision)

Services for Children (ARM 37.86.2201–2221)
The Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) Program is a comprehensive approach to health care for Medicaid members ages 20 and under. It is designed to prevent, identify, and then treat health problems before they become disabling. Under EPSDT, Medicaid eligible children may receive any medically necessary covered service, including all school-based services described in this manual. All applicable prior authorization requirements apply. (See the Prior Authorization chapter in this manual.)

Services within Scope of Practice (ARM 37.85.401)
Services provided under the School-Based Services Program are covered only when they are within the scope of the provider’s license.

Provider Requirements
Most school-based services must be provided by licensed health care providers. The exception is that activities of daily living services may be provided by personal care paraprofessionals. Medicaid does not cover services provided by a teacher or teacher’s aide; however, teachers or teacher aides may be used to assist in the development of child care planning. School-based services must be provided by only those providers listed in the table below.

Provider Requirements

Provider Type:
Private duty nursing services provided by:

  • Licensed registered nurse
  • Licensed practical nurse

Provider Requirements:
Nurses must have a valid certificate of registration issued by the Board of Nurse Examiners of the State of Montana or the Montana Board of Nursing Education and Nurse Registration.

 

Provider Type:
Mental health services provided by:

  • Credentialed school psychologist
  • Licensed psychologist
  • Licensed clinical professional counselor
  • Licensed clinical social worker

Provider Requirements:
Mental health providers must be licensed according to Montana’s state requirements. School psychologist services are provided by a professional with a Class 6 specialist license with a school psychologist endorsement.

 

Provider Type:
Therapy services provided by:

  • Licensed occupational therapist
  • Licensed physical therapist
  • Licensed speech language pathologists


Provider Requirements:
These therapists are required to meet appropriate credentialing requirements as defined by the Montana Licensing Board.

 

Provider Type:
Audiology

Provider Requirements:
Must meet credentialing requirements as defined by the Montana Licensing Board.

 

Provider Type:
Personal care paraprofessional

Provider Requirements:
No licensing requirements.

 

Provider Type:
Comprehensive School and Community Treatment (CSCT)

Provider Requirements:
Must be provided by a licensed mental health center with a CSCT endorsement.

 

Provider Type:
Orientation and Mobility Specialist

Provider Requirements:
Must have certification of the Academy for Certification of Vision Rehabilitation & Education Professionals (ACVREP) or a National Blindness Professional Certification (NOMC) from the National Blindness Professional Certification Board (NBPCB).

 

It is the responsibility of the school district to assure appropriately licensed providers perform all Medicaid covered services. Each school district must maintain documentation of each rendering practitioner’s license, certification, registration or credential to practice in Montana. Medicaid providers who have had their license suspended by a state or federal government entity may not provide school-based services. 

Services provided to Medicaid members must be documented in the member’s IEP.

IEP Requirements
Services provided to Medicaid members must be covered by Medicaid and documented in the member’s Individualized Education Plan (IEP), unless otherwise specified. School-based providers may bill Medicaid for Medicaid-covered health-related services provided to children with those services written into the IEP, even though the services may be provided to non-Medicaid children for free. However, if a child is covered by both Medicaid and private insurance, the private insurance must be billed prior to Medicaid. Exception to billing other insurance: Blue Cross and Blue Shield of Montana and HMK. Medicaid does not cover health-related services that are not included in an IEP unless all of the following requirements are met:

  • Youth is enrolled in Medicaid.
  • Services are medically necessary.
  • A fee schedule is established for health-related services (can be a sliding scale to adjust for individuals with low incomes).
  • The provider determines if each individual who receives services has insurance coverage or will be billed on a private-pay basis.
  • The provider bills all individuals and/or the insurance carrier for the medical service provided.

Member Qualifications
To qualify for Medicaid school-based services, the member must be a Medicaid member and meet all the following criteria:

  • Be Medicaid-eligible on the date of service.
  • Be between the ages 3 and 20.
  • Be entitled to school district services under the Individuals with Disabilities Education Act (IDEA).
  • Have Medicaid reimbursable services referenced in his or her Individual Educational Plan (IEP). This shows that Medicaid covered services are recommended by the school district.
  • In the case of CSCT services, the member must have an SED diagnosis and services may or may not be included in the client’s IEP.

Cooperatives, joint boards, and non-public schools that do not receive state general funds for special education can not participate in the Medicaid program as a school-based provider.

School Qualifications
Only public school districts, full-service education cooperatives and joint boards of trustees may enroll in the Montana Medicaid School-Based Services Program. To qualify, the district, cooperative or joint board must receive special education funding from the state’s Office of Public Instruction general fund for public education. School districts include elementary, high school and K–12 districts that provide public educational services. Full-service education cooperatives and joint boards include those cooperatives eligible to receive direct state aid payments from the Superintendent of Public Instruction for special education services.

Schools That Employ Medical Service Providers:

  • Schools that employ all or most of their medical service providers for whom the school submits bills can be enrolled with a single NPI for all services.
  • Schools may use this single NPI to bill for any Medicaid covered service provided by a licensed provider.
  • Schools that wish to have separate NPIs for each provider type (e.g., speech therapists, occupational therapists, and physical therapists) can request separate NPIs from the National Plan and Provider Enumeration System (NPPES).

Schools That Contract with External Medical Service Providers:

  • Schools that contract with all or most of their providers must have the provider of service bill for each service they provide with their own individual NPI.
  • Providers and schools can arrange with the Department for payments to be made to the school. If payments are assigned to the school, the school will also have the responsibility to collect third party liability payments on behalf of the service providers.

For more information on enrollment, visit the Provider Information website or contact Provider Enrollment. (See Key Contacts.)

Physician Order/Referral
Medicaid does not require physician orders or referrals for health-related services that are documented in the member’s IEP. The exception is private duty nursing services and personal care assistant services, which require a written order for private-duty nursing or physician signature for personal care assistance services. Other health-related services can be authorized by a licensed school practitioner meeting the State of Montana provider requirements to secure health-related services under an IEP.

Documentation Requirements
School-based service providers must maintain appropriate records. All case records must be current and available upon request. Records can be stored in any readily accessible format and location, and must be kept for six years and three months from the date of service. For more information on record keeping requirements, see the Surveillance/Utilization Review chapter in the General Information for Providers manual.

Medical documentation must include the following:

  • Keep legible records.
  • Date of service and the child’s name.
  • The services provided during the course of each treatment and how the child responded.
  • Except for CSCT, the services for which the school is billing Medicaid must be written into the child’s IEP.
  • If the service is based on time units, (i.e., 15 minutes per unit), the provider of service should indicate begin and end times or the amount of time spent for each service. A service must take at least 8 minutes to bill one unit of service if the procedure has “per 15 minutes” in its description.
  • Providers must sign and date each record documented on the day the medical service was rendered. Provider initials on daily records are acceptable providing their signature is included in other medical documentation within the child’s record.
  • Documentation must, at least quarterly, include notes on member progress toward their goals.  This is for the support of medical necessity and reviewing of the progress to maintain the rehabilitative nature of the service.
  • The service provider must keep sufficient documentation to support the procedures billed to Medicaid. If a service is not documented, it did not happen.
  • Documentation must not be created retroactively. Providers are responsible for maintaining records at the time of service.
  • CSCT services are not required to be included in the IEP because often members that require these services do not fit the special education requirements. The clinical assessment must document the medical necessity and the clinical treatment plan must demonstrate how the CSCT services will address the medical necessity. In addition to the above requirements, CSCT documentation must also include:
    • Where services were provided;
    • Result of service and how it relates to the treatment plan and goals;
    • Progress notes for each individual therapy and other direct service;
    • Monthly overall progress notes; and
    • Individual outcomes compared to baseline measures and established benchmarks.

The Montana Medicaid School-Based Services Program is subject to both state and federal audits. As the Medicaid provider, the school certifies that the services being claimed for Medicaid reimbursement are medically necessary and furnished under the provider’s direction. Both fiscal and clinical compliance are monitored. In the event of adverse findings, the district/cooperative (not the mental health provider) will be held responsible for any paybacks to Medicaid. If school districts have included a program area for CSCT in their accounting system, then the district can book revenue received from third party insurers or parents that paid privately for CSCT services, providing audit documentation. To assist in document retention for audit purposes, see the Audit Preparation Checklist on the Montana Medicaid Provider Information website.

Noncovered Services (ARM 37.85.207)
The following is a list of services not covered by Medicaid.

  • A provider’s time while attending member care meetings, Individual Educational Plan (IEP) meetings, individual treatment plan meetings, or member-related meetings with other medical professionals or family members.
  • A provider’s time while completing IEP related paperwork or reports, writing the CSCT individualized treatment plans or documenting medical services provided
  • CSCT services provided without an individualized treatment plan for this service.
  • Services considered experimental or investigational.
  • Services that are educational or instructional in nature.
  • Services that are not medically necessary. The Department may review for medical necessity at any time before or after payment.

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

Importance of Fee Schedules
The easiest way to verify coverage for a specific service is to check the Department’s school-based services fee schedule. In addition to being listed on the fee schedule, all services provided must also meet the coverage criteria listed in the Provider Requirements chapter of the General Information for Providers manual and in this chapter. Use the fee schedule in conjunction with the more detailed coding descriptions listed in the CPT and HCPCS coding books. Take care to use the fee schedule and coding books that pertain to the date of service. Fee schedules are available on the Provider Information website. (See Key Websites.)

Coverage of Specific Services

The following are coverage rules for specific school-based services.

Assessment to Initiate an IEP
Medicaid covers medical evaluations (assessments) to develop an IEP as long as an IEP is subsequently established and health-related needs are identified.

Comprehensive School and Community Treatment (CSCT)
As of July 2012, the CSCT program moved from the Health Resources Division to the Children’s Mental Health Bureau (CMHB). Guidance related to the CSCT program can now be found in the Youth Mental Health Services manual, which can be found on the Provider Information.

Therapy Services
Therapy includes speech, occupational and physical therapy services. Services may be performed by a therapy assistant or therapy aide but must be billed to Medicaid under the school’s supervising licensed therapist’s NPI. (See the Billing Procedures chapter in this manual.)

  • Telehealth services are allowed for Speech Therapists.  no additional reimbursement other than the therapy itself for this type of service will be given.
  • Speech therapy aides require personal, direct supervision by the licensed provider in accordance with the following guidelines:
  • Speech therapy aides:
    • Aide 1 = supervised on-site a minimum of 10% of member contact time. At the discretion of the supervising speech-language pathologist, the on-site supervision requirement may be reduced to 2% after the first year of supervision.
    • Aide 2 = shall be supervised on-site 10% of member contact time.
    • Aide 3 = shall be supervised on-site 20% of member contact time. Refer to ARM 24.222.702.

The levels of supervision for occupational and physical therapy aides and assistants are as follows:

  • Direct: The licensed provider must be present in the office and immediately available to furnish assistance and direction throughout the performance of the procedure. The licensed provider must be in the direct treatment area of the member-related procedure being performed.
  • Routine: The licensed provider must provide direct contact at least daily at the site of work, with interim supervision occurring by other methods, such as telephonic, electronic or written communication.
  • General: Procedure is furnished under the licensed provider's direction and control, but the licensed provider's presence is not required during the performance of the procedure.
  • Temporary Practice Permit holders (new graduates from occupational therapy school who are waiting for their national exam results) must work under routine supervision of the licensed therapist. If the exam is failed, the Temporary Practice Permit immediately becomes void. Routine supervision requires direct contact at least daily at the site of work.
  • Occupational Therapy Assistants require general supervision, meaning the licensed provider does not have to be physically on the premises at the time of the service. However, the licensed therapist must provide face-to-face supervision at least monthly.
  • Occupational Therapy Aides require direct supervision by a licensed occupational therapist or a certified occupational therapy assistant. This means the licensed provider must be present in the office and immediately available to the aide.
  • Physical Therapy Assistants are licensed professionals and do not require any form of supervision.
  • Physical Therapy Aides require direct supervision, meaning that the licensed provider must be on the premises.
  • Physical Therapy services are allowed as Telehealth.  No additional reimbursement is available other than the therapy service itself.
  • Temporarily licensed therapists can never supervise anyone.

Services Included
Covered therapy services include the following:

  • Restorative therapy services when the particular services are reasonable and necessary to the treatment of the member’s condition and subsequent improvement of function. The amount and frequency of services provided must be indicated on the member’s IEP.
  • Assessment services to determine member medical needs and/or to establish an IEP, as long as the assessment results in health-related services documented in the IEP.

Service Requirements
For all therapies being billed, they must be included in the student’s IEP.

Services Restricted

  • Montana Medicaid does not cover therapy services that are intended to maintain a member’s current condition but only covers services to improve member functions.

Private Duty Nursing Services
Private duty nursing services are skilled nursing services provided by a registered or licensed practical nurse.

Service Requirements
Medicaid covers private duty nursing services when all of the following requirements are met:

  • When the member’s attending physician or mid-level practitioner orders these services in writing
  • When prior authorization (PA) is obtained. (See the Prior Authorization chapter in this manual for PA requirements.)

School Psychologists and Mental Health Services
Psychological services in schools are based on determining eligibility for inclusion in special education programming and not necessarily to determine a medical diagnosis outside of the guidelines of the Individuals with Disabilities Education Act.

Services Included
Psychological and mental health services include the following:

  • Individual psychological therapy.
  • Psychological tests and other assessment procedures when the assessment results in health-related services being written into the IEP.
  • Interpreting assessment results.
  • Obtaining, integrating and interpreting information about child behavior and conditions as it affects learning, if it results in an IEP. This only includes direct face-to-face service.
  • Mental health and counseling services that are documented on the member’s IEP.
  • Consultation with the child’s parent as part of the child’s treatment.

Service Requirements
Medicaid covers psychological counseling services when the following two criteria are met:

  • The member’s IEP includes a behavior management plan that documents the need for the services.
  • Service is not provided concurrently with CSCT services (unless prior authorization has been obtained).

Services Restricted
Montana Medicaid does not cover the following psychological services:

  • Testing for educational purposes
  • Psychological evaluation, if provided to a child when an IEP is not subsequently established
  • Review of educational records
  • Classroom observation
  • Scoring tests

Personal Care Paraprofessional Services
Personal care paraprofessional services are medically necessary in-school services provided to members whose health conditions cause them to be limited in performing activities of daily living. That is, these services are provided for members with functional limitations.

The school district must maintain documentation of each service provided, which may take the form of a trip log.

Services Included
These activities of daily living services include:

  • Dressing
  • Eating
  • Escorting on bus
  • Exercising (ROM)
  • Grooming
  • Toileting
  • Transferring
  • Walking

Service Requirements

  • These services must be listed on the member’s IEP.
  • Approval must be given by the member’s primary care provider prior to billing for Medicaid covered services. Billing for these services cannot be claimed until the primary care provider signs and dates the Child Profile form.  Claiming can start on the date of the signature.  This is done by use of the Child Profile Form located in Appendix B.

Services Restricted
Medicaid does not cover the following services provided by a personal care paraprofessional:

  • Skilled care services that require professional medical personnel
  • Instruction, tutoring or guidance in academics
  • Behavioral management

See the Personal Care Paraprofessional Services Documentation, which includes the child profile and service delivery record. The child profile provides detailed examples of activities of daily living.

Medicaid does not cover special transportation services on a day that the member does not receive a Medicaid covered service that is written into the IEP.

Special Needs Transportation
Special needs transportation includes transportation services for members with special needs for the purpose of obtaining non-emergency medical services that are outside of traditional transportation services provided for members without disabilities.

Services Include
Special needs transportation services are covered when all of the following criteria are met:

  • Transportation is provided to and/or from a Medicaid-covered service on the day the service was provided.
  • The Medicaid-covered service is included in the member’s IEP.
  • The member must be in need of a specialized wheelchair or subject to transport by stretcher.

Specialized transportation services are covered if one of the following conditions exists :

  • A member requires transportation in a vehicle adapted to service the needs of students with disabilities, including a specially adapted school bus.
  • A member resides in an area that does not have school bus transportation (such as those in close proximity to a school).
  • The school incurs the expense of the service regardless of the type of transportation rendered.

Services Included
Special needs transportation includes the following:

  • Transportation from the member’s place of residence to school (where the member receives health-related services covered by the Montana School-Based Services Program, provided by school), and/or return to the residence.
  • Transportation from the school to a medical provider’s office who has a contract with the school to provide health-related services covered by the Montana School-Based Services Program, and return to school.
     

Services Restricted
Members with special education needs who ride the regular school bus to school with other non-disabled children in most cases will not have a medical need for transportation services and will not have transportation listed in their IEP. In this case, the bus ride should not be billed to the Montana School-Based Services Program. The fact that members may receive a medical service on a given day does not necessarily mean that special transportation also would be reimbursed for that day.

Audiology
Audiology assessments are performed by individuals possessing the state of Montana credentials for performing audiology services.

Services Included
Covered audiology services include the following:

  • Assessment to determine member’s medical needs and/or to establish an IEP, as long as the assessment results in health-related services documented in the IEP.
  • Services provided must be documented in the member’s IEP.

Service Requirements
Medicaid covers audiology services when the services to be provided during a school year are written into the child’s IEP.

Services Restricted
Medicaid does not cover the following audiology services:

  • Testing for educational purposes.
  • Services provided during Child Find assessments.

Orientation and Mobility Specialist Services
Orientation and Mobility Specialist services are medically necessary in-school services provided to students to alleviate movement deficiencies resulting from a lack of vision.

Orientation and Mobility Specialists need to have a certification by the Academy for Certification of Vision Rehabilitation and Education Professionals (ACVREP) or a National Orientation & Mobility Certification (NOMC) offered by the National Blindness Professional Certification Board (NBPCB). The credential is valid for a period of 5 years and is renewable by documenting work and/or participation in professional activities.

Services Included
Orientation & Mobility Specialist service include the following:

  • Sensory integrative techniques to enhance sensory processing and promote adaptive responses to environmental demands, direct one-on-one patient contact by provider. This includes assessment type services.
  • Self-care/home management training (e.g., ADLs and compensatory training, instruction in use of assistive technology devices/adaptive equipment) direct one-on-one contact by provider.
  • See School-Based fee schedule online for the correct CPT codes to use when billing.

Authorization Requirements Summary
The following table is a summary of authorization requirements for school-based services that were described in each section above. For more information on how to obtain prior authorization and Passport provider approval, see the Prior Authorization and Passport to Health chapters in this manual.

Authorization Requirements

Service:  Therapy
Prior Authorization:  No
Passport Provider Approval:  No
Written Physician Order/Referral:  No

Service:  Private Duty Nursing
Prior Authorization:  Yes
Passport Provider Approval:  No
Written Physician Order/Referral:  Yes
 

Service:  School Psychologist and Mental Health
Prior Authorization:  No
Passport Provider Approval:  No
Written Physician Order/Referral:  No

Service:  Personal Care Paraprofessional
Prior Authorization:  No
Passport Provider Approval:  No
Written Physician Order/Referral:  Yes (Child Profile Form is signed by child’s physician.)

Service:  Specialized Transportation
Prior Authorization:  No
Passport Provider Approval:  No
Written Physician Order/Referral:  No

Service:  Audiology
Prior Authorization:  No
Passport Provider Approval:  No
Written Physician Order/Referral:  No

Service:  Orientation & Mobility
Prior Authorization:  No
Passport Provider Approval:  No
Written Physician Order/Referral:  No

Other Programs

This is how the information in this chapter applies to Department programs other than Medicaid.

Children’s Mental Health Services Plan (CMHSP)
The school-based services in this manual are not covered benefits of the Children’s Mental Health Services Plan (CMHSP) administered by the Children’s Mental Health Bureau. However, the mental health services in this chapter are covered benefits for Medicaid members. For more information on the CMHSP program, see the mental health annual available on the Provider Information website (see Key Contacts).

Healthy Montana Kids (HMK)
The school-based services in this manual are not covered benefits of Healthy Montana Kids (HMK). Additional information regarding HMK benefits is available by contacting Blue Cross and Blue Shield of Montana (BCBSMT) at 1-800-447-7828 (toll-free) or 406-447-7828 (Helena).

 

End of Covered Services Chapter

 

Passport to Health Program

 

What Is Passport to Health? (ARM 37.86.5101–5120, ARM 37.86.5303, and ARM 37.86.5201–5206)

Passport to Health is the managed care program for Montana Medicaid and
Healthy Montana Kids (HMK) Plus members. The four Passport programs encourage
and support Medicaid and HM Plus members and providers in establishing a
medical home and in ensuring the appropriate use of Medicaid and HMK Plus services:

  • Passport to Health Primary Care Case Management
  • Team Care
  • Nurse First Advice Line
  • Health Improvement Program

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

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

Passport to Health Primary Care Case Management (ARM 37.86.5101–5120)
The Passport provider provides primary care case management (PCCM) services to their members. This means he/she provides or coordinates the member’s care and makes referrals to other Montana Medicaid and HMK Plus providers when necessary. Under Passport, Medicaid, and HMK Plus members choose one primary care provider (PCP) and develop an ongoing relationship that provides a medical home. The medical home is a concept that encourages a strong doctor–member relationship. An effective medical home is accessible, continuous, comprehensive, coordinated, and operates within the context of family and community.

With some exceptions, all services to Passport members must be provided or approved by the member’s Passport provider or Medicaid/HMK Plus will not reimburse for those services. The member’s Passport provider is also referred to as the PCP. (See the section titled Services That Do Not Require Passport Provider Approval in this chapter.)

Different codes are issued for Passport approval and prior authorization, and both must be recorded on the claim form, if appropriate.

Team Care (ARM 37.86.5303)
Team Care is designed to educate members to effectively access medical care. Members with a history of using services at an amount or frequency that is not medically necessary are enrolled in Team Care. Members enrolled in Team Care are also enrolled in Passport. Team Care follows the same Passport rules and guidelines for referrals, enrollment/disenrollment, prior authorization, and billing processes. However, while Passport members can change providers without cause, as often as once a month, Team Care members are locked in to one provider and one pharmacy. Providers are encouraged to make a referral to the Team Care Program Officer if they feel one of their members is appropriate for the program. A Passport provider receives an enhanced case management fee of $6 per member per month for Team Care members. When checking Medicaid or HMK Plus eligibility on the MATH web portal, a Team Care member’s provider and pharmacy will be listed. (See Key Websites.) Write all Medicaid and HMK Plus prescriptions to the designated pharmacy.

Nurse First Advice Line
The Nurse First Advice Line, 1-800-330-7847, is a 24/7, toll-free, confidential nurse triage line staffed by licensed registered nurses, and is available to all Montana Medicaid, HMK, and HMK Plus members. There is no charge to members or providers. Members are encouraged to use the Nurse First Advice Line as their first resource when they are sick or hurt. Registered nurses are available 24/7 to triage members over the phone and recommend appropriate care. Health coaches are also available to answer general health or medication questions. Nurses do not diagnose or provide treatment. The Nurse First Advice Line will fax a triage report to the Passport PCP when one of their members calls to be triaged.

Passport providers are encouraged to provide education to their members regarding the appropriate use of the emergency department (ED), including using the Nurse First Advice Line before going to the ED.

Health Improvement Program (ARM 37.86.5201–5206)
The Health Improvement Program (HIP) is for Medicaid and HMK Plus members with chronic illnesses or risks of developing serious health conditions. HIP is operated statewide through a regional network of 14 community and tribal health centers. Medicaid and HMK Plus members eligible for the Passport program are enrolled and assigned to a health center for case management. Current Passport members stay with their PCPs for primary care, but are eligible for case management services through HIP. Nurses and health coaches certified in professional chronic care will conduct health assessments; work with PCPs to develop care plans; educate members in self-management and prevention; provide pre- and post-hospital In practice, providers will most often encounter Medicaid and HMK Plus members
who are enrolled in Passport. Specific services may also require prior authorization
(PA) even if the member is a Passport enrollee. Specific PA requirements
can be found in the provider fee schedules. For more information on Passport to
Health, see the General Information for Providers manual.discharge planning; help with local resources; and remind members about scheduling needed screening and medical visits.

Medicaid uses predictive modeling software to identify chronically ill members. This software uses medical claims, pharmacy and demographic information to generate a risk score for each member. Although the software will provide a great deal of information for interventions, it will not identify members who have not received a diagnosis or generated claims. PCPs may also identify and recommend Passport members at high risk for chronic health conditions that would benefit from case management from HIP using the HIP referral form included at the health Improvement Program link on the Provider Information website. (See Key Websites.)

In practice, providers will most often encounter Medicaid and HMK Plus members who are enrolled in Passport. Specific services may also require prior authorization (PA) even if the member is a Passport enrollee. Specific PA requirements can be found in the provider fee schedules. For more information on Passport to Health, see the General Information for Providers manual.

Other Programs

Members who are enrolled in the Mental Health Services Plan (MHSP) or Healthy Montana Kids (HMK) are not enrolled in Passport, so the Passport requirements in this chapter do not apply.

For more HMK information, contact Blue Cross and Blue Shield of Montana at 1-800-447-7828 (toll-free) or 447-7828 (Helena) Additional HMK information is available on the HMK website. (See Key Websites.)

 

End of Passport to Health Program Chapter

 

Prior Authorization

 

What Is Prior Authorization (ARM 37.86.5101–5120)

Prior authorization (PA), Passport to Health, and Team Care are three examples of the Department’s efforts to ensure the appropriate use of Medicaid services. In most cases, providers need approval before services are provided to a particular member. Passport approval and PA are different, and some services may require both. A different code is issued for each type of approval and must be included on the claim. (See the Submitting a Claim chapter in this manual.)

If a service requires PA, the requirement exists for all Medicaid members. When PA is granted, the provider is issued a PA number which must be on the claim. See below for instructions on how to obtain PA for covered services.

Some services require PA before they are provided, such as private duty nursing services. When seeking PA, keep in mind the following:

  • Always refer to the current Medicaid fee schedule to verify if PA is required for specific services.
  • The PA Criteria for Specific Services table lists services that require PA, who to contact, and specific documentation requirements.
  • Have all required documentation included in the packet before submitting a request for PA. (See the PA Criteria for Specific Services table for documentation requirements.)
  • When PA is granted, providers will receive notification containing a PA number. This PA number must be included on the claim.

Getting Questions Answered

The Key Contacts chapter at the front of this manual provides important phone numbers and addresses. Help lines are available to get general Medicaid questions answered.

PA Criteria for Specific Services

Service:  Private duty nursing

PA Contact:

Medicaid Utilization Review Dept.
Mountain Pacific Quality Health
P.O. Box 6488
Helena, MT 59604-6488

Questions regarding this process can be answered by calling:

Helena
(406) 443-4020 X150

Outside Helena
(800) 262-1545 X50

Fax
(406) 443-4585

Requirements:

The number of units approved for private duty nursing services is based on the time required to perform a skilled nursing task.

  • A prior authorization request must be sent to the Medicaid Utilization Review Department’s peer review organization accompanied by a physician or mid-level practitioner order/referral for private duty nursing.
  • Prior authorization must be requested at the time of initial submission of the nursing plan of care and any time the plan of care is amended.
  • Providers of private duty nursing services are responsible for requesting prior authorization and obtaining renewal of prior authorization.
  • Requests for prior authorization must be obtained for the regular school year (August/September through May/June). Services provided during the summer months must be prior authorized in addition to the services provided during the regular school year. Remember, schools are responsible for obtaining the physician orders for new or amended requests for prior authorization. Prior authorization requests must be submitted to Mountain Pacific Quality Health in advance of providing the service.
  • Providers are required to send in prior authorization requests two weeks prior to the current prior authorization request end date for members receiving ongoing services.
  • Total number for units of service paid on claims must not exceed those authorized by the Medicaid Utilization Review Department. Payment will not be made for units of service in excess of those approved.
  • No retrospective prior authorization reviews will be allowed.
  • To request prior approval submit a completed Request for Private Duty Nursing Services form located on the Provider Information website under Forms. Send completed requests to the contact shown in the second column.

 

Other Programs

The Children’s Mental Health Services Plan (CMHSP) and Healthy Montana Kids (HMK) do not cover school-based services. For more information on these programs, visit the Provider Information website. (See Key Websites.)

 

End of Prior Authorization Chapter

 

Coordination of Benefits

 

When Members Have 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 must bill other carriers before billing Medicaid, but there are some exceptions. (See Exceptions to Billing Third Party First later in this chapter.) Medicare coverage is processed differently than other sources of coverage.

Identifying Other Sources of Coverage

The member’s Medicaid eligibility verification may identify other payers such as
Medicare or other third party payers. (See Member Eligibility and Responsibilities
in the General Information for Providers manual.) If a member has Medicare, the
Medicare ID number is provided. If a member has other coverage (excluding
Medicare), it will be shown under the TPL section. 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 Medicaid eligibility verification.

Providers must 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 claims involving other payers. The other sources of coverage are referred to as third party liability (TPL), but Medicare is not.

Medicare Part B Crossover Claims
Medicare Part B covers outpatient hospital care, physician care, and other services including those provided in a school setting. The Department has an agreement with Medicare Part B carrier for Montana (Noridian) and the Durable Medical Equipment Regional Carrier [DMERC]). Under this agreement, the carrier provide the Department with a magnetic tape of 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 NPI on file with Medicaid.

To avoid confusion and paperwork, submit Medicare Part B crossover claims to Medicaid only when necessary.

In these situations, providers need not submit Medicare Part B crossover claims to Medicaid. 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 Billing Procedures.)

When Medicare Pays or Denies a Service

  • When Medicare automatic crossover claims are paid or denied, they should automatically cross over to Medicaid for processing, so the provider does not need to submit the claim to Medicaid.
  • When Medicare crossover claims are billed on paper and are paid or denied, the provider must submit the claim to Medicaid with the Medicare EOMB (and the explanation of denial codes).

When submitting electronic claims with paper attachments, see the Billing Electronically with Paper Attachments section of the Billing Procedures chapter in this manual.

When Medicaid Does Not Respond to Crossover Claims
When Medicaid does not respond within 45 days of the provider receiving the Medicare EOMB, submit a claim with a copy of the Medicare EOMB to Medicaid for processing.

Submitting Medicare Claims to Medicaid

When submitting a paper claim to Medicaid, use Medicaid billing instructions and codes. Medicare’s instructions, codes, and modifiers may not be the same as Medicaid’s. The claim must include the provider’s NPI and Medicaid member ID number. The Medicare EOMB and explanation of denial codes are required only if the claim was denied.

Remember to submit Medicare crossover claims to Medicaid only when:

 

  • The referral to Medicaid statement is missing from the provider’s EOMB.
  • The provider does not hear from Medicaid within 45 days of receiving the Medicare EOMB.
  • Medicare denies the claim.

 

All Part B crossover claims submitted to Medicaid before Medicare’s 45-day response time will be returned to the provider.

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.

If a parent determines that billing their insurance would cause a financial hardship (e.g., decrease lifetime coverage or increase premiums), and refuses to let the school bill the insurance plan, the school cannot bill Medicaid for these services based on requirements of IDEA.

Providers are required to notify their members that any funds the member receives from third party payers equal to what Medicaid paid (when the services were billed to Medicaid) must be turned over to the Department. Amounts in excess of what Medicaid paid must be returned to the provider. The following words printed on the member’s statement will fulfill this requirement: “When services are covered by Medicaid and another source, any payment the member receives from the other source must be turned over to Medicaid.”

If a parent refuses to let the school bill their insurance plan, Medicaid cannot be billed either.

CSCT Services
Procedure H0036 and H2027 are Medicaid-only code and other insurances do not recognize them as a valid procedure codes. Providers of CSCT services must bill the appropriate CPT codes to other payers, as those payers require (i.e., licensed staff may provide an individual therapy to a child in CSCT, bill CPT code that best describes service provided). When billing Medicaid after TPL, submit total charges/units for that date under the H0036 code and enter the amount paid by the other insurance on the claim. Do not bill CSCT services under any other code than H0036 to Medicaid.

Billing for Medicaid Covered Services When No IEP Exists
In order to bill for Medicaid covered services that are not in the member’s IEP, the school must meet all the following requirements:

  • A fee schedule is established for health-related services (can be a sliding scale to adjust for individuals with low incomes)
  • The provider determines if each individual who receives services has insurance coverage or will be billed on a private-pay basis
  • The provider bills all individuals and/or the insurance carrier for the medical service provided

If the school bills private pay members, then they must bill as follows for the services provided:

Member Insurance Status: Medicaid only*
Billing Process: Bill Medicaid

Member Insurance Status: Private pay, no Medicaid
Billing Process: Bill family

Member Insurance Status: Private insurance/Medicaid*
Billing Process: Bill private insurance before Medicaid

Member Insurance Status: Private insurance, no Medicaid*
Billing Process: Bill private insurance

*Note: Under FERPA, schools must have written parental permission for release of information before billing Medicaid. For billing third party insurances, schools must have written permission for billing and written permission for release of information.

 

Billing for Medicaid Covered Services under an IEP
If a child is covered by both Medicaid and private insurance, and the services are provided under an IEP, providers must bill as follows:

Member Insurance Status: Medicaid only*
Billing Process: Bill Medicaid

Member Insurance Status: Private pay, no Medicaid
Billing Process: Not required to bill family

Member Insurance Status: Private insurance/Medicaid*
Billing Process: Bill private insurance before Medicaid

Member Insurance Status: Private insurance, no Medicaid
Billing Process: Not required to bill private insurance

*Note: Under FERPA, schools must have written parental permission for release of information before billing Medicaid. For billing third party insurances, schools must have written permission for billing and written permission for release of information.

 

 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 Montana Crime Victims Compensation Fund, providers must bill Medicaid before IHS or Crime Victims. These are not considered third party liability.
  • When a member has Medicaid eligibility and Children’s Mental Health Services Plan (CMHSP) eligibility for the same month, Medicaid must be billed before CMHSP.
  • When a child is covered under BCBSMT or HMK, providers may bill Medicaid first since these insurances do not cover services provided in a school setting.
  • Medicaid must be billed before IDEA funds are used.
  • Effective April 1, 2013, when a child is also covered by another insurance, and the service is provided by a school-based provider, no blanket denial form is required nor is any  information from the third party liability.

Requesting an Exemption
Providers may request to bill Medicaid first under certain circumstances. In each of these cases, the claim and required information must be sent directly to the TPL Unit. (See Key Contacts.)

  • If another insurance has been billed, and 90 days have passed with no response, include a note with the claim explaining that the insurance company has been billed, or include 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 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 directly to Medicaid in order to avoid missing the timely filing deadline.
  • When the Child Support Enforcement Division has required an absent parent to have insurance on a child, the claim can be submitted to Medicaid when 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.

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 in the “prior payments” form locator of the claim when submitting to Medicaid for processing.
  • Allows the claim, and the allowed amount went toward member’s deductible, include the insurance EOB when billing Medicaid.
  • Denies the claim, include a copy of the denial (including the denial reason codes) with the claim and submit to Medicaid. If a blanket denial is provided, the Department will accept and allow this denial for a period of no more than two years. The school must include a copy of this blanket denial with each submission for health-related services for each member. The blanket denial must be specific to the provider, member, and health related services provided to the member. Blanket denials issued to schools without a member’s name will not be accepted.
  • Denies a line on the claim, bill the denied lines together on a separate claim and submit to Medicaid. Include the explanation of benefits (EOB) from the other payer as well as an explanation of the reason for denial (e.g., definition of denial codes).

If the provider receives a payment from a third party after the Department has paid the provider, the provider must return the lower of the two payments to the Department within 60 days.

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:

  • Include a note with the claim explaining that the insurance company has been billed, or include 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. (See Key Contacts.)

 

End of Coordination of Benefits Chapter

Billing Procedures

 

Claim Forms

Services provided by the health care professionals covered in this manual must be billed either electronically on a Professional claim or on a CMS-1500 paper claim form. CMS-1500 forms 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

For claims involving Medicare or TPL, if the 12-month time limit has passed, providers must submit clean claims to Medicaid.

  • Medicare Crossover Claims: Six months from the date on the Medicare explanation of benefits approving the service (if the Medicare claim was timely filed and the member was 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. (See Key Contacts.)
  • If another insurer has been billed and 90 days have passed with no response, you can bill Medicaid. (See the Coordination of Benefits chapter in this manual for more information.)
  • To meet timely filing requirements for Medicare/Medicaid crossover claims, see the Coordination of Benefits chapter in this manual.

When Providers Cannot Bill Medicaid Members (ARM 37.85.406)

In most circumstances, providers may not bill Medicaid members for services covered under Medicaid.

More specifically, providers cannot bill members directly:

  • For the difference between charges and the amount Medicaid paid.
  • For a covered service provided to a Medicaid-enrolled member who was accepted as a Medicaid member by the provider, even if the claim was denied.
  • When the provider bills Medicaid for a covered service, and Medicaid denies the claim because of billing errors.
  • When a third-party payer does not respond.
  • When a member fails to arrive for a scheduled appointment.
  • When services are free to the member and free to non-Medicaid covered individuals.

If a provider bills Medicaid and the claim is denied because the member is not eligible, the provider may bill the member directly.

Member Cost Sharing (ARM 37.85.204 and 37.85.402)

There is no member cost sharing for school-based services.

Billing for Members with Other Insurance

If a Medicaid member is also covered by Medicare, has other insurance, or some other third party is responsible for the cost of the member’s health care, see the Coordination of Benefits chapter in this manual.

Billing for Retroactively Eligible Members

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 private-pay.

When the provider accepts the member’s retroactive eligibility, the provider has 12 months from the date retroactive eligibility was determined to bill for those services. When submitting claims for retroactively eligible members, attach a copy of the FA-455 (eligibility determination letter) to the claim if the date of service is more than 12 months earlier than the date the claim is submitted. Providers may need to contact the member’s local office of public assistance. (See the General Information for Providers manual.)

When a provider chooses to accept the member from the date retroactive eligibility was effective, and the member has made a full or partial payment for services, the provider must refund the member’s payment for the services before billing Medicaid for the services.

Service Fees

The Office of Management and Budget (OMB A-87) federal regulation specifies one government entity may not bill another government entity more than their cost. Schools should bill Medicaid their cost of providing a service, not the fee published by Medicaid for the service. The Medicaid fee schedule is to inform provider of the maximum fee Medicaid pays for each procedure.

Coding Tips

The procedure codes listed in the following table are valid procedures for schools to use for billing Medicaid.

School-Based Services Codes

Occupational Therapist


Service: Occupational therapy – individual therapeutic activities
CPT Code: 97530
Unit Measurement: 15-minute unit

Service: Occupational therapy – group therapeutic procedures
CPT Code: 97150
Unit Measurement: Per visit

Service: Occupational therapy evaluation - low 20 minutes
CPT Code: 97165
Unit Measurement: Per visit

Service: Occupational therapy evaluation - moderate - 30 minutes
CPT Code: 97166
Unit Measurement: Per visit

Service: Occupational therapy evaluation - high - 45minutes
CPT Code: 97167
Unit Measurement: Per visit

Service: Occupational therapy re-evaluation
CPT Code: 97168
Unit Measurement: Per visit

Physical Therapist


Service: Physical therapy – individual therapeutic activities
CPT Code: 97530
Unit Measurement: 15-minute unit

Service: Physical therapy – group therapeutic procedures
CPT Code: 97150
Unit Measurement: Per visit

Service: Physical therapy evaluation - low - 20 minutes
CPT Code: 97161
Unit Measurement: Per visit

Service: Physical therapy evaluation - moderate - 30 minutes
CPT Code: 97162
Unit Measurement: Per visit

Service: Physical therapy evaluation - high 45 minutes
CPT Code: 97163
Unit Measurement: Per visit

Service: Physical therapy re-evaluation
CPT Code: 97164
Unit Measurement: Per visit


Speech Therapists


Service: Evaluation of speech fluency
CPT Code: 92521
Unit Measurement: Per visit

Service: Evaluation of speech sound production
CPT Code: 92522
Unit Measurement: Per visit

Service: Evaluation of speech sound with language comprehension
CPT Code: 92523
Unit Measurement: Per visit


Private Duty Nursing


Service: Private duty nursing services provided in school
CPT Code: T1000
Unit Measurement: 15-minute unit


School Psychologist/Mental Health Services


Service: Psychological therapy – individual
CPT Code: 90832
Unit Measurement: Per 30-minute unit

Service: Psychological therapy – group
CPT Code: 90853
Unit Measurement: Per visit


CSCT Program

Service: CSCT services
CPT Code: H0036
Unit Measurement: 15-minute unit

Service: Psychoeducational Services (CSCT)
CPT Code: H2027
Unit Measurement: 15-minute unit

Personal Care Paraprofessionals


Service: Personal care services
CPT Code: T1019
Unit Measurement: 15-minute unit


Special Needs Transportation


Service: Special needs transportation
CPT Code: T2003
Unit Measurement: Per one-way trip


Audiology


Service: Audiology evaluation
CPT Code: 92557
Unit Measurement: Per visit

Service: Tympanometry
CPT Code: 92567
Unit Measurement: Per visit

Service: Evoked otoacoustic emission; limited
CPT Code: 92587
Unit Measurement: Per visit

Orientation & Mobility


Service: Sensory integrative techniques
CPT Code: 97533
Unit Measurement: 15-minute unit

Service: Self-care/home management training
CPT Code: 97535
Unit Measurement: 15-minute unit

 

Using Modifiers
School-based services providers only use modifiers for coding when the service provided to a member is not typical. The modifiers are used in addition to the CPT codes. The following modifiers may be used in schools:

  • Modifier 52 is billed with the procedure code when a service is reduced from what the customary service normally entails. For example, a service was not completed in its entirety as a result of extenuating circumstances or the well being of the individual was threatened.
  • Modifier 22 is billed with the procedure code when a service is greater than the customary service normally entails. For example, this modifier may be used when a service is more extensive than usual or there was an increased risk to the individual. Slight extension of the procedure beyond the usual time does not validate the use of this modifier.
  • Modifier 59 is billed for therapies in accordance with the Correct Coding Initiative (CCI) and to be used when codes are considered mutually exclusive or a component of one another.
  • Modifiers may also be required when providing two services in the same day that use the same code. See the section titled Multiple Services on the Same Date” for more information.

Multiple Services on the Same Date
When a provider bills Medicaid for two services that are provided on the same day that use the same CPT code and are billed under the same NPI and taxonomy, a modifier should be used to prevent the second service from being denied. The modifier GO is used for occupational therapy, and modifier GP is used for physical therapy. One of the codes needs to have modifier 59 also for the CCI edit. For example, a school bills with one NPI and taxonomy for all services. The school provided occupational therapy for a member in the morning, and physical therapy for the same member in the afternoon of October 14, 2003. The claim would be billed like this:

Image of two line items from a claim for multiple services on the same date.

Time and Units

  • A provider may bill only time spent directly with a member. Time spent traveling to provide a service and paperwork associated with the direct service cannot be included in the time spent providing a service.
  • Some CPT codes are designed to bill in units of 15 minutes (or other time increment) and others are per visit.
  • If the service provided is using a per visit code, providers should use one unit of service per visit.
  • When using codes that are based on a 15-minute time unit, providers should bill one unit of service for each 15-minute period of service provided. Units round up to the next unit after 8 minutes.

Place of Service
The only place of service code Montana Medicaid will accept is “03” (schools).

Billing for Specific Services

The following are instructions for billing for school-based services. For details on how to complete a CMS-1500 claim form, see the Submitting a Claim chapter in this manual.

School-based providers can only bill services in the amount, scope, and duration listed in the IEP. 

Assessment to Initiate an IEP
When billing for assessments (evaluations), use the CPT code for the type of service being billed. When the unit measurement is “per visit,” only one unit may be billed for the assessment/evaluation. If the evaluation is completed over the course of several days, it is considered one evaluation. Bill the date span with 1 unit of service, not multiple units of service. For example, a speech/hearing evaluation completed over a three-day period would be billed like this:

Speech/hearing evaluation sample biling

A two-hour psychological assessment (evaluation) would be billed like this (the unit measurement for this code is “per hour”):

Two Hour Psychiatric Assessment Biling Example

Therapy Services
Services may be performed by a therapy assistant or therapy aide but must be billed to Medicaid under the school’s NPI and taxonomy. Schools are responsible for assuring the proper supervision is provided for aides/assistants. (See the Covered Services chapter.) Remember to use the CCI edit modifier for all three types of therapy: speech, occupational and physical. See the Submitting a Claim chapter in this manual. Thirty minutes of individual physical therapy would be billed like this (the unit measurement for this code is “15-minute unit”):

Image of line item for therapy services.

Private Duty Nursing Services
Prior authorization is required for these services, so remember to include the prior authorization number on the claim. (See the Submitting a Claim chapter in this manual.) Private duty nursing services provided for 15 minutes would be billed like this:

Image of a single line of a claim from private duty nursing services.

Medicaid covered services provided under an IEP are exempt from the “free care rule.”

School Psychologists and Mental Health Services
A psychological therapy session of 30 minutes would be billed like this (the unit measurement for this code is per 30-minute unit):

Psychological therapy sample billing

Personal Care Paraprofessional Services
Personal care services provided to a member for 2 hours during a day would be billed like this (the unit measurement for this code is per 15-minute unit):

Image of a claim line for Personal Care services.

Special Needs Transportation
School districts must maintain documentation of each service provided, which may take the form of a trip log. Schools must bill only for services that were provided. Special transportation should be billed on a per one-way trip basis. For example, if a member was transported from his/her residence to school and received Medicaid covered health-related services that day, and then transported back to his/her residence, it would be billed like this:

Image of a claim line for Special needs transportation services.

Audiology
An audiology assessment would be billed like this (the unit measurement for this code is per visit):

Image of a claim line for audiology services.

Submitting Electronic Claims

Providers who submit claims electronically experience fewer errors and quicker payment.  Claims may be submitted using the methods below.  For detailed submission methods, see the electronic submissions manual on the Electronic Billing page of the website.

  • WINASAP 5010. This free software provided by Conduent allows for the creation of basic claim submissions.  Please note that this software is not compatible with Windows 10 and has limited support as it is free software.

o    Utilizes either a dial-up modem or submissions through the Montana Access to Health (MATH) Web Portal.

o    Requires completion of the X12N Transaction Packet to allow for claim submissions.

  • Clearinghouses/Contracted Claim Submitter.  Providers can make arrangements with a clearinghouse/contracted claim submitter for claim submission.  Please note that the clearinghouse must be enrolled to submit claims to Montana Medicaid.

o    To have an 835 file be delivered to the clearinghouse, an 835 Request form will need to be completed.

  • Montana Access to Health (MATH) Web Portal.  A secure website that allows providers to verify eligibility, check claim status, and view medical claims history.  Valid X12N files can be uploaded through this website.

o    Requires completion of the X12N Transactions Packet to allow for claim submissions.

  • MoveIt DMZ.  This secure transfer protocol is for providers and clearinghouses that submit large volumes of files (in excess of 20 per day) or are regularly submitting files larger than 2 MB.  This utilizes SFTP and an intermediate storage area for the exchange of files.

o    A request for this must be made through Conduent Provider Relations for established trading partners.

Providers should be familiar with federal rules and regulations related to electronic claims submission.

For more information on electronic claims submission options, contact Provider Relations or the EDI Technical Help Desk. (See the Key Contacts chapter.) Providers should be familiar with federal rules and regulations and Montana-specific information for sending and receiving electronic transactions. They are available on the EDI Gateway website. (See Key Websites.)

Billing Electronically with Paper Attachments

When submitting claims that require additional supporting documentation, the Attachment Control Number field must be populated with an identifier. Identifier formats can be designed by software vendors or clearinghouses, but the preferred method is the provider’s NPI followed by the member’s ID number and the date of service, each separated by a dash:

Attachment Control Number 1st box NPI, 2nd Box Member ID Number, 3rd Box Date of Service in the MMDDYYYY format

The supporting documentation must be submitted with a paperwork attachment cover sheet. See the Forms page of the Provider Information website. The number in the paper Attachment Control Number field must match the number on the cover sheet.

Submitting Paper Claims

For instructions on completing a paper claim, see the Submitting a Claim chapter in this manual. Unless otherwise stated, all paper claims must be mailed to:

Claims Processing
P.O. Box 8000
Helena, MT 59604

Claim Inquiries

Contact Provider Relations for claim questions, or questions regarding payments, denials, member eligibility.

Provider Relations will respond to the inquiry within 10 days. The response will include the status of the claim: paid (date paid), denied (date denied), or in process. Denied claims will include an explanation of the denial and steps to follow for payment (if the claim is payable).

The Most Common Billing Errors and How to Avoid Them

Paper claims are often returned to the provider before they can be processed, and many other claims (both paper and electronic) are denied.

To avoid unnecessary returns and denials, double check each claim to confirm the following items are included and accurate.

Common Billing Errors


Reasons for Return or Denial: Provider NPI missing or invalid
How to Prevent Returned or Denied Claims: The provider NPI is a 10-digit number assigned to the provider by the National Plan and Provider Enumeration System. Verify the correct provider NPI is on the claim.

Reasons for Return or Denial: Authorized signature missing
How to Prevent Returned or Denied Claims: Each claim must have an authorized signature belonging to the provider, billing clerk, or office personnel. The signature may be typed, stamped, hand-written, or computer generated.

Reasons for Return or Denial: Signature date missing
How to Prevent Returned or Denied Claims: Each claim must have a signature date.

Reasons for Return or Denial: Incorrect claim form used
How to Prevent Returned or Denied Claims: The claim must be the correct form for the provider type. Services covered in this manual require a CMS-1500 claim form (or electronic Professional claim).

Reasons for Return or Denial: Information on claim form not legible
How to Prevent Returned or Denied Claims: Information on the claim form must be legible. Use dark ink and center the information in the form locator. Information must not be obscured by lines.

Reasons for Return or Denial: Member number not on file, or member was not eligible on date of service
How to Prevent Returned or Denied Claims: Before providing services to the member, verify member eligibility by using one of the methods described in the Member Eligibility and Responsibilities chapter of the General Information for Providers manual. Medicaid eligibility may change monthly.

Reasons for Return or Denial: Prior authorization number is missing
How to Prevent Returned or Denied Claims: Prior authorization (PA) is required for certain services, and the PA number must be on the claim. See the Prior Authorization chapters in this manual.

Reasons for Return or Denial: Prior authorization does not match current information
How to Prevent Returned or Denied Claims: Claims must be billed and services performed during the prior authorization span. The claim will be denied if it is not billed according to the spans on the authorization.

Reasons for Return or Denial: Duplicate claim
How to Prevent Returned or Denied Claims: Check all remittance advices (RAs) for previously submitted claims before resubmitting. When making changes to previously paid claims, submit an adjustment form rather than a new claim (see the Remittance Advices and Adjustments chapter in this manual).

Reasons for Return or Denial: TPL on file and no credit amount on claim
How to Prevent Returned or Denied Claims: If the member has any other insurance (or Medicare), bill the other carrier before Medicaid. See the Coordination of Benefits chapter in this manual. If the member’s TPL coverage has changed, providers must notify the TPL unit (see the Key Contacts chapter) before submitting a claim.

Reasons for Return or Denial: Claim past 12-month filing limit
How to Prevent Returned or Denied Claims: The Claims Processing Unit must receive all clean claims and adjustments within the timely filing limits described in this chapter. To ensure timely processing, claims and adjustments must be mailed to Claims Processing at the address shown in the Key Contacts chapter.

Reasons for Return or Denial: Missing Medicare EOMB
How to Prevent Returned or Denied Claims: All denied Medicare crossover claims must have an Explanation of Medicare Benefits (EOMB) with denial reason codes attached, and be billed to Medicaid on paper.

Reasons for Return or Denial: Provider is not eligible during dates of services, enrollment has lapsed due to licensing requirements, or provider NPI terminated
How to Prevent Returned or Denied Claims: Out-of-state providers must update licensure for Medicaid enrollment early to avoid denials. If enrollment has lapsed due to expired licensure, claims submitted with a date of service after the expiration date will be denied until the provider updates his or her enrollment. New providers cannot bill for services provided before Medicaid enrollment begins. If a provider is terminated from the Medicaid program, claims submitted with a date of service after the termination date will be denied.

Reasons for Return or Denial: Procedure is not allowed for provider type
How to Prevent Returned or Denied Claims: Provider is not allowed to perform the service. Verify the procedure code is correct using current HCPCS and CPT billing manual. Check the appropriate Medicaid fee schedule to verify the procedure code is valid for your provider type.

 

Other Programs

The Mental Health Services Plan (MHSP) and Healthy Montana Kids (HMK) do not cover school-based services. For more information on these programs, visit the Provider Information website.

Additional information regarding HMK benefits is available on the HMK website or by contacting Blue Cross and Blue Shield of Montana (BCBSMT) at 1-800-447-7828 (toll-free) or 406-447-7828 (Helena).

 

End of Billing Procedures Chapter

 

Submitting a Claim

 

The services described in this manual are billed either electronically on a Professional claim or on a CMS-1500 paper claim form. Claims submitted with all of the necessary information are referred to as “clean” and are usually paid in a timely manner (see the Billing Procedures chapter in this manual). When completing a claim, remember the following:

  • Required fields are indicated by *.
  • Fields that are required if the information is applicable to the situation or member are indicated by **.
  • Field 24h, EPSDT/Family Planning, is used as an indicator to specify additional details for certain members or services. The following are accepted codes:

EPSDT/Family Planning Indicator

Code: 1    Member/Service: EPSDT
Purpose: Overrides some benefit limits for client under age 21.

Code: 2    Member/Service: Family planning
Purpose: Overrides the Medicaid cost sharing and Passport authorization on the line.

Code: 3    Member/Service: EPSDT and family planning
Purpose: Overrides Medicaid cost sharing and Passport authorization for persons under the age of 21.

Code: 4    Member/Service: Pregnancy (any service provided to a pregnant woman)
Purpose: Overrides Medicaid cost sharing on the claim.

Code: 6    Member/Service: Nursing facility client
Purpose: Overrides the Medicare edit for oxygen services on the line.

 

  • Unless otherwise stated, all paper claims must be mailed to the following address:

Claims Processing Unit
P.O. Box 8000
Helena, MT 59604

Sample Claim

Member Information


Field: 2*
Field Title: Member's Name
Instructions: Enter patient's name as seen on member’s Montana Health Care Programs information

Field: 10d *
Field Title: Member’s ID
Instructions: Enter the member’s ID number as it appears on the member’s Montana Health Care Programs information.

Field: 1a, 9a, 11**
Field Title: Member’s ID
Instructions: If member’s ID is not located in 10d these three fields are searched for the number.

Field: 24h*
Field Title: EPSDT Family Planning
Instructions: When billing electronically, use “Y.” When billing on paper, use “1.”

Provider Information


Field: 24a shaded area
Field Title: NDC
Instructions: Enter the qualifier, N4, followed by the NDC (NDC should not have punctuation, dashes or spaces), units qualifier and units as described by the qualifier

Field: 24i  shaded**
Field Title: ID Qualifier
Instructions: ZZ for the Taxonomy qualifier.

Field: 24j shaded**
Field Title: Taxonomy Code
Instructions: Enter the Taxonomy code for the rendering provider.

Field: 24j **
Field Title: NPI, Rendering Prov
Instructions: Enter NPI Number for the rendering provider.

Field: 31*
Field Title: Signature and Date
Instructions: Enter Signature and Date.

Field: 33*
Field Title: Billing Provider Info
Instructions: Enter Physical Address with a 9 digit ZIP code and phone number.

Field: 33a*
Field Title: NPI #
Instructions: Enter NPI number for billing/pay-to provider.

Field: 33b*
Field Title: Taxonomy #
Instructions: Enter the qualifier (ZZ) and the billing provider's taxonomy code.

Billing Information


Field: 21.1 - 21.4*
Field Title: Diagnosis codes Enter at least one diagnosis.

Field: 24a*
Field Title: Date(s) of Service
Instructions: Enter the dates of service include beginning and ending date even if same.

Field: 24b*
Field Title: Place of Service
Instructions: Enter the code for place of service.

Field: 24c**
Field Title: EMG
Instructions: Emergency Indicator if applicable.

Field: 24d*
Field Title: Procedure Code
Instructions: Enter the procedure code used.  Enter modifiers if applicable.

Field: 24e*
Field Title: Diagnosis Pointer
Instructions: Enter the corresponding diagnosis pointer (1,2,3,or 4) that refers to the codes in field 21

Field: 24f*
Field Title: Charges
Instructions: Enter the total charge for this line

Field: 24g*
Field Title: Days/Units
Instructions: Enter the days or units used for the procedure.

Field: 28*
Field Title: Total Charges
Instructions: Enter total charges from all line items.

*Required Field   **Required if applicable

 

Image of a CMS 1500 Claim form. 

CMS-1500 Agreement

Your signature on the CMS-1500 constitutes your agreement to the terms presented on the back of the form. This form is subject to change by the Centers for Medicare and Medicaid Services (CMS).

CMS 1500 Instructions and disclosures

Avoiding Claim Errors

Claims are often denied or even returned to the provider before they can be processed. To avoid denials and returns, double-check each claim to confirm the following items are accurate. For more information on returned and denied claims, see the Billing Procedures chapter in this manual.

Common Claim Errors

 

Claim Error: Required field is blank
Prevention: Check the claim instructions earlier in this chapter for required fields (indicated by * or **). If a required field is blank, the claim may either be returned or denied.

Claim Error: Member ID number missing or invalid
Prevention: This is a required field (field 10d); verify that the member’s Medicaid ID number is listed as it appears on the member’s ID card.

Claim Error: Member name missing
Prevention: This is a required field (field 2); check that it is correct.

Claim Error: Provider NPI missing or invalid
Prevention: The provider NPI is a 10-digit number assigned to the provider by the National Plan and Provider Enumeration System. Verify the correct provider NPI is on the claim.

Claim Error: Prior authorization number missing
Prevention: When prior authorization (PA) is required for a service, the PA number must be listed on the claim in field 23. (See the Prior Authorization chapter in this manual.)

Claim Error: Not enough information regarding other coverage
Prevention: Fields 1a and 11d are required fields when a member has other coverage. (Refer to the examples earlier in this chapter.)

Claim Error: Authorized signature missing
Prevention: Each claim must have an authorized signature belonging to the provider, billing clerk, or office personnel. The signature may be typed, stamped, or hand-written.

Claim Error: Signature date missing
Prevention: Each claim must have a signature date. Incorrect claim form used Services covered in this manual require a CMS-1500 claim form (or electronic Professional claim).
 
Claim Error: Information on claim form not legible
Prevention: Information on the claim form must be legible. Use dark ink and center the information in the field. Information must not be obscured by lines.

Claim Error: Medicare EOMB not attached
Prevention: When Medicare is involved in payment on a claim, the Medicare EOMB must be attached to the claim or it will be denied.

 

Other Programs

This chapter also applies to claims forms completed for MHSP services and Healthy Montana Kids (HMK) eyeglass services.

 

End of Submitting a Claim Chapter

 

Remittance Advices and Adjustments

 

The Remittance Advice

The Remittance Advice (RA) is the best tool providers have to determine the status of a claim. RAs accompany payment for services rendered. The RA provides details of all transactions that have occurred during the previous RA cycle. Each line of the RA represents all or part of a claim, and explains whether the claim or service has been paid, denied, or suspended (also referred to as pending).

The pending claims section of the RA is informational only. Do not take any action on claims displayed here.

If the claim was suspended or denied, the RA also shows the reason.

To access the MATH web portal, you must first complete a Provider Enrollment Form and an Trading Partner Agreement (see the following table). To receive an electronic RA, the provider must complete a Trading Partner Agreement and register for the Montana Access to Health (MATH) web portal. You can access your electronic RA through the MATH web portal by going to the Provider Information website and selecting Log in to Montana Access to Health.

After these forms have been processed, you will receive a user ID and password that you can use to log on to the web portal. The verification process also requires a provider ID, a submitter ID, and a tax ID number. Each provider must complete an EDI Trading Partner Agreement, but if there are several providers in one location who are under one tax ID number, they can use one submitter number. These providers should enter the submitter ID in both the provider number and submitter ID fields. Otherwise, enter the provider number in the provider number field.

If a claim was denied, read the description of the EOB before taking any action on the claim.

RAs are available in PDF format. You can read, print, or download PDF files using Adobe Acrobat Reader, which is available on the Provider Information website. Due to space limitations, each RA is only available for 90 days.

Electronic RAs are available for only 90 days on the web portal.

The RA is divided into the following sections:

Sections of the Paper RA

 

Section: RA Notice
Description: The RA Notice is on the first page of the remittance advice. This section contains important messages about rate changes, revised billing procedures, and many other items that may affect providers and claims.

Section: Paid Claims
Description: This section shows claims paid during the previous cycle. It is the provider’s responsibility to verify that claims were paid correctly. If Medicaid overpays a claim and the problem is not corrected, it may result in an audit requiring the provider to return the overpayment plus interest. If a claim was paid at the wrong amount or with incorrect information, the claim must be adjusted. (See Adjustments later in this chapter.)

Section: Denied Claims
Description: This section shows claims denied during the previous cycle. If a claim has been denied, refer to the Reason/Remark column (Field 18). The Reason and Remark Code Description located at the end of the RA explains why the claim was denied. See the section titled The Most Common Billing Errors and How to Avoid Them in the Billing Procedures chapter.

Section: Pending Claims
Description: All claims that have not reached final disposition will appear in this area of the paper RA (pended claims are not available on X12N 835 transactions). The RA uses suspended and pending interchangeably. They both mean that the claim has not reached final disposition. If a claim is pending, refer to the Reason/Remark Code section (Field 18) located at the end of the RA will explain why the claim is suspended. This section is informational only. Do not take any action on claims displayed here. Processing will continue until each claim is paid or denied.

Claims shown as pending with Reason Code 133 require additional review before a decision to pay or deny is made. If a claim is being held while waiting for member eligibility information, it may be suspended for a maximum of 30 days. If Medicaid receives eligibility information within the 30-day period, the claim will continue processing. If no eligibility information is received within 30 days, the claim will be denied. When a claim is denied for lack of eligibility, the provider should verify that the correct Medicaid ID number was billed. If the ID number was incorrect, resubmit the claim with the correct ID number.

Section: Credit Balance Claims
Description: Credit balance claims are shown here until the credit has been satisfied.

Section: Gross Adjustments
Description: Any gross adjustments performed during the previous cycle are shown here.

Section: Reason and Remark Code Description
Description: This section lists the reason and remark codes that appear throughout the RA with a brief description of each.

 

Sample Remittance Notice

Image of a remittance notice with corresponding numbering.

Key Fields on the Remittance Advice


Field: 1. Provider name and address
Description: Provider’s business name and address as recorded with the Department.

Field: 2. Vendor #
Description: The 7-digit number assigned to the provider.

Field: 3. Remittance advice number
Description: The remittance advice number.

Field: 4. EFT/Check number
Description: The EFT or check number of payment

Field: 5. Date
Description: The date the RA was issued.

Field: 6. Page number
Description: The page number of the RA.

Field: 7. NPI
Description: A unique 10-digit identification number required by HIPAA for all U.S. health care providers. Providers must use their NPI to identify themselves in all HIPAA transactions.

Field: 8. Taxonomy
Description: Alphanumeric code that indicates the provider’s specialty.

Field: 9. Member ID
Description: The member’s Medicaid ID number.

Field: 10. Name
Description: The member’s name.

Field: 11. Internal control number (ICN)
Description: Each claim is assigned a unique 17-digit number (ICN). Use this number when you have any questions concerning your claim. The claim number represents the following information:

0 00111 11 123 000123
A B C D E
A = Claim medium

0 = Paper claim
2 = Electronic claim
3 = Encounter claim
4 = System generated claim (mass adjustment, nursing home turn-around
document, or point-of-sale (POS) pharmacy claim)
6 = Pharmacy

B = Julian date (e.g. April 20, 2000 was the 111th day of 2000)
C = Microfilm number

00 = Electronic claim
11 = Paper claim

D = Batch number
E = Claim number

If the first number is:

0 = Regular claim
1 = Negative side adjustment claim (Medicaid recovers payment)
2 = Positive side adjustment claim (Medicaid reprocesses)
 

Field: 12. Service dates
Description: Dates services were provided. If services were performed in a single day, the same date will appear in both columns.

Field: 13. Unit of service
Description: The units of service rendered under this procedure or NDC code.

Field: 14. Procedure/Revenue/NDC
Description: The procedure code (CPT or HCPCS), National Drug Code (NDC), or revenue code will appear in this column. If a modifier was used, it will also appear in this column.

Field: 15. Total charges
Description: The amount a provider billed for this service.

Field: 16. Allowed
Description: The Medicaid allowed amount.

Field: 17. Copayment
Description: A “Y” indicates cost sharing was deducted from the allowed amount, and an “N” indicates cost sharing was not deducted.

Field: 18. Reason and remark codes
Description: A code which explains why the specific service was denied or pended. Descriptions of these codes are listed at the end of the RA.

Field: 19. Deductions, billed amount, and paid amount
Description: Any deductions, such as cost sharing or third party liability are listed first. The amount the provider billed is next, followed by the amount of Medicaid reimbursement.

 

Credit Balances
Credit balances occur when claim adjustments reduce original payments causing the provider to owe money to the Department. These claims are considered in process and continue to appear on the RA until the credit has been satisfied.

The credit balance section is informational only. Do not post from credit balance statements.

Credit balances can be resolved in two ways:

  1. By working off the credit balance. Remaining credit balances can be deducted from future claims. These claims will continue to appear on consecutive RAs until the credit has been paid.
  2. By sending a check payable to DPHHS for the amount owed. This method is required for providers who no longer submit claims to Montana Medicaid. Attach a note stating that the check is to pay off a credit balance and include your NPI. Send the check to the attention of the Third Party Liability Unit at the address in Key Contacts.

Rebilling and Adjustments

Rebillings and adjustments are important steps in correcting any billing problems you may experience. Knowing when to use the rebilling process versus the adjustment process is important.

Medicaid does not accept any claim for resubmission or adjustment after 12 months from the date of service (see Timely Filing Limits in Billing Procedures chapter).

How Long Do I Have to Rebill or Adjust a Claim?

  • Providers may resubmit or adjust any initial claim within the timely filing limits described in the Billings Procedure chapter of this manual.
  • These time periods do not apply to overpayments that the provider must refund to the Department. After the 12-month time period, a provider may not refund overpayments to the Department by completing a claim adjustment. The provider may refund overpayments by issuing a check or asking the TPL unit to complete a gross adjustment.

Rebilling Medicaid
Rebilling is when a provider submits a claim to Medicaid that was previously submitted for payment but was either returned or denied. Claims are often returned to the provider before processing because key information such as NPI and taxonomy or authorized signature and date are missing or unreadable. For tips on preventing returned or denied claims, see the Billing Procedures and Submitting a Claim chapters.

When to Rebill Medicaid

  • Claim Denied. Providers can rebill Medicaid when a claim is denied in full, as long as the claim was denied for reasons that can be corrected. When the entire claim is denied, check the Reason and Remark Code/Description, make the appropriate corrections, and resubmit the claim (not an adjustment).

Rebill denied claims only after appropriate corrections have been made.

  • Line Denied. When an individual line is denied on a multiple-line claim, correct any errors and rebill Medicaid. Do not use an adjustment form.
  • Claim Returned. Rebill Medicaid when the claim is returned under separate cover. Occasionally, Medicaid is unable to process the claim and will return it to the provider with a letter stating that additional information is needed to process the claim. Correct the information as directed and resubmit your claim.

How to Rebill

  • Check any Reason and Remark Code listed and make your corrections on a copy of the claim, or produce a new claim with the correct information.
  • When making corrections on a copy of the claim, remember to cross out or omit all lines that have already been paid. The claim must be neat and legible for processing.
  • Enter any insurance (TPL) information on the corrected claim, or include insurance denial information, and submit to Medicaid.

Adjustments
If a provider believes that a claim has been paid incorrectly, the provider may call Provider Relations or submit a claim inquiry for review. (See the Billing Procedures chapter, Claim Inquiries.) Once an incorrect payment has been verified, the provider may submit an Individual Adjustment Request to Provider Relations. If incorrect payment was the result of a Conduent keying error, contact Provider Relations.

When adjustments are made to previously paid claims, the Department recovers the original payment and issues appropriate repayment. The result of the adjustment appears on the provider’s RA as two transactions. The original payment will appear as a credit transaction. The replacement claim reflecting the corrections will be listed as a separate transaction and may or may not appear on the same RA as the credit transaction. The replacement transaction will have nearly the same ICN number as the credit transaction, except the 12th digit will be a 2, indicating an adjustment. See Key Fields on the Remittance Advice earlier in this chapter. Adjustments are processed in the same time frame as claims.

Adjustments can only be made to paid claims.

When to request an adjustment

  • Request an adjustment when a claim was overpaid or underpaid.
  • Request an adjustment when a claim was paid but the information on the claim was incorrect (e.g., member ID, provider NPI, date of service, procedure code, diagnoses, units).

How to Request an Adjustment
To request an adjustment, use the Individual Adjustment Request form. The requirements for adjusting a claim are as follows:

  • Claims Processing must receive individual claim adjustment requests within 12 months from the date of service (see Timely Filing Limits in the Billing Procedures chapter).After this time, gross adjustments are required (see Definitions).
  • Use a separate adjustment request form for each ICN.
  • If you are correcting more than one error per ICN, use only one adjustment request form, and include each error on the form.
  • If more than one line of the claim needs to be adjusted, indicate which lines and items need to be adjusted in the Remarks section of the adjustment form.

Image of a claim adjustment form.

Completing an Adjustment Request Form

  1. Download the Individual Adjustment Request from the Provider Information website. (See Key Websites.) Complete Section A with provider and member information and the claim’s ICN number.
  2. Complete Section B with information about the claim. Fill in only the items that need to be corrected:
    1. Enter the date of service or the line number in the Date of Service or Line Number column.
    2. Enter the information from the claim that was incorrect in the Information on Statement column.
    3. Enter the correct information in the Corrected Information column.
  3. Attach copies of the RA and a corrected claim if necessary.
    1. If the original claim was billed electronically, a copy of the RA will suffice.
    2. If the RA is electronic, attach a screen print of the RA.
  4. Verify the adjustment request has been signed and dated.
  5. Send the adjustment request to Claims Processing. (See Key Contacts.)
    1. If an original payment was an underpayment by Medicaid, the adjustment will result in the provider receiving the additional payment amount allowed.
    2. If an original payment was an overpayment by Medicaid, the adjustment will result in recovery of the overpaid amount through a credit. If the result is a credit balance, it can be worked off or the provider can pay off the balance by check. (See Credit Balances earlier in this chapter.)
    3. Any questions regarding claims or adjustments must be directed to Provider Relations. (See Key Contacts.)

Completing an Individual Adjustment Request Form

Section A


Field: 1. Provider name and address
Description: Provider’s name and address (and mailing address if different).

Field: 2. Member name
Description: The member’s name is here.

Field: 3.* Internal control number (ICN)
Description: There can be only one ICN per adjustment request form. When adjusting a claim that has been previously adjusted, use the ICN of the most recent claim.

Field: 4.* Provider NPI
Description: The provider’s NPI.

Field: 5.* Member Medicaid number
Description: Member’s Medicaid ID number.

Field: 6. Date of payment
Description: Date claim was paid is found on remittance advice field 5 (see the sample RA earlier in this chapter).

Field: 7. Amount of payment
Description: The amount of payment from the remittance advice field 17 (see the sample RA earlier in this chapter.).

Section B


Field: 1. Units of service
Description: If a payment error was caused by an incorrect number of units, complete this line.

Field: 2. Procedure code/NDC/Revenue code
Description: If the procedure code, NDC, or revenue code is incorrect, complete this line.

Field: 3. Dates of service (DOS)
Description: If the date of service is incorrect, complete this line.

Field: 4. Billed amount
Description: If the billed amount is incorrect, complete this line.

Field: 5. Personal resource (nursing facility)
Description: If the member’s personal resource amount is incorrect, complete this line.

Field: 6. Insurance credit amount
Description: If the member’s insurance credit amount is incorrect, complete this line.

Field: 7. Net (Billed – TPL or Medicare paid)
Description: If the payment error was caused by a missing or incorrect insurance credit, complete this line. Net is billed amount minus the amount third party liability or Medicare paid.

Field: 8. Other/Remarks
Description: If none of the above items apply, or if you are unsure what caused the payment error, complete this line.

*Indicates a required field.

 

Mass Adjustments
Mass adjustments are done when it is necessary to reprocess multiple claims.
They generally occur when:

  • Medicaid has a change of policy or fees that is retroactive. In this case federal laws require claims affected by the changes to be mass adjusted.
  • A system error that affected claims processing is identified.

Providers are informed of mass adjustments on the first page of the RA in the RA Notice section. Mass adjustment claims shown on the RA have an ICN that begins with a 4. (See Key Fields on the Remittance Advice earlier in this chapter.)

Electronic RAs are available for only 90 days on the web portal.

Payment and the RA

Providers receive their Medicaid payment and remittance advice weekly. Payment can be via check or electronic funds transfer (EFT). Direct deposit is another name for EFT.

With EFT, the Department deposits the funds directly to the provider’s bank account. If the scheduled deposit day is a holiday, funds will be available on the next business day. This process does not affect the delivery of the remittance advice that providers currently receive with payments. RAs will continue to be mailed to providers unless they specifically request an electronic RA.

To participate in EFT, providers must complete a Direct Deposit Sign-Up Form (Standard Form 1199A). One form must be completed for each provider NPI. See the following table, Required Forms for EFT and/or Electronic RA.

Once electronic transfer testing shows payment to the provider’s account, all Medicaid payments will be made through EFT. See Direct Deposit Arrangements under Key Contacts for questions or changes regarding EFT.

Required Forms for EFT and/or Electronic RA

Form:

  • EDI Provider Enrollment Form
  • EDI Trading Partner Agreement

Purpose:

Allows providers to access their RAs on the Montana Access to Health (MATH) web portal.

Must also include:

  • EDI Provider Enrollment Form
  • EDI Trading Partner Agreement

Where to Get:

  • Provider Information website
  • Provider Relations (See Key Contacts.)

Where to Send:

Fax to number on form.

 

Form:

  • Direct Deposit Sign-Up Form (Standard Form 1199A)

Purpose:

Allows the Department to automatically deposit Medicaid payment into provider’s bank account

Where to Get:

  • Provider Information website (Forms)
  • Provider’s bank Provider Relations (See Key Contacts.)

 

 

End of Remittance Advices and Adjustments 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 payment methods described do not apply to services provided under Healthy Montana Kids (HMK)/Children’s Health Insurance Program (CHIP).

Payment for School-Based Services

Federal regulations specify that one government entity may not bill another government entity more than their cost (OMB A-87). The following describes payment methods for various services that can be provided in the school setting. Payment for these services is limited to the lower of the calculated fee or the billed amount.

Speech, Occupational and Physical Therapy Services
Speech and language therapy services, occupational therapy services and physical therapy services are paid by the Resource Based Relative Value Scale (RBRVS) method of reimbursement. As noted above, only the federal portion will be paid. For more detail on the RBRVS system, see the How Payment Is Calculated chapter of the Physician-Related Services provider manual, which is available on the Provider Information website. (See Key Websites.)

Each RBRVS fee is the product of a relative value times a conversion factor. This total is always multiplied by the current Federal Matching Assistance Percentage (FMAP).

The Department publishes relative weights, the current conversion factor, and the current FMAP figure. The conversion factor is determined by the Department, and set at a level intended to achieve legislatively set budget targets.

Private Duty Nursing
The only code available for this service is T1000. Payment for this code is based on the Medicaid fee schedule, and is calculated as follows:

Fee x number of 15-minute units = payment

The current FMAP is then calculated against this total for final reimbursement

School Psychologist
Both codes available for billing school psychologist services are paid by the RBRVS method.

Each RBRVS fee is the product of a relative value times a conversion factor.  This total is always multiplied by the current FMAP for a total reimbursement.

The Department publishes relative weights, the current conversion factor, and the current FMAP figure. The conversion factor is determined by the Department, and set at a level intended to achieve legislatively set budget targets.

Personal Care Paraprofessionals
The only code available for this service is T1019. Payment for this code is based on the Medicaid fee schedule, and is calculated as follows:

Fee x number of 15 minute units = payment

The current FMAP is then calculated against this total for final reimbursement.

CSCT Program
The only code available for this service is H0036. Payment for this code is based on the Medicaid fee schedule, and is calculated as follows:

Fee x number of 15 minute units = payment

The current FMAP is then calculated against this total for final reimbursement.

All payments for CSCT services are made to the school district/cooperative. Schools may not assign payment from Medicaid directly to the mental health center provider. The purpose of this policy is to:

  • Ensure that districts are fully aware of the amount of federal Medicaid funds generated by their CSCT providers, allowing districts to determine their obligation for match.
  • Control variables are in place to account for districts revenue and expenditures.

How Payment Is Calculated on TPL Claims
When a member has coverage from both Medicaid and another insurance company, the other insurance company is 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. Medicaid will make a payment only when the TPL payment is less than the Medicaid allowed amount.

How Payment Is Calculated on Medicare Crossover Claims
When a member has coverage from both Medicare and Medicaid, Medicare is the primary payer. Medicaid will pay the coinsurance and deductible amounts for these dually eligible individuals. See the How Payment is Calculated chapter in the Physician-Related Services manual for examples on how payment is calculated on Medicare crossover claims.

 

End of How Payment is Calculated Chapter

 

Appendix A: Forms

 

 

End of Appendix A: Forms Chapter

 

Appendix B: Personal Care Paraprofessional Services Documentation

 

Personal Care Paraprofessional Services Provided in Schools – Child Profile

Purpose
The Child Profile is intended to:

  • To provide an instrument for collecting and documenting essential information needed to establish the Medicaid child’s functional limitations and ability to perform activities of daily living.
  • To document information on service planning issues for personal care services.
  • To provide a worksheet for determining the daily units per week needed by the child.

Procedure
The Profile must be completed by the Individualized Education Plan (IEP) team at the initial meeting for services, at the annual review, and whenever a significant change in the child’s condition occurs causing the service need to change.

Instructions

  1. Child Name: Enter the child's full name.
  2. Child ID: Enter child's Medicaid ID number.
  3. DOB: Child’s date of birth.
  4. Date Span: The time period the child will receive personal care services, up to one year.
  5. Level of Impairment: Rate the child's impairment level according to the following scale for each task listed:

0 = Independent: No functional impairment. The child is able to conduct the activities without difficulty and has no need for assistance. Need is met with adaptive equipment or service animal.
1 = Standby/Cuing: Mild functional impairment. The child is able to conduct the activity but does require standby assist or cuing.
2 = Limited Assist: Moderate functional impairment. The child is able to conduct the activity with moderate difficulty and requires minimal assistance.
3 = Extensive Assist: Severe functional impairment. The child has considerable difficulty completing the activity and requires extensive assistance.
4 = Total Dependence: Total functional impairment. The child is completely unable to carry out any part of the activity.

An IEP team member must decide which of the five impairment levels best describes the child reviewed. An impairment in this context is a functional limitation (i.e., a limitation in the ability to carry out an activity or function). A member is considered to have an impairment with respect to a particular activity if he/she is limited, either physically or mentally, in his/her ability to carry out that activity.

The “0” and “4” rating is absolute in the sense that they indicate no functional impairment or total dependency. For example, if a child can perform any of the dressing tasks for themselves, a “4” is not appropriate. If he/she can perform the dressing task without difficulty, a “0” is appropriate.

If a child is able to conduct an activity only with difficulty, and the difficulty is such that the child frequently cannot complete some part of the activity, then the child is impaired, even if the child at other times can complete the entire activity. In addition, if the degree of difficulty is such that the child should have at least minimal assistance with that activity, then the child is impaired, even if the child can (with difficulty) conduct the activity without assistance. If the child can complete the activity but needs cuing to do so, or, because of safety considerations needs someone there while completing the task, they would require standby assistance. If the difficulty with an activity does not affect the child's conduct of the activity or does not cause any problems for the child, the child is not impaired.

Enter a Level for Each Task
The Personal Care Paraprofessional Services Profile is designed to rate a child's capacity for self-care. Determine the level for each task according to the capacity for self-care and not according to the child's access to a resource to assist with the task. In rating each item, use the child's response, your own observations of activity, and any knowledge provided about the child from other sources. To determine the severity of the child's impairment, consider the following factors:

  1. Child Perception of the Impairment: Does the child view the impairment as a major or minor problem?
  2. Congruence: Is the child's response to a particular question consistent with the child's response to other questions and, also, consistent with what you have observed?
  3. Child History: Probe for an understanding of the child's history as it relates to the current situation and of the child's attitude about the severity of the impairment. How has the impairment changed the child's lifestyle?
  4. Adaptation: If the child has adapted his physical environment or clothing to the extent that he is able to function without assistance, the degree of impairment will be lessened, but the child will still have an impairment. This includes the use of adaptive equipment.

Use the following examples for each item to help you differentiate between scores of 2 or 3.


ADL: Grooming
2 = Limited Assist: Child may set out supplies. Child may accomplish tasks an adaptive device for assistance.
3 = Extensive: Child needs to have help with shaving or shampooing, etc., because of inability to see well, to reach, or to successfully use equipment. Child needs someone to put lotion on body or to comb or brush hair.

ADL: Toileting
2 = Limited Assist: Child has instances of urinary incontinence, and needs help because of this from time to time. Fecal incontinence does not occur unless child has a specific illness episode. Child may have catheter or colostomy bag, and occasionally needs assistance with management.
3 = Extensive: Child often is unable to get to the bathroom on time to urinate. Child has occasional episodes of fecal incontinence. Child may wear diapers to manage the problem and needs some assistance with them. Child usually needs assistance with catheter or colostomy bag.

ADL: Dressing
2 = Limited Assist: Child needs occasional help with zippers, buttons, or putting on shoes and socks. Child may need help laying out and selecting clothes.
3 = Extensive: Child needs help with zippers, buttons, or shoes and socks. Child needs help getting into garments, including putting arms in sleeves, legs in pants, or pulling up pants. Child may dress totally inappropriately without help or would not finish dressing without physical assistance.

ADL: Transferring
2 = Limited Assist: Child usually can get out of bed or chair with minimal assistance.
3 = Extensive: Child needs hands-on assistance when rising to a standing position or moving into a wheelchair to prevent losing balance or falling. Child is able to help with the transfer by holding on, pivoting, and/or supporting himself.

ADL: Ambulation
2 = Limited Assist: Child walks alone without assistance for only short distances. Child can walk with minimal difficulty using an assistive device or by holding onto walls or furniture.
3 = Extensive: Child has considerable difficulty walking even with an assistive device. Child can walk only with assistance from another person. Child never walks alone outdoors without assistance. Child may use a wheelchair periodically.

ADL: Eating
2 = Limited Assist: Child may need occasional physical help. Child eats with adaptive devices but requires help with their positioning.
3 = Extensive: Child usually needs extensive hands-on assistance with eating. Child may hold eating utensils but needs continuous assistance during meals. Child would not complete meal without continual help. Spoon-feeding of most foods is required, but child can eat some finger foods.

ADL: Exercise
2 = Limited Assist: Child may need occasional assistance in completing exercise routine. Child may need occasional support or guidance.
3 = Extensive: Child needs some assistance in completing exercise routine. Child needs support or guidance.

ADL: Bus Escort
2 = Limited Assist: Child requires minimal assistance on bus en route to or from school. Child does not have family or caregiver to assist. Child receives a medical service at school on this date.
3 = Extensive: Child requires assistance on bus en route to or from school. Child does not have family or caregiver to assist. Child receives a medical service at school on this date.

 

Check the appropriate column that indicates the degree to which the child's need for help in the completion of each task is met. Check one column for each task:

M = Met: The child's needs are met. The child may be independent in this task or someone other than the Personal Care Paraprofessional is meeting the child’s need for help. Other sources for meeting the need include family or friends. No time can be authorized for any task coded with an “M”.

P = Partially Met: The child requires help with the task. Someone other than the personal care paraprofessional is providing that help part of the time, or the child may participate
in the task.

U = Unmet: The child requires help with the task and the need is currently unmet.

  1. Notes: Enter any appropriate notes.
  2. Minutes Per Day: For each task to be provided, enter the daily number of minutes needed to conduct that task.
  3. Days Per Week: For each task to be provided, enter the number of days per week the child will require assistance with the task.
  4. Total Minutes: Multiply the minutes per day times the days per week to obtain the total minutes per week for each task.

The amount of time allowed for any particular task should be determined by taking into account:

  1. The amount of assistance the child will usually need.
  2. Which specific activities need to be accomplished.
  3. Environmental/housing factors that may hinder (or facilitate) service delivery.
  4. Child’s unique circumstances.

Personal Care Paraprofessional Services Provided In Schools Child Profile - Form

Task/Hour Guide Instructions

Purpose
The purpose of this form is to record the amount of time that is spent providing Personal Care services. This form is a sample and can be recreated by district personnel to meet specific needs.

Specific Tasks
Each task has one or more activities or sub-tasks that forms the overall task. When calculating time, carefully consider which activities were provided.

  1. Dressing:
    1. Dressing member
    2. Undressing member
    3. Cuing assistance
  2. Exercise:
    1. Range of motion
  3. Grooming:
    1. Brushing teeth
    2. Laying out supplies
    3. Combing/brushing hair
    4. Applying nonprescription lotion to skin
    5. Washing hands and face
    6. Cuing assistance
  4. Toileting:
    1. Changing diapers
    2. Changing colostomy bag/emptying catheter bag
    3. Assisting on/off bed pan
    4. Assisting with use of urinal
    5. Assisting with feminine hygiene needs
    6. Assisting with clothing during toileting
    7. Assisting with toilet hygiene: includes use of toilet paper & washing hands
    8. Set-up supplies and equipment (Does NOT include preparing catheter equipment)
    9. Standby assistance
  5. Transfer:
    1. Non-ambulatory movement from one stationary position to another (transfer)
    2. Adjusting/changing member’s position in bed or chair (positioning)
  6. Ambulation (Walking):
    1. Assisting child in rising from a sitting to a standing position and/or position for use of walking apparatus
    2. Assisting with putting on and removing leg braces and prostheses for ambulation
    3. Assisting with ambulation/using steps
    4. Standby assistance with ambulation
    5. Assistance with wheelchair ambulation
      NOTE: Do not include exercise as ambulation.
  7. Eating:
    1. Spoon feeding
    2. Bottle feeding
    3. Set up of utensils/adaptive devices
    4. Assistance with using eating or drinking utensils/adaptive devices
    5. Cutting up foods
    6. Standby assistance/encouragement
      NOTE: Tube feeding is not an allowable service.
  8. Bus Escort:
    1. Accompanying a child on the bus when the child is functionally limited and receives medical service at the school on that date. Not for purposes of behavioral management.

Task/Hour Guide

 

End of Appendix B: Personal Care Paraprofessional Services Documentation Chapter

 

Definitions and Acronyms

 

This section contains definitions, abbreviations, and acronyms used in this manual.

270/271 Transactions

The ASC X12N eligibility inquiry (270) and response (271) transactions.

276/277 Transactions

The ASC X12N claim status request (276) and response (277) transactions.

278 Transactions

The ASC X12N request for services review and response used for prior authorization.

835 Transactions

The ASC X12N payment and remittance advice (explanation of benefits) transaction.

837 Transactions

The ASC X12N professional, institutional, and dental claim transactions (each with its own separate Implementation Guide).

Accredited Standards Committee X12, Insurance Subcommittee (ASC X12N)

The ANSI-accredited standards development organization, and one of the six Designated Standards Maintenance Organizations (DSMO), that created and is tasked with maintaining the administrative and financial transactions standards adopted under HIPAA for all health plans, clearinghouses, and providers who use electronic transactions.

Administrative Rules of Montana (ARM)

The rules published by the executive departments and agencies of the state government.

Allowed Amount

The maximum amount reimbursed to a provider for a health care service as determined by Medicaid/MHSP/HMK or another payer. Other cost factors, (such as cost sharing, TPL, or incurment) are often deducted from the allowed amount before final payment. Medicaid’s allowed amount for each covered service is listed on the Department fee schedule.

Ancillary Provider

Any provider that is subordinate to the member’s primary provider, or providing services in the facility or institution that has accepted the member as a Medicaid member.

Assignment of Benefits

A voluntary decision by the member to have insurance benefits paid directly to the provider rather than to the member. The act requires the signing of a form for the purpose. The provider is not obligated to accept an assignment of benefits. However, the provider may require assignment in order to protect the provider’s revenue.

Authorization

An official approval for action taken for, or on behalf of, a Medicaid member. This approval is only valid if the member is eligible on the date of service.

Basic Medicaid

Patients with Basic Medicaid have limited Medicaid services. See the Medicaid Covered Services chapter General Information for Providers manual.

Bundled

Items or services that are deemed integral to performing a procedure or visit are not paid separately in the APC system. They are packaged (also called bundled) into the payment for the procedure or visit. Medicare developed the relative weights for surgical, medical and other types of visits so that the weights reflect the packaging rules used in the APC method. Items or services that are packaged receive a status code of “N”.

Cash Option

Cash option allows the member to pay a monthly premium to Medicaid and have Medicaid coverage for the entire month rather than a partial month.

Centers for Medicare and Medicaid Services (CMS)

Administers the Medicare program and oversees the state Medicaid programs.

Children’s Health Insurance Program (CHIP)

The Montana plan is now known as Healthy Montana Kids (HMK).

Children’s Special Health Services (CSHS)

CSHS assists children with special health care needs who are not eligible for Medicaid by paying medical costs, finding resources, and conducting clinics.

Clean Claim

A claim that can be processed without additional information from or action by the provider of the service.

Member

An individual enrolled in a Department medical assistance program.

Code of Federal Regulations (CFR)

Rules published by executive departments and agencies of the federal government.

Coinsurance

The member’s financial responsibility for a medical bill as assigned by Medicaid or Medicare (usually a percentage). Medicaid coinsurance is usually 5% of the Medicaid allowed amount, and Medicare coinsurance is usually 20% of the Medicare allowed amount.

Conversion Factor

A state specific dollar amount that converts relative values into an actual fee. This calculation allows each payer to adopt the RBRVS to its own economy.

Copayment

The member’s financial responsibility for a medical bill as assigned by Medicaid (usually a flat fee).

Cosmetic

Serving to modify or improve the appearance of a physical feature, defect, or irregularity.

Cost Sharing

The member’s financial responsibility for a medical bill assessed by a flat fee or percentage of charges.

CPT

Physicians’ Current Procedural Terminology contains procedure codes which are used by medical practitioners in billing for services rendered. The book is published by the American Medical Association.

Credit Balance Claims

Adjusted claims that reduce original payments, causing the provider to owe money to the Department. These claims are considered in process and continue to appear on the remittance advice until the credit has been satisfied.

Crossovers

Claims for members who have both Medicare and Medicaid. These claims may come electronically from Medicare or directly from the provider.

DPHHS, State Agency

The Montana Department of Public Health and Human Services (DPHHS or the Department) is the designated State Agency that administers the Medicaid program. The Department's legal authority is contained in Title 53, Chapter 6 MCA. At the federal level, the legal basis for the program is contained in Title XIX of the Social Security Act and Title 42 of the Code of Federal Regulations (CFR). The program is administered in accordance with the Administrative Rules of Montana (ARM), Title 37, Chapter 86.

Dual Eligibles

Members who are covered by Medicare and Medicaid.

Early and Periodic Screening, Diagnosis,and Treatment (EPSDT)

This program provides Medicaid-covered children with comprehensive health screenings, diagnostic services, and treatment of health problems.

Electronic Funds Transfer (EFT)

Payment of medical claims that are deposited directly to the provider’s bank account.

Emergency Services

A service is reimbursed as an emergency if one of the following criteria is met:

  • The service is billed with CPT Code 99284 or 99285
  • The member has a qualifying emergency diagnosis code. A list of emergency diagnosis codes is available on the Provider Information website.
  • The services did not meet one of the previous two requirements, but the hospital believes an emergency existed. In this case, the claim and documentation supporting the emergent nature of the service must be mailed to the emergency department review contractor.

Experimental

A noncovered item or service that researchers are studying to investigate how it affects health.

Explanation of Medicare Benefits (EOMB)

A notice sent to providers informing them of the services which have been paid by Medicare.

Fiscal Agent

Conduent State Healthcare, LLC, is the fiscal agent for the State of Montana and processes claims at the Department's direction and in accordance with ARM 37.86 et seq.

Full Medicaid

Patients with Full Medicaid have a full scope of Medicaid benefits. See the General Information for Providers manual, Medicaid Covered Services.

Gross Adjustment

A lump sum debit or credit that is not claim specific made to a provider.

HCPCS

Acronym for the Healthcare Common Procedure Coding System, and is pronounced “hickpicks.” There are two types of HCPCS codes:

  • Level 1 includes the CPT codes.
  • Level 2 includes the alphanumeric codes A–V which CMS maintains for a wide range of services from ambulance trips to hearing aids which are not addressed by CPT coding.

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.

Health Insurance Portability and Accountability Act (HIPAA)

A federal plan designed to improve efficiency of the health care system by establishing standards for transmission, storage, and handling of data.

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. DPHHS administers the program and purchases health insurance from Blue Cross and Blue Shield of Montana (BCBSMT). Benefits for dental services and eyeglasses are provided by DPHHS through the same contractor (Conduent State Healthcare, LLC) that handles Medicaid provider relations and claims processing.

International Classification of Disease (ICD)

The International Classification of Diseases contains the diagnosis codes used in coding claims and the procedure codes used in billing for services performed in a hospital setting.

Indian Health Service (IHS)

IHS provides health services to American Indians and Alaska Natives.

Individual Adjustment

A request for a correction to a specific paid claim.

Internal Control Number (ICN)

The unique number assigned to each claim transaction that is used for tracking.

Investigational

A noncovered item or service that researchers are studying to investigate how it affects health.

Mass Adjustment

Adjustments made to multiple claims at the same time. They generally occur when the Department has a change of policy or fees that is retroactive, or when a system error that affected claims processing is identified.

Medicaid/HMK Plus

A program that provides health care 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.

Medically Necessary

A term describing a requested service which is reasonably calculated to prevent, diagnose, correct, cure, alleviate or prevent worsening of conditions in the member. These conditions must be classified as one of the following: endanger life, cause suffering or pain, result in an illness or infirmity, threaten to cause or aggravate a handicap, or cause physical deformity or malfunction. There must be no other equally effective, more conservative or substantially less costly course of treatment available or suitable for the member requesting the service. For the purpose of this definition, course of treatment may include mere observation or, when appropriate, no treatment at all.

Medicare

The federal health insurance program for certain aged or disabled members.

Mental Health Services Plan (MHSP)

This plan is for individuals who have a severe and disabling mental illness (SDMI), are ineligible for Medicaid, and have a family income that does not exceed an amount established by the Department.

Mentally Incompetent

According to CFR 441.251, a mentally incompetent individual means an individual who has been declared mentally incompetent by a federal, state, or local court of competent jurisdiction for any purpose, unless the individual has been declared competent for purposes which include the ability to consent to sterilization.

Montana Access to Health (MATH) Web Portal

A secure website on which providers may view members’ medical history, verify member eligibility, submit claims to Medicaid, check the status of a claim, verify the status of a warrant, and download remittance advice reports.

Montana Breast and Cervical Cancer Treatment Program

This program provides Full 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.

Nurse First Advice Line

The Nurse First Advice Line is a toll-free, confidential number members may call any time any day for advice from a registered nurse about injuries, diseases, health care, or medications.

Passport Referral Number

This is a 7-digit number assigned to Passport providers. When a Passport provider refers a member to another provider for services, this number is given to the other provider and is required when processing the claim.

Passport to Health

A Medicaid medical home program where the member selects a primary care provider who manages the member’s health care needs.

Pay-and-Chase

Medicaid pays a claim and then recovers payment from the third party carrier that is financially responsible for all or part of the claim.

Pending Claim

These claims have been entered into the system, but have not reached final disposition. They require either additional review or are waiting for member eligibility information.

Potential Third Party Liability

Any entity that may be liable to pay all or part of the medical cost of care for a Medicaid, MHSP or HMK member.

Prior Authorization (PA)

The approval process required before certain services or supplies are paid by Medicaid. Prior authorization must be obtained before providing the service or supply.

Private-Pay

When a member chooses to pay for medical services out of his or her own pocket.

Protocols

Written plans developed by a public health clinic in collaboration with physician and nursing staff. Protocols specify nursing procedures to be followed in giving a specific exam, or providing care for particular conditions. Protocols must by updated and approved by a physician at least annually.

Provider or Provider of Service

An institution, agency, or person:

  • • Having a signed agreement with the Department to furnish medical care and goods and/or services to members; and
  • Eligible to receive payment from the Department.

Qualified Medicare Beneficiary (QMB)

QMB members are members for whom Medicaid pays their Medicare premiums and some or all of their Medicare coinsurance and deductibles.

Reason and Remark Code

A code which prints on the Medicaid remittance advice (RA) that explains why a claim was denied or suspended. The explanation of the Reason/Remark codes is found at the end of the RA (formerly called EOB code).

Referral

When providers refer members to other Medicaid providers for medically necessary services that they cannot provide.

Remittance Advice (RA)

The results of claims processing (including paid, denied, and pending claims) are listed on the RA.

Relative Value Scale (RVS)

A numerical scale designed to permit comparisons of appropriate prices for various services. The RVS is made up of the relative value units (RVUs) for all the objects in the class for which it is developed.

Relative Value Unit (RVU)

The numerical value given to each service in a relative value scale.

Resource-Based Relative Value Scale (RBRVS)

A method of determining physicians’ fees based on the time, training, skill, and other factors required to deliver various services.

Retroactive Eligibility

When a member is determined to be eligible for Medicaid effective prior to the current date.

Sanction

The penalty for noncompliance with laws, rules, and policies regarding Medicaid. A sanction may include withholding payment from a provider or terminating Medicaid enrollment.

School-Based Services

Medically necessary health-related services provided to Medicaid eligible children up to and including age 20. These services are provided in a school setting by licensed medical professionals.

Specified Low-Income Medicare Beneficiaries (SLMB)

For these members, Medicaid pays the Medicare premium only. They are not eligible for other Medicaid benefits, and must pay their own Medicare coinsurance and deductibles.

Spending Down

Members with high medical expenses relative to their income can become eligible for Medicaid by “spending down” their income to specified levels. The member is responsible to pay for services received before eligibility begins, and Medicaid pays for remaining covered services.

Team Care

A restricted services program that is part of Passport to Health. Restricted services programs are designed to assist members in making better health care decisions so that they can avoid overutilizing health services. Team Care members are joined by a team assembled to assist them in accessing health care. The team consists of the member, the PCP, a pharmacy, the Department, the Department’s quality improvement organization, and the Nurse First Advice Line. The team may also include a community-based care manager from the Department's Health Improvement Program.

Third Party Liability (TPL)

Any entity that is, or may be, liable to pay all or part of the medical cost of care for a Medicaid, MHSP or HMK member.

Timely Filing

Providers must submit clean claims (claims that can be processed without additional information or documentation from or action by the provider) 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; or
    • 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.

Usual and Customary

The fee that the provider most frequently charges the general public for a service or item.

WINASAP 5010

WINASAP 5010 is a Windows-based electronic claims entry application for Montana Medicaid. This software was developed as an alternative to submitting claims on paper. For more information, contact the EDI Technical Help Desk. (See Key Contacts.)

 

End of Definitions and Acronyms Chapter

 

Index

Previous editions of this manual contained an index.

This edition has three search options.

1.Search the whole manual. Open the Complete Manual pane.  From your keyboard press the Ctrl and F keys at the same time.  A search box will appear.  Type in a descriptive or key word (for example "Denials". The search box will show all locations where denials discussed in the manual.

2.Search by Chapter. Open any Chapter tab (for example the "Billing Procedures" tab).  From your keyboard press the Ctrl and F keys at the same time.  A search box will appear.  Type in a descriptive or key word (for example "Denials". The search box will show where denials discussed in just that chapter.

3.Site Search.  Search the manual as well as other documents related to a particular search term on the Montana Healthcare Programs Site Specific Search page.

 

End of Index Chapter

End of School-Based Services Manual