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Manual Review Page

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General Manual - Billings Procedure Chapter

Billing Procedures

 

Claim Forms

Services provided by the healthcare professionals covered in this manual may be billed electronically or on paper claim forms, which are available from various publishing companies; they are not available from the Department or Provider Relations.

Timely Filing Limits (ARM 37.85.406)

Providers must submit clean claims to Medicaid within:

  • Twelve months from whichever is later:
    • the date of service
    • the date retroactive eligibility or disability is determined
  • Six months from the date on the Medicare explanation of benefits approving the service.
  • Six months from the date on an adjustment notice from a third party payer who has previously processed the claim for the same service, and the adjustment notice is dated after the periods described above.

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

  • Medicare Crossover Claims. Six months from the date on the Medicare explanation of benefits, if the Medicare claim was timely filed and the member eligible for Medicare at the time the Medicare claim was filed.
  • Claims Involving Other Third Party Payers (excluding Medicare). Six months from the date on an adjustment notice from a third party payer who has previously processed the claim for the same service, and the adjustment notice is dated after the periods described above.

Clean claims are claims that can be processed without additional information or action from the provider. The submission date is defined as the date that the claim was received by the Department or the claims processing contractor. All problems with claims must be resolved within this 12-month period.

Tips to Avoid Timely Filing Denials

  • Correct and resubmit denied claims promptly. (See the Remittance Advices and Adjustments chapter in this manual.)
  • If a claim submitted to Medicaid does not appear on the remittance advice within 45 days, contact Provider Relations for claim status.
  • If another insurer has been billed and 90 days have passed with no response, a provider can bill Medicaid. (See the Member Eligibility and Responsibilities chapter in this manual for more information.)
  • To meet timely filing requirements for Medicare/Medicaid crossover claims, see the Member Eligibility and Responsibilities chapter in this manual and, if applicable, the Coordination of Benefits chapter in your provider type manual.

When to Bill Medicaid Members (ARM 37.85.406)

In most circumstances, providers may not bill Medicaid members for services covered under Medicaid. The main exception is that providers may collect cost sharing from members.

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

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, such as in a public health clinic.

Under certain circumstances, providers may need a signed agreement to bill a member.

When to bill a medicaid member chart

 

Private-Pay Agreement. A nonspecific private-pay agreement between the provider and member stating that the member is not accepted as a Medicaid member, and that he/she must pay for the services received.

Custom Agreement. A specific agreement that includes the dates of service, actual services or procedures, and the cost to the member. It states the services are not covered by Medicaid and the member will pay for them.

Member Cost Sharing (ARM 37.85.204)

Each Medicaid member must pay cost share to the provider of service unless otherwise noted. Members with income at or below 100% Federal Poverty Level (FPL) have a set payment amount:

  • $4 for outpatient services
  • $75 for inpatient services
  • $4 for pharmacy – preferred brand
  • $8 for pharmacy – non-preferred brand

Members with income above 100% of the FPL are responsible for cost share of 10% of the provider reimbursed amount; except for pharmacy:

  • $4 for pharmacy – preferred brand
  • $8 for pharmacy – non-preferred brand

Members with the following statuses are exempt from cost sharing:

  • persons under 21 years of age;
  • pregnant women;
  • American Indians/Alaska Natives who are eligible for, currently receiving,or have ever received an item or service furnished by:
    • An Indian Health Service (IHS) provider;
    • A Tribal 638 provider;
    • An IHS Tribal or Urban Indian Health provider; or
    • Through referral under contract health services.
  • Persons who are terminally ill receiving hospice services;
  • Persons who are receiving services under the Medicaid breast and cervical cancer treatment category;
  • Institutionalized persons who are inpatients in a skilled nursing facility, intermediate care facility, or other medical institution if the person is required to spend for the cost of care all but their personal needs allowance, as defined in ARM 37.82.1320.

Cost sharing may not be charged to members for the following services:

  • Emergency services;
  • Family planning services;
  • Hospice services;
  • Home and community based waiver services;
  • Transportation services;
  • Eyeglasses purchased by the Medicaid program under a volume purchasing arrangement;
  • Early and periodic screening, diagnostic and treatment (EPSDT) services;
  • Provider preventable health care acquired conditions as provided for in 42 CFR 447.26(b);
  • Generic drugs;
  • Preventive services as approved by CMS through the Health and Economic Livelihood Plan (HELP) Medicaid 1115 waiver;
  • Services for Medicare crossover claims where Medicaid is the secondary payer under ARM 37.85.406(18). If a service is not covered by Medicare but is covered by Medicaid, cost sharing will be applied; and
  • Services for third party liability (TPL) claims where Medicaid is the secondary payor under ARM 37.85.407. If a service is not covered by the TPL but is covered by Medicaid, cost sharing will be applied.

Cost share may not be charged to the member until the claim has been processed through the claims adjudication process and the provider has been notified of payment and amount owing.

The total of Medicaid premiums and cost sharing incurred by a Medicaid household may not exceed an aggregate limit of five percent of the family's income applied quarterly. There may not be further cost sharing applied to the household members in a quarter once a household has met the quarterly aggregate cap.

Billing for Members with Other Insurance

A Medicaid member may also be covered by Medicare or have other insurance, or some other third party is responsible for the cost of the member’s healthcare,

When completing a claim for members with Medicare and Medicaid, Medicare coinsurance and deductible amounts must correspond with the payer listed. For example, if the member has Medicare and Medicaid, any Medicare deductible and coinsurance amounts must be listed and preceded by an A1, A2, etc. Because these amounts are for Medicare, Medicare must be listed in the corresponding field. (See the Submitting a Claim section 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 a private-pay member.

Always refer to the long descriptions in coding books.

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 in which the date of service is more than 12 months earlier than the date the claim is submitted, attach a copy of the Provider Notice of Eligibility (Form 160-M). To obtain this form, the provider should contact the member’s county Office of Public Assistance. See http://dphhs.mt.gov/hcsd/OfficeofPublicAssistance.

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.

Coding Tips

Standard use of medical coding conventions is required when billing Medicaid. Provider Relations or the Department cannot suggest specific codes to be used in billing for services. See the Coding Resources table. The following may reduce coding errors and unnecessary claim denials:

  • Use current CPT, CDT, HCPCS, and ICD diagnosis coding books.
  • Always read the complete description and guidelines in the coding books. Relying on short descriptions can result in inappropriate billing.
  • Attend classes on coding offered by certified coding specialists.
  • Use specific codes rather than unlisted codes.
  • Bill for the appropriate level of service provided. Evaluation and management services have 3 to 5 levels. See your CPT manual for instructions on determining appropriate levels of service.
  • CPT codes that are billed based on the amount of time spent with the member must be billed with the code that is closest to but not over the time spent.
  • Revenue Codes 25X are required to have valid and rebateable National Drug Codes (NDCs) on each line to be paid.
  • Revenue Codes 27X do not require CPT or HCPCS codes; however, providers are advised to place appropriate NDC, CPT, and/or HCPCS codes on each line. Providers are paid based on the presence of line item CPT and HCPCS codes. If these codes are omitted, hospitals may be underpaid.
  • Take care to use the correct units measurement. In general, Medicaid follows the definitions in the CPT and HCPCS coding books. Unless otherwise specified, one unit equals one visit or one procedure. For specific codes, however, one unit may be “each 15 minutes.” Always check the long text of the code description published in the CPT or HCPCS coding books.

Coding Resources

Please note that the Department does not endorse the products of any particular publisher.

CDT - http://www.ada.org/en/publications/

 

Description:
The CDT is the official coding used by dentists.

Contact:
American Dental Association
(312) 440-2500
 

 

CPT - https://commerce.ama-assn.org/store/

 

Description:
CPT codes and definitions.
Updated each January.

Contact:
American Medical Association
(800) 621-8335
 

 

 

 CPT Assistant - https://commerce.ama-assn.org/store/

 

Description:
A newsletter on CPT coding issues.

Contacts:
American Medical Association
(800) 621-8335
 

 

 HCPCS Level II

 

Description:
HCPCS codes and definitions.
Updated each January and throughout the year.

Contact:
Available through various publishers and bookstores or from CMS at www.cms.gov.

 

 ICD

 

Description:
ICD diagnosis and procedure code definitions.
Updated each October.

Contact:
Available through various publishers and bookstores.

 

Miscellaneous - www.shopingenix.com

 

Description:
Various newsletters and other coding resources.

Contact:
Medicode (Ingenix)
 

 

UB-04 National Uniform Billing Expert

 

Description:
National UB-04 billing instructions.

Contact:
Available through various publishers and editors.

 

Number of Lines on Claim

The Montana claims processing system supports 40 lines on a UB-04 claim, 21 lines on a CMS-1500, and 21 lines on a dental claim.

Multiple Services on Same Date

Outpatient hospital providers must submit a single claim for all services provided to the same member on the same day. If services are repeated on the same day, use appropriate modifiers. The only exception to this is if the member has multiple emergency room visits on the same date. Two or more emergency room visits on the same day must be billed on separate claims with the correct admission hour on each claim.

Span Bills

Outpatient hospital providers may include services for more than one day on a single claim, so long as the service is paid by fee schedule (e.g., partial hospitalization, therapies) and the date is shown on the line. However, the Outpatient Code Editor (OCE) will not price APC procedures when more than one date of service appears at the line level, so we recommend billing for only one date at a time when APC services are involved.

Reporting Service Dates

All line items must have a valid date of service. The revenue codes on the following page require a separate line for each date of service and a valid CPT or HCPCS code:

Revenue Codes That Require a Separate Line for Each Date of Service and a Valid CPT or HCPCS Code

 

26X - IV Therapy
28X - Oncology
30X - Laboratory
31X - Laboratory Pathological
32X  -Radiology – Diagnostic
33X - Radiology – Therapeutic
34X - Nuclear Medicine
35X - Computed Tomographic (CT) Scan
36X - Operating Room Services
38X - Blood
39X - Blood Storage and Processing
40X - Other Imaging Services
41X - Respiratory Services
42X - Physical Therapy
43X - Occupational Therapy
44X - Speech-Language Pathology
45X - Emergency Department
46X - Pulmonary Function
47X - Audiology
48X - Cardiology
49X - Ambulatory Surgical Care
51X - Clinic
52X - Free-Standing Clinic
61X - Magnetic Resonance Imaging (MRI)
63X - Drugs Requiring Specific Identification
70X - Cast Room
72X - Labor Room/Delivery
73X - Electrocardiogram (EKG/ECG)
74X - Electroencephalogram (EEG)
75X - Gastro-Intestinal Services
76X - Treatment or Observation Room
77X - Preventive Care Services
79X - Lithotripsy
82X - Hemodialysis – Outpatient or Home
83X - Peritoneal Dialysis – Outpatient or Home
84X - Continuous Ambulatory Peritoneal Dialysis (CAPD) – Outpatient
85X - Continuous Cycling Peritoneal Dialysis (CCPD) – Outpatient
88X - Miscellaneous Dialysis
90X - Psychiatric/Psychological Treatments
91X - Psychiatric/Psychological Services
92X - Other Diagnostic Services
94X - Other Therapeutic Services

 

Using Modifiers

  • Review the guidelines for using modifiers in the most current CPT book, HCPCS book, and other helpful resources (e.g., CPT Assistant, APC Answer Letter, and others).
  • Always read the complete description for each modifier; some modifiers are described in the CPT manual while others are in the HCPCS book.
  • Medicaid accepts most of the same modifiers as Medicare, but not all.
  • The Medicaid claims processing system recognizes three pricing modifiers and one informational modifier per claim line on the CMS-1500. Providers are asked to place any modifiers that affect pricing in the first two modifier fields.
  • Discontinued or reduced service modifiers must be listed before other pricing modifiers on the CMS-1500. For a list of modifiers that change pricing, see the How Payment Is Calculated chapter in this manual.

Billing Tips for Specific Services

Prior authorization is required for some services. Passport and prior authorization are different; some services may require both. Different numbers are issued for each type of approval and must be included on the claim form.

Abortions
A completed Montana Healthcare Programs Physician Certification for Abortion Services (MA-37) form must be attached to every abortion claim or payment will be denied. Complete only one section of this form. This is the only form Medicaid accepts for abortions.

Drugs and Biologicals
While most drugs are bundled, there are some items that have a fixed payment amount and some that are designated as transitional pass-through items. (See the Pass-Through section in the How Payment Is Calculated chapter of this manual.) Bundled drugs and biologicals have their costs included as part of the service with which they are billed. The following drugs may generate additional payment:

  • Vaccines, antigens, and immunizations
  • Chemotherapeutic agents and the supported and adjunctive drugs used with them
  • Immunosuppressive drugs
  • Orphan drugs
  • Radiopharmaceuticals
  • Certain other drugs, such as those provided in an emergency department for heart attacks

Lab Services
If all tests that make up an organ or disease organ panel are performed, the panel code should be billed instead of the individual tests.

Some panel codes are made up of the same test or tests performed multiple times. When billing one unit of these panels, bill one line with the panel code and one unit. When billing multiple units of a panel (the same test is performed more than once on the same day) bill the panel code with units corresponding to the number of times the panel was performed.

Outpatient Clinic Services

When Medicaid pays a hospital for outpatient clinic or provider-based clinic services, the separate CMS-1500 claim for the physician’s services must show the hospital as the place of service (i.e., POS 22 for hospital outpatient). For imaging and other services that have both technical and professional components, physicians providing services in hospitals must bill only for the professional component if the hospital is going to bill Medicaid for the technical component. Refer to the Physician-Related Services manual and the Billing Procedures chapter in this manual for more information. Provider type manuals are located on the provider type pages of the Provider Information website.

Partial Hospitalization

Partial hospitalization services must be billed with the national code for partial hospitalization, the appropriate modifier, and the prior authorization code.

Current Payment Rates for Partial Hospitalization

 

Code:  H0035 Modifier:  —   Service Level:  Partial hospitalization, sub-acute, half day

Code:  H0035 Modifier:  U6  Service Level:  Partial hospitalization, sub-acute, full day

Code:  H0035 Modifier:  U7  Service Level:  Partial hospitalization, acute, half day

Code:  H0035 Modifier:  U8  Service Level:  Partial hospitalization, acute, full day

 

Sterilization/Hysterectomy (ARM 37.86.104)
Elective sterilizations are sterilizations done for the purpose of becoming sterile. Medicaid covers elective sterilization for men and women when all of the following requirements are met:

  1. Member must complete and sign the Informed Consent to Sterilization (MA-38) form at least 30 days, but not more than 180 days, prior to the sterilization procedure. This form is the only form Medicaid accepts for elective sterilizations. If this form is not properly completed, payment will be denied. The 30-day waiting period may be waived for either of the following:
    1. Premature Delivery. The Informed Consent to Sterilization must be completed and signed by the member at least 30 days prior to the estimated delivery date and at least 72 hours prior to the sterilization.
    2. Emergency Abdominal Surgery. The Informed Consent to Sterilization form must be completed and signed by the member at least 72 hours prior to the sterilization procedure.
  2. Member must be at least 21 years of age when signing the form.
  3. Member must not have been declared mentally incompetent by a federal, state, or local court, unless the member has been declared competent to specifically consent to sterilization.
  4. Member must not be confined under civil or criminal status in a correctional or rehabilitative facility, including a psychiatric hospital or other correctional facility for the treatment of the mentally ill.

Before performing a sterilization, the following requirements must be met:

  • The member must have the opportunity to have questions regarding the sterilization procedure answered to his/her satisfaction.
  • The member must be informed of his/her right to withdraw or withhold consent anytime before the sterilization without being subject to retribution or loss of benefits.
  • The member must be made aware of available alternatives of birth control and family planning.
  • The member must understand the sterilization procedure being considered is irreversible.
  • The member must be made aware of the discomforts and risks which may accompany the sterilization procedure being considered.
  • The member must be informed of the benefits and advantages of the sterilization procedure.
  • The member must know that he/she must have at least 30 days to reconsider his/her decision to be sterilized.
  • An interpreter must be present and sign for members who are blind or deaf, or do not understand the language to assure the person has been informed.

Informed consent for sterilization may not be obtained under the following circumstances:

  • If the member is in labor or childbirth.
  • If the member is seeking or obtaining an abortion.
  • If the member is under the influence of alcohol or other substance which affects his/her awareness.

For elective sterilizations, a completed Informed Consent to Sterilization (MA-38) form must be attached to the claim for each provider involved or payment will be denied. This form must be legible, complete, and accurate. It is the provider’s responsibility to obtain a copy of the form from the primary or attending physician.

For medically necessary sterilizations, including hysterectomies, oophorectomies, salpingectomies, and orchiectomies, one of the following must be attached to the claim, or payment will be denied:

  • A completed Medicaid Hysterectomy Acknowledgement form (MA-39) for each provider submitting a claim. It is the billing provider’s responsibility to obtain a copy of the form from the primary or attending physician. Complete only one section of this form. When no prior sterility (Section B) or life-threatening emergency (Section C) exists, the member (or representative, if any) and physician must sign and date Section A of this form prior to the procedure. (See 42 CFR 441.250 for the federal policy on hysterectomies and sterilizations.) Also, for Section A, signatures dated after the surgery date require manual review of medical records by the Department. The Department must verify that the member (and representative, if any) was informed orally and in writing, prior to the surgery, that the procedure would render the member permanently incapable of reproducing. The member does not need to sign this form when Sections B or C are used.
  • For members who have become retroactively eligible for Medicaid, the physician must certify in writing that the surgery was performed for medical reasons and must document one of the following:
    • The individual was informed prior to the hysterectomy that the operation would render the member permanently incapable of reproducing.
    • The reason for the hysterectomy was a life-threatening emergency.
    • The member was already sterile at the time of the hysterectomy and the reason for prior sterility.

When submitting claims for retroactively eligible members, for which the date of service is more than 12 months earlier than the date the claim is submitted, contact the member’s local Office of Public Assistance and request a Notice of Retroactive Eligibility (160-M). Attach the form to the claim.

Supplies
Supplies are generally bundled, so they usually do not need to be billed individually. A few supplies are paid separately by Medicaid. The fee schedules on the website lists the supply codes that may be separately payable.

Submitting a Claim

Paper Claims
Unless otherwise stated, all paper claims must be mailed to:

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

On the CMS-1500, 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 Indicators

 

Code:  Member/Service:  EPSDT
Purpose:  Used when the member is under age 21.

Code:  Member/Service:  Family planning
Purpose:  Used when providing family planning services.

Code:  Member/Service:  EPSDT and family planning
Purpose:  Used when the member is under age 21 and is receiving family planning services.

Code:  Member/Service:  Pregnancy (any service provided to a pregnant woman)
Purpose:  Used when providing services to pregnant women.

Code:  Member/Service:  Nursing facility member
Purpose:  Used when providing services to nursing facility residents.

 

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.

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 Medicaid ID number followed by the member's ID number and the date of service, each separated by a dash:

Attachment Control Number Format

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 Medicaid ID number followed by the member's ID number and the date of service, each separated by a dash:

The supporting documentation must be submitted with a Paperwork Attachment Cover Sheet. (See Forms page on the Provider Information website.) The number in the paper Attachment Control Number field must match the number on the cover sheet.

Claim Inquiries

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

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’s National Provider Identifier (NPI) and/or Taxonomy is 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 enumerator system. Verify the correct NPI and Taxonomy are 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.

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 ID 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 this manual. Medicaid eligibility may change monthly.

Reasons for Return or Denial:  Procedure requires Passport provider referral – No Passport provider number on claim
How to Prevent Returned or Denied Claims: 

  • A Passport provider number must be on the claim form when a referral is required. Passport approval is different from prior authorization. See the Passport to Health provider manual.

Reasons for Return or Denial:  Prior authorization number is missing
How to Prevent Returned or Denied Claims: 

  • Prior authorization is required for certain services, and the prior authorization number must be on the claim form. Prior authorization is different from Passport. See the Prior Authorization chapter 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 for previously submitted claims before resubmitting.
  • When making changes to previously paid claims, submit an adjustment form rather than a new claim form. (See Remittance Advices and Adjustments 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.
  • If the member’s TPL coverage has changed, providers must notify the TPL unit before submitting a claim.

Reasons for Return or Denial:  Claim past 365-day 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.

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 number 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.
  • After updating his/her license, the claims that have been denied must be resubmitted by the provider.

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 coding books.
  • Check the appropriate Medicaid fee schedule to verify the procedure code is valid for your provider type.

 

Other Programs

The information in this chapter also applies to those services covered under the Mental Health Services Plan (MHSP).

 

End of Billing Procedures Chapter

School Services Billings Procedure 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