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Manual Review Page

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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: Treatment of Speech Distorder; individual
CPT Code: 92507
Unit Measurement: Per visit

Service: Treatement of Speech Disorder; group
CPT Code: 92508
Unit Measurement: Per visit

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

Service: Psychological testing by Psychologist
CPT Code: 96101
Unit Measurement: Per 1 hour


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: Comprehensive Hearing Test
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