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Manual Review Page

This page is for the review of manual changes.


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FAQs - Adjustments

Adjustments

When can we submit an Individual Adjustment Request (IAR)?
An Individual Adjustment Request (IAR) is intended to correct or change specific information on a claim that has already been paid.  Denied claims cannot be adjusted.
Some examples of when to submit an IAR:

  • The claim was overpaid or underpaid.
  • The claim was paid, but the information on the claim was incorrect, such as the member ID, date-of-service, diagnosis code, etc.
  • An individual line has been denied on a multiple-line UB-04 claim.  The denied service must be submitted as an adjustment, not a resubmission.
  • If a professional claim has an individual line deny on a multiple-line claim, the individual line can be resubmitted.  Previously paid lines will deny as duplicates, if not adjusted.

What documentation is required when submitting an Individual Adjustment Request?
In order for an Individual Adjustment Request to be processed, the Medicaid Statement of Remittance (ESOR) is required, in addition to the Individual Adjustment Request Form.  A copy of the claim is optional.

  • Please ensure that every line of Section A on the Individual Adjustment Request Form is complete.  If the payment amount on the original claim was $0.00, that amount needs to be entered.  Claims paid at $0.00 are considered paid claims.  Please keep in mind, only paid claims can be adjusted. 
  • If a claim has been split into multiple claims, disclose all Internal Control Numbers (ICNs) on the Individual Adjustment Request Form on line A3 of the Individual Adjustment Form.  All relevant remittances from the split claims will need to be attached.
  • If the reason for the adjustment is explained in boxes 1 through 7, box 8 can be used to provide clarification or additional information.
  • If you are adjusting a claim that initially required additional documentation, please include a copy of the original documentation with the adjustment.
  • When changing units, please remember to change the charge amount, if applicable.

Are there any resources for assistance in completing an Individual Adjustment Request?
Please visit our Training Page to access the “Provider 102” PowerPoint, which has beneficial information regarding Individual Adjustment Requests.  
As always, please feel free to contact Provider Relations at 1-800-624-3958 if you would like to speak to one of our Montana Healthcare Programs Agents.

If we are sending an adjustment to add a Third-Party Liability payment, do we send the Explanation of Benefits?
No, we do not require the Explanation of Benefits in this case.  Disclose the information in the correct box in Section B of the Individual Adjustment Request form.  Please ensure that you include all TPL information in the appropriate box or the claim will deny.

How do we submit an adjustment if we receive payment for a member that is not one of our patients?
Please contact Provider Relations at (800) 624-3958 for assistance.
 

FAQs - Billing and Electronic Transactions

Billing & Electronic Transactions
 

How can claims be submitted?
Electronic claims can be submitted through a Clearinghouse, Billing Agent, WINASAP or Direct Submission.

  • A Clearinghouse is usually a large business specifically set up to handle mass electronic billing transactions
  • A Billing Agent is an individual that handles the electronic billing directly for providers.
  • Windows Accelerated Submission and Processing (WINASAP) creates an X12N HIPAA compliant electronic message that can be used to submit claims data.  WINASAP is free, but also has very limited technical support available.  It is not a Practice Management Software and only creates the claim file.  Please note, WINASAP is not compatible with Windows 10.

Will our claims be processed faster if we submit them electronically or via paper?
The suggested method for efficiency and minimal delays in processing is electronic submission.  Claims submitted electronically are processed at an average of 14 days faster than paper claims.

What is EDI?

  • EDI = Electronic Data Interchange
  • ASC = Accredited Standards Committee is a subcommittee of American National Standards Institute (ANSI)
  • X12N = Insurance format for the transfer of sensitive information
  • X12N = Became a requirement for insurance transactions with the passage of HIPAA in 1996

We received a rejection stating that our NPI number is not on file.  What could be the cause?
If you are submitting a professional claim, please ensure that you have received a welcome letter from Montana Healthcare Programs for the Rendering and Billing NPI numbers, both NPI numbers on the claim are required to be enrolled prior to submission of the claim.
If you are submitting a UB-04 claim, please ensure that the Billing NPI number is enrolled prior to submitting the claim.
There are rare exceptions when a provider does not require a NPI.  These exemptions are for Personal Assistance or Home and Community Based Services (Waiver) providers.  In this case, the provider will bill with an Atypical number.
Please contact Provider Relations at (800) 624-3958 if you have confirmed that all appropriate NPI numbers are enrolled and you are still receiving the rejection.

Why is a taxonomy code required?
The taxonomy code is one of several important data elements used to match the enrollment.  If an organization has multiple enrollments under the same NPI number, the taxonomy code is what the claims processing system uses to distinguish the difference in the files (e.g. Pharmacy, Durable Medical Equipment, etc.)
There are rare exceptions in which a provider file does not require a taxonomy code, such as a Personal Assistance or Home and Community Based (Waiver) file.  In this case, the provider will bill without the taxonomy code.

What qualifier do we use to reflect taxonomy code?

  • Use qualifier PXC on CMS 1500 electronic claims 
  • Use qualifier ZZ on CMS 1500 paper claims
  • Use qualifier B3 on UB-04 institutional claims 

What are the most common errors with Electronic Submissions?
•    Provider did not complete the EDI Enrollment (X12N) packet to enable electronic billing.  Enrollment with Montana Healthcare Programs does not automatically enroll you for billing electronically.

  • Missing or invalid taxonomy code
  • Invalid zip code.  The full nine digits of the zip code (including the plus four) must be valid.
  • National Provider Identification (NPI) number not enrolled
  • Invalid/missing/unenrolled Rendering provider
  • Clearinghouse is not sending Montana specific requirements.  For example, the Passport number is sent in the wrong place.
  • No PWK indicator on electronic claim when a paperwork attachment has been sent. 

What type of claim do I use?

  • The electronic version of the Professional Claim (CMS-1500) is known as an 837P
  • The electronic version of the Institutional Claim (UB-04) is knows as an 837I
  • The electronic version of the Dental Claim (ADA 2012) is knows as an 837D

How many diagnosis codes can be used for processing?

  • CMS-1500/837P – 12 diagnoses codes
  • UB-04/837I – 18 diagnoses codes

We submit our claims electronically.  What are the requirements for paper attachments?

  • A Paperwork Attachment Coversheet indicating the Attachment Control number must be included.
    • A copy can be found at www.medicaidprovider.mt.gov > Forms
  • The electronic claim file must indicate that paperwork is being sent.
    • Loop 2300, PWK segment
  • The paper attachments must be received within 30 days from the electronic submission date.
    • After 30 days, the claim will be denied and will require resubmission by the provider.

What is considered the receipt date for electronic claims?
The receipt date is the date that the claim is uploaded into the mainframe.  Typically, this is the business day after it is received.

What are the timely filing guidelines for Montana Healthcare Programs?
In general, providers are given 365 days from the date of service to submit claims before the claim is denied for timely filing.

There are exceptions to timely filing guidelines, so please refer to your provider manual.

What if we have more than one rendering provider on our professional claim form?
The Montana Healthcare Programs claims processing system can only process one rendering provider per professional claim.

If a provider enters more than one rendering provider on a paper professional claim, the system will choose the rendering provider that appears on the first line and complete adjudication using that rendering NPI number.  Additional rendering providers billed on the claim will not be processed.  

Professional claims submitted electronically with multiple rendering providers will be split into separate claims.

I have an individual NPI number for myself and a group NPI number for my clinic.  Which NPI number do I use when I am billing for services that I render?
In this case, please submit claims with your individual NPI number as the rendering NPI number and your group’s NPI number as the billing NPI number on the professional claim.
Please keep in mind that all rendering and billing NPI numbers must be enrolled with Montana Healthcare Programs in order for professional claims to be successfully processed.

An additional provider joined my practice.  I would like my group to receive payment for all services provided.  How do I submit claims?
Please keep in mind that all rendering and billing NPI numbers must be enrolled with Montana Healthcare Programs in order for professional claims to be successfully processed.  
This means that you must obtain a group NPI number from NPPES and enroll with Montana Healthcare Programs as a group.  Additionally, you must ensure that the individual provider is also enrolled with Montana Healthcare Programs.
Once both NPI numbers are enrolled with Montana Healthcare Programs, you will submit professional claims with the individual provider as the rendering NPI number and the group as the billing NPI number on the professional claim.
Payment is always directed to the provider that is disclosed as the billing NPI number on claims.

An additional provider joined my practice.  I would like the individual provider to be paid for the services that they render directly from Montana Healthcare Programs, instead of my group.  How do I complete the enrollment and submit claims?
In this case, the individual provider will need to be enrolled with Montana Healthcare Programs with the full enrollment and their own tax reporting and banking information.

When claims are submitting the individual provider’s NPI number will need to be submitted as the rendering and billing NPI number on the professional claim.

Payment is always directed to the provider that is disclosed as the billing NPI number on claims.

Our organization provides Durable Medical Equipment (DME) services and Pharmacy services.  How do we complete our enrollment and how do we bill?
Although the organization may share the same NPI number, a separate enrollment will need to be completed for each provider type service that the organization is planning on billing.

Each provider file will be set up with the appropriate taxonomy code for the services/provider type that the organization plans to bill.  When claims are submitted, the appropriate NPI number and taxonomy code will need to be submitted on claims to route them to the appropriate provider file.  If you need assistance or clarification, please contact Provider Relations at (800) 624-3958.

DME services provided to HMK members are submitted to Blue Cross and Blue Shield of Montana (BCBSMT). Providers must enroll at BCBSMT as HMK DME providers and submit medical claims to BCBMT. HMK member IDs for BCBSMT are the MATH portal ID number with a leading YDE00

What do we do if a Medicare crossover claim does not crossover to Medicaid?
A notification from Centers for Medicare and Medicaid Services (CMS) states that 98% of all claims crossover.  The remaining 2% of the cases may have issues with HIPAA compliance failures or issues with the information being sent from the Medicare contractor.

It can take up to 45 days for the claim to reach Montana Healthcare Programs from Medicare.  The claim from Medicare must have the required Montana information, including the taxonomy code, which will be transmitted by Medicare.  

If the claim is rejected, you should receive a notification letter at the correspondence address on file within 5 business days from the rejection action.  Prior to resubmitting the claim to Montana Healthcare Programs after the rejection, please ensure that 45 days from the original submission has passed to avoid duplicates.

Please remember that Medicare Part A and Part C will never crossover.  These claims must be sent directly to Montana Healthcare Programs from the provider.

A member has Medicare and became dually eligible for Montana Healthcare Programs during his hospital stay.  He was admitted into the hospital on 11/30/2018, but not eligible for Medicaid until 12/01/2018.  Medicare requires dates of service from 11/30/2018.  How should we submit the claim?
The provider will have to prorate the stay for Medicaid eligibility on the Medicare Explanation of Benefits and on the Medicaid claim.

Where can we get a new fee schedule?
Fee schedules are available on the Provider Information website by following the Resources by Provider Type link and accessing your specific provider type.

What does HIPAA mean?
HIPAA is the acronym for the Health Care Portability and Accountability Act. In October 2003, it was mandated that all electronic health care transactions be submitted in a standard format, regardless of the payer to which they were submitted. 

All providers and billers covered by HIPAA must submit claims electronically using the approved format, which is known as ASC X12 005010.  This format may also be called HIPAA 5010.
 

FAQs - Claim Processing

Claim Processing


How long are we required to keep Remittance Advices?
Please retain all remittances advices for 6 years and 3 months (ARM 37.85.414)

What type of claim form do we use?

  • CMS 1500 – Professional Billing
  • UB-04 – Institutional Billing
  • ADA 2012 – Dental Billing
  • MA-3 – Nursing Home

When submitting the claim forms, please use the original forms, not copies.  This is a Center for Medicare and Medicaid (CMS) requirement.  Claim forms can be purchased from most office supply stores.

Where do we send paper claims?
Claims Processing
P.O. Box 8000
Helena, MT 59604

Will our claims be processed faster if we submit them electronically or via paper?
The suggested method for efficiency and minimal delays in processing is electronic submission.  Paper claims that are mailed are processed faster than paper claims that are faxed.  

Electronic claims can take between 1 to 4 weeks to process, mailed paper claims can take between 4 to 6 weeks to process and faxed paper claims can take between 6 to 8 weeks to process, pending any issues.
Please remember that faxing a claim is not considered an Electronic Submission.

What are some common billing errors?

  • The provider’s National Provider Identifier (NPI) and/or taxonomy is missing or invalid.  
    • Verify that the correct NPI and taxonomy code are on the claim.
  • Member ID number not on file, or member was not eligible on date of service.
    • Medicaid eligibility may change monthly.  Prior to providing services to the member, verify member eligibility.
      • Member eligibility can be verified through the provider services portal or by contacting Provider Relations at 1-800-624-3958.
  • Procedure requires Passport provider referral; No Passport provider number on the claim.
    • A Passport provider number must be on the claims form when referral is required.  Passport approval is different from prior authorization.  Please see the Passport to Health provider manual for specifics.
  • Prior authorization does not match current information.
    • The dates of service of the claim must fall within the dates authorized on the prior authorization span.

Additional common errors can be found in the General Provider Manual and in “The Top 15” in the monthly Claim Jumper.

What fields of the claim form are required?
There are specific field requirements, dependent on the type of claims form you will be submitting for your type of facility/organization.


We submit our claims electronically.  What are the requirements for paper attachments?

  • A Paperwork Attachment Cover Sheet must be included.
  • The electronic claim file must indicate that paperwork is being sent.
    • Loop 2300, PWK segment
  • The paper attachments must be received within 30 days from the electronic submission date.
    • After 30 days, the claim will be denied and will require re-submission.

What is considered the receipt date for electronic claims?
The receipt date is the date that the claim is uploaded onto the mainframe.  Typically, this is the business day after it is received.   

What are the timely filing guidelines for Montana Healthcare Programs?
Providers are given 365 days from the date of service to submit claims before the claim is denied for timely filing.

There are exceptions to timely filing guidelines, so please refer to your provider manual.
 

Does Montana Healthcare Programs pay for claims with a total billed amount below $5.00?
If only one claim under the total billed amount of $5.00 is submitted, Montana Healthcare Programs will wait until the following claim is submitted and issue one payment.  

Twice a year, the payment threshold is reduced to $0.01 to release all small payments.
 
How many diagnosis codes can be used for processing?

  • CMS-1500/837P – 12 diagnoses codes
  • UB-04/837I – 18 diagnoses codes 

If a provider has performed a sterilization and the member retroactively becomes eligible for Montana Healthcare Programs is the sterilization form still required?
If the provider suspects that that the member may become eligible for Medicaid, the provider should obtain the member’s signature on the form 30 days prior to the sterilization.

If the sterilization is medically necessary, the provider can submit the claim and supporting documentation, including operative notes and the Physician’s statement.  The Department will review all supporting documentation.

What if we have more than one rendering provider on our professional claim form?
The Montana Healthcare Programs claims processing system can only process one rendering provider per professional claim.

If a provider enters more than one rendering provider on a paper professional claim, the system will choose the rendering provider that appears on the first line and complete adjudication using that rendering NPI number.  Additional rendering providers billed on the claim will not be processed.  

Professional claims submitted electronically with multiple rendering providers will be split into separate claims. 

I have an individual NPI number for myself and a group NPI number for my clinic.  Which NPI number do I use when I am billing for services that I render?
In this case, please submit claims with your individual NPI number as the rendering NPI number and your group’s NPI number as the billing NPI number on the professional claim.

Please keep in mind that all rendering and billing NPI numbers must be enrolled with Montana Healthcare Programs in order for professional claims to be successfully processed. 

An additional provider joined my practice.  I would like my group to receive payment for all services provided.  How do I submit claims?
Please keep in mind that all rendering and billing NPI numbers must be enrolled with Montana Healthcare Programs in order for professional claims to be successfully processed.  

This means that you must obtain a group NPI number from NPPES and enroll with Montana Healthcare Programs as a group.  Additionally, you must ensure that the individual provider is also enrolled with Montana Healthcare Programs.

Once both NPI numbers are enrolled with Montana Healthcare Programs, you will submit professional claims with the individual provider as the rendering NPI number and the group as the billing NPI number on the professional claim.

Payment is always directed to the provider that is disclosed as the billing NPI number on claims.  

An additional provider joined my practice.  I would like the individual provider to be paid for the services that they render directly from Montana Healthcare Programs, instead of my group.  How do I complete the enrollment and submit claims?
In this case, the individual provider will need to be enrolled with Montana Healthcare Programs with the full enrollment and their own tax reporting and banking information.

When claims are submitting the individual provider’s NPI number will need to be submitted as the rendering and billing NPI number on the professional claim.

Payment is always directed to the provider that is disclosed as the billing NPI number on claims.  

Our organization provides Durable Medical Equipment (DME) services and Pharmacy services.  How do we complete our enrollment and how do we bill?
Although the organization may share the same NPI number, a separate enrollment will need to be completed for each provider type service that the organization is planning on billing.

Each provider file will be set up with the appropriate taxonomy code for the services/provider type that the organization plans to bill.  When claims are submitted, the appropriate NPI number and taxonomy code will need to be submitted on claims to route them to the appropriate provider file.

DME services provided to HMK members are submitted to Blue Cross and Blue Shield of Montana (BCBSMT). Providers must enroll at BCBSMT as HMK DME providers and submit medical claims to BCBMT. HMK member IDs for BCBSMT are the MATH portal ID number with a leading YDE00.  

A member has Medicare and became dually eligible for Montana Healthcare Programs during his hospital stay.  He was admitted into the hospital on 11/30/2018, but not eligible for Medicaid until 12/01/2018.  Medicare requires dates of service from 11/30/2018.  How should we submit the claim?
The provider will have to prorate the stay for Montana Healthcare Programs eligibility on the Medicare Explanation of Benefits and on the Montana Healthcare Program claim.
 

FAQs - Eligibility

Eligibility


What provider number do we use when contacting Provider Relations for eligibility information?
Utilize your National Provider Identification (NPI) number.  If you are an atypical provider, you will use your Provider Identification number disclosed on your welcome letter from Montana Healthcare Programs.

Please keep in mind that you must be enrolled with Montana Healthcare Programs during the dates that you are seeking member specific information.

Is there a temporary identification number to submit on a claim for a newborn that has not been assigned an ID yet?
Unfortunately, the system cannot process a claim without a member identification number.  Member ID numbers are assigned by the Office of Public Assistance (OPA).  

If a Montana Healthcare Programs patient gives birth, does her infant automatically get coverage too?
If the mother is eligible and receiving non-medically needy Montana Healthcare Program eligibility at the time of the birth, then the baby is eligible for the Medicaid Newborn Program. 

The program will provide the infant coverage for up to one year, as long as the baby continues to live in Montana.


How often can member eligibility change and why would they terminate?
A member’s eligibility can change from month-to-month.  The Office of Public Assistance (OPA) determines if an individual meets the criteria to be eligible for Montana Healthcare Program and passes the information to Provider Relations.  

In order to receive information about why a member is no longer eligible, the member will have to contact the OPA at (888) 706-1535.

What is incurment and what does it have to do with eligibility?
Incurments apply to members who do not meet the financial eligibility requirements for Montana Healthcare Program until they spend down (incur) some of their income on medical services.

On one date of service, the member may be eligible for everything, except for a specific provider or a portion of a specific provider’s services.  lf this happens, the provider will receive a 160-M form from the Office of Public Assistance advising them to bill some or all services to Montana Healthcare Programs on the date that the incurment was met.

The start date appearing on the eligibility verification system will be the date after the incurment was met.

Paid and unpaid bills may be applied toward the incurment for up to 3 months after the month in which they are incurred.  If the bills have not already been applied to a previous incurment and the provider has not written off the bill, current payments made toward an outstanding bill that is over 3 months old may also be applied toward the incurment.

What does SLMB stand for?
SLMB stands for Specified Low-Income Medicare Beneficiary.  Montana Healthcare Programs pays the Medicare premium only for SLMB members.  

The member is responsible for the Medicare coinsurance and deductible, as Montana Healthcare Programs does not provide reimbursement for the deductible, coinsurance or medical services.

What does QMB stand for?
QMB stands for Qualified Medicare Beneficiary.  Montana Healthcare Programs pays the Medicare premiums and a portion of the Medicare coinsurance and deductibles up to the qualified amount.  The member must be eligible and enrolled in Medicare and members are only covered for Medicare’s allowed services.

What is the difference between HMK Plus and HMK? 
Healthy Montana Kids Plus (HMK Plus), also known as Children’s Medicaid, is health care coverage for low-income children and youth up to age 19 who reside in the state of Montana and are at or below 143% of the federal poverty level guidelines. 

Healthy Montana Kids (HMK), also known as the Children’s Health Insurance Plan (CHIP), is a free or low-cost health coverage program for youth up to age 19 who reside in the state of Montana with a household income above 143% through 261% of the federal poverty level.  

Blue Cross & Blue Shield of Montana administers the medical benefits and Montana Healthcare Programs administers the following benefits for HMK members: dental, glasses, pharmacy, ambulance, autism and services provided at Rural Health Clinics and Federally Qualified Health Centers.

Please note that if you are a Dentist, you are required have an enrollment record for both programs if you are providing services to both types of members.  Both programs can be selected on one application; however, if you are currently enrolled with only one program, a new application and supplemental material will be required to enroll the second file.

HMK and HMK Plus have different dental payment methodologies.  HMK has a limit of $1,900 of billed charges with a maximum payable amount of $1,615, when 85% of billable charges are paid.  The limits are applied during the dental benefit year of July 1st through June 30th of the following year.

Where can individuals receive an application for Montana Healthcare Programs?
Applications are available at any local Office of Public Assistance or online at https://apply.mt.gov/.

Where can individuals receive an application for Healthy Montana Kids (HMK)?
Applications care available at any local Office of Public Assistance or online at https://apply.mt.gov/.
If the individual would like to receive the application by mail, they can contact 1-877-KIDS-NOW (1-877-543-7669).
 

FAQs - Enrollment

Enrollment


What is the difference between the Rendering, Billing, and Abbreviated Enrollment Online Applications?

  • A Rendering Only Provider as an individual that performs services on patients at one or more locations and will never receive payment directly.  The Rendering Only Enrollment Application is the best option for Providers that will always be Rendering services at any enrolled Organization.  Claims will deny if a Provider enrolled with a Rendering enrollment attempts to bill as a Billing Provider.
  • A Billing Provider is required to use the Full Enrollment Online Application.  This application collects tax reporting and banking information.  An individual Provider type enrolled as a Billing provider can still submit claims as a Rendering Provider when practicing at multiple enrolled Organizations.
  • The Abbreviated Enrollment Online Application is intended for Providers that will never directly provide in-person services to a Montana Healthcare Programs Member.  These Providers order, refer and prescribe services, and are knows as Attending Providers.  Claims will deny if a Provider enrolled with an Abbreviated enrollment attempts to submit claims as a Rendering or Billing Provider.

How many enrollments can each individual Provider have at one time?
Each NPI number is limited to one enrollment for an individual provider type at a time.  This means that if a Provider is already active with Montana Healthcare Programs and is practicing at a new location, a re-enrollment is not required, and an additional Provider file cannot be added.

An individual Provider enrolled as a Billing Provider with tax reporting and banking information on their individual file can still be disclosed as a Rendering Provider on a professional claim and the enrolled Group/Clinic will receive payment.  For Billing purposes, a Provider file does not tie an individual Provider to a Group, the claim does.  The information disclosed in the Billing Provider section of the claim will be where payment is directed, regardless of what tax reporting and banking information is on the individual Provider’s file.  The only time that a re-enrollment is required is when the provider is enrolled as a Billing Provider and the tax ID number is no longer valid for that Provider.  

If the Provider is enrolled as a Rendering or Attending Provider, a re-enrollment is not required for an address update.  Please visit the Provider File Update section for an address correction form.

Is the online application or paper application encouraged and why?
Montana Healthcare Programs encourages Providers to submit the online application for two reasons.

  • The online application will issue a reference number that Providers can use to locate their application when contacting Provider Relations with any questions.  This makes it easier for Providers to track the status of their applications from beginning to end.
  • If there are no issues, paper applications take an additional business day to process, since an Enrollment Specialist is required to enter the information from the paper application into an online application to get the information into the system.

We have submitted the required supplemental documents for our application.  How long does the enrollment process take and how will I be notified that I can start submitting claims?
After submitting the application, there will be a button to download the accompanying supplemental material.  The requirements of the material vary dependent on provider type and the type of application submitted.  Processing of the application does not begin until the supplemental material has been received.  The documents can be sent by email, mail or fax and must be received within 90 days from the online application submission date, to avoid denial of the application.

Once the supplemental material has been received, a confirmation email will be sent to the email address disclosed on the application.  Typical enrollment processing time is around 15 business days, pending any issues or Department approval.  If there are issues with the application, an Enrollment Specialist will reach out to the email address on the application and call the contact phone number if no response is received over email.

Once the enrollment has been approved, a welcome letter will be sent to the correspondence address on file, advising the Provider of the effective date and taxonomy code on file.  A separate letter will be sent with instructions for registering for the Web Portal.

Why does my welcome letter have a different taxonomy code than what I selected on the application?
As part of the enrollment process, the Provider’s information is validated in the National Provider Registry (NPPES).  Each Provider is enrolled with the primary taxonomy code registered in NPPES, regardless of the taxonomy code selected on the application.  The only exception to the primary taxonomy code policy is when an Organization is enrolling multiple files for different Provider types.  

If you cannot find the Provider’s taxonomy code on the application, please select the closest one and the Enrollment Specialist will make the appropriate corrections.  If the taxonomy code in NPPES is a different specialty than the Provider Type and taxonomy code selected on the application, an Enrollment Agent will reach out to the Provider to correct the taxonomy code in NPPES or clarification on the Provider type selected.

How do I submit the ownership/control information when the facility does not have an owner?
Being that there must be an owner disclosed on each Provider file, the facility must be listed as the owner, if the facility is not owned by any individuals.  In this case, any individual that makes day-to-day or financial decisions must also be disclosed as a Managing Employee, including Board Members.

If an individual Provider is practicing for a group that is owned by additional individuals, how do I submit the ownership/control information?
Montana Healthcare Programs refers to the owner of the Provider file as the owner of the NPI number.  When an individual Provider is enrolling, the only individual that can be disclosed as the owner on the Provider file is the enrolling Provider.  If there are individuals that manage their information, they can be disclosed as Managing Employees on the file.

I am a dental provider and am having claim issues when I attempt to submit a claim for a Healthy Montana Kids (HMK)/CHIP patient.  My claims typically pay, so what can be the cause?
If you are a Dentist, you are required have an enrollment record for HMK/Medicaid (CHIP) and HMK Plus if you are providing services to both types of members.  Both programs can be selected on one application; however, if you are currently enrolled with only one program, a new application and supplemental material will be required to enroll the second file.

HMK and HMK Plus have different dental payment methodologies.  HMK has a limit of $1,900 of billed charges with a maximum payable amount of $1,615, when 85% of billable charges are paid.  The limits are applied during the dental benefit year of July 1st through June 30th of the following year.

We are a School-Based provider that contracts with a Mental Health Contractor for CSCT services.  What information can the Mental Health Contractor request to change or add to our provider files on our behalf?
All changes to existing CSCT enrollments and new enrollments must come from a School contact.  Montana Healthcare Programs is enrolling the school’s NPI number, tax reporting and banking information; therefore, the school is considered the provider.

We are a School-Based provider enrolled in the CSCT program.  How do we request to change Mental Health Contractors?
When a school ends a CSCT contract with a Mental Health Contractor and awards a new contract, the school must submit the ‘CSCT Contractor/Team Change Form’, which can be located in the Forms section of our provider website, https://medicaidprovider.mt.gov.  A copy of the new CSCT contract between the School and the Mental Health Contractor is also required.

Provider Relations will process the new contractor’s information and re-enroll the new team number(s) using the date that the new contract started and terminate the old team number.  The new information will be sent to the School Contact to verify prior to the final approval.

If the tax ID is changing, the school is required to submit a new application and supplemental packet for re-enrollment of each team.  Please note in the supplemental material that the tax ID number is changing and which team numbers you wish to terminate.

I’ve already submitted my online application and realized that I need to make a correction to some information.  How can I make a change to my application if it has already been submitted?
Unfortunately, there is not a way to make changes to an application that has already been submitted by logging back into the application.  

If you have not sent your supplemental material, you can include a letter in your documents with the requested change and the Enrollment Specialist that processes your application can make the appropriate changes in the system.

If your supplemental documents have already been emailed, faxed or mailed, you can contact Provider Relations at (800) 624-3958 with your application reference number to speak with the Enrollment Specialist working on your application.

An additional provider joined my practice.  I would like my group to receive payment for all services provided.  How do I link the two together?
Please keep in mind that all rendering and billing NPI numbers must be enrolled with Montana Healthcare Programs in order for professional claims to be successfully processed.  

This means that you must obtain a group NPI number from NPPES and enroll with Montana Healthcare Programs as a group.  Additionally, you must ensure that the individual provider is also enrolled with Montana Healthcare Programs.

Once both NPI numbers are enrolled with Montana Healthcare Programs, you will submit professional claims with the individual provider as the rendering NPI number and the group as the billing NPI number on the professional claim.
Payment is always driven to the provider that is disclosed as the billing NPI number on claims.  

An additional provider joined my practice.  I would like the individual provider to be paid for the services that they render directly from Montana Healthcare Programs, instead of my group.  How do I complete the enrollment and submit claims?
In this case, the individual provider will need to be enrolled with Montana Healthcare Programs with the full enrollment and their own tax reporting and banking information.

When claims are submitting the individual provider’s NPI number will need to be submitted as the rendering and billing NPI number on the professional claim.

Payment is always driven to the provider that is disclosed as the billing NPI number on claims.

Our organization provides Durable Medical Equipment (DME) services and Pharmacy services.  How do we complete our enrollment and how do we bill?
Although the organization may share the same NPI number, a separate enrollment will need to be completed for each provider type service that the organization is planning on billing.

Each provider file will be set up with the appropriate taxonomy code for the services/provider type that the organization plans to bill.  When claims are submitted, the appropriate NPI number and taxonomy code will need to be submitted on claims to route them to the appropriate provider file.

DME services provided to HMK members are submitted to Blue Cross and Blue Shield of Montana (BCBSMT). Providers must enroll at BCBSMT as HMK DME providers and submit medical claims to BCBMT. HMK member IDs for BCBSMT are the MATH portal ID number with a leading YDE00.
 

FAQs - Fraud and Abuse

Fraud and Abuse
 

Who do we contact to report provider fraud or elder abuse?
To report provider fraud and elder abuse, contact the Medicaid Provider Fraud hotline at (800) 376-1115. 



Reporting Medicaid Provider Fraud and/or Elder Abuse
Montana Department of Justice, Investigations Bureau, Medicaid Fraud Control Unit (MFCU) Section
The Medicaid Fraud Control Section is responsible for investigating any crime that occurs in a health care facility, including theft, drug diversion, sexual assault, homicide, and elder exploitation.

This section also investigates provider fraud within the Montana Healthcare Program system, including investigations into Doctors, Dentists, Durable Medical Equipment Providers, Mental Health Providers and additional Montana Healthcare Program provider types.

Who do we contact to report member fraud, waste or abuse?
To report member fraud, waste or abuse, contact the Member Fraud hotline at (800) 201-6308.

Reporting Medicaid Member Waste, Fraud and/or Abuse
DPHHS, Quality Assurance Division, Program Compliance Bureau


Member fraud can be one or more of the following:

  • A false application submitted for Montana Healthcare Programs.
  • False or misleading information provided about income, assets, family members or resources.
  • The member shared his or her Montana Healthcare Program card with another individual.
  • An individual bought or sold a Montana Healthcare Program card.
  • The member sold prescription drugs, medical supplies and other benefits after receiving Montana Healthcare Program reimbursement.
  • Participated in doctor or pharmacy “shopping” to obtain extra prescriptions
  • Paid cash for controlled substances
  • Forged prescriptions
  • Obtained Montana Healthcare Program benefits that they were not entitled to through additional   fraudulent means.

FAQs - MATH Web Portal, FaxBack, and IVR

MATH Web Portal, FaxBack, and IVR
 

What is the Montana Access to Health (MATH) Web Portal?
The MATH Web Portal is a provider portal that is beneficial for obtaining access to:

  • Claim status
  • Electronic Statement of Remittance (eSORS)
  • Eligibility

Where can the MATH Web Portal be found?
The MATH Portal can be found at the following two sites:
https://mtaccesstohealth.portal.conduent.com/mt/general/home.do
https://medicaidprovider.mt.gov/ 

How do we register for the Web Portal?
Currently, when you enroll with Montana Healthcare Program, you should automatically receive Web Portal access.  You will receive a welcome letter for enrollment with Montana Healthcare Programs and a separate letter for Web Portal access.  

Prior to 2017, a provider was only given Web Portal access if requested by completing a Trading Partner Agreement.  If you were enrolled prior to 2017 and have not received Web Portal access, please complete the Trading Partner Agreement.  

If you do not receive your Trading Partner Identification letter for Web Portal access, please contact Provider Relations at 1-800-624-3958 to obtain a copy.

After receiving the Trading Partner Identification letter, the following steps will need to be followed, in order to get registered:

  • Use the Trading Partner number on the letter as both the NPI number and the Submitter ID.
  • Use the Tax Identification number or SSN that you enrolled with for tax reporting on your provider file.
  • The Submitter Password is obtained from the EDI letter as “Password/User ID”.

Once we are registered for the Web Portal can we manage authorized users and reset the password?
Yes, once you are logged into the Web Portal as the Office Administrator, you will have access to add, update and remove users, limit privileges for users, and reset the password.

If the only Office Administrator is no longer employed with the business, a signed and dated request to change the Office Administrator can be submitted to Provider Relations on company letter head by fax, mail or email.
•    Mail: PO Box 4936, Helena, MT 59604
•    Fax: (406) 442-4402
•    Email: MTPRHelpdesk@conduent.com

How do I obtain Electronic Statement of Remittance (eSORS) or Remits?

  • Once you are logged into the provider services Web Portal, you can click on ‘View e!SOR Reports’ under the Retrievals tab.
  • Enter your NPI number or Provider Number and click “Submit”.
  • Click on the remittance advice that you would like to download.  They are sorted by payment date.
    • Please note that after 90 days, the files will be deleted from the Web Portal.

How do I view eligibility for a member?
Please remember member eligibility can change from month-to-month, so please ensure that the member is eligible prior to providing services.

  • Once you are logged in, you can click on “Eligibility” under the Inquiries tab.
  • Enter the your NPI number or provider number, the patient’s Medicaid ID number and date of service.  You can also search by the last name, first name, date of birth and date of service.
    • Never change the “Service Type Code” or it may display incorrect information.
    • Keep in mind that copay information displayed on the portal is not correct. Copays are determined once the claim has been adjudicated. Copays may not be collected on date of service.
  • Verify the member’s name and date of birth on the eligibility screen to ensure that you have the correct member.  Their eligibility information and Passport provider will be displayed.
    • Backdated coverage will not reflect in the Web Portal
    • Members with a suspension span will show as “inactive” on the Web Portal.  This does not mean that they do not have coverage.
    • Department of Corrections will display as inactive.
    • You must look at the “Insurance Type Code” and the “Payor Name” to determine the type of coverage that the member has.

I’m a dental provider and would like to know if a member has met their dental limit.  Can I view the amount that the member has accumulated toward their dental limit on the Web Portal?
Yes, the Dental Treatment Information will display what the member’s dental treatment limit is, the amount used and remaining reimbursement balance.  

Please note, if there are claims in process, the claims that pay before your claim is submitted may reduce this amount.  Limits should be verified on each visit for the current date of service.

We are not yet registered for the Web Portal.  What are some additional ways that we can check eligibility?
As always, you can contact Provider Relations with any questions at (800) 624-3958, or you can use the following methods:

  • Integrated Voice Response (IVR) - (800) 714-0060
  • Fax Back – (800) 714-0075

When we use the MATH Web Portal, the only information that we receive is our own.  How do we access how many units have been used for a service that has limits, such as prior authorized limits?
Please contact Provider Relations at 1-800-624-3958 in order to get information about prior authorization limits.
 

FAQs - Montana Healthcare Programs Policy

Montana Healthcare Program Policy
 

If a Montana Healthcare Programs patient gives birth, does her infant automatically get coverage too?
If the mother is eligible and receiving non-medically needy Montana Healthcare Program eligibility at the time of the birth, then the baby is eligible for the Medicaid Newborn Program. 

The program will provide the infant coverage for up to one year, as long as the baby continues to live in Montana.

Infants born to HMK teens are not automatically enrolled. Application for these infants must be made separately. 

What is the difference between HMK Plus and HMK? 
Healthy Montana Kids Plus (HMK Plus), also known as Children’s Medicaid, is health care coverage for low-income children and youth up to age 19 who reside in the state of Montana and are at or below 143% of the federal poverty level guidelines. 

Healthy Montana Kids (HMK), formerly known as the Children’s Health Insurance Plan (CHIP), is a free or low-cost health coverage program for youth up to age 19 who reside in the state of Montana with a household income above 143% through 261% of the federal poverty level.  

Blue Cross & Blue Shield of Montana administers the medical benefits and Montana Healthcare Programs administers the following benefits for HMK members: dental, glasses, pharmacy, ambulance, and services provided at Rural Health Clinics and Federally Qualified Health Centers.

Please note, if you are a Dentist, you are required have an enrollment record for both programs if you are providing services to both types of members.  Both programs can be selected on one application; however, if you are currently enrolled with only one program, a new application and supplemental material will be required to enroll the second file.

HMK and HMK Plus have different dental payment methodologies.  HMK has a limit of $1,900 of billed charges with a maximum payable amount of $1,615, when 85% of billable charges are paid.  The limits are applied during the dental benefit year of July 1st through June 30th of the following year.

Can we bill the member for a service that Montana Healthcare Programs does not cover or a non-referred service?
The only way that the member can be billed for a non-covered service or non-referred service is if the member signs a private-pay agreement in advance that states that they acknowledge that they are responsible for payment.

If a private-pay agreement is established for a non-covered service, can we bill Montana Healthcare Programs for the covered service?
Yes, you can bill Montana Healthcare Programs for the covered service if a private-pay agreement is established for the non-covered service.

If we do not know that member was eligible for Montana Healthcare Programs until after services have been rendered, can we bill them?
We encourage providers to use one of the several methods available to check eligibility prior to rendering services:

  • The MATH Web Portal
  • FaxBack
  • Automated Voice Response (IVR)
  •  Montana Provider Relations – 1-800-624-3958

If a provider cannot verify Montana Healthcare Program eligibility, the provider can accept the member as a private-pay member with an agreement until eligibility is verified.  If the provider later verifies Montana Healthcare Program eligibility for a member accepted as private-pay, the provider can opt to bill Montana Healthcare Program (within timely filing rules) or continue the private-pay arrangement with the member.

Once the provider has opted to bill Montana Healthcare Programs, the private-pay agreement is no longer in effect and the provider must accept Montana Healthcare Programs’ payment as payment in full.

Can we bill the member and advise the member to submit the invoice to Montana Healthcare Programs for reimbursement?
No, only enrolled providers may submit claims to Montana Healthcare Programs for reimbursement.  
The only way that an enrolled provider can bill the member is with a private-pay agreement, prior to services, when the member agrees to pay for non-covered or non-referred services.

If a provider is not enrolled with Montana Healthcare Programs, they can bill the member.  Only enrolled providers receive payment from Montana Medicaid.

If a member is continuing to utilize the Emergency Department with non-emergent symptoms, can we arrange a private pay agreement? 
(Scott mentioned that he does not think this is accurate)
The Emergency Medical Treatment and Active Labor Act (EMTALA) prohibits a delay in providing the required screening and stabilization treatment in order to inquire about payment methods or insurance eligibility.
It is acceptable to ask what insurance the member has and make a copy of the insurance card, as long as you are not delaying the screening and stabilization treatment.
A script may be followed that states that seeing the member for the medical screening examination and stabilization treatment does not imply that you have accepted their method of payment, if an emergency does not exist.  Payment will be discussed after completion of the medical screening exam and at that time it could be decided that the member will be required to pay privately.
EMTALA prohibits making the private pay arrangement prior to initiating the medical screening examination. Not sure of this information either. 

We have an insurance form for each patient to sign.  Can we add a line that states that the member will be responsible if Montana Healthcare Programs does not cover the service or if the member is not eligible?
You cannot have a blanket form for non-covered services.  The private pay agreement needs to be specific to the services that are not covered and what the member will be expected to pay.

If a member is not eligible for Montana Healthcare Programs than he/she is in a private pay status, unless they have other insurance.

Can we bill Montana Medicaid for a member that does not show up to their appointment?
No, you can only bill Montana Medicaid if the eligible member had services rendered.

Is it okay to post a notice in our office advising members that after three no-shows, we will not accept the member anymore?
Yes, as long as you treat private pay and Montana Healthcare Program patients the same.

If you are the member’s Passport Provider, you will be required to follow the process for disenrolling the Passport member, as outlined in your Passport Provider Handbook.

We billed the member as private pay and the balance was turned over to collections.  We were just advised that the member has Montana Healthcare Programs.  What are our options at this point?
If the member presented as private pay, you are not required to submit the claim to Montana Healthcare Programs.  You may at any time accept Montana Healthcare Programs, as long as you are an enrolled provider.

Please be aware that timely filing rules still apply.

Where can we find the Administrative Rules of Montana (ARMs)?
The ARMs can be found at http://www.sos.mt.gov/ARM/index.asp. Most of the Montana Healthcare Programs rules are disclosed in Section 37.

Where can we find Montana Code Annotated (MCA)?
You can access the MCA from the link on each provider type page: http://leg.mt.gov/bills/mca_toc/index.htm.

If we receive a payment for a service, but the payment is later recovered by the Surveillance & Utilization Review (SURS) Department, can we bill the member for that service?
If there was an error that resulted in overpayment, the provider cannot bill the member.
 

FAQs - Medicare

Medicare
 

What does SLMB stand for?
SLMB stands for Specified Low-Income Medicare Beneficiary.  Montana Healthcare Programs pays the Medicare premium only for SLMB members.  

The member is responsible for the Medicare coinsurance and deductible, as Montana Healthcare Programs does not provide reimbursement for the deductible, coinsurance or medical services.

What does QMB stand for?
QMB stands for Qualified Medicare Beneficiary.  Montana Healthcare Programs pay the Medicare premiums and a portion of the Medicare coinsurance and deductibles up to the qualified amount.  The member must be eligible and enrolled in Medicare and members are only covered for Medicare’s allowed services.

What do we do if a Medicare crossover claim does not crossover to Medicaid?
A notification from Centers for Medicare and Medicaid Services (CMS) states that 98% of all claims crossover.  The remaining 2% of the cases may have issues with HIPAA compliance failures or issues with the information being sent from the Medicare contractor.

It can take up to 45 days for the claim to reach Montana Healthcare Programs from Medicare.  The claim from Medicare must have the required Montana information, including the taxonomy code, which will be transmitted by Medicare.  
If the claim is rejected, you should receive a notification letter at the correspondence address on file within 5 business days from the rejection action.  Prior to resubmitting the claim to Montana Healthcare Programs after the rejection, please ensure that 45 days from the original submission has passed to avoid duplicates.

Please remember that Medicare Part A and Part C will never crossover.  These claims must be sent directly to Montana Healthcare Programs from the provider.

A member has Medicare and became dually eligible for Montana Healthcare Programs during his hospital stay.  He was admitted into the hospital on 11/30/2018, but not eligible for Medicaid until 12/01/2018.  Medicare requires dates of service from 11/30/2018.  How should we submit the claim?
The provider will have to prorate the stay for Montana Healthcare Program eligibility on the Medicare Explanation of Benefits and on the Montana Healthcare Program claim.

If we receive a denial from Montana Healthcare Programs and we have to resubmit a particular line item for a dually-eligible member, do we also have to resubmit Medicare’s Explanation of Benefits (EOB)?
Yes, we need the Medicare EOB every time.

What happens if the message says that the claim crossed over, but the member ID was not correct?  If we send it on paper will it get paid or deny?
If a member ID number was incorrect, you can resubmit the claim electronically or via paper with the corrected member ID and appropriate Medicare EOB.

Is it true that providers billing on a UB claim (including RHCs, FQHCs and Home Health) do not have to include a Medicare Explanation of Benefits?
Yes, the Medicare payment needs to be in form locator 54.  The coinsurance and deductibles go in form locator 39-41, with appropriate value code.

On the electronic claims transaction, the coinsurance and deductibles are reported in Loop 2430, CAS segment.

Which fields on the UB-04 are used to indicate Medicare coinsurance and deductibles if form locator (FL) 39 is used by the provider for something else?
The provider may also use FL- 40-41 to report that information.

We are not a Medicare provider.  What can we do when a claim that we sent to Montana Healthcare Programs denied because there was no Medicare Explanation of Benefits?

Medicare has a legal obligation to process these claims as the primary insurance.  This obligation is not waved because of a provider’s enrollment status with Medicare.

Montana Healthcare Programs is required to deny the claim because Medicare is the liable third party.  The only exception to this rule is for provider types not permitted to enroll as Medicare providers.  Blanket denials may be used to process claims in this case.

We are not able to adjust only one line when we adjust a claim with Medicare, we are required to adjust the whole claim.  Deductible amounts change and then we are required to complete a Montana Healthcare Programs adjustment.  Is there a simpler way to process these requests?
Adjustments do not come to Montana Healthcare Programs from Medicare electronically.  You can send an adjustment with the new Medicare EOB that indicates on the face that Medicare information has changed.  We will review the coinsurance and deductible. 

How do we bill for a member that is eligible for Medicare Part D, but is not enrolled in a prescription drug plan yet?
The Limited Income Newly Eligible Transition (LI NET) Program, administered by Humana, is designed to eliminate any gaps in coverage for low-income individuals transitioning to Medicare Part D drug coverage. 
The 4-step LI NET billing process can be found at the LI NET pharmacy website, http://www.humana.com/pharmacists/pharmacy_resources/information.aspx, or by calling (800) 783-1307.

What drugs will Medicaid pay for a member eligible for Medicare Part D?
Please see the related provider notice and the Prescription Drug Services manual on the Pharmacy page of the provider website.
 

FAQs - Ownership

Ownership
 

Our facility does not have an owner.  How do we enter the ownership information on our enrollment?
Each enrollment file must have an owner on file and the online application will not let you proceed without entering an owner.  When a facility is non-profit or does not have an individual(s) that own it, the facility must be disclosed as the owner and all board members and/or any individual that makes business or financial decisions must be disclosed as managing employees.

The online application gives the appearance that the owner fields are designed for an individual; however, you can enter the facility name in the last name field, ‘NA’ in the first name field, the tax ID number as the social security number and ‘01/01/1964’ or the date that the facility was established as the date of birth. 

I am an individual provider that practices at a group and am applying for enrollment with Montana Healthcare Programs.  Who should be disclosed as owners?
Ownership with Montana Healthcare Programs is NPI number driven.  This means that if an individual is enrolling with Montana Healthcare Programs, the individual must be disclosed as the only owner of that NPI number, although the provider may practice at a group that may be owned by different individuals.  You are always welcome to disclose owners of the group as managing employees on an individual’s provider file.

Our business is changing ownership.  How do we update the ownership on our provider file?
As long as the tax ID number is not changing, please submit an Ownership Update Form, which can be found on the Forms page of our provider website https://medicaidprovider.mt.gov.

If the tax ID number is changing because of the ownership change, a re-enrollment will need to be completed with a new application and supplemental material.
 

FAQs - Passport

Passport

Where on the CMS-1500 claim form is the Passport referral number placed?

  • Paper claim: Box 17A
  • Electronic claim: Loop 2300, reference segment, data element 02, with qualifier 9F in Loop 2300, reference segment data element 01.

What services do not require Passport referrals?
Please refer to the Physician-Related Manual on the Montana Healthcare Programs Provider Information website under Resources by Provider Type.
You can also refer to the “Medicaid Covered Services” chapter in the General Information for Providers Manual.

Do we need to speak to the Passport Primary Care Provider (PCP) to get a Passport referral?
Office staff can relay the referral; however, the PCP providers document the referral.

Is it the member’s responsibility to get a referral prior to visiting a provider who is not the member’s PCP?
No, it is the responsibility of the non-PCP provider to get a referral from the PCP.

How are Passport providers assigned?
The Passport member can select their own Passport Provider or be assigned a Passport provider by Montana Healthcare Programs if the member does not select one.
The Passport to Health Provider Handbook explains how assignment is made.  Once the Passport provider is assigned, the member is notified of the assignment.
When checking eligibility, a provider that is not the member’s Passport provider also checks the identity of the member’s Passport provider and contacts the Passport provider for a referral.

Our Passport number has changed.  If a provider contacts us for a Passport referral for a date of service that occurred prior to the Passport number change, what Passport number do we give?
Provide the Passport number that was effective on the date of service.

We are a member’s Passport provider and refer the member to another provider.  The provider that we referred the member to is requesting to refer the member to a third provider.  Who is responsible for the referral?
Once a Passport provider issues a referral, the provider that requested the referral cannot refer the member to a third provider.
It is the responsibility of the Passport provider to refer the member to the third provider.

I suspect that my Passport number is being used without my referral.  What should I do?
If you suspect that your Passport number is being used without a referral, you are encouraged to contact Provider Relations at (800) 624-3958 or 406-442-1837.

If I send a written referral is that sufficient?
A written referral that includes the Passport number is sufficient.  A phone call is not required.

Are all Montana Healthcare Program members Passport-eligible?
Members are not eligible for Passport providers if they:

  • Live in a Nursing home or another type of institution.
  • Are covered by Medicare and Montana Healthcare Program.
  • Are covered by Montana Healthcare Programs for less than 3 months.
  • Are eligible under subsidized adoption.
  • Have only retro-active Montana Healthcare Program eligibility.
  • Receive Home and Community Based Waiver Services.

Exemptions from Passport may be granted for additional reasons on a case-by-case basis.

What is the process to change the Passport Provider when a member moves?
When a member moves, the member can select a new Passport provider on the website or by calling the Member Help Line at (800) 362-8312.
Until the member selects a new Passport Provider, the member will remain with the current Passport provider in the system.

Is the Passport approval number the same as the provider’s Medicaid ID number?
No, the Passport number is a 7-digit number that is strictly issued for Passport purposes and is issued upon successful enrollment.  The provider will receive their Passport number through a welcome letter.

How often can a member change their Passport provider?
A member can change their Passport provider as many times as they would like; however, it only takes effect in the system once a month, at the beginning of the month.

What do we do if a member comes to the appointment with no referral?
It is the provider’s responsibility to get a Passport referral.
After confirming that the member is Medicaid eligible, contact the Passport provider for a referral.  If you are unable to get a Passport referral at that time, you may still provide services and pursue Passport approval after the services are rendered, or you may ask the member to sign a private-pay agreement.
If you pursue a private-pay agreement, the agreement must clearly state that the member will be responsible for the bill, not that they may be responsible.  If you accept the member as private-pay and the member pays you, you may still try to get Passport approval after the services and then refund the member’s money.

If the Passport referral was denied by the Passport provider because the Passport provider has not seen the member.  What can we do?
In this case, these are the options:

  • Encourage the member to see their Passport provider
  • Ask the member to sign a private pay agreement
  • Refuse to see the member

The Passport provider has the right to refuse the referral in this case.

If a Passport provider will not give a referral, can the member go to Montana Healthcare Programs to get a referral?
Montana Healthcare Programs does not override a Passport provider’s decision.

Can a provider disenroll a member, or is the member the only one who can make this change?
A provider may disenroll the member based on the four approved disenrollment reasons detailed in the Passport Provider agreement.  A provider must give the member a 30-day notice by sending a letter to the member and Montana Healthcare Programs.
 

FAQs - Prior Authorization

Prior Authorization

How do we know if a service requires prior authorization?

Prior authorization is based off the code that you plan on billing.  Please refer to your provider type’s fee schedule.  Fee schedules are located at https://medicaidprovider.mt.gov > Resources by Provider Type.
Locate the code on the most current fee schedule.  If the service requires prior authorization, there will be a ‘Y’ in the ‘PA’ column.

How do we submit a prior authorization request?
Most prior authorizations for Montana Healthcare Programs are administered through Mountain Pacific Quality Health.  They can be contacted at, (800) 497-8283 for medical services and (800) 385-7961 for pharmacy related services; However, please contact Provider Relations at (800) 624-3958 to ensure that the authorization is not a service that needs to be administered through Conduent or the Department of Public Health & Human Services.

If the prior authorization span is only valid for a portion of the date-of-service span on the claim, will the claim still pay?
No, the date-of-service span on the claim must be within the prior authorization span, or the claim will deny.  
In order for the claim to pay, it will need to be split into two claims; one claim for the dates covered under the prior authorization span and one claim for the additional dates.  You can also request to extend the prior authorization dates.

If we receive prior authorization for a certain number of units, do we have to bill that exact number of units on the claim?
If you bill fewer units, the claim will process; however, if you attempt to bill more units than the authorized amount, the claim will deny.

If I receive prior authorization for multiple lines, but the CMS-1500 claim form can only fit 6 lines, can we submit multiple claims?
Yes, you may submit multiple claims, as long each claim has the appropriate prior authorization number and matches the authorization information.

FAQs - TPL

Third Party Liability (TPL)

If we know that the primary insurance is going to deny a service, are we still required to send the claim to the other payer prior to sending to Montana Medicaid every time?
If a primary insurance carrier will never cover a service or product, you can request a blanket denial from Third Party Liability (TPL) to allow you to bypass the primary provider and bill Montana Healthcare Programs directly.
The blanket denial request form is available on the Forms page of the provider website, https://medicaidprovider.mt.gov/forms.  Please include an Explanation of Benefits from the primary carrier with your blanket denial.

Blanket denials are valid for two years.

What are the top reasons for TPL denials?
Please remember that Montana Healthcare Programs is always the payer of last resort, except for Indian Health Services (IHS).

  • The member has TPL, but no explanation of benefits is attached.
  • The claim information and the explanation of benefits do not match.
  • The TPL denial does not contain a reason/remark.
    • Please remember to send the last page of the EOB with the remarks on them, as many providers forget to attach this to the claim or paperwork attachment (something along those lines). 
  • Medicare information is entered as a TPL amount.
    • Medicare is not considered TPL
  • IHS is listed in the other insurance field
    • Generally, Montana Healthcare Programs is the payer of last resort

What is the process for Pay and Chase?
Montana Healthcare Programs has a 90-day policy, which means that once it has been 90 days from the date-of-service, providers can request that Montana Montana Healthcare Programs processes the claim and subsequently bill the other payer.  
There must be documentation showing that the provider attempted to bill the TPL carrier.  A signed letter indicating the date that the other carrier was billed and the name of the insurance company is acceptable as proof of billing.
Specific circumstances result in an automatic Pay and Chase.  Some prenatal codes and pediatric codes fall into this category.

Medicaid is showing a TPL carrier as primary, but I can’t get any information from the member or the other carrier.  How can I verify coverage?
You are welcome to request assistance from the Montana Healthcare Program’s TPL Department at (800) 624-3958.  An individual from the TPL Department will contact the other insurance carrier to verify coverage and ensure the member’s records are updated.

What documentation needs to be submitted if the TPL carrier does not pay?
Submit the TPL Explanation of Benefits, ensuring that the header information and verbiage identifying the reason for denial are present.

When a member is currently on workers’ compensation and they come in for an unrelated reason, is a denial required?
A denial is not required, but an indication that the claim is not related to workers’ compensation is.

There are some members who have TPL cancer policies.  What do we do when the member is not being seen for a cancer-related illness?
You can obtain a blanket denial form from the Forms page on the Montana Healthcare Programs Provider Information website.
For a blanket denial request, send a copy of the Explanation of Benefits from the other payer, reflecting the denial from the other insurance.

What happens when the primary insurance company sends the payment for a claim to the Montana Healthcare Program member, rather than the provider?  Can we bill the member the entire amount?
No, you can only bill the Montana Healthcare Program member for the amount disclosed on the primary insurance company’s Explanation of Benefits.