This page is for proposed changes to existing manuals only. To view the actual, approved manual, please visit the applicable provider type page.
General Information for Providers Manual
To print this manual, right click your mouse and choose "print". Printing the manual material found at this website for long-term use is not advisable. Department of Public Health and Human Services (DPHHS) policy material is updated periodically, and users are responsible for ensuring that the policy they are researching or applying has the correct effective date for their circumstances.
Update Log
Publication History
This publication supersedes all versions of previous General Information for Provider Manuals and Handbooks. This publication is to be used conjunction with provider type manuals. Published by the Montana Department of Public Health & Human Services, February 2002.
Updated September 2002, October 2003, September 2004, November 2004, April 2005, April 2008, February 2012, April 2012, June 2014, July 2014, September 2014, November 2014, August 2015, November 2015, January 2016, July 2016, August 2016, February 2017, September 2017, November 2017, April 2018, June 2018, May 2019, November 2019, January 2020, February 2020, and January 2023.
CPT codes, descriptions and other data only are copyright 1999 American Medical Association (or such other date of publication of CPT). All Rights Reserved. Applicable FARS/DFARS Apply.
Update Log
01/31/2023
Entire manual. May need to bullet out specific areas.
02/20/2020
SURS and Billing Procedures chapters updated to include acceptable minutes for billing a 15-minute unit of service.
01/01/2020
- Cost Share references removed from the Provider Requirements, Member Eligibility and Responsibility, and Billing Procedures chapters.
- Term "Medicaid" replaced with "Montana Healthcare Programs" throughout the manual.
- Terms "client" and "patient" replaced with "member".
11/18/2019
The EPSDT Well-Child chapter language was updated to included current age, rule, and service information.
05/03/2019
The Provider Requirements chapter was revised to include rule language for usual and customary billing practices. The Billing Procedures chapter was revised to included updated NDC information.
06/04/2018
Removed commercial resource references.
04/30/2018
The Outpatient Clinic Services section of the Billing Procedure chapter was updated to include current provider-based clinic status.
11/24/2017
The Billings Procedure chapter was updated with current electronic submission information.
09/21/2017
- General Information for Providers Manual converted to an HTML format and adapted to 508 Accessibility Standards.
- An additional paragraph was added under the EPSDT Well Child chapter regarding caregiver depression screening coverage.
- Language was changed regarding manual maintenance in the Introduction chapter.
02/06/2017
In summary, the Telemedicine chapter was added as a new chapter. And the Medically Needy section of the Member Responsibilities chapter page 6.5 was updated.
08/02/2016
- The Introduction chapter contains updated links in the HELP section.
- Cost Share was updated in the Billing Procedures chapter.
- A duplicate word was removed in the RA chapter.
- The Cover Page was changed to reflect the current date of the new General Manual revision.
07/12/2016
- Table of Contents was amended by changing the title of “Basic Medicaid Waiver” to “Waiver for Additional Services and Populations (formerly Basic Medicaid Waiver)”.
- Index was amended by changing the title of “Basic Medicaid Waiver” to “Waiver for Additional Services and Populations (formerly Basic Medicaid Waiver)”.
- Page 1.3 changed the title “Basic Medicaid Waiver for Additional Services and Populations” to “Waiver for Additional Services and Populations (formerly Basic Medicaid Waiver)”
01/19/2016
General Information for Providers, January 2016: Introduction Regarding HELP Plan Information
01/15/2016
General Information for Providers, January 2016: Introduction Regarding HELP Plan Information
12/31/2015
General Information for Providers, January 2016: HELP Plan-Related Updates and Others
11/17/2015
General Information for Providers, November 2015: Billing Procedures, Revenue Codes 25X and 27X
07/31/2015
General Information for Providers, August 2015: Entire Manual
11/19/2014
General Information for Providers, November 2014: Billing Procedures
10/08/2014
General Information for Providers, September 2014: Billing Procedures
07/22/2014
General Information for Providers, July 2014: Member Eligibility and Responsibilities
06/30/2014
General Information for Providers, June 2014: General Information for Providers
If information is found on the website, it has been removed from the manual, and a link to the source is provided.
04/13/2012
General Information for Providers, April 2012: Medicaid Covered Services and Member Eligibility
End of Update Log Chapter
Table of Contents
Key Contacts and Key Websites
Introduction
Provider Requirements
EPSDT Well-Child
Prior Authorization
What Is Prior Authorization?
Telemedicine
Member Eligibility and Responsibilities
Verifying Member Eligibility
Surveillance and Utilization Review (SURS)
Billing Procedures
Remittance Advices and Adjustments
Appendix A: Forms
Appendix B: Place of Service Codes
Appendix C: Local Offices of Public Assistance
Definitions and Acronyms
Index
End of Table of Contents Chapter
Key Contacts and Key Websites
End of Key Contacts and Key Websites Chapter
Introduction
The Montana Healthcare Programs plays an essential role in providing health coverage for Montanans. Before the enactment of Medicare and Medicaid, healthcare for the elderly and the indigent was provided through a patchwork of programs sponsored by governments, charities, and community hospitals.
Today, Medicare is a federal program that provides coverage for persons aged 65 and over and for people with severe disabilities, regardless of income. Montana Healthcare Programs provides healthcare coverage to specific populations, especially low-income families with children, pregnant women, disabled people, and the elderly for conditions not covered by Medicare. Medicaid is administered by state governments under broad federal guidelines. Recent healthcare laws have greatly increased the number of people who qualify for Medicaid. See the Medicaid in Montana 2021 – Report to the 2021 Montana State Legislature.
Administrative Rules of Montana (ARM) References
Providers must be familiar with current rules and regulations governing Montana Healthcare Programs. The provider type manuals are meant to assist providers in billing; they do not contain all rules and regulations.
Rule citations in the text are a reference tool; they are not a summary of the entire rule. If a manual conflicts with a rule, the rule prevails.
The Administrative Rules of Montana are available on the Secretary of State website.
Providers may order individual titles through the Secretary of State website. Choose the ARM option in the top menu, then Contact Us and Purchasing ARM in Print or click the direct link: Purchasing ARM in Print – Montana Secretary of State (sos.mt.gov).
Manual Organization
The General Information for Providers Manual provides answers to general questions about provider enrollment, member eligibility, and surveillance and utilization review.
This manual is designed to work with provider type manuals, which contain program information on covered services, prior authorization, and billing for specific services.
This manual divided by chapters, and a table of contents and search options allow providers to find answers to most questions. For eligibility and coordination of benefit information, see the Member Eligibility and Responsibilities chapter in this manual. Provider-specific information is in provider type manuals. Contact Provider Relations at (800) 624-3958 with questions.
Manual Maintenance
The manual on the website is the latest approved version. Printing the manual for long-term use is not advisable. Department policy material is updated periodically and incorporated into the provider manuals. It is the user’s responsibility to ensure that the policy they are applying has the correct effective date for their circumstances.
Notification of manual updates are provided through the weekly web postings. The list of web postings is found by clicking the Recent Website Posts button on the bottom of the Home page of the Provider Website. Older versions of the manual may be found through the Archive page on the Provider Information Website.
Provider Information Website Information
Providers can stay informed with the latest Montana Healthcare Programs news and events and access provider manuals, provider notices, fee schedules, newsletters, forms, and other resources. See the menu for the most-accessed pages and the Site Index for a comprehensive list of pages available on the Provider Information website.
Provider Training Opportunities
Montana Healthcare Programs offers a variety of training opportunities that are announced on the Provider Information website and in the Claim Jumper newsletter.
See the Provider Enrollment page for enrollment support information.
Training sessions in PDF format are available on the Training page of the website.
Contractor Services
Montana Healthcare Programs works with various contractors who represent Montana Healthcare Programs through the services they provide. The information below is provided as informational.
- Conduent State Healthcare, LLC. answers provider inquiries and enrolls providers in Montana Healthcare Programs and Passport to Health; third-party liability – blanket denials, pay and chase, and coordination of benefits; processes claims for Montana Healthcare Programs, MHSP, HMK, pharmacy, dental, and eyeglasses, and HELP claims listed in the HELP Plan section.
- Mountain-Pacific Quality Health. Provides prior authorization for many Montana Healthcare Programs services.
- Ambulance transports
- Behavioral health
- Acute inpatient hospital services (out of state)
- Ambulance transports
- Behavioral Health Group Home (BHGH)
- Crisis stabilization program
- Extraordinary needs aide services
- Genetic testing (youth with behavioral health diagnosis)
- Home support services (adult)
- Intensive community-based rehabilitation
- Medically monitored intensive inpatient (ASAM 3.7)
- Montana Assertive Community Treatment (MACT)
- Montana State Hospital
- Partial hospitalization (youth)
- Program for Assertive Community Treatment (PACT)
- Psychiatric residential treatment (in and out of state)
- SUD Intensive outpatient program (ASAM 2.1)
- SUD Clinically managed high-intensity (adult) and medium-intensity (adolescent) residential (ASAM 3.5)
- SUD Clinically managed low-intensity residential (ASAM 3.1)
- Therapeutic group home (youth)
- Therapeutic home visit (youth)
- Transcranial Magnetic Stimulation (TMS)
- EPSDT
- Durable medical equipment (DME)
- DME EPSDT
- Home health
- Medical and surgical services that require prior authorization
- Out-of-state inpatient hospital admissions
- Out-of-state inpatient rehabilitation admissions
- Out-of-state inpatient adult and pediatric behavioral health admissions
- Personal assistance/Community First Choice
- Physician administered drugs
- Private duty nursing
- Transplants
Standard Medicaid
Standard Medicaid Benefits
All Medicaid members are eligible for Standard Medicaid services if medically necessary. Covered services include, but are not limited to, audiology services, clinic services, community health centers services, dental services, doctor visits, hospital services, immunizations, Indian Health Services, laboratory services, mental health services, nursing facility, occupational therapy, pharmacy, public health clinic services, substance dependency services, tobacco cessation, transportation, vision services, well-child checkups, and x-rays.
This waiver includes two populations that do not receive the Standard coverage:
- Non-expansion Medicaid-covered individuals whose eligibility is based on MAGI. These individuals receive 12-month continuous eligibility periods as the only service provided under this waiver.
- Individuals determined categorically eligible for ABD for dental treatment services above the $1,125 State Plan dental treatment cap. The additional dental services are the only service provided to these individuals under this waiver.
This waiver includes one population that does receive the Standard coverage. Individuals aged 18 or older with Severe Disabling Mental Illnesses (SDMI) who qualify for or are enrolled in the state-financed Mental Health Services Plan (MHSP), but are otherwise ineligible for Medicaid benefits and either have:
- Income 0–138% of the federal poverty level (FPL) and are eligible for or enrolled in Medicare; or
- Income 139–150% of the FPL regardless of Medicare status (they can be covered or not covered by Medicare and be eligible).
Members covered under this waiver receive Standard Medicaid benefits. To apply or for more information, contact the Addictive and Mental Disorders Division at (406) 444-2878 or visit the BHDD website, https://dphhs.mt.gov/bhdd.
Medicaid Expansion
The Montana Health and Economic Livelihood Partnership (HELP) Plan provides health coverage to adults ages 19–64 with incomes up to 138% of the FPL; who are not enrolled or eligible for Medicare; who are not incarcerated; and who are U.S. citizens or documented, qualified aliens who are Montana residents. Information regarding coverage for individuals covered under Medicaid Expansion is at https://dphhs.mt.gov/helpplan.
Other Programs
In addition to Medicaid, the Department of Public Health and Human Services (DPHHS, the Department) offers other programs. In addition to those listed below, other subsidized health insurance plans may be available from programs funded by the federal government or private organizations.
Substance Use Disorder Non-Medicaid Services
For individuals who are ineligible for Montana Healthcare Programs and whose family income is within program standards. https://dphhs.mt.gov/bhdd/SubstanceAbuse/index.
Children’s Mental Health Bureau Non-Medicaid Services
Funding sources for short-term use, not entitlement programs. Planning efforts toward family reunification are the primary objective, with transition planning essential for youth in out-of-home care. For information, call (406) 444-4545, or refer to the Non-Medicaid Services Provider Manual at https://dphhs.mt.gov/bhdd/cmb/Manuals.
Children’s Special Health Services (CSHS)
A program that assists children with special healthcare needs who are not eligible for Medicaid by paying medical costs, finding resources, and conducting clinics. For more information, call (406) 444-3622 or (800) 762-9891 or visit https://dphhs.mt.gov/ecfsd/cshs/index.
Health Insurance Premium Payment (HIPP)
A program that allows Medicaid funds to be used to pay for health insurance coverage when it is cost effective to do so. Visit https://dphhs.mt.gov/MontanaHealthcarePrograms/HIPP.
Healthy Montana Kids (HMK)
HMK offers low-cost or free health insurance for low-income children younger than 19. Children must be uninsured U.S. citizens or qualified aliens, Montana residents who are not eligible for Montana Medicaid. Visit https://dphhs.mt.gov/HMK.
Mental Health Services Plan (MHSP)
A program for adults who are ineligible for Medicaid and whose family income is within program standards. Visit https://dphhs.mt.gov/bhdd/mentalhealthservices/index.
Plan First
If a member loses coverage under Montana Healthcare Programs, family planning services may be paid by Plan First, which is a separate program option that covers family planning services for eligible women. Some of the services covered include office visits, contraceptive supplies, laboratory services, and testing and treatment of sexually transmitted diseases (STDs).
Visit https://dphhs.mt.gov/PlanFirst.
End of Introduction Chapter
Provider Requirements
Provider Enrollment
To be eligible for enrollment, a provider must:
- Provide proof of licensure, certification, accreditation, or registration according to Montana state laws and regulations.
- Provide a completed W-9. This does not apply to OPR Providers.
- Meet the conditions in this chapter and in program instructions regulating the specific type of provider, program, and/or service.
Providers must complete enrollment available online. This serves as a contract between the provider and the Department.
Healthcare providers must have a National Provider Identifier (NPI) to enroll. Providers who are not required to have an NPI and enroll with Montana Healthcare Programs will be assigned an atypical provider identifier (API).
Providers must choose the type(s) of service they provide. For example, a pharmacy that also sells durable medical equipment (DME) would choose provider type of Suppliers with specialty of pharmacy and specialty of durable medical equipment and medical supplies.
To enroll online as a Montana Healthcare Programs provider, visit the MPATH Provider Services Portal at https://mtdphhs-provider.optum.com/.
Payment is made only to enrolled providers.
Enrollment Materials
Each newly enrolled provider is sent a Welcome Letter confirming enrollment. Providers will receive a Welcome Letter for each unique enrollment unit (EU).
Letters to atypical providers include their API.
Montana Healthcare Programs enrollment-related forms are available on the Provider Enrollment page of the Provider Information website. Providers must order CMS-1500, UB-04, and dental claim forms from an authorized vendor.
Montana Healthcare Programs Credentials
For continued Montana Healthcare Programs participation, providers must maintain a valid license or certificate. If licensure or certification cannot be confirmed, the provider is contacted.
NOTE: In state providers do not receive the credential expiration letter but must update their own licensure at this time.
Out-of-state providers will receive letters of notification when their credentials are about to expire.
To update enrollment information, providers should log into the MPATH Services Portal, initiate an Update Maintenance and edit applicable credentialing fields.
Providers can avoid denials and late payments by maintaining current credentialing information within their enrollment record (i.e., licensure, accreditation, certification, DEA, DEAX, CLIA).
Changes in Enrollment
Most changes and updates can be done by the provider through the MPATH Provider Services Portal using the Update Maintenance feature, including (but not limited to) changes to address, telephone/fax, ownership, and licensure.
Any additional documentation can be uploaded during an Update Maintenance request by using the Additional Documentation feature.
During a physical address change, providers would include an updated W-9 form.
Change of Ownership
When ownership changes, the new owner must enroll in Montana Healthcare Programs. For income tax reporting purposes, the provider must notify Provider Relations at least 30 days in advance about any changes to a tax identification number. Early notification helps avoid payment delays and claim denials.
Electronic Claims
Providers who submit claims electronically experience fewer errors and quicker payment. For more information on electronic claims submission options, see the Electronic Claims section in the Billing Procedures chapter in this manual.
Montana Healthcare Programs Disenrollment
Providers may disenroll from Montana Healthcare Programs by following the Disenrollment Procedure in the MPATH Provider Services Portal.
If the provider NPI enrollment is in a status of enrolled, the provider may click the radio button under actions, select Disenrollment from the left tile, and follow the instructions in the pop-ups.
The Department may also disenroll a provider’s enrollment under the following circumstances:
- Breaches of the provider agreement.
- Demonstrated inability to perform under the terms of the provider agreement.
- Failure to abide by applicable Montana and U.S. laws.
- Failure to abide by the regulations and policies of the U.S. Department of Health and Human Services or the Montana Healthcare Programs
Authorized Signature (ARM 37.85.406)
All correspondence and claim forms submitted to Montana Healthcare Programs must have an NPI (healthcare providers) or API (atypical providers) and an authorized signature. The signature may belong to the provider, billing clerk, or office personnel, and may be handwritten, typed, stamped, or computer-generated. When a signature is from someone other than the provider, that person must have written authority to bind and represent the provider for this purpose. Changes in enrollment information require the provider’s original signature.
Provider Rights
- Providers have the right to end participation in Montana Healthcare Programs in writing at any time; however, some provider types have additional requirements.
- Providers may bill Montana Healthcare Programs members when the conditions are met outlined in ARM 37.85.204.
- Providers may bill Montana Healthcare Programs members for services not covered by Montana Healthcare Programs if the provider and member have agreed in writing prior to providing services.
- When the provider does not accept the member as a Montana Healthcare Programs member, a specific custom agreement is required stating that the member agrees to be financially responsible for the services received.
- A provider may bill a member for non-covered services if the provider has informed the member in advance of providing the services that Montana Healthcare Programs will not cover the services and that the member will be required to pay privately for the services, and if the member has agreed to pay privately for the services. Non-covered services are services that may not be reimbursed for the particular member by the Montana Healthcare Programs program under any circumstances and covered services are services that may be reimbursed by the Montana Healthcare Programs program for the particular member if all applicable requirements, including medical necessity, are met (ARM 37.85.406).
- Providers have the right to choose Montana Healthcare Programs members, subject to the conditions in Accepting Montana Healthcare Programs Members later in this chapter.
- Providers have the right to request administrative reviews and fair hearings for a Department action that adversely affects the provider’s rights or the member’s eligibility (ARM 37.85.411).
Administrative Reviews and Fair Hearings (ARM 37.5.310)
A provider may request an administrative review if he/she believes the Department has made a decision that fails to comply with applicable laws, regulations, rules, or policies.
To request an administrative review, state in writing the objections to the Department’s decision and include substantiating documentation for consideration in the review. The request must be addressed to the division that issued the decision and delivered (or mailed) to the Department. The Department must receive the request within 30 days from the date the Department’s contested determination was mailed. Providers may request extensions in writing within this 30 days. See the Contact Us link on the Provider Information website.
If the provider is not satisfied with the administrative review results, a fair hearing may be requested. Fair hearing requests must contain concise reasons the provider believes the Department’s administrative review determination fails to comply with applicable laws, regulations, rules, or policies. This document must be signed and received by the Fair Hearings Office within 30-days from the date the Department mailed the administrative review determination. A copy must be delivered or mailed to the division that issued the determination within 3 working days of filing the request.
Provider Participation (ARM 37.85.401)
By enrolling in the Montana Healthcare Programs program, providers must comply with all applicable state and federal statutes, rules, and regulations, including but not limited to, federal regulations and statutes found in Title 42 of the Code of Federal Regulations and the United States Code governing the Montana Healthcare Programs program and all applicable Montana statutes and rules governing licensure and certification.
Accepting Montana Healthcare Programs Members (ARM 37.85.406)
Institutional providers, eyeglass providers, and non-emergency transportation providers may not limit the number of Montana Healthcare Programs members they will serve. Institutional providers include nursing facilities, skilled care nursing facilities, intermediate care facilities, hospitals, institutions for mental disease, inpatient psychiatric hospitals, and residential treatment facilities.
Other providers may limit the number of Montana Healthcare Programs members. They may also stop serving private-pay members who become eligible for Montana Healthcare Programs. Any such decisions must follow these principles:
- No member should be abandoned in a way that would violate professional ethics.
- Members may not be refused service because of race, color, national origin, age, or disability.
- Members enrolled in Montana Healthcare Programs must be advised in advance if they are being accepted only on a private-pay basis.
- In service settings where the member is admitted or accepted as a Montana Healthcare Programs member by a provider, facility, institution, or other entity that arranges provision of services by other or ancillary providers, all other or ancillary providers will be deemed to have accepted the individual as a Montana Healthcare Programs member and may not bill the member for the services unless, prior to provision of services, the particular provider informed the member of their refusal to accept Montana Healthcare Programs and the member agreed to pay privately for the services. See ARM 37.85.406(11)(d) for details.
- Most providers may begin Montana Healthcare Programs coverage for retroactively eligible members at the current date or from the date retroactive eligibility was effective. See the Retroactive Eligibility section in the Member Eligibility and Responsibilities chapter of this manual for details.
- When a provider bills Montana Healthcare Programs for services rendered to a member, the provider has accepted the member as a Montana Healthcare Programs member.
- Once a member has been accepted as a Montana Healthcare Programs member, the provider may not accept Montana Healthcare Programs payment for some covered services but refuse to accept Montana Healthcare Programs payment for other covered services.
Non-Discrimination (ARM 37.85.402)
Providers may not discriminate illegally in the provision of service to eligible Montana Healthcare Programs members or in employment of persons on the grounds of race, creed, religion, color, sex, national origin, political ideas, marital status, age, or disability. Providers shall comply with the Civil Rights Act of 1964 (42 USC 2000d, et seq.), the Age Discrimination Act of 1975 (42 USC 6101, et seq.), the Americans With Disabilities Act of 1990 (42 USC 12101, et seq.), section 504 of the Rehabilitation Act of 1973 (29 USC 794), and the applicable provisions of Title 49, MCA, as amended and all regulations and rules implementing the statutes.
Providers are entitled to Montana Healthcare Programs payment for diagnostic, therapeutic, rehabilitative or palliative services when the following conditions are met:
- Provider must be enrolled in Montana Healthcare Programs. (ARM 37.85.402)
- Services must be performed by practitioners licensed and operating within the scope of their practice as defined by law. (ARM 37.85.401)
- Member must be enrolled in Montana Healthcare Programs and be nonrestricted. See Member Eligibility and Responsibilities for restrictions. (ARM 37.85.415 and ARM 37.85.205)
- Service must be medically necessary. The Department may review medical necessity at any time before or after payment. (ARM 37.85.410)
- Service must be covered by Montana Healthcare Programs and not be considered cosmetic, experimental, or investigational. (ARM 37.82.102, ARM 37.85.207, and ARM 37.86.104)
- Montana Healthcare Programs and/or third party payers must be billed according to rules and instructions as described in the Billing Procedures chapter, current provider notices and manual replacement pages, and according to ARM 37.85.406 (Billing, reimbursement, claims processing and payment) and ARM 37.85.407 (third party liability).
- Charges must be usual and customary. (ARM 37.85.212 and ARM 37.85.406)
For all purposes of this rule, the amount of the provider's usual and customary charge may not exceed the reasonable charge usually and customarily charged to all payers. ARM 37.85.406(19) - Reimbursement to providers from Montana Healthcare Programs and all other payers may not exceed the total Montana Healthcare Programs fee. For example, if payment to the provider from all responsible parties ($75.00) is greater than the Montana Healthcare Programs fee ($70.00), Montana Healthcare Programs will pay at $0. (ARM 37.85.406)
- Claims must meet timely filing requirements. See the Billing Procedures chapter in this manual for timely filing requirements. (ARM 37.85.406)
Medicaid Payment Is Payment in Full (ARM 37.85.406)
Providers must accept Medicaid payment as payment in full for any covered service. Zero paid claims are considered paid.
Payment Return (ARM 37.85.406)
If Medicaid pays a claim, and then discovers that the provider was not entitled to the payment for any reason, the provider must return the payment.
Disclosure
- Providers are required to fully disclose ownership and control information when requested by the Department. (ARM 37.85.402)
- Providers are required to make all medical records available to the Department. (ARM 37.85.410 and ARM 37.85.414)
Member Services
- All services must be made a part of the medical record. (ARM 37.85.414)
- Providers must treat Medicaid members and private-pay members equally in terms of scope, quality, duration, and method of delivery of services unless specifically limited by regulations. (ARM 37.85.402)
Confidentiality (ARM 37.85.414)
All Montana Healthcare Programs member and applicant information and related medical records are confidential. Providers are responsible for maintaining confidentiality of healthcare information subject to applicable laws.
Record Keeping (ARM 37.85.414)
Providers must maintain all Montana Healthcare Programs-related medical and financial records for 6 years and 3 months following the date of service. The provider must furnish these records to the Department or its designee upon request. The Department or its designee may review any Montana Healthcare Programs-related records and services at any time. Such records may include but are not limited to:
- Original prescriptions
- Certification of medical necessity
- Treatment plans
- Medical records and service reports including but not limited to:
- Member’s name and date of birth
- Date and time of service
- Name/title of person providing service (other than billing practitioner)
- Chief complaint or reason for each visit
- Pertinent medical history
- Pertinent findings on examination
- Medication, equipment, and/or supplies prescribed or provided
- Description and length of treatment
- Recommendations for additional treatments, procedures, or consultations
- X-rays, tests, and results
- Dental photographs/teeth models
- Plan of treatment and/or care, and outcome
- Specific claims and payments received for services
- Each medical record entry must be signed and dated by the person ordering or providing the service.
- Prior authorization information
- Claims, billings, and records of Montana Healthcare Programs payments and amounts received from other payers for services provided to Montana Healthcare Programs members
- Records/original invoices for items prescribed, ordered, or furnished
- Any other related medical or financial data
Compliance with Applicable Laws, Regulations, and Policies
All providers must follow all applicable rules of the Department and all applicable state and federal laws, regulations, and policies. Provider manuals are to assist providers in billing Montana Healthcare Programs; they do not contain all Montana Healthcare Programs rules and regulations. Rule citations in the text are a reference tool; they are not a summary of the entire rule. In the event that a manual conflicts with a rule, the rule prevails.
The following are references for some of the rules that apply to Montana Healthcare Programs. The provider manual for each individual program contains rule references specific to that program.
- Title XIX Social Security Act 1901 et seq.
- 42 U.S.C. 1396 et seq.
- Code of Federal Regulations (CFR)
- CFR Title 42 – Public Health
- Montana Codes Annotated (MCA)
- MCA Title 53 – Social Services and Institutions
- Administrative Rules of Montana (ARM)
- ARM Title 37 – Public Health and Human Services
Links to rules are available on the provider type pages of the Provider Information website. Paper copies of rules are available through the Secretary of State’s office, https://sos.mt.gov/arm. Choose ARM from the menu at the top. Under Contact Us, choose the Purchasing ARM in Print option. Follow instructions on the webpage.
Provider Sanctions (ARM 37.85.501–507 and ARM 37.85.513)
The Department may withhold a provider’s payment, suspend, disenroll, or terminate Montana Healthcare Programs enrollment if the provider has failed to abide by terms of the Montana Healthcare Programs contract, federal and state laws, regulations, and policies.
Providers are responsible for keeping informed about applicable laws, regulations, and policies.
Other Programs
Below is a list of non-Montana Healthcare Programs Department of Public Health and Human Services (DPHHS) programs.
- Chemical Dependency Bureau Substance Dependency/Abuse Treatment https://dphhs.mt.gov/bhdd/SubstanceAbuse/index
- Children’s Mental Health Bureau Non-Montana Healthcare Programs Services https://dphhs.mt.gov/bhdd/cmb/Manuals
- Health Insurance Premium Payment (HIPP) https://dphhs.mt.gov/MontanaHealthcarePrograms/HIPP
- Healthy Montana Kids (HMK) https://dphhs.mt.gov/HMK
- Mental Health Services Plan (MHSP) https://dphhs.mt.gov/bhdd/mentalhealthservices/index
- Plan First https://dphhs.mt.gov/MontanaHealthcarePrograms/PlanFirst
End of Provider Requirements Chapter
EPSDT Well-Child
The Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) Services program is the federally sponsored, comprehensive healthcare benefits package for Medicaid-enrolled children through age 20. It helps families get early identification and treatment of medical, dental, vision, mental health, and developmental problems for their children. All Medicaid families are encouraged to use these services. See ARM 37.86.2201–2235.
EPSDT Well-Child Check-Ups
At the core of EPSDT is the well child visit. These regularly scheduled check-ups help your child’s primary care provider identify problems and assist with a treatment plan for your child. By following the Bright Futures schedule of well child visits, parents can ensure their children receive the full benefit of their comprehensive health care coverage.
EPSDT Well-Child visits include:
- Comprehensive health & developmental history
- Comprehensive unclothed physical examination
- Assessment of physical, emotional & developmental health
- Immunizations appropriate to age & health history
- Laboratory tests (including blood lead levels)
- Assessment of mental/behavioral health
- Assessment of mouth, oral cavity & teeth, including referral to a dentist
- Assessment of nutritional status
- Assessment of vision, including referrals
- Assessment of overall health, including referrals
- Health education (also called anticipatory guidance)
- Family planning services and adolescent maternity care
In addition to well child visits, EPSDT includes inter-periodic sick visits, or other visits as needed by the individual child.
EPSDT Provider Resources
Immunization Schedule The Bright Futures/American Academy of Pediatrics recommended immunization schedule for children through the age of 18.
Medicaid and Healthy Montana Kids Plus Member Guide Learn more about Medicaid coverage through the Early and Periodic Screening, Diagnosis and Treatment Program at in the handbook.
Bright Futures A link to the American Academy of Pediatrics Bright Futures website.
Additional Services Under EPSDT
If a child (up to the age of 21), needs medically necessary services, outside the normal realm of covered services (non-covered, over the limit, does not meet criteria, etc.), these can be approved on a case-by-case basis. EPSDT prior authorization requests must be submitted by a child’s primary care provider or medical specialist, within their scope of practice, who determines the child needs additional treatment, services, or supplies for a primary health condition.
These requests are reviewed, and decision determinations completed within 2 weeks of receipt of all required documentation.
The EPSDT Prior Authorization & Medical Necessity Form is found on the Forms Page of the Provider Information Website.
For more information regarding EPSDT services contact the DPHHS Health Resources Division, Maternal and Child Health Nurse .
Who Can Provide EPSDT Screenings?
- Physicians
- Advanced Registered Nurse Practitioners (ARNP)
- Physician assistants
- Registered nurse under guidance of a physician or ARNP may perform the screenings but not diagnose or treat.
- Providers must be Medicaid-enrolled to receive payment from Medicaid.
The Well-Child Screen
The foundation of EPSDT is the well-child screen. These screens should begin as early as possible in a child’s life or as soon as the child is enrolled in Medicaid. The well-child screens are based on a periodicity schedule established by medical, dental, and other healthcare experts, including the American Academy of Pediatrics. The Recommendations for Preventive Pediatric Health Care are found on the Bright Futures website, https:/brightfutures.aap.org.
Every infant should have a newborn evaluation after birth. If a child comes under care for the first time at any point on the schedule, or if any items are not accomplished at the suggested age, the schedule should be brought up to date at the earliest possible time. If a well-child screen shows that a child is at risk based on the child’s environment, history, or test results, the provider should perform required or recommended tests even though they may not be indicated for the child’s age. Developmental, psychosocial, and chronic disease issues for children and adolescents may require frequent counseling and treatment visits separate from preventive care visits.
Using an evidence-based screening tool, a caregiver depression screening is covered under an enrolled child's Medicaid benefit, during their first year of life. This includes anyone that is considered a child's primary care provider. Positive screenings must be appropriately referred. Screenings are covered under the child’s Medicaid benefit due to the dyadic relationship of a caregiver and child. The service is directed at treating the health and well-being of the child, with a goal of providing a healthy start to their life.
Initial/Interval History
A comprehensive history, obtained from the parent or other responsible adult who is familiar with the child’s history should be done during the initial visit. Once it is done, it only needs to be updated at subsequent visits. The history should include the following:
- Developmental history to determine whether the child’s individual developmental processes fall within a normal range of achievement compared to other children of his/her age and cultural background.
- Discussion of the child’s development, as well as techniques to enhance the child’s development, with the parents.
- Nutritional history and status. Questions about dietary practices identify unusual eating habits, such as pica, or extended use of bottle feedings, or diets that are deficient or excessive in one or more nutrients.
- Complete dental history.
Developmental Assessments
Appropriate Developmental Surveillance
Providers should administer an age-appropriate developmental screen at each well-child visit. Any concerns raised during the surveillance should be promptly addressed with standardized developmental screening tests. See the recommended algorithm provided by Bright Futures at http://pediatrics.aappublications.org/content/118/1/405.full.
Appropriate Developmental Screening
Providers should administer an age appropriate developmental screen at age 9, 18, and 30 months. Results should be considered in combination with other information gained through the history, physical examination, observation, and reports of behavior. If developmental problems are identified, appropriate follow-up and/or referral to proper resources should be made.
Speech and language screens identify delays in development. The most important readiness period for speech is 9 to 24 months. Parents should be urged to talk to their children early and frequently. Refer the child for speech and language evaluation as indicated.
Depression Screening
Signs and symptoms of emotional disturbances represent deviations from or limitations in healthy development. These problems usually will not warrant a psychiatric referral but can be handled by the provider. He/she should discuss problems with parents and give advice. If a psychiatric referral is warranted, the provider should refer the child to an appropriate provider. Recommended screening using the Member Health Questionnaire (PHQ-2) or other tools found on the Bright Futures website.
Alcohol and Drug Use Screen
The provider should screen for risky behaviors (e.g., substance abuse, unprotected sexual activity, tobacco use, firearm possession). In most instances, indications of such behavior will not warrant a referral but can be handled by the provider, who should discuss the problems with the member and the parents and give advice. If a referral is warranted, the provider should refer to an appropriate provider. Recommended screening tool can be found on the Bright Futures website.
Nutritional Screen
Providers should assess the nutritional status at each well-child screen. Children with nutritional problems may be referred to a licensed nutritionist or dietician for further assessment or counseling.
Unclothed Physical Inspection
At each visit, a complete unclothed examination is essential. Infants should be totally unclothed, and older children undressed and suitably draped.
Vision Screen
A vision screen appropriate to the age of the child should be conducted at each well-child screen. If the child is uncooperative, rescreen within six months.
Hearing Screen
A hearing screen appropriate to the age of the child should be conducted at each well-child screen. All newborns should be screened.
Autism Screen
Autism screenings are recommended at age 18 and 24 months, and a recommended tool is provided on the Bright Futures website.
Critical Congenital Heart Defect Screen
Screening using pulse oximetry should be performed in newborns, after 24 hours old and before discharge.
Laboratory Tests
Providers who conduct well-child screens must use their medical judgment in determining applicability of performing specific laboratory tests. Appropriate tests should be performed on children determined at risk through screening and assessment.
Hematocrit and Hemoglobin
Hematocrit or hemoglobin tests should be done for at-risk (premature and low birth weight) infants at ages newborn and 2 months. For children who are not at risk, follow the recommended schedule.
Blood Lead Level
All children in Medicaid are at risk of lead poisoning. To ensure their good health, the federal government requires that all Medicaid-enrolled children be tested for lead poisoning. Testing is recommended at 12 and 24 months of age. Children up to age 6 years who have not been checked for lead poisoning before should also be tested.
A blood lead level test should be performed on all children at 12 and 24 months of age.
All Medicaid children at other ages should be screened. Complete a verbal risk assessment for all Medicaid children up to age 6 years at each EPSDT screening:
- Does your child live in Butte, Walkerville, or East Helena, which are designated high-risk areas?
- Does your child live near a lead smelter, battery recycling plant, or other industry (operating or closed) likely to release lead?
- Does your child live in or regularly visit a house built before 1960, which contains lead paint?
- Does your child live near a heavily traveled major highway where soil and dust may be contaminated with lead?
- Does your child live in a home where the plumbing consists of lead pipes or copper with lead solder joints?
- Does your child frequently come in contact with an adult who works with lead, such as construction, welding, pottery, reloading ammunition (making own bullets), etc.?
- Is the child given any home or folk remedies? If yes, discuss.
If the answer to all questions is no, a child is considered at low risk for high doses of lead exposure. Children at low risk for lead exposure should receive a blood test at 12 and 24 months.
If the answer to any question is yes, a child is considered at high risk for high doses of lead exposure and a blood lead level test must be obtained immediately regardless of the child’s age.
Tuberculin Screening
Tuberculin testing should be done on individuals in high-risk populations or if historical findings, physical examination, or other risk factors so indicate.
Dyslipidemia Screening
Screening should be considered based on risk factors and family history at 24 months, 4, 6, 8, 12, 13, 14, 15, 16, and 17 years, and is indicated at or around 10 and 20 years of age.
STI/HIV Screening
All adolescent members should be screened for sexually transmitted infections (STIs) and HIV based on risk assessment starting at age 11 and reassessed annually with at least one assessment occurring between the ages of 16–18 years old.
Cervical Dysplasia Screening
Adolescents are not routinely screened for cervical dysplasia until age 21. See the 2010 AAP statement for indications at https:/www.aap.org/en-us/Pages/Default.aspx.
Immunizations
The immunization status of each child should be reviewed at each well-child screen. This includes interviewing parents or caretakers, reviewing immunization records, and reviewing risk factors.
The Recommended Childhood Immunization schedule is available on the AMA website and the Centers for Disease Control and Prevention website.
Dental Screen
The child’s provider should perform annual dental screens, and results should be included in the child’s initial/interval history. Annual dental screens include an oral inspection, fluoride varnish (as available) and making a referral to a dentist for any of the following reasons:
- When the first tooth erupts, and every six months thereafter.
- If a child with a first tooth has not obtained a complete dental examination by a dentist in the past 12 months.
- If an oral inspection reveals cavities or infection, or if the child is developing a handicapping malocclusion or significant abnormality.
Discussion and Counseling/Anticipatory Guidance
Providers should discuss examination results, address assessed risks, and answer any questions in accordance with parents’ level of understanding. Age-appropriate discussion and counseling should be an integral part of each visit. Allow sufficient time for unhurried discussions.
At each screening visit, provide age-appropriate anticipatory guidance concerning such topics as the following:
- Auto safety: Car seats, seat belts, air bags, positioning young or lightweight children in the backseat.
- Recreational safety: Helmets and protective padding, playground equipment.
- Home hazards: Poisons, accidents, weapons, matches/lighters, staying at home alone, use of detectors for smoke, radon gas, and carbon monoxide.
- Exposure to sun and secondhand smoke.
- Adequate sleep, exercise, and nutrition, including eating habits and eating disorders.
- Peer pressure.
- General health: Immunizations, patterns of respiratory infections, skin eruptions, care of teeth.
- Problems such as whining, stealing, setting fires, etc. as indicated by parental concern.
- Behavior and development: Sleep patterns, temper, attempts at independence (normal and unpleasant behavior), curiosity, speech and language, sex education and development, sexual activities, attention span, toilet training, alcohol and tobacco use, substance abuse.
- Interpersonal relations: Attitude of father; attitude of mother; place of child in family; jealousy; selfishness, sharing, taking turns; fear of strangers; discipline, obedience; manners, courtesy; peer companionship/relations; attention getting; preschool, kindergarten and school readiness and performance; use of money; assumption of responsibility; need for affection and praise; competitive athletics.
End of EPSDT Well-Child Chapter
Prior Authorization
What Is Prior Authorization?
Prior authorization refers to a list of services that require Department authorization before they are performed. Some services may require both Passport referral and prior authorization.
Medicaid does not pay for services when prior authorization, Passport, or Team Care requirements are not met.
In practice, providers will often encounter members who are enrolled in Passport. Whether the member is enrolled in Passport or Team Care, the eligibility information denotes the member’s primary care provider. Services are only covered when they are provided or approved by the designated Passport provider or Team Care pharmacy shown in the eligibility information.
If a service requires prior authorization, the requirement exists for all Medicaid members. Prior authorization is usually obtained through the Department or a prior authorization contractor.
When both Passport and prior authorization are required, they must be recorded in different places on the claim.
If both Passport referral and prior authorization are required for a service, then both numbers must be recorded in different fields on the Medicaid claim form. (See the Submitting a Claim section in this manual.)
Most Montana Healthcare Programs fee schedules indicate when prior authorization is required for a service. For more information, see your provider type fee schedule and/or the Prior Authorization page of the Provider Information website.
End of Prior Authorization Chapter
Telemedicine
Program Overview
Telemedicine is the use of interactive audio-video equipment to link practitioners and members located at different sites. The Medicaid program reimburses providers for medically necessary telemedicine services furnished to eligible members.
Telemedicine is not itself a unique service but a means of providing selected services approved by Medicaid. Telemedicine involves two collaborating providers, an originating provider and a distance provider. The provider where the member is located is the originating provider or originating site. In most cases, the distant provider is a clinician who acts as a consultant to the originating provider. However, in some cases the distant provider may be the only provider involved in the service.
Providers must be enrolled as Medicaid providers and be licensed in the State of Montana in order to:
- Treat a Medicaid member; and
- Submit claims for payment to Medicaid.
When to Use Telemedicine
Medicaid considers the primary purposes of telemedicine are to bring providers to people living in rural areas, and to allow members access to care that is not available within their community. Providers should weigh these advantages against quality of care and member safety considerations. Members may choose which is more convenient for them when providers make telemedicine available.
Telemedicine should not be selected when face-to-face services are medically necessary. Members should establish relationships with primary care providers who are available on a face-to-face basis.
Telemedicine can be provided in member’s residence; the distance provider is responsible for the confidentiality requirements. Member’s residences do not qualify for originating provider reimbursement.
Telemedicine Confidentiality Requirements
All Medicaid providers using telemedicine to deliver Medicaid services must employ existing quality-of-care protocols and member confidentiality guidelines when providing telemedicine services. Health benefits provided through telemedicine must meet the same standard of care as in-person care. Record keeping should comply with Medicaid requirements in Administrative Rules of Montana (ARM) 37.85.414.
Transmissions must be performed on dedicated secure lines or must utilize an acceptable method of encryption adequate to protect the confidentiality and integrity of the transmission. Transmissions must employ acceptable authentication and identification procedures by both the sender and receiver.
General Billing Instructions
Providers may only bill procedure codes for which they are already eligible to bill. Services not otherwise covered by Medicaid are not covered when delivered via telemedicine. The use of telecommunication equipment does not change prior authorization or any other Medicaid requirements established for the services being provided.
The availability of services through telemedicine in no way alters the scope of practice of any health care provider; or authorizes the delivery of health care services in a setting or manner not otherwise authorized by law.
Telemedicine reimbursement does not include:
- Consultations provided by telephone (interactive audio); or
- Facsimile machine transmissions.
- Crisis hotlines
The originating and distant providers may not be within the same facility or community. The same provider may not be the pay to for both the originating and distance provider.
If a rendering provider’s number is required on the claim for a face-to-face visit, it is required on a telemedicine claim.
Originating Provider Requirements
The originating site provider must have secure and appropriate equipment to ensure confidentiality, including camera(s), lighting, transmission, and other needed electronics.
Originating providers bill using procedure code Q3014 (telemedicine originating site fee) for the use of a room and telecommunication equipment. The telehealth place of service code 02 does not apply to originating site facilities billing a facility fee.
The following provider types may bill procedure code Q3014:
- Outpatient Hospital
- Critical Access Hospital*
- Federally Qualified Health Center*
- Rural Health Center*
- Indian Health Service*
- Physician
- Psychiatrist
- Mid-Levels
- Dieticians
- Psychologists
- Licensed Clinical Social Worker
- Licensed Professional Counselor
- Mental Health Center
- Chemical Dependency Clinic
- Group/Clinic
- Public Health Clinic
- Family Planning Clinic
*Reimbursement for Q3014 is a set fee and is paid outside of both the cost to charge ratio and the all-inclusive rate.
Originating provider claims must include a specific diagnosis code to indicate why a member is being seen by the distance provider. The originating site must request the diagnosis code(s) from the distance site prior to billing the telemedicine appointment.
The originating provider may also, as appropriate; bill for clinical services provided on-site the same day that a telemedicine originating site service is provided. This originating site may not bill for assisting the distant provider with an examination, this includes any services that would be normally included in a face-to-face visit.
Distance Provider Requirements
Distance providers should submit claims for telehealth services using the appropriate CPT or HCPCS code for the professional service along with the GT modifier (interactive communication). Effective January 1, 2017, providers must also use the telehealth place of service of 02 for claims submitted on a CMS-1500 claim. By coding with the GT modifier and the 02 place of service, the provider is certifying that the service was a face-to-face visit provided via interactive audio-video telemedicine.
Any out of state distance providers must be licensed in the State of Montana and enrolled in Medicaid in order to provide telemedicine services to Medicaid members. Providers must contact the Montana Department of Labor and Industry to find out details on licensing requirements for their applicable professional licensure.
End of Telemedicine Chapter
Member Eligibility and Responsibilities
Montana Healthcare Programs ID Cards
Each Medicaid member is issued his/her own permanent Montana Access to Health Medicaid ID card (including QMB only members) or Healthy Montana Kids Plus (HMK Plus) card.
Members must never throw away the card, even if their Medicaid eligibility ends.
The ID card lists the member’s name, member number, and date of birth. The member number may be used for checking eligibility and for billing Montana Healthcare Programs.
Since eligibility information is not on the card, providers must verify eligibility before providing services. See the Verifying Member Eligibility section below.
Providers should verify eligibility before providing services.
Verifying Member Eligibility
Member eligibility may change monthly. Providers should verify eligibility at each visit using any of the methods described in the following table.
| Contact | Information Available | Instructions |
|---|---|---|
| FaxBack (800) 714-0075 Available 24/7 |
Managed care and other restrictions Member eligibility Third-party liability |
Before using FaxBack, your fax number must be on file with Provider Relations. Call FaxBack and enter your NPI/API, the member’s ID, and specific dates of service. When prompted, ask for the audit number or the transaction will not be completed. |
| Integrated Voice Response (IVR) (800) 362-8312 |
Amount of last payment Managed care and other restrictions Member eligibility Third-party liability |
Call IVR and enter your NPI/API, a member ID, and specific dates of service. Verify eligibility for up to 5 members in one call. Program benefit limits not available here. Contact Provider Relations for limits. |
| Montana Access to Health (MATH) Web Portal Available 24/7 |
Claim history Electronic remittance advices Managed care and service restrictions Member demographics Member eligibility Member status history Payment status Provider enrollment Third-party liability |
Before accessing the MATH web portal, providers must be enrolled in Montana Healthcare Programs and be registered for the MATH web portal. From the Provider Information website, click on the MATH Web Portal link under Online Services in the left menu. If the member is not currently eligible, any managed care or third-party liability information will not be displayed. The user will receive a response with a status of “inactive” reported in the Member Demographic Information. |
| Provider Relations Phone: (800) 624-3958 Fax: (406) 442-4402 8 a.m.–5 p.m. Monday–Friday |
Amount of last payment Claim status Enrollment status Member eligibility Prior authorization status Service limits |
Have NPI and member ID number ready when calling. |
| Local Offices of Public Assistance | Member eligibility | For local office information, see the website: https://dphhs.mt.gov/hcsd/OfficeofPublicAssistance |
| Presumptive Eligibility (406) 655-7683/ (406) 883-7848 8 a.m.–5 p.m. Monday–Friday |
Verify presumptive eligibility | To become a provider who determines presumptive eligibility, call (406) 655-7683. To verify presumptive eligibility, call (406) 655-7683 or (406) 883-7848. For information on presumptive eligibility, visit the Presumptive Eligibility webpage: https://medicaidprovider.mt.gov/presumptiveeligibility |
The list below shows information returned to the provider in response to an eligibility inquiry:
| Information | Description |
|---|---|
| Member's Medicaid ID number | Used when billing Medicaid. |
| Eligibility Status | Medicaid eligibility status for the requested dates. |
| Standard Medicaid | Member is eligible for all Montana Healthcare Programs covered services. |
| QMB | Member is a qualified Medicare beneficiary. See the section titled When a Member Has Other Coverage in this chapter. |
| Team Care | TC indicator means member is enrolled in the Team Care program. All services must be provided or approved by the designated Passport provider. |
| Designated Provider | The member’s primary care provider’s name and phone number are shown for members who are enrolled in Passport to Health or Team Care. In either case, all services must be provided or approved by the designated provider. See the Passport to Health provider manual. |
| TPL | If the member has other insurance coverage (TPL), the name of the other insurance carrier is shown. |
| Medicaid ID number | A Medicare identification number for members who are eligible for both Montana Healthcare Programs and Medicare. |
Member without Card
Since eligibility information is not on the card, it is necessary for providers to verify eligibility before providing services whether or not the member presents a card. Confirm eligibility using one of the methods shown in the Verifying Member Eligibility table. If eligibility is not available, the provider may contact the member’s local Office of Public Assistance (OPA).
Newborns
Care rendered to newborns can be billed under the newborn’s original Medicaid ID number assigned by the mother’s local OPA until a permanent ID number becomes available. The hospital or the parents may apply for the child’s Social Security number. Parents are responsible for notifying their local OPA when they have received the child’s new Social Security number.
Inmates in Public Institutions (ARM 37.82.1321)
Medicaid does not cover members who are inmates in a public institution.
Presumptive Eligibility
Presumptive eligibility is available to hospitals and their affiliated facilities that participate with Medicaid.
Personnel must be trained and certified to make presumptive eligibility determinations for short-term, temporary coverage for the following coverage groups:
- Adults between the ages of 18 and 26 who were in Foster Care and receiving Medicaid at age 18
- Healthy Montana Kids Plus
- Healthy Montana Kids
- Parent/Caretaker Relative Medicaid
- Pregnant women (ambulatory prenatal care)
- Women between the ages of 19 and 64 who have been screened and diagnosed with breast or cervical cancer.
To encourage prenatal care, uninsured pregnant women may receive presumptive eligibility for Medicaid.
Presumptive eligibility may be for only part of a month and does not cover inpatient hospital services, but does include other applicable Medicaid services.
Retroactive Eligibility
When a member is determined retroactively eligible for Medicaid, the member should give the provider a Notice of Retroactive Eligibility (160-M). The provider has 12 months from the date retroactive eligibility was determined to bill for those services.
Retroactive Medicaid eligibility does not allow a provider to bypass prior authorization requirements. See specific provider manuals for requirements.
When a member becomes retroactively eligible for Medicaid, the provider may:
- Accept the member as a Medicaid member from the current date
- Accept the member as a Medicaid member from the date retroactive eligibility was effective
- Require the member to continue as a private-pay member
Institutional providers (nursing facilities, skilled care nursing facilities, intermediate care facilities for the mentally retarded, institutions for mental disease, inpatient psychiatric hospitals, and residential treatment facilities) must accept retroactively eligible member from the date eligibility was effective. Non-emergency transportation and eyeglass providers cannot accept retroactive eligibility. For more information on billing Medicaid for retroactive eligibility services, see the Billing Procedures chapter in this manual.
Coverage for the Medically Needy
This coverage is for members who have an income level that is higher than the SSI-eligible Medicaid program standards. However, when a member has high medical expenses relative to income he/she can become eligible for Medicaid by incurring medical expenses and/or making a cash payment equal to the spend down amount on a monthly basis. The spend down amount is based on the member's countable income. When the member chooses to use the Medical Expense option to meet their spend down, he/she is responsible to pay for medical services before Medicaid eligibility begins and Medicaid pays for remaining covered services.
Providers should verify if medically needy members are covered by Medicaid on the date of service to determine whether to bill the member or Medicaid.
Because eligibility does not cover an entire month, when the medical expense option is used the member’s eligibility information may show eligibility for only part of the month and the provider may receive a One Day Authorization Notice. The One Day Authorization Notice , sent by the local OPA, states the date eligibility began and the portion of the bill the member must pay. If the provider has not received a One Day Authorization Notice , they should verify eligibility for the date of service by any method described in this chapter or by contacting the member’s local OPA. Since this eligibility may be determined retroactively, the provider may receive the One Day Authorization Notice weeks or months after services have been provided.
Members may choose the cash option process where they can pay a monthly premium to Medicaid equal to the spend down amount, instead of making payments to providers, and have Medicaid coverage for the entire month. This method results in quicker payment, simplifies the eligibility process, and eliminates spend down notices. Providers may encourage but not require members to use the cash option.
It is important to note that after a member submits their payment to Medicaid, the Department requires time to process the payment. Once the payment is processed, the system will provide the Medicaid coverage. The member may choose to submit their payment to Medicaid after medical services have been provided. In that situation, the member's Medicaid eligibility information will not be available at the time the service is provided and any claims submitted at that time will be denied. Once the spend down has been paid and processed, active eligibility will display and claims can be submitted.
Montana Breast and Cervical Cancer Treatment Program
This program provides Standard Medicaid coverage for women who have been screened through the Montana Breast and Cervical Health Program (MBCHP) and diagnosed with breast and/or cervical cancer or a pre-cancerous condition. All other policies and procedures in this chapter apply. For information regarding screening through the MBCHP program, call (888) 803-9343.
When a Member Has Other Coverage
Medicaid members often have coverage through Medicare, workers’ compensation, employment-based coverage, individually purchased coverage, etc. Coordination of benefits is the process of determining which source of coverage is the primary payer in a particular situation. In general, providers should bill other carriers before billing Medicaid, but there are some exceptions. (See the section titled Exceptions to Billing Third Party First in this chapter.) Medicare is processed differently than other sources of coverage.
Identifying Additional Coverage
The member’s Medicaid eligibility verification may identify other payers such as Medicare or other third party payers. If a member has Medicare, the Medicare ID number is provided. If a member has additional coverage, the carrier is shown. Some examples of third party payers include:
- Private health insurance
- Employment-related health insurance
- Workers’ compensation insurance*
- Health insurance from an absent parent
- Automobile insurance*
- Court judgments and settlements*
- Long-term care insurance
*These third party payers (and others) may not be listed on the member’s eligibility verification.
Providers should use the same procedures for locating third party sources for Medicaid members as for their non-Medicaid members. Providers cannot refuse service because of a third party payer or potential third party payer.
When a Member Has Medicare
Medicare claims are processed and paid differently than other non-Medicaid claims. The other sources of coverage are called third party liability or TPL, but Medicare is not.
Medicare Part A Claims
Medicare Part A carriers and Medicaid use electronic exchange of institutional claims covering Part A services. Providers must submit these claims first to Medicare. After Medicare processes the claim, an Explanation of Medicare Benefits (EOMB) is sent to the provider. The provider then reviews the EOMB and submits the claim to Medicaid.
Medicare Part B Crossover Claims
The Department has an agreement with the Medicare Part B carrier for Montana (Noridian) and the Durable Medical Equipment Regional Carrier (DMERC) under which the carriers provide the Department with claims for members who have both Medicare and Medicaid coverage. Providers must tell Medicare that they want their claims sent to Medicaid automatically, and must have their Medicare provider number on file with Medicaid.
When members have both Medicare and Medicaid covered claims and have made arrangements with both Medicare and Medicaid, Part B services need not be submitted to Medicaid. When a crossover claim is submitted only to Medicare, Medicare will process the claim, submit it to Medicaid, and send the provider an explanation of Medicare benefits (EOMB). Providers must check the EOMB for the statement indicating that the claim has been referred to Medicaid for further processing. It is the provider’s responsibility to follow up on crossover claims and make sure they are correctly billed to Medicaid within the timely filing limit. (See the Billing Procedures chapter in this manual.)
Providers should submit Medicare crossover claims to Medicaid only when:
- The referral to Medicaid statement is missing. In this case, submit a claim and a copy of the Medicare EOMB to Medicaid for processing.
- The referral to Medicaid statement is present, but there is no response from Medicaid within 45 days of receiving the Medicare EOMB. Submit a claim and a copy of the Medicare EOMB to Medicaid for processing.
- Medicare denies the claim. The provider may submit the claim to Medicaid with the EOMB and denial explanation (as long as the claim has not automatically crossed over from Medicare).
When submitting electronic claims with paper attachments, see the Billing Electronically with Paper Attachments section of the Billing Procedures chapter.
When submitting a claim with the Medicare EOMB, use Medicaid billing instructions and codes. Medicare’s instructions, codes, and modifiers may not be the same as Medicaid's. The claim must also include the Medicaid provider number and Medicaid member ID number. It is the provider’s responsibility to follow up on crossover claims and make sure they are correctly billed to Medicaid within the timely filing limit.
When a Member Has TPL (ARM 37.85.407)
When a Medicaid member has additional medical coverage (other than Medicare) it is often referred to as third party liability or TPL. In most cases, providers must bill other insurance carriers before billing Medicaid.
Providers are required to notify their members that any funds the member receives from third party payers (when the services were billed to Medicaid) must be turned over to the Department. These words printed on the member’s statement fulfill this obligation: When services are covered by Medicaid and another source, any payment the member receives from the other source must be turned over to Medicaid.
Exceptions to Billing Third Party First
In a few cases, providers may bill Medicaid first:
- When a Medicaid member is also covered by Indian Health Service (IHS) or the Crime Victim Compensation Program, providers must bill Medicaid first. These are not considered a third party liability.
- When a member has Medicaid eligibility and MHSP eligibility for the same month, Medicaid must be billed first.
- ICD prenatal and ICD preventive pediatric diagnosis conditions may be billed to Medicaid first. In these cases, Medicaid will “pay and chase” or recover payment itself from the third party payer.
- The following services may also be billed to Medicaid first:
- Nursing facility (as billed on nursing home claims)
- Audiology
- Eyeglasses
- Hearing aids and batteries
- Home and community-based services (waiver)
- Optometry
- Oxygen in a nursing facility
- Personal assistance/Community First Choice
- Transportation (other than ambulance)
Requesting an Exemption
Providers may request to bill Medicaid first under certain circumstances. In each of these cases, the claim and required information should be sent directly to the Third Party Liability unit.
- When a provider is unable to obtain a valid assignment of benefits, the provider should submit the claim with documentation that he/she attempted to obtain assignment and certification that the attempt was unsuccessful.
- When the provider has billed the third party insurance and has received a non-specific denial (e.g., no member name, date of service, amount billed), submit the claim with a copy of the denial and a letter of explanation.
- When the Child Support Enforcement Division has required an absent parent to have insurance on a child, the claim can be submitted to Medicaid then the following requirements are met:
- The third party carrier has been billed, and 30 days or more have passed since the date of service.
- The claim is accompanied by a certification that the claim was billed to the third party carrier, and payment or denial has not been received.
- If another insurance has been billed, and 90 days have passed with no response, submit the claim with a note explaining that the insurance company has been billed (or a copy of the letter sent to the insurance company). Include the date the claim was submitted to the insurance company and certification that there has been no response.
When the Third Party Pays or Denies a Service
When a third party payer is involved (excluding Medicare) and the other payer:
- Pays the claim, indicate the amount paid when submitting the claim to Medicaid for processing.
- Allows the claim, and the allowed amount went toward the member’s deductible, include the insurance explanation of benefits (EOB) when billing Medicaid.
- Denies the claim, submit the claim and a copy of the denial (including the reason explanation) to Medicaid.
- Denies a line on the claim, bill the denied line on a separate claim and submit to Medicaid. Include the EOB from the other payer and an explanation of the reason for denial (e.g., definition of denial codes).
When the Third Party Does Not Respond
If another insurance has been billed, and 90 days have passed with no response, bill Medicaid as follows:
- Submit the claim and a note explaining that the insurance company has been billed, or submit a copy of the letter sent to the insurance company
- Include the date the claim was submitted to the insurance company
- Send this information to the Third Party Liability Unit
Coordination Between Medicare and Medicaid
Coordination of benefits between Medicare and Medicaid is generally accomplished through electronic crossover of claims. It is important to always bill Medicare prior to Medicaid for healthcare services. After Medicare processes the claim, it will automatically cross over to Medicaid.
If a claim does not cross automatically to Medicaid from Medicare, the provider should not submit the claim to Medicaid until Medicare has processed.
Medicaid payment is subsequent to Medicare and will only pay up to the Medicaid fee after considering the payment from Medicare. See the How Payment Is Calculated chapter in the provider type manuals to learn how Medicaid payments are calculated.
- Qualified Medicare Beneficiary (QMB): For QMBs, Medicaid pays their Medicare A and B premiums and some or all of the Medicare coinsurance and deductibles (up to the Medicaid fee). QMB members may or may not also be eligible for Medicaid benefits.
- QMB Only: Medicaid will make payments only toward the Medicare coinsurance and deductible.
- QMB and Medicaid: Covered services include the same services as for Medicaid only members. If a service is covered by Medicare but not by Medicaid, Medicaid will pay all or part of the Medicare coinsurance and deductible. If a service is covered by Medicaid but not by Medicare, then Medicaid will be the primary payer for that service.
- Specified Low-Income Medicare Beneficiary (SLMB): Medicaid pays the Medicare Part B premium only.
- SLMB Only: Members do not receive Medicaid cards, are not eligible for other Medicaid benefits, and must pay their own Medicare coinsurance and deductibles.
- SLMB and Medicaid: For services Medicare covers, Medicaid will pay the lower of the Medicare coinsurance and deductible or the Medicaid fee less Medicare payments for Medicaid covered services. If a service is covered by Medicare but not by Medicaid, Medicaid will not pay coinsurance, deductible, or any other cost of the service. For services Medicare does not cover but Medicaid covers, Medicaid will be the primary payer for that service.
- Qualifying Individual (QI): Medicaid pays the Medicare Part B premium only. Members should not have a dual eligibility when qualifying under the QI program. In other words, members cannot have QI and Medicaid at the same time. When a QI recipient becomes Medicaid-eligible, the QI benefit is canceled and replaced by the Medicaid eligibility.
| Type of Dual Eligible | Medicaid Premium Paid by | Medicare Coinsurance and Deductible paid by |
|---|---|---|
| QMB only | Medicaid | Medicaid* |
| QMB/Montana Healthcare Programs | Medicaid | Medicaid |
| Other dual eligibles | Member | Medicaid* |
| Specified Low-Income Medicare Beneficiary (SLMB) | Medicaid | Member |
Note: See the How Payment Is Made chapter in your provider type manual to learn how Montana Healthcare Programs calculates payment for Medicare coinsurance and deductibles.
Members with Other Sources of Coverage
Medicaid members may also have coverage through workers’ compensation, employment-based coverage, individually purchased coverage, etc. Other parties also may be responsible for healthcare costs. Examples of these situations include communal living arrangements, child support, or auto accident insurance. These other sources of coverage have no effect on what services Medicaid covers. However, other coverage does affect the payment procedures. (See the How Payment Is Calculated chapter in your provider type manual.)
The Health Insurance Premium Payment (HIPP) Program
Some Medicaid members have access to private insurance coverage, typically through a job, but do not enroll because they cannot afford the premiums. In these cases, Medicaid may pay the premiums, at which time the private insurance plan becomes the primary insurer. The member also remains eligible for Medicaid. When Medicaid members have access to private insurance coverage, they may apply for the HIPP program.
Indian Health Service (IHS)
The Indian Health Service (IHS) provides federal health services to American Indians and Alaska Natives. IHS is a secondary payer to Medicaid. For more information, see the Subsidized Health Insurance Programs in Montana table at the end of this chapter.
Crime Victims
The Crime Victim Compensation Program is designed to help victims of crime heal. This program may provide funding for medical expenses, mental health counseling, lost wages support, funerals, and attorney fees. Crime Victim Compensation is a secondary payer to Medicaid. For more information, see the Subsidized Health Insurance Programs in Montana table later in this chapter.
When Members Are Uninsured
Several state and federal programs are available to help the uninsured; see the Subsidized Health Insurance Programs in Montana table at the end of this chapter.
Member Responsibilities
Medicaid members are required to:
- Know and understand what Standard Medicaid benefits include
- Notify providers that they have Medicaid coverage
- Present a valid Montana Access to Health (MATH) or Healthy Montana Kids (HMK) Plus card at each visit
- Notify providers of any other coverage, such as Medicare or private insurance
- Notify providers of any change in coverage
- Forward any money received from other insurance payers to the provider
- Inform their local office of public assistance about any changes in address, income, etc
Medicaid members may see any Medicaid-enrolled provider as long as Passport to Health and prior authorization guidelines are followed, and as long as they are not enrolled in Team Care.
Other Programs
Member eligibility provisions also apply to Department of Public Health and Human Services programs other than Medicaid. The information covered in this chapter applies to members enrolled in the Mental Health Services Plan (MHSP) and Healthy Montana Kids (HMK) dental services and eyeglasses only.
Chemical Dependency Bureau State Paid Substance Dependency/Abuse Treatment Program (CDB-SPSDATP)
Members in this program are not issued a Montana Access to Health card. Members should apply for services directly from the state-approved programs. For a list of these programs, call 406-444-9408. Services require prior authorization and authorization for continued stay review.
Healthy Montana Kids (HMK)
Few children are eligible for both Medicaid and HMK simultaneously. If a patient presents both cards, check the dates of Medicaid eligibility and the child’s HMK enrollment. If both cards are valid, treat the patient as an HMK patient. Services not covered by HMK may be covered by Medicaid.
If a member presents an HMK card for dental services, the provider should refer to the HMK dental services manual for information about coverage and billing. If a member presents an HMK card for eyeglasses, the card is valid only with the HMK program’s designated supplier. (See the HMK section of the Optometric and Eyeglass Services Manual.) If a member presents an HMK card for any other service, see the HMK provider manual published by Blue Cross and Blue Shield of Montana. Call 1-800-447-7828 for more information.
Mental Health Services Plan (MHSP)
MHSP members will present a hard white plastic card. Their MHSP card makes them eligible only for those services covered by MHSP, which are described in the mental health and prescription drug manuals. Medicaid members do not need an MHSP card to receive mental health services.
Plan First
If a member loses Medicaid, they may get family planning services paid by Plan First, which is a separate Medicaid program that covers family planning services for eligible women. Some of the services covered include office visits, contraceptive supplies, laboratory services, and testing and treatment of STDs. Visit https://dphhs.mt.gov/MontanaHealthcarePrograms/PlanFirst.
| Program | Administered by | Target Populations | For Information on Eligibility |
|---|---|---|---|
| Children’s Special Health Services | Montana DPHHS | Children with special healthcare needs. | (800) 762-9891 (406) 444-3622 |
| Crime Victim Compensation Program | Montana Department of Justice | Crime victims and their dependents and relatives. | (406) 444-3653 (800) 498-6455 https://dojmt.gov/victims/ crime-victim-compensation/ |
| Indian Health Service | Billings Area Indian Health Service | All enrolled members of federally recognized tribes. | 406-247-7107 www.ihs.gov/ |
| Montana Healthcare Programs | Montana DPHHS | Low-income children and their family members, and disabled individuals. | Local Office of Public Assistance https://dphhs.mt.gov/hcsd/ OfficeofPublicAssistance |
| Medicare | Centers for Medicare and Montana Healthcare Programs Services | People who are age 65 and over, have a disability, or have end-stage renal disease. | U.S. Social Security Administration office www.medicare.gov/ |
| Mental Health Services Plan (MHSP) | Montana DPHHS | Individuals with a qualifying mental health diagnosis who are ineligible for Montana Healthcare Programs. | Community Mental Health Center https://dphhs.mt.gov/BHDD/mentalhealthservices/MHSP/index |
| Workers’ Compensation | State Fund and independent workers’ compensation insurers | People with injuries or illnesses related to their work. | 406-444-6543 Workers Compensation |
Note: Eligibility rules are complex; members and providers should check with the program administrator for specifics. Providers may refer member to these programs.
End of Member Eligibility and Responsibilities Chapter
Surveillance and Utilization Review (SURS)
Claims Review (MCA 53-6-111, ARM 37.85.406)
The Department is committed to paying Montana Healthcare Programs providers’ claims as quickly as possible. Montana Healthcare Programs claims are electronically processed and usually are not reviewed by medical experts prior to payment to determine if the services provided were appropriately billed. Although the computerized system can detect and deny some erroneous claims, there are many erroneous claims it cannot detect. For this reason, payment of a claim does not mean the service was correctly billed or the payment made to the provider was correct. Periodic retrospective reviews are performed that may lead to the discovery of incorrect billing or incorrect payment. If a claim is paid and the Department later discovers the service was incorrectly billed or paid or the claim was erroneous in some other way, the Department is required by federal regulation to recover any overpayment, regardless of whether the incorrect payment was the result of Department or provider error or other cause.
Statewide Surveillance and Utilization Control Program (42 CFR 456.3)
The Department’s Surveillance Utilization Review Section (SURS) performs federally mandated retrospective reviews of paid claims (42 CFR 456). SURS is required to safeguard against unnecessary and inappropriate use of Montana Healthcare Programs services and against excess payments. If the Department pays a claim, but subsequently discovers that the provider was not entitled to payment for any reasons, the Department is entitled to recover the resulting overpayment (ARM 37.85.406).
SURS monitors compliance with state and federal rules, laws, and policies in several ways:
- New Provider Reviews: SURS reviews the billing data of newly enrolled providers and may also review documentation.
- Provider Self-Audits: A self-audit is an opportunity for the provider to perform an review and self-disclose errors to SURS. Providers may access the website for Office of Inspector General (OIG) provider self-disclosure protocol resources at http://oig.hhs.gov/compliance/self-disclosure-info/index.asp.
- Individual Reviews: An individual review is conducted by the Program Integrity Compliance Specialist in charge of reviewing the provider type being reviewed.
- Team Reviews: Team reviews are conducted by a team of Program Integrity Compliance Specialists whose individual expertise contributes to the review of the issue being reviewed.
- Data Mining Reviews: A review conducted by data mining which reviews the appropriateness of the data submitted on the claim, such as dates of service, procedure code, units, etc.
- Statistical Sampling: When a provider is reviewed, claims data is gathered for the review time frame. If a provider has a large number of claims for which records collection and submission for a complete review would be burdensome to the provider, a statistical sample of the claims may be reviewed at the option of the Department. SURS uses a program called RAT-STATS to pull a random subset (sample) of the total claims under review (universe). The review is then completed on the sample of claims. The determination made on the sample is then extrapolated to the entire universe. If a provider disagrees with the final determination, a 100% review of claims may be requested by the provider. More information about the statistical sampling process can be found in ARM 37.85.416.
During an review, SURS personnel send a spreadsheet to the provider with paid claims data. The provider is required to send supporting documentation for the items listed on the spreadsheet. A SURS Program Integrity Compliance Specialist reviews the documentation and/or data submitted by the provider.
If SURS determines an overpayment that exceeds $5,000, the review is presented to the Montana Healthcare Programs Review Committee for review and approval. With the approval of the committee, an overpayment letter will be sent to the provider.
If SURS determines an overpayment that is less than $5,000, the case is reviewed by the associated program bureau chief, program officer, SURS supervisor, and Program Compliance bureau chief. Their approval will initiate an overpayment letter to the provider.
The overpayment letter specifies the amount of the overpayment, the date the funds are due, how to appeal the Department’s decision, and the appropriate contact person.
Key Points
- The SURS unit encourages providers to call with any questions or concerns regarding the review of paid claims.
- The Department is entitled to recover payment made to providers when a claim was paid incorrectly for any reason. (MCA 53-6-111, ARM 37.85.406)
- The Department may charge interest on recovered funds. (MCA 53-6-111)
- When an inappropriate payment has been identified, the Department may recover the overpayment by any legal means, including withholding of provider payments on subsequent claims. (MCA 53-6-111)
- The Department may sanction a provider, including suspension or termination of Montana Healthcare Programs enrollment, if the provider has failed to abide by terms of the Montana Healthcare Programs contract, federal and state laws, regulations and/or policies. (MCA 53-6-111, ARM 37.85.501–502, ARM 37.85.513)
- Prior authorization does not guarantee payment; a claim may be denied or money paid to providers may be recovered if the claim is found to be inappropriate. (MCA 53-6-111, ARM 37.85.406, ARM 37.85.410)
- The provider must upon request provide to the Department or its designated review organization without charge any records related to services or items provided to a member. The provider shall submit a true and accurate copy of each record of the service or item being reviewed as it existed within 90 days after the date on which the claim was submitted to Montana Healthcare Programs. (ARM 37.85.410, ARM 37.85.414)
Billing Tips
The following suggestions may help reduce billing errors but are not inclusive of all possible errors and recoupment scenarios.
- Be familiar with the Montana Healthcare Programs provider manuals, fee schedules, and provider notices that are in effect for the claim dates of service. Read the Claim Jumper provider newsletter. These are available on the Provider Information website.
- Comply with applicable state and federal regulations, including but not limited to the Administrative Rules of Montana. (ARM 37.85.401)
- Use CPT, HCPCS, and ICD coding books that are in effect for the claim dates of service, and refer to the long descriptions. Relying on short descriptions can result in inappropriate billing. Additional coding resources such as those noted in CPT are also recommended.
- All providers of services must maintain complete records which fully demonstrate the extent, nature, and medical necessity of services and items provided to Montana Healthcare Programs members. Information regarding the minimum requirements for records are found in ARM 37.85.414. In addition to complying with these minimum requirements, providers must also comply with any specific record keeping requirements applicable to the type of services the provider furnishes. See the Record Keeping section in the Provider Requirements chapter in this manual.
- When reimbursement is based on the length of time spent providing the service, the records must specify the time spent or the time treatment began and ended for each procedure. (ARM 37.85.414)
- Attend classes on coding offered by certified coding specialists.
- Avoid billing for the same service/supply twice. Contact Provider Relations for the status of submitted claims.
- Use specific codes rather than miscellaneous codes. For example, Code 99213 is more specific (problem-focused visit) than Code 99499 (unlisted evaluation and management service).
- Verify that the item/service meets criteria for payment by the Department. (See current fee schedule, provider manuals, and Administrative Rules of Montana.)
- Bill only under your own provider number.
- Bill only for services you provided.
- Bill for the appropriate level of service provided. For example, the CPT coding book contains detailed descriptions and examples of what differentiates a level 1 office visit (Code 99201) from a level 5 office visit (Code 99205).
- Services covered within “global periods” for certain CPT procedures are not paid separately and should not be billed separately. Most surgical and obstetric procedures and some medical procedures include routine care before and after the procedure. Montana Healthcare Programs fee schedules show the global period for each CPT service.
- Pay close attention to modifiers used with CPT and HCPCS codes on both CMS-1500 bills and UB-04 bills. Modifiers are becoming more prevalent in healthcare billing, and they often affect payment calculations.
- Choose the least costly alternative. For example, if a member is able to operate a standard wheelchair, then a motorized wheelchair should not be prescribed or provided.
- For repeat members, use an established patient code (e.g., Code 99213) instead of a first time patient code (e.g., Code 99203).
- Use the correct units measurement on CMS-1500 and UB-04 bills. In general, Montana Healthcare Programs follows the definitions in the CPT and HCPCS coding books. Unless otherwise specified, one unit equals one visit or one procedure. For specific codes, however, one unit may be 15 minutes, a percentage of body surface area, or another quantity. Always check the long text of the code description. A service must take at least 8 minutes to bill one unit of service if the procedure has “per 15 minutes” in its description.
End of Surveillance and Utilization Review (SURS) Chapter
Billing Procedures
Claim Forms
Services provided by the healthcare professionals covered in this manual may be billed electronically or on paper claim forms. The 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 Montana Healthcare Programs within:
- Twelve months from whichever is later:
- the date of service
- the date retroactive eligibility or disability is determined
- Six months from the date on the Medicare explanation of benefits approving the service.
- Six months from the date on an adjustment notice from a third party payer who has previously processed the claim for the same service, and the adjustment notice is dated after the periods described above.
For claims involving Medicare or TPL, if the 12-month time limit has passed, providers must submit clean claims to Montana Healthcare Programs within:
- Medicare Crossover Claims. Six months from the date on the Medicare explanation of benefits, if the Medicare claim was timely filed and the member eligible for Medicare at the time the Medicare claim was filed.
- Claims Involving Other Third Party Payers (excluding Medicare). Six months from the date on an adjustment notice from a third party payer who has previously processed the claim for the same service, and the adjustment notice is dated after the periods described above.
Clean claims are claims that can be processed without additional information or action from the provider. The submission date is defined as the date that the claim was received by the Department or the claims processing contractor. All problems with claims must be resolved within this 12-month period.
Tips to Avoid Timely Filing Denials
- Correct and resubmit denied claims promptly. (See the Remittance Advices and Adjustments chapter in this manual.)
- If a claim submitted to does not appear on the remittance advice within 45 days, contact Provider Relations for claim status.
- If another insurer has been billed and 90 days have passed with no response, a provider can bill Montana Healthcare Programs . (See the Member Eligibility and Responsibilities chapter in this manual for more information.)
- To meet timely filing requirements for Medicare/Montana Healthcare Programs crossover claims, see the Member Eligibility and Responsibilities chapter in this manual and, if applicable, the Coordination of Benefits chapter in your provider type manual.
When to Bill Medicaid Members (ARM 37.85.406)
Providers may not bill Medicaid members for services covered under Medicaid.
If a provider bills Medicaid and the claim is denied because the member is not eligible, the provider may bill the member directly.
More specifically, providers cannot bill members directly:
- For the difference between charges and the amount Medicaid paid
- For a covered service provided to a Medicaid-enrolled member who was accepted as a Medicaid member by the provider, even if the claim was denied
- When a third party payer does not respond
- When a member fails to arrive for a scheduled appointment. Medicaid may not be billed for no-show appointments either.
- When services are free to the member, such as in a public health clinic. Medicaid may not be billed for those services either.
Under certain circumstances, providers may need a signed agreement to bill a member.
|
Member Eligibility |
Is the service is Covered by Medicaid | Can the provider bill the member? |
|---|---|---|
| Member is Medicaid enrolled and provider accepts the member as a Medicaid Member | Yes | Provider can bill member only for cost sharing. |
| Member is Medicaid enrolled and provider accepts the member as a Medicaid Member | No | Provider can bill member if the member has signed a custom agreement before they provide the service. |
| Member is Medicaid enrolled and provider does not accept the member as a Medicaid Member | Yes | Provider can bill Medicaid member if the member has signed a private pay agreement before they provide the service. |
| Member is Medicaid enrolled and provider does not accept the member as a Medicaid Member | No | Provider can bill member if the member has signed a custom agreement before they provide the service. |
| Patient is not Medicaid enrolled | Yes | Yes |
| Patient is not Medicaid enrolled | No | Yes |
Private-Pay Agreement: A nonspecific private-pay agreement between the provider and member stating that the member is not accepted as a Medicaid member, and that they must pay for the services received.
Custom Agreement: A specific agreement that includes the dates of service, actual services or procedures, and the cost to the member. It states the services are not covered by Medicaid and the member will pay for them.
Member Co-Payment (ARM 37.85.204)
Effective for claims paid on or after January 1, 2020, members covered under Medicaid or Medicaid Expansion will not be assessed a co-payment, as denied in ARM 37.84.102, for any covered service.
Billing for Members with Other Insurance
A Medicaid member may also be covered by Medicare or have other insurance, or some other third party is responsible for the cost of the member’s healthcare,
When completing a claim for members with Medicare and Medicaid, Medicare coinsurance and deductible amounts must correspond with the payer listed. For example, if the member has Medicare and Medicaid, any Medicare deductible and coinsurance amounts must be listed and preceded by an A1, A2, etc. Because these amounts are for Medicare, Medicare must be listed in the corresponding field. (See the Submitting a Claim section in this manual.)
Billing for Retroactively Eligible Members
When a member becomes retroactively eligible for Montana Healthcare Programs , the provider may:
- Accept the member as a Montana Healthcare Programs member from the current date.
- Accept the member as a Montana Healthcare Programs member from the date retroactive eligibility was effective.
- Require the member to continue as a private-pay member.
Always refer to the long descriptions in coding books.
When the provider accepts the member’s retroactive eligibility, the provider has 12 months from the date retroactive eligibility was determined to bill for those services. When submitting claims for retroactively eligible members in which the date of service is more than 12 months earlier than the date the claim is submitted, attach a copy of the Provider Notice of Eligibility (Form 160-M). To obtain this form, the provider should contact the member’s county Office of Public Assistance. See https://dphhs.mt.gov/hcsd/OfficeofPublicAssistance.
When a provider chooses to accept the member from the date retroactive eligibility was effective, and the member has made a full or partial payment for services, the provider must refund the member’s payment for the services before billing Montana Healthcare Programs for the services.
Coding Tips
Standard use of medical coding conventions is required when billing Montana Healthcare Programs. Provider Relations or the Department cannot suggest specific codes to be used in billing for services. See the Coding Resources table. The following may reduce coding errors and unnecessary claim denials:
- Use current CPT, CDT, HCPCS, and ICD diagnosis coding books.
- Always read the complete description and guidelines in the coding books. Relying on short descriptions can result in inappropriate billing.
- Attend classes on coding offered by certified coding specialists.
- Use specific codes rather than unlisted codes.
- Bill for the appropriate level of service provided. Evaluation and management services have 3 to 5 levels. See your CPT manual for instructions on determining appropriate levels of service.
- CPT codes that are billed based on the amount of time spent with the member must be billed with the code that is closest to but not over the time spent.
- Revenue Codes 25X are required to have valid and rebateable National Drug Codes (NDCs) on each line to be paid.
- Revenue Codes 27X do not require CPT or HCPCS codes; however, providers are advised to place appropriate NDC, CPT, and/or HCPCS codes on each line. Providers are paid based on the presence of line item CPT and HCPCS codes. If these codes are omitted, hospitals may be underpaid.
- Take care to use the correct units measurement. In general, Montana Healthcare Programs follows the definitions in the CPT and HCPCS coding books. Unless otherwise specified, one unit equals one visit or one procedure. For specific codes, however, one unit may be “each 15 minutes. A service must take at least 8 minutes to bill one unit of service if the procedure has “per 15 minutes” in its description. Always check the long text of the code description published in the CPT or HCPCS coding books.
Coding Resources
Please note that the Department does not endorse the products of any particular publisher.
| Resource | Description | Contact |
|---|---|---|
| CDT - http://www.ada.org/en/publications/ | The CDT is the official coding used by dentists. | American Dental Association (312) 440-2500 |
| CPT - https:/commerce.ama-assn.org/store/ | CPT codes and definitions. Updated each January. |
American Medical Association (800) 621-8335 |
| CPT Assistant - https://commerce.ama-assn.org/store/ | A newsletter on CPT coding issues. | American Medical Association (800) 621-8335 |
| HCPCS Level II | HCPCS codes and definitions. Updated each January and throughout the year. |
Available through various publishers and bookstores or from CMS at www.cms.gov. |
| ICD | ICD diagnosis and procedure code definitions. Updated each October. |
Available through various publishers and bookstores. |
Various newsletters and other coding resources are available in the commercial marketplace.
Number of Lines on Claim
The Montana claims processing system supports 40 lines on a UB-04 claim, 21 lines on a CMS-1500, and 21 lines on a dental claim.
Multiple Services on Same Date
Outpatient hospital providers must submit a single claim for all services provided to the same member on the same day. If services are repeated on the same day, use appropriate modifiers. The only exception to this is if the member has multiple emergency room visits on the same date. Two or more emergency room visits on the same day must be billed on separate claims with the correct admission hour on each claim.
Span Bills
Outpatient hospital providers may include services for more than one day on a single claim, so long as the service is paid by fee schedule (e.g., partial hospitalization, therapies) and the date is shown on the line. However, the Outpatient Code Editor (OCE) will not price APC procedures when more than one date of service appears at the line level, so we recommend billing for only one date at a time when APC services are involved.
Reporting Service Dates
All line items must have a valid date of service. The revenue codes on the following page require a separate line for each date of service and a valid CPT or HCPCS code:
Revenue Codes That Require a Separate Line for Each Date of Service and a Valid CPT or HCPCS Code
26X - IV Therapy
28X - Oncology
30X - Laboratory
31X - Laboratory Pathological
32X -Radiology – Diagnostic
33X - Radiology – Therapeutic
34X - Nuclear Medicine
35X - Computed Tomographic (CT) Scan
36X - Operating Room Services
38X - Blood
39X - Blood Storage and Processing
40X - Other Imaging Services
41X - Respiratory Services
42X - Physical Therapy
43X - Occupational Therapy
44X - Speech-Language Pathology
45X - Emergency Department
46X - Pulmonary Function
47X - Audiology
48X - Cardiology
49X - Ambulatory Surgical Care
51X - Clinic
52X - Free-Standing Clinic
61X - Magnetic Resonance Imaging (MRI)
63X - Drugs Requiring Specific Identification
70X - Cast Room
72X - Labor Room/Delivery
73X - Electrocardiogram (EKG/ECG)
74X - Electroencephalogram (EEG)
75X - Gastro-Intestinal Services
76X - Treatment or Observation Room
77X - Preventive Care Services
79X - Lithotripsy
82X - Hemodialysis – Outpatient or Home
83X - Peritoneal Dialysis – Outpatient or Home
84X - Continuous Ambulatory Peritoneal Dialysis (CAPD) – Outpatient
85X - Continuous Cycling Peritoneal Dialysis (CCPD) – Outpatient
88X - Miscellaneous Dialysis
90X - Psychiatric/Psychological Treatments
91X - Psychiatric/Psychological Services
92X - Other Diagnostic Services
94X - Other Therapeutic Services
Using Modifiers
- Review the guidelines for using modifiers in the most current CPT book, HCPCS book, and other helpful resources (e.g., CPT Assistant, APC Answer Letter, and others).
- Always read the complete description for each modifier; some modifiers are described in the CPT manual while others are in the HCPCS book.
- Montana Healthcare Programs accepts most of the same modifiers as Medicare, but not all.
- The Montana Healthcare Programs claims processing system recognizes three pricing modifiers and one informational modifier per claim line on the CMS-1500. Providers are asked to place any modifiers that affect pricing in the first two modifier fields.
- Discontinued or reduced service modifiers must be listed before other pricing modifiers on the CMS-1500. For a list of modifiers that change pricing, see the How Payment Is Calculated chapter in this manual.
Billing Tips for Specific Services
Prior authorization is required for some services. Passport and prior authorization are different; some services may require both. Different numbers are issued for each type of approval and must be included on the claim form.
Abortions
A completed Montana Healthcare Programs Physician Certification for Abortion Services (MA-37) form must be attached to every abortion claim or payment will be denied. Complete only one section of this form. This is the only form Montana Healthcare Programs accepts for abortions.
Drugs and Biologicals
While most drugs are bundled, there are some items that have a fixed payment amount and some that are designated as transitional pass-through items. (See the Pass-Through section in the How Payment Is Calculated chapter of this manual.) Bundled drugs and biologicals have their costs included as part of the service with which they are billed. The following drugs may generate additional payment:
- Vaccines, antigens, and immunizations
- Chemotherapeutic agents and the supported and adjunctive drugs used with them
- Immunosuppressive drugs
- Orphan drugs
- Radiopharmaceuticals
- Certain other drugs, such as those provided in an emergency department for heart attacks
NDC Requirements
The Federal Deficit Reduction Act of 2005 mandates that all State Montana Healthcare Programs require the submission of National Drug Codes (NDCs) on claims submitted with certain procedure codes for physician-administered drugs. This mandate affects all providers who submit claims for procedure-coded drugs both electronically and manually.
Montana Healthcare Programs require all claims submitted for physician administered drugs to include the NDC(s), the corresponding CPT/HCPCS code(s), unit of measure, and the units administered for each code. Montana Healthcare Programs will only reimburse for drugs manufactured by companies that have a signed rebate agreement with the Centers for Medicare and Montana Healthcare Programs Services (CMS). A list of drug manufacturers who have a rebate agreement with CMS can be found on the provider website, https://medicaidprovider.mt.gov/, under the Rebateable Manufacturers list in the Site Index.
When a procedure or revenue code requires an NDC, Montana Healthcare Programs covers only those NDCs that are rebateable. An NDC is considered rebateable ONLY if all the following conditions are met:
-
The drug is a Montana Healthcare Programs covered drug
-
The NDC on the drug dispensed is valid
-
The drug dispensed is NOT terminated
-
The drug is a product of an eligible manufacturer
-
The DESI indicator is NOT 5 or 6.
NDC Formatting
When billing Montana Healthcare Programs, the required NDC is 11-digits. The NDC should be structured in the 5-4-2 format. Some manufacturers omit leading zeros in one of the three positions. This results in a 10-digit number, which is invalid. To ensure proper reimbursement, the provider must add the appropriate leading zero to the affected segment of the format.
The below table provides examples of where the leading zero should be placed in three separate instances.
| Leading Zero Location | Examples of 10 Digit Format | Add a zero (0) to |
|---|---|---|
| 5 digit segment | XXXX-XXXX-XX | 0XXXX-XXXX-XX |
| 4 digit segment | XXXXX-XXX-XX | XXXXX-0XXX-XX |
| 2 digit segment | XXXXX-XXXX-X | XXXXX-XXXX-0X |
Reporting a NDC on paper CMS-1500, under Form Locator 24(A) must include the following:
- Enter the NDC qualifier of “N4” in the first two positions on the left side of the field.
- Enter the 11-digit NDC numeric code in the 5-4-2 format, without the hyphens.
- Enter the NDC unit of measure qualifier, such as:
- F2 — International Unit
- GR — Gram (includes mg, mcg)
- ML — Milliliter
- UN — Units (includes “each”)
- Enter the NDC quantity (the administered amount) with up to three decimal places.
- When using the paper CMS-1500, insert a space between the 11-digit NDC and the unit of measure.
- Example only: N459148001665 ML0.8
Reporting a NDC on a paper UB-04, in Form Locator 43, in the Revenue Description Field must include the following:
- Enter the NDC qualifier of “N4” in the first two positions on the left side of the field.
- Enter the 11-digit NDC numeric code in the 5-4-2 format., without delimiters such as hyphens or commas
- Enter the NDC unit of measure qualifier, such as:
- F2 — International Unit
- GR — Gram (includes mg, mcg)
- ML — Milliliter
- UN — Units (includes “each”)
- Enter the NDC quantity (the administered amount) with up to three decimal places.
- Any unused spaces for the entire quantity are left blank.
- The Description Field allows for a maximum of 24 total characters.
- Example only: N459148001665ML0.8
The NDC on the claim MUST be the NDC that was dispensed to the member. DO NOT include the name of the physician-administered drug when reporting the NDC.
Compound Drugs
Professional providers that bill compound drugs using the paper CMS-1500 must bill them using the corresponding CPT/HCPCS codes and NDC on paper claim forms and must attach the supplier’s invoice. The invoice must contain an NDC for each component of the compound. Invoices that do not include NDCs will be denied. Payment will be made from the NDCs listed on the invoices that qualify for rebates.
Crossover Claims
Dual-eligible claims billed to Medicare with an NDC will cross to Montana Healthcare Programs with the NDC. Any claim with a physician-administered drug crossing to Montana Healthcare Programs from Medicare without an NDC will be denied. Claims denied for this reason may be re-billed with the proper NDC within one year of the date of service.
340B Drug Pricing Programs or Vaccines
Providers participating in the 340B Drug Pricing Programs are not required to include NDC information on the claim. Vaccines do not require NDC information.
Lab Services
If all tests that make up an organ or disease organ panel are performed, the panel code should be billed instead of the individual tests.
Some panel codes are made up of the same test or tests performed multiple times. When billing one unit of these panels, bill one line with the panel code and one unit. When billing multiple units of a panel (the same test is performed more than once on the same day) bill the panel code with units corresponding to the number of times the panel was performed.
Outpatient Clinic Services
Montana Healthcare Programs does not recognize provider-based clinic status in reimbursing evaluation and management codes on the institutional claims (UB-04/8381) transactions. Clinic services provided by an individual physician or mid-level practitioner in the clinic must be billed on a CMS 1500 with place of service (POS) 11.
For services that have both technical and professional components, physicians providing services in hospitals must bill only for the professional component if the hospital is going to bill Montana Healthcare Programs for the technical component. Refer to the Physician-Related Services manual and the Billing Procedures chapter in this manual for more information. Provider type manuals are located on the provider type pages of the Provider Information website.
Partial Hospitalization
Partial hospitalization services must be billed with the national code for partial hospitalization, the appropriate modifier, and the prior authorization code.
| Code | Modifier | Service Level |
|---|---|---|
| H0035 | Partial hospitalization, sub-acute, half day | |
| H0035 | U6 | Partial hospitalization, sub-acute, full day |
| H0035 | U7 | Partial hospitalization, acute, half day |
| H0035 | U8 | Partial hospitalization, acute, full day |
Sterilization/Hysterectomy (ARM 37.86.104)
Elective sterilizations are sterilizations done for the purpose of becoming sterile. Montana Healthcare Programs covers elective sterilization for men and women when all of the following requirements are met:
- Member must complete and sign the Informed Consent to Sterilization (MA-38) form at least 30 days, but not more than 180 days, prior to the sterilization procedure. This form is the only form Montana Healthcare Programs accepts for elective sterilizations. If this form is not properly completed, payment will be denied. The 30-day waiting period may be waived for either of the following:
- Premature Delivery. The Informed Consent to Sterilization must be completed and signed by the member at least 30 days prior to the estimated delivery date and at least 72 hours prior to the sterilization.
- Emergency Abdominal Surgery. The Informed Consent to Sterilization form must be completed and signed by the member at least 72 hours prior to the sterilization procedure.
- Member must be at least 21 years of age when signing the form.
- Member must not have been declared mentally incompetent by a federal, state, or local court, unless the member has been declared competent to specifically consent to sterilization.
- Member must not be confined under civil or criminal status in a correctional or rehabilitative facility, including a psychiatric hospital or other correctional facility for the treatment of the mentally ill.
Before performing a sterilization, the following requirements must be met:
- The member must have the opportunity to have questions regarding the sterilization procedure answered to his/her satisfaction
- The member must be informed of his/her right to withdraw or withhold consent anytime before the sterilization without being subject to retribution or loss of benefits
- The member must be made aware of available alternatives of birth control and family planning
- The member must understand the sterilization procedure being considered is irreversible
- The member must be made aware of the discomforts and risks which may accompany the sterilization procedure being considered
- The member must be informed of the benefits and advantages of the sterilization procedure
- The member must know that he/she must have at least 30 days to reconsider his/her decision to be sterilized
- An interpreter must be present and sign for members who are blind or deaf, or do not understand the language to assure the person has been informed
Informed consent for sterilization may not be obtained under the following circumstances:
- If the member is in labor or childbirth
- If the member is seeking or obtaining an abortion
- If the member is under the influence of alcohol or other substance which affects his/her awareness
For elective sterilizations, a completed Informed Consent to Sterilization (MA-38) form must be attached to the claim for each provider involved or payment will be denied. This form must be legible, complete, and accurate. It is the provider’s responsibility to obtain a copy of the form from the primary or attending physician.
For medically necessary sterilizations, including hysterectomies, oophorectomies, salpingectomies, and orchiectomies, one of the following must be attached to the claim, or payment will be denied:
- A completed Montana Healthcare Programs Hysterectomy Acknowledgement form (MA-39) for each provider submitting a claim. It is the billing provider’s responsibility to obtain a copy of the form from the primary or attending physician. Complete only one section of this form. When no prior sterility (Section B) or life-threatening emergency (Section C) exists, the member (or representative, if any) and physician must sign and date Section A of this form prior to the procedure. (See 42 CFR 441.250 for the federal policy on hysterectomies and sterilizations.) Also, for Section A, signatures dated after the surgery date require manual review of medical records by the Department. The Department must verify that the member (and representative, if any) was informed orally and in writing, prior to the surgery, that the procedure would render the member permanently incapable of reproducing. The member does not need to sign this form when Sections B or C are used.
- For members who have become retroactively eligible for Montana Healthcare Programs , the physician must certify in writing that the surgery was performed for medical reasons and must document one of the following:
- The individual was informed prior to the hysterectomy that the operation would render the member permanently incapable of reproducing.
- The reason for the hysterectomy was a life-threatening emergency.
- The member was already sterile at the time of the hysterectomy and the reason for prior sterility.
When submitting claims for retroactively eligible members, for which the date of service is more than 12 months earlier than the date the claim is submitted, contact the member’s local Office of Public Assistance and request a Notice of Retroactive Eligibility (160-M). Attach the form to the claim.
Supplies
Supplies are generally bundled, so they usually do not need to be billed individually. A few supplies are paid separately by Montana Healthcare Programs . The fee schedules on the website lists the supply codes that may be separately payable.
Submitting a Claim
Paper Claims
Unless otherwise stated, all paper claims must be mailed to:
Claims Processing
P.O. Box 8000
Helena, MT 59604
On the CMS-1500, EPSDT/Family Planning, is used as an indicator to specify additional details for certain members or services. The following are accepted codes:
EPSDT/Family Planning Indicators
| Code | Member/Service | Purpose |
|---|---|---|
| 1 | EPSDT | Used when the member is under age 21. |
| 2 | Family planning | Used when providing family planning services. |
| 3 | EPSDT and family planning | Used when the member is under age 21 and is receiving family planning services. |
| 4 | Pregnancy (any service provided to a pregnant woman) | Used when providing services to pregnant women. |
| 6 | Nursing facility member | Used when providing services to nursing facility residents. |
Submitting Electronic Claims
Providers who submit claims electronically experience fewer errors and quicker payment. Claims may be submitted using the methods below. For detailed submission methods, see the electronic submissions manual on the Electronic Billing page of the website.
- WINASAP 5010. This free software provided by Conduent allows for the creation of basic claim submissions. Please note that this software is not compatible with Windows 10 and has limited support as it is free software.
o Utilizes either a dial-up modem or submissions through the Montana Access to Health (MATH) Web Portal.
o Requires completion of the X12N Transaction Packet to allow for claim submissions.
- Clearinghouses/Contracted Claim Submitter. Providers can make arrangements with a clearinghouse/contracted claim submitter for claim submission. Please note that the clearinghouse must be enrolled to submit claims to Montana Healthcare Programs .
- Montana Access to Health (MATH) Web Portal . A secure website that allows providers to verify eligibility, check claim status, and view medical claims history. Valid X12N files can be uploaded through this website.
o Requires completion of the X12N Transactions Packet to allow for claim submissions.
- MoveIt DMZ. This secure transfer protocol is for providers and clearinghouses that submit large volumes of files (in excess of 20 per day) or are regularly submitting files larger than 2 MB. This utilizes SFTP and an intermediate storage area for the exchange of files.
o A request for this must be made through Conduent Provider Relations for established trading partners.
Providers should be familiar with federal rules and regulations related to electronic claims submission.
Billing Electronically with Paper Attachments
When submitting claims that require additional supporting documentation, the Paperwork Attachment Control Number field must be populated with an identifier.
The accepted method is the provider's NPI/API followed by the member's ID number and the date of service, each separated by a dash:
| NPI | Member ID | Date of Service |
|---|---|---|
| XXXXXXXXXX | XXXXXXXXX | MMDDYYYY |
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 Montana Healthcare Programs ID number followed by the member's ID number and the date of service, each separated by a dash:
The supporting documentation must be submitted with a Paperwork Attachment Cover Sheet. ( See Forms page on the Provider Information website.) The number in the paper Attachment Control Number field must match the number on the cover sheet.
Claim Inquiries
Contact Provider Relations for general claim questions and questions regarding payments, denials, and member eligibility.
Common Billing Errors
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.
| Reasons for Return or Denial | How to Prevent Returned or Denied Claims |
|---|---|
| Provider’s NPI and/or Taxonomy is missing or invalid | The provider NPI is a 10-digit number assigned to the provider by the national plan and provider enumerator system. Verify the correct NPI and Taxonomy are on the claim. |
| Authorized signature missing | 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. |
| Signature date missing | Each claim must have a signature date. |
| Incorrect claim form used | The claim must be the correct form for the provider type. |
| Information on claim form not legible | 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. |
| Member ID number not on file, or member was not eligible on date of service | Before providing services to the member, verify member eligibility by using one of the methods described in the Member Eligibility and Responsibilities chapter of this manual. Montana Healthcare Programs eligibility may change monthly. |
| Passport provider number is missing or invalid | A Passport provider number must be on the claim form when a referral is required. Passport approval is different from prior authorization. See the Passport to Health provider manual. |
| Prior authorization number is missing | Prior authorization is required for certain services, and the prior authorization number must be on the claim form. Prior authorization is different from Passport. See the Prior Authorization chapter in this manual. |
| Prior authorization does not match current information | 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. |
| Duplicate claim | Check all remittance advices for previously submitted claims before resubmitting. When making changes to previously paid claims, submit an adjustment form rather than a new claim form. (See Remittance Advices and Adjustments in this manual.) |
| TPL on file and no credit amount on claim | If the member has any other insurance (or Medicare), bill the other carrier before Montana Healthcare Programs. If the member’s TPL coverage has changed, providers must notify the TPL unit before submitting a claim. |
| Claim past 365-day filing limit | 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. |
| Missing Medicare EOMB | All denied Medicare crossover claims must have an Explanation of Medicare Benefits (EOMB) with denial reason codes attached and be billed to Montana Healthcare Programs on paper. |
| Provider is not eligible during dates of services, enrollment has lapsed due to licensing requirements, or provider number terminated | Out-of-state providers must update licensure for Montana Healthcare Programs 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 Montana Healthcare Programs enrollment begins. If a provider is terminated from the Montana Healthcare Programs program, claims submitted with a date of service after the termination date will be denied. After updating his/her license, the claims that have been denied must be resubmitted by the provider. |
| Procedure is not allowed for provider type | Provider is not allowed to perform the service. Verify the procedure code is correct using current HCPCS and CPT coding books. Check the appropriate Montana Healthcare Programs fee schedule to verify the procedure code is valid for your provider type. |
Other Programs
The information in this chapter also applies to those services covered under the Mental Health Services Plan (MHSP).
End of Billing Procedures Chapter
Remittance Advices and Adjustments
The Remittance Advice
The remittance advice is the best tool providers have to determine the status of a claim. Remittance advices accompany payment for services rendered. The remittance advice provides details of all transactions that have occurred during the previous remittance advice cycle. Each line represents all or part of a claim and explains whether the claim or service has been paid, denied, or suspended/pending. If the claim was suspended or denied, the remittance advice also shows the reason.
Remittance advices are available electronically through the Montana Access to Health (MATH) web portal. To access the web portal and receive electronic remittance advices, providers must first complete an EDI Provider Enrollment Form and an EDI Trading Partner Agreement, and then register for the web portal.
Each provider must complete an EDI Trading Partner Agreement, but if there are several providers in one location who are under one tax ID number, they can use one submitter number. These providers should enter the submitter ID in both the provider number and submitter ID fields. Otherwise, enter the provider number in the provider number field.
After the forms have been processed, the provider receives a user ID and password to use to log into the MATH web portal. The verification process also requires a provider ID, a submitter ID, and a tax ID number.
Remittance advices are available in PDF format. Providers can read, print, or download PDF files using PDF reader software available online. Due to space limitations, each remittance advice is only available for 90 days. The remittance is divided into the following sections:
Remittance Advice Notice
This section is on the first page of the remittance advice. It contains important messages about rate changes, revised billing procedures, and many other items that may affect providers and claims.
Remittance advices are available for only 90 days on the web portal.
Paid Claims
This section shows claims paid during the previous cycle. It is the provider’s responsibility to verify that claims were paid correctly. If Montana Healthcare Programs overpays a claim and the problem is not corrected, it may result in a review and the provider having to return the overpayment plus interest. If a claim was paid at the wrong amount or with incorrect information, the claim must be adjusted. (See the Adjustments section later in this chapter.)
Denied Claims
This section shows claims denied during the previous cycle. If a claim has been denied, refer to the Reason/Remark column. The Reason and Remark Code description explains why the claim was denied and is located at the end of the remittance advice. See the section titled The Most Common Billing Errors and How to Avoid Them in the Billing Procedures chapter.
Pending Claims
All claims that have not reached final disposition will appear in this area of the remittance advice (pended claims are not available on X12 835 transactions). The remittance advice uses suspended and pending interchangeably. They both mean that the claim has not reached final disposition. If a claim is pending, refer to the Reason/Remark Code column. The Reason and Remark Code description located at the end of the remittance advice explains why the claim is suspended. This section is informational only and no action should be taken on claims displayed here. Processing continues until each claim is paid or denied.
Claims shown as pending with reason code 133 require additional review before a decision to pay or deny is made. If a claim is being held while waiting for member eligibility information, it may be suspended for a maximum of 30 days. If Montana Healthcare Programs receives eligibility information within the 30-day period, the claim will continue processing. If no eligibility information is received within 30 days, the claim will be denied. When a claim is denied for lack of eligibility, the provider should verify that the correct Montana Healthcare Programs ID number was billed. If the ID number was incorrect, resubmit the claim with the correct ID number.
Credit Balance Claims
Credit balance claims are shown in this section until the credit has been satisfied.
Gross Adjustments
Any gross adjustments performed during the previous cycle are shown in this section.
Reason and Remark Code Description
This section lists the reason and remark codes that appear throughout the remittance advice with a brief description of each.
Credit Balance Claims
Credit balances occur when claim adjustments reduce original payments causing the provider to owe money to the Department. These claims are considered in process and continue to appear on the remittance advice until the credit has been satisfied. Credit balances can be resolved in two ways:
- By working off the credit balance: Remaining credit balances can be deducted from future claims. These claims will continue to appear on consecutive remittance advices until the credit has been paid.
- By sending a check payable to DPHHS for the amount owed: This method is required for providers who no longer submit claims to Montana Healthcare Programs. Please attach a note stating that the check is to pay off a credit balance and include your provider number. Send the check to the attention of the Third Party Liability unit.
Rebilling and Adjustments
Rebillings and adjustments are important steps in correcting any billing problems providers may experience. Knowing when to use the rebilling process versus the adjustment process is important.
Timeframe for Rebilling or Adjusting a Claim
Providers may resubmit, modify, or adjust any initial claim within the timely filing limits described in the Billing Procedures chapter.
The time periods do not apply to overpayments that the provider must refund to the Department. After the 12-month time period, a provider may not refund overpayments to the Department by completing a claim adjustment. The provider may refund overpayments by issuing a check or requesting a gross adjustment be made.
Rebilling Montana Healthcare Programs
Rebilling is when a provider submits a claim to Montana Healthcare Programs that was previously submitted for payment but was either returned or denied. Claims are often returned to the provider before processing because key information such as Montana Healthcare Programs provider number or authorized signature and date are missing or unreadable. For tips on preventing returned or denied claims, see the Billing Procedures chapter in this manual.
When to Rebill Montana Healthcare Programs
- Claim Denied: Providers may rebill Montana Healthcare Programs when a claim is denied. Check the reason and remark codes, make the appropriate corrections and resubmit the claim. Do not attempt to adjust denied claims.
- Line Denied: When an individual line is denied on a multiple-line claim, correct any errors and rebill Montana Healthcare Programs. For CMS-1500 claims, do not use an adjustment form. In the case of a UB-04, the line should be adjusted rather than rebilled. (See the Adjustments section.)
- Claim Returned: Rebill Montana Healthcare Programs when the claim is returned under separate cover. Occasionally, Montana Healthcare Programs is unable to process the claim and will return it to the provider with a letter stating that additional information is needed to process the claim. Correct the information as directed and resubmit the claim.
How to Rebill
- Check any reason and remark code listed and make corrections on a copy of the claim or produce a new claim with the correct information
- When making corrections on a copy of the claim, remember to line out or omit all lines that have already been paid
- Submit insurance information with the corrected claim
Adjustments
If a provider believes that a claim has been paid incorrectly, the provider may call Provider Relations. Once an incorrect payment has been verified, the provider should submit an Individual Adjustment Request form to Provider Relations. If incorrect payment was the result of a Conduent keying error, contact Provider Relations.
When adjustments are made to previously paid claims, the Department recovers the original payment and issues appropriate repayment. The result of the adjustment appears on the provider’s remittance advice as two transactions. The original payment will appear as a credit transaction. The replacement claim reflecting the corrections will be listed as a separate transaction and may or may not appear on the same remittance as the credit transaction. The replacement transaction will have nearly the same ICN number as the credit transaction, except the 12th digit will be a 2, indicating an adjustment. Adjustments are processed in the same time frame as claims.
When to Request an Adjustment
- Request an adjustment when the claim was overpaid or underpaid
- Request an adjustment when the claim was paid but the information on the claim was incorrect (e.g., member ID, provider number, date of service, procedure code, diagnoses, units)
- Request an adjustment when an individual line is denied on a multiple-line UB-04 claim. The denied service must be submitted as an adjustment rather than a rebill
How to Request an Adjustment
To request an adjustment, use the Individual Adjustment Request form available on the Forms page of the website. Requirements for adjusting a claim are:
- Adjustments can only be submitted on paid claims; denied claims cannot be adjusted
- Claims Processing must receive individual claim adjustments within 12 months from the date of service. (See the Timely Filing section in the Billing Procedures chapter in this manual.) After this time, gross adjustments are required
- Use a separate adjustment request form for each ICN
- If correcting more than one error per ICN, use only one adjustment request form, and include each error on the form
- If more than one line of the claim needs to be adjusted, indicate which lines and items need to be adjusted in the Remarks section
Completing an Adjustment Request Form
- Download the Individual Adjustment Request form from the Provider Information website. Complete Section A with provider and member information and the claim’s ICN (see following table).
- Complete Section B with information about the claim. Remember to fill in only the items that need to be corrected (see following table):
- Enter the date of service or the line number in the Date of Service or Line Number column.
- Enter the information from the claim form that was incorrect in the Information on Statement column.
- Enter the correct information in the Corrected Information column.
- Attach copies of the remittance advice and a corrected claim if necessary.
- If the original claim was billed electronically, a copy of the remittance advice will suffice.
- If the remittance advice is electronic, attach a screen print of it.
- Verify the adjustment request has been signed and dated.
- Send the adjustment request to Claims Processing.
- If an original payment was an underpayment by Montana Healthcare Programs, the adjustment will result in the provider receiving the additional payment amount allowed.
- If an original payment was an overpayment by Montana Healthcare Programs, the adjustment will result in recovery of the overpaid amount from the provider. This can be done in two ways, by the provider issuing a check to the Department, or by maintaining a credit balance until it has been satisfied with future claims. (See Credit Balance earlier in this chapter.)
- Direct questions regarding claims or adjustments to Provider Relations.
| Section | Field | Description |
|---|---|---|
| A | 1 | Provider’s name, address, and phone. |
| A | 2 | The member’s name. |
| A | 3 | ICN. There can be only one ICN per Adjustment Request Form. When adjusting a claim that has been previously adjusted, use the ICN of the most-recent claim. |
| A | 4 | The provider’s NPI/API. |
| A | 5 | Member’s Montana Healthcare Programs ID number. |
| A | 6 | Date claim was paid. |
| A | 7 | The amount of payment from the remittance advice. |
| B | 1 | If a payment error was caused by an incorrect number of units, complete this line. |
| B | 2 | If the procedure code, NDC, or revenue code are incorrect, complete this line. |
| B | 3 | If the date of service is incorrect, complete this line. |
| B | 4 | If the billed amount is incorrect, complete this line. |
| B | 5 | If the member’s personal resource amount is incorrect, complete this line. |
| B | 6 | If the member’s insurance credit amount is incorrect, complete this line. |
| B | 7 | If the payment error was caused by a missing or incorrect insurance credit, complete this line. Net is billed amount minus the amount TPL or Medicare paid. |
| B | 8 | If none of the above items apply, or if unsure what caused the payment error, complete this line. |
Mass Adjustments
Mass adjustments are done when it is necessary to reprocess multiple claims. They generally occur when:
- Montana Healthcare Programs has a change of policy or fees that is retroactive. In this case federal laws require claims affected by the changes to be mass adjusted.
- A system error that affected claims processing is identified.
Providers are informed of mass adjustments on the first page of the remittance advice, the monthly Claim Jumper, or provider notices. Mass adjustment claims shown on the remittance advice have an ICN that begins with a 4.
Payment and the Remittance Advice
Montana Healthcare Programs payment and remittance advices are available weekly. Payment is via electronic funds transfer (EFT). Direct deposit is another name for EFT. The electronic remittance advices (ERAs) are available on the web portal for 90 days.
With EFT, the Department deposits the funds directly to the provider’s financial institution account. Holidays may delay payments until the next business day.
Other Programs
The information in this chapter also applies to the Mental Health Services Plan (MHSP), and Healthy Montana Kids (HMK) dental and eyeglasses benefits.
End of Remittance Advice and Adjustments Chapter
Appendix A: Forms
The forms listed below and others are available on the Forms page of the Montana Healthcare Programs Provider Information website. See the left menu on https://medicaidprovider.mt.gov.
- Presumptive Eligibility Notice of Decision
- Montana Healthcare Programs Incurment Notice
- Montana Healthcare Programs Form Order
- Individual Adjustment Request Form
- Paperwork Attachment Cover Sheet
- Provider Address Correction Form
- Blanket Denial
End of Appendix A: Forms Chapter
Appendix B: Place of Service Codes
End of Appendix B: Place of Service Codes Chapter
Appendix C: County Offices of Public Assistance
See the DPHHS webpage https://dphhs.mt.gov/hcsd/OfficeofPublicAssistance.
End of Appendix C: County Offices of Public Assistance Chapter
Definitions and Acronyms
End of Definitions and Acronyms Chapter
Search Options
This edition has three search options.
- Search the whole manual. Open the Complete Manual pane. From your keyboard press the Ctrl and F keys at the same time. A search box will appear. Type in a descriptive or key word (for example "Denials"). The search box will show all locations where denials are discussed in the manual.
- Search by Chapter. Open any Chapter tab (for example the "Billing Procedures" tab). From your keyboard press the Ctrl and F keys at the same time. A search box will appear. Type in a descriptive or key word (for example "Denials"). The search box will show where denials are discussed in just that chapter.
- Site Search. Search the manual as well as other documents related to a particular search term on the Montana Healthcare Programs Site Specific Search page.
End of Search Options Chapter
End of General Information for Providers Manual
Complete Indian Health Service Provider Manual
Printing the manual material found at this website for long-term use is not advisable. Department Policy material is updated periodically, and it is the responsibility of the users make sure that the policy they are researching or applying has the correct effective date for their circumstances.
If you experience any difficulty opening a section or link from this page, please email the webmaster.
How to search this manual:
This edition has three search options.
1. Search the whole manual. Open the Complete Manual pane. From your keyboard press the Ctrl and F keys at the same time. A search box will appear. Type in a descriptive or key word (for example "Denials"). The search box will show all locations where denials are discussed in the manual.
2. Search by Chapter. Open any Chapter tab (for example the "Billing Procedures" tab). From your keyboard press the Ctrl and F keys at the same time. A search box will appear. Type in a descriptive or key word (for example "Denials"). The search box will show where denials are discussed in just that chapter.
3. Site Search. Search the manual as well as other documents related to a particular search term on the Montana Healthcare Programs Site Specific Search page.
Prior manuals may be located through the provider website archives.
Update Log
Publication History
This publication supersedes all previous Medicaid Indian Health Service/Tribal 638 handbooks. Published by the Montana Department of Public Health & Human Services, April 2006.
Updated April 2013, July 2013, February 2014, June 2014, July 2015, August 2016, August 2017, January 2020, and July 2023.
CPT codes, descriptions and other data only are copyright 1999 American Medical Association (or such other date of publication of CPT). All Rights Reserved. Applicable FARS/DFARS Apply.
Update Log
07/26/2023
- Full review and changes to entire manual.
- Tribal 638 now has a separate manual and provider type page.
07/28/2022
- Updated Passport to Health Chapter to remove Nurse First Advice references.
- Updated Index to Search Options.
01/01/2020
- Cost Share references removed from the Billing Procedures Chapter.
- Term "Medicaid" replaced with "Montana Healthcare Programs" throughout the manual.
- Terms "client" and "patient" replaced with "member".
08/15/2017
Indian Health Service/Tribal 638 Manual converted to an HTML format and adapted to 508 Accessibility Standards.
08/08/2016
Indian Health Service, August 2016:
In Summary, the Cost Share section of the Billing Procedure Chapter was removed and replaced with a referral to the Cost Share section of the General Manual. The Cover Page was changed to reflect the current manual edition date.
07/01/2015
Indian Health Service, July 2015: Entire Manual
08/01/2014
Indian Health Service, June 2014: Billing Procedures
04/04/2014
Indian Health Service, February 2014: Multiple Chapters
08/29/2013
Indian Health Service, July 2013: Key Contacts and Billing Procedures
05/15/2013
Indian Health Service, April 2013: Entire Manual
This set of replacement pages includes the entire IHS manual. Content changes are indicated by the addition of a change bar (black line). Text in tables and paragraphs in which text was deleted are not indicated with change bars. For a complete manual without the change bars, see the Provider Manuals section at the top of this page.
End of Update Log Chapter
Table of Contents
Key Contacts
Introduction
Covered Services
Passport to Health Program
Prior Authorization
Coordination of Benefits
Billing Procedures
Remittance Advices and Adjustments
How Payment Is Calculated
Appendix A: Forms
Appendix B: Definitions and Acronyms
Appendix C: Search Options
End of Table of Contents Chapter
Key Contacts
DPHHS IHS Program
(406) 444-4455
(406) 444-1861 Fax
IHS/Tribal 638/Urban Program Officer
Health Resources Division
DPHHS
P.O. Box 202951
Helena, MT 59620-2951
Indian Health Service Area Office
(406) 247-7100 Main
Billings Area IHS Office
2900 4th Avenue North
Billings, MT 59101
Indian Health Service Units
| Unit | Address | Main Number | Fax |
| Blackfeet Service Unit | Blackfeet Community Hospital P.O. Box 760 Browning, MT 59417 |
(406) 338-6100 | (406) 338-2959 |
| Blackfeet Service Unit | Heart Butte Health Station P.O. Box 80 Heart Butte, MT 59448 |
(406) 338-2151 | (406) 338-5613 |
| Crow Service Unit | Crow/Northern Cheyenne Hospital P.O. Box 9 Crow Agency, MT 59022 |
(406) 638-3500 | (406) 638-3569 |
| Crow Service Unit | Lodge Grass Health Clinic P.O. Box AD Lodge Grass, MT 59050 |
(406) 639-2317 | (406) 639-2976 |
| Crow Service Unit | Pryor Health Station P.O. Box 9 Pryor, MT 59066 |
(406) 259-8238 | (406) 259-8290 |
| Fort Belknap Service Unit | Fort Belknap Hospital 669 Agency Main Street Harlem, MT 59526 |
(406) 353-3100 | (406) 353-3227 |
| Fort Belknap Service Unit | Eagle Child Health Station P.O. Box 610 Hays, MT 59527 |
(406) 673-3777 | (406) 673-3835 |
| Fort Peck Service Unit | Chief Redstone Clinic 550 6th Avenue North P.O. Box 729 Wolf Point, MT 59201 |
(406) 653-1641 | N/A |
| Fort Peck Service Unit | Verne E. Gibbs Clinic 107 H. Street P.O. Box 67 Poplar, MT 59255 |
(406) 768-3491 | N/A |
| Little Shell Chippewa Service Unit | Little Shell Health Clinic 425 Smelter Ave NE Great Falls, MT 59404 |
(406) 546-0665 | N/A |
| Northern Cheyenne Service Unit | Lame Deer Health Center P.O. Box 70 Lame Deer, MT 59043 |
(406) 477-4400 | (406) 477-4427 |
End of Key Contacts Chapter
Introduction
Thank you for your willingness to serve members of the Montana Healthcare Programs administered by the Department of Public Health and Human Services.
Manual Organization
This manual provides information specifically for Indian Health Service (IHS) providers who provide services to members who are eligible for both Montana Healthcare Programs and Indian Health Service. Other essential information for providers is contained in the separate General Information for Providers Manual, available on the IHS page of the Provider Information website. Providers are asked to review both manuals.
A table of contents outlines the chapters in this manual. There is a list of contacts at the beginning of this manual and additional contacts and websites on the Contact Us page of the Provider Information website.
Manual Maintenance
Notification of manual updates are provided through the weekly web postings under “Recent Website Posts” at the bottom of the Home page of the Provider website. Older versions of the manual may be found through the Archive page on the Provider website. Printing the manual material found at this website for long-term use is not advisable. Department Policy material is updated periodically, and it is the responsibility of the users to check that the policy they are researching or applying has the correct effective date for their circumstances.
Rule References
Providers, office managers, billers, and other medical staff should familiarize themselves with all current administrative rules and regulations governing the Montana Healthcare Programs. Provider manuals are to assist providers in billing Montana Healthcare Programs; they do not contain all Montana Healthcare Programs rules and regulations. Rule citations in the text are a reference tool; they are not a summary of the entire rule. In the event that a manual conflicts with a rule, the rule prevails. Links to rules are available on the Provider Information website. Paper copies of rules are available through the Secretary of State’s office. Choose the Contact Us option under the ARM menu item across the top of the webpage.
Providers are responsible for knowing and following current Montana Healthcare Programs laws and regulations.
In addition to the general Montana Healthcare Programs rules outlined in the General Information for Providers Manual, the following rules and regulations are also applicable to the Indian Health Service program:
- Code of Federal Regulations (CFR)
- 42 CFR Part 136 and 136A
- Montana Codes Annotated (MCA)
- MCA 53-6-101
- Administrative Rules of Montana (ARM)
- ARM 37.82.101
Claims Review (MCA 53-6-111, ARM 37.85.406)
The Department is committed to paying providers’ claims as quickly as possible. Claims are electronically processed and usually are not reviewed by medical experts prior to payment to determine if the services provided were appropriately billed. Although the computerized system can detect and deny some erroneous claims, there are many erroneous claims it cannot detect. For this reason, payment of a claim does not mean the service was correctly billed or the payment made to the provider was correct. Periodic retrospective reviews are performed that may lead to the discovery of incorrect billing or incorrect payment. If a claim is paid and the Department later discovers the service was incorrectly billed or paid or the claim was erroneous in some other way, the Department is required by federal regulation to recover any overpayment, regardless of whether the incorrect payment was the result of Department or provider error or other cause.
Getting Questions Answered
The provider manuals are designed to answer most questions; however, questions may arise that require a call to a specific group (such as a program officer, Provider Relations, or a prior authorization unit). See the Contact Us page on the Provider Information website. Montana Healthcare Programs manuals, provider notices, replacement pages, fee schedules, forms, and more are available on the Provider Information website.
End of Introduction Chapter
Covered Services
General Coverage Principles
This chapter provides covered services information that applies specifically to Indian Health Service (IHS) providers who provide services to members who are eligible for both Montana Healthcare Programs and IHS. Services provided to members must also meet the general requirements listed in the Provider Requirements chapter of the General Information for Providers Manual.
Members of federally recognized Indian tribes and their descendants are eligible for services provided by IHS, an agency of the U.S. Public Health Service, Department of Health and Human Services.
Provider Requirements (ARM 37.85.402)
The facilities and providers must be enrolled in Montana Healthcare Programs. Current enrollment requirements can be found on the Montana Healthcare Programs Provider Enrollment page on the Provider website.
IHS providers are not required to have a Montana license, but the Department must be satisfied that the physicians can demonstrate they are authorized to practice medicine. A copy of the physicians' current license from another state would satisfy this requirement.
Additional information for Physician requirements is available in the Physician-Related Services Manual available on the Provider Information website.
Registered nurses and licensed practical nurses providing services at an IHS are not eligible to enroll with Montana Healthcare Programs.
Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) Services Program (ARM 37.86.2201–2235)
The EPSDT Well-Child program covers all medically-necessary services for children aged 20 and under. Providers are encouraged to use a series of screening and diagnostic procedures designed to detect diseases, disabilities, and abnormalities in the early stages. Some services are covered for children that are not covered for adults, such as the following:
- Nutritionist services
- Private duty nursing
- Respiratory therapy
- Therapeutic family and group home care
- School-based services
All prior authorization and Passport approval requirements must be followed. For more information about the recommended well-child screen and other components of EPSDT, see the EPSDT Well-Child chapter in the General Information for Providers Manual.
Coverage of Specific Services
Montana Healthcare Programs covers the same services for members who are enrolled in Montana Healthcare Programs and IHS as those members who are enrolled in Montana Healthcare Programs only. All requirements for Montana Healthcare Programs services (such as prior authorization, Passport and others) also apply to Montana Healthcare Programs enrolled members who qualify for IHS services.
Noncovered Services (ARM 37.85.207 and ARM 37.86.3002)
Some services are not covered by Montana Healthcare Programs. Some of these services may be covered under the EPSDT program for children aged 20 and under based on medical necessity for individuals covered under the Qualified Medicare Beneficiary program. Refer to Member Eligibility in the General Information for Providers Manual.
Importance of Fee Schedules
The easiest way to verify coverage for a specific service is to check the Department’s fee schedule for your provider type (the majority of the services provided are listed under the IHS fee schedule). In addition to being listed on the fee schedule, all services provided must also meet the coverage criteria listed in the Provider Requirements chapter of the General Information for Providers Manual on the Provider Information website and in this chapter.
Use the fee schedule in conjunction with the more detailed coding descriptions listed in the current CPT and HCPCS coding books. Take care to use the fee schedule and coding books that pertain to the date of service. Fee schedules are also available on the Provider Information website.
End of Covered Services Chapter
Passport to Health Program
What Is Passport to Health? (ARM 37.86.5101–5120)
Passport to Health is the managed care program for Montana Medicaid members. The Passport programs encourage and support Montana Medicaid members and providers in establishing a medical home and in ensuring the appropriate use of Montana Medicaid services:
• Passport
• Team Care
• Tribal-Health Improvement Program
Passport and Indian Health Service
Members who are eligible for both IHS and Montana Medicaid may choose an IHS provider or another provider as their Passport provider. Members who are eligible for IHS do not need a referral from their Passport provider to obtain services from IHS. If IHS refers the member to a non-IHS provider or specialist, a Passport or Team Care referral is not needed.
Refer to the Passport to Health Provider Manual for additional information.
End of Passport to Health Program Chapter
Prior Authorization
Prior authorization (PA) refers to a list of services that require approval prior to the service being rendered. If a service requires PA, the requirement exists for all Medicaid members. When PA is granted, the provider is issued a PA number, which must be included on the claim.
When seeking a PA request, keep in mind:
- Always refer to the current Medicaid fee schedule to verify if the PA is required for specific services.
- The Prior Authorization Criteria for Specific Services table on the Provider Information website lists services that require PA, who to contact, and specific documentation requirements. For details on services, call the PA contact listed. PA criteria for most services are available on the Provider Information website.
- PA criteria for most services are available on the Provider Information website.
- If a service required requires PA, the requirements exist for all Montana Healthcare Program members. PA is usually obtained through the Department or a PA contractor.
- For PA criteria for prescription drugs, see the Prescription Drug Program Manual on the Provider Information Website.
Services will not be reimbursed when PA requirements are not met. See the Prior Authorization Information link in the left menu on the Provider Information website.
End of Prior Authorization Chapter
Coordination of Benefits (COB)
For COB information, refer to the Third Party Liability section in the Member Eligibility and Responsibilities chapter of the General Information for Providers Manual, available on the Provider Information website.
End of Coordination of Benefits Chapter
Billing Procedures
Claim Forms
Services provided by the healthcare professionals covered in this manual must be billed either electronically or on a UB-04 claim form. UB-04 forms are available from various publishing companies; they are not available from the Department or Provider Relations.
Member Copayment (ARM 37.85.204 and 37.85.402)
Effective for all claims paid on or after January 1, 2020 copayment will not be assessed.
IHS Revenue Codes
IHS providers may bill with the revenue codes shown in the current fee schedule.
Billing for Specific Services
Prior authorization (PA) is required for some services. Passport and prior authorization are different, and some services may require both. Different numbers are issued for each type of approval and must be included on the claim form. (See the Submitting a Claim section in the General Information for Providers Manual.)
Some services provided by an IHS are billed with the IHS provider number and codes specific to IHS. Other services require the IHS to enroll as a provider for the type of services provided (e.g., ambulance services, personal care services, home health) and are billed using the provider number assigned to that provider type. All providers must be enrolled with Montana Healthcare Programs before billing for services.
Every claim for services must indicate the provider of service. Claims for services rendered in IHS facilities are submitted using the IHS facility’s provider number. However, when services are rendered in a non-IHS facility, the claim should be submitted using the individual’s provider number.
Medicaid Specific Services
Provider manuals are available on the Provider Information website.
| Service | Billing Method | Provider Enrollment Type |
| Ambulance | Refer to the instructions in the Ambulance Services Manual. | Ambulance Provider |
| Audiology | Refer to the current IHS fee schedule. | IHS Provider |
| Chiropractor (children aged 20 and under) | Refer to the instructions in the Children’s Chiropractic Services Manual. | Chiropractic Provider |
| CT Scan | Refer to the current IHS fee schedule. | IHS Provider |
| Dental | Refer to the current IHS fee schedule. | IHS Provider |
| Dialysis Clinic | Refer to the instructions in the Dialysis Clinic Services Manual. | Dialysis Clinic Provider |
| Durable Medical Equipment, Prosthetics, Orthotics, and Medical Supplies (DMEPOS) | Refer to the current IHS fee schedule. | IHS Provider |
| EPSDT (children aged 20 and under) | Refer to the current IHS fee schedule. | IHS Provider |
| Eyeglasses Dispensing | Refer to the current IHS fee schedule. | IHS Provider |
| Home and Community Services (HCBS) | Refer to the instructions in the Home- and Community- Based Services Manual. | HCBS Provider |
| Home Infusion Therapy | Refer to the instructions in the Home Infusion Therapy Services Manual. | Home Infusion Therapy Provider |
| Inpatient Hospital | Refer to the current IHS fee schedule. | IHS Provider |
| Laboratory | Refer to the current IHS fee schedule. | IHS Provider |
| Licensed Professional Counselor | Refer to the current IHS fee schedule. | IHS Provider |
| Medical/Surgical Supplies | Refer to the current IHS fee schedule. | IHS Provider |
| Nursing Facility | Refer to the instructions in the Nursing Facility and Swing Bed Service Manual | Nursing Facility or Swing Bed Provider |
| Occupational Therapy | Refer to the current IHS fee schedule. | IHS Provider |
| Optical Exam | Refer to the current IHS fee schedule. | IHS Provider |
| Outpatient Clinic | Refer to the current IHS fee schedule. | IHS Provider |
| Outpatient Surgery | Refer to the current IHS fee schedule. | IHS Provider |
| Personal Assistance | Refer to the instructions in the Personal Assistance Manual. | Personal Assistance Provider |
| Pharmacy | Refer to the instructions in the Pharmacy Provider Manual. | Pharmacy Provider |
| Physical Therapy | Refer to the current IHS fee schedule | IHS Provider |
| Podiatry | Refer to the current IHS fee schedule. | IHS Provider |
| Radiology | Refer to the current IHS fee schedule. | IHS Provider |
| Radiology, Diagnostic | Refer to the current IHS fee schedule. | IHS Provider |
| Speech Therapy | Refer to the current IHS fee schedule. | IHS Provider |
| Telemedicine | Refer to the current IHS fee schedule. | IHS Provider |
| Transportation | Refer to the instructions in the Commercial and Specialized Non-Emergency Transportation Services manual. | Transportation Provider |
End of Billing Procedures Chapter
Remittance Advices and Adjustments
End of Remittance Advices and Adjustments Chapter
How Payment Is Calculated
IHS Rates Established by the Code of Federal Regulations (CFR)
Although providers do not need the information in this chapter to submit claims, the information allows providers to understand how payment is calculated and to predict approximate payment for particular claims.
Payments to IHS enrolled facilities are made in accordance with the Medicaid State Plan, which states that services provided by IHS facilities are paid with federal funds according to rates prescribed by the Centers for Medicare and Medicaid Services (CMS) and established by the U.S. Public Health Services for IHS as set forth in the Federal Register. IHS facilities are paid in accordance with the current Federal Register Notice. Subsequent payment adjustments will be made pursuant to changes published in the Federal Register.
End of How Payment is Calculated Chapter
Appendix A: Forms
- Individual Adjustment Request
- Paperwork Attachment Cover Sheet
End of Appendix A: Forms Chapter
Appendix B: Definitions and Acronyms
End of Definitions and Acronyms Chapter
Search Options
This manual has 3 search options.
- Search the whole manual. Open the Complete Manual pane. From your keyboard press the Ctrl and F keys at the same time. A search box will appear. Type in a descriptive or key word (for example "Denials"). The search box will show all locations where denials are discussed in the manual.
- Search by chapter. Open any Chapter tab (for example the "Billing Procedures" tab). From your keyboard press the Ctrl and F keys at the same time. A search box will appear. Type in a descriptive or key word (for example "Denials"). The search box will show where denials are discussed in just that chapter.
- Site search. Search the manual as well as other documents related to a particular search term on the Medicaid Site Specific Search page.
End of Search Options Chapter
End of Indian Health Services Manual
Complete Tribal 638 Provider Manual
To print this manual, right click your mouse and choose "print". Printing the manual material found at this website for long-term use is not advisable. Department Policy material is updated periodically and it is the responsibility of the users to check that the policy they are researching or applying has the correct effective date for their circumstances.
Update Log
Publication History
This publication supersedes all previous Montana Healthcare Programs IHS/Tribal 638 Provider Manuals posted on the IHS webpage. Published by the Montana Department of Public Health & Human Services, July 2023.
Update Log
07/26/2023
• New provider manual developed.
End of Update Log Chapter
Table of Contents
Key Contacts
Introduction
Covered Services
• Early Periodic Screening, Diagnostic, and Treatment (EPSDT) Services Program (ARM 37.86.2201-2235)
Non-Covered Services (ARM 37.85.207 and 37.86.3002)
Importance of Fee Schedules
Passport to Health Program
Prior Authorization
Coordination of Benefits
Billing Procedures
Remittance Advices and Adjustments
How Payment is Calculated
Tribal 638 Rates
Appendix A: Forms
Appendix B: Definitions and Acronyms
Appendix C: Search Options
End of Table of Contents Chapter
Key Contacts
DPHHS Tribal 638 Program
(406) 444-4455
(406) 444-1861 Fax
IHS/Tribal 638/Urban Program Officer
Health Resources Division
DPHHS
P.O. Box 202951
Helena, MT 59620-2951
Montana Tribal Health Departments
| Tribal Health Department | Address | Main Telephone Number | Fax Number |
| Blackfeet Nation | Blackfeet Nation Health Services PO Box 850 Browning, MT 59417 |
(406) 338-7521 | (406) 338-6311 |
| Chippewa Cree Tribe | Rocky Boy Health Center 6850 Upper Box Elder Road Box Elder, MT 59521 |
(406) 395-4486 | (406) 395-4408 |
| Confederated Salish and Kootenai Tribes | Confederated Salish and Kootenai Tribal Health Department PO Box 880 St. Ignatius, MT 59865 |
(406) 745-3525 |
(406) 745-4231 |
| Crow Tribe | Crow Tribal Health Department PO BOX 159 Crow Agency, MT 59022 |
(406) 998-4782 | (406) 353-2884 |
| Fort Belknap Tribes | Fort Belknap Tribal Health Department 656 Agency Main Street Harlem, MT 59526 |
(406) 353-8323 | (406) 768-5780 |
| Fort Peck Tribes | Fort Peck Tribal Health Department PO Box 1027 Poplar, MT 59255 |
(406) 768-5790 | (406) 315-2401 |
| Little Shell Chippewa | Little Shell Tribal Health Department 615 Central Ave West Great Falls, MT 59404 |
(406) 315-2400 | (406) 315-2401 |
| Northern Cheyenne Tribe | Northern Cheyenne Board of Health PO Box 67 Lame Deer, MT 59043 |
(406) 477-6722 | (406) 477-6829 |
End of Key Contacts Chapter
Introduction
Thank you for your willingness to serve members of the Montana Healthcare Programs administered by the Department of Public Health and Human Services.
Manual Organization
This manual provides information specifically for Tribal 638 providers who provide services to members who are eligible for both Montana Healthcare Programs and Tribal 638 Health Services. Other essential information for providers is contained in the separate General Information for Providers Manual, available on the Provider Information website. Providers are asked to review both manuals.
A table of contents outlines the chapters in this manual. There is a list of contacts at the beginning of this manual and additional contacts and websites on the Contact Us page of the Provider Information website.
Manual Maintenance
Notification of manual updates are provided through the weekly web postings under “Recent Website Posts” at the bottom of the Home page of the Provider website. Older versions of the manual may be found through the Archive page on the Provider website. Printing the manual material found at this website for long-term use is not advisable. Department Policy material is updated periodically and it is the responsibility of the users to check that the policy they are researching or applying has the correct effective date for their circumstances.
Rule References
Providers, office managers, billers, and other medical staff should familiarize themselves with all current administrative rules and regulations governing the Montana Healthcare Programs. Provider manuals are to assist providers in billing Montana Healthcare Programs; they do not contain all Montana Healthcare Programs rules and regulations. Rule citations in the text are a reference tool; they are not a summary of the entire rule. In the event that a manual conflicts with a rule, the rule prevails. Links to rules are available on the Provider Information website. Paper copies of rules are available through the Secretary of State’s office. Choose the Contact Us option under the ARM menu across the top of the webpage.
Providers are responsible for knowing and following current Montana Healthcare Programs laws and regulations.
In addition to the general Montana Healthcare Programs rules outlined in the General Information for Providers Manual, the following rules and regulations are also applicable to the Tribal 638 program:
- Code of Federal Regulations (CFR)
- 42 CFR Part 136 and 136A
- Montana Code Annotated (MCA)
- MCA 53-6-101
- Administrative Rules of Montana (ARM)
- ARM 37.82.101
Claims Review (MCA 53-6-111, ARM 37.85.406)
The Department is committed to paying providers’ claims as quickly as possible. Claims are electronically processed and usually are not reviewed by medical experts prior to payment to determine if the services provided were appropriately billed. Although the computerized system can detect and deny some erroneous claims, there are many erroneous claims it cannot detect. For this reason, payment of a claim does not mean the service was correctly billed or the payment made to the provider was correct. Periodic retrospective reviews are performed that may lead to the discovery of incorrect billing or incorrect payment. If a claim is paid and the Department later discovers the service was incorrectly billed or paid or the claim was erroneous in some other way, the Department is required by federal regulation to recover any overpayment, regardless of whether the incorrect payment was the result of Department or provider error or other cause.
Getting Questions Answered
The provider manuals are designed to answer most questions; however, questions may arise that require a call to a specific group (such as a program officer, Provider Relations, or a prior authorization unit). See the Contact Us page on the Provider Information website. M anuals, provider notices, replacement pages, fee schedules, forms, and more are available on the Provider Information website.
End of Introduction Chapter
Covered Services
General Coverage Principles
This chapter provides covered services information that applies specifically to Tribal 638 providers who provide services to members who are eligible for both Montana Healthcare Programs and Tribal 638. Services must also meet the general requirements listed in the Provider Requirements chapter of the General Information for Providers Manual.
Provider Requirements (ARM 37.85.402)
The facilities and providers must be enrolled in Montana Healthcare Programs. Current enrollment requirements can be found on the Montana Healthcare Programs Provider Enrollment page on the Montana Healthcare Programs Provider Enrollment page on the Provider website.
Tribal 638 providers are not required to have a Montana license, but the Department must be satisfied that the physicians can demonstrate they are authorized to practice medicine. A copy of the physician’s current license from another state would satisfy this requirement.
Additional information for Physician requirements are available in the Physician-Related Services Manual available on the Provider Information website.
Registered nurses and licensed practical nurses providing services at a Tribal 638 facility are not eligible to enroll with Montana Healthcare Programs.
Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) Services Program (ARM 37.86.2201–2235)
The EPSDT Well-Child program covers all medically-necessary services for children aged 20 and under. Providers are encouraged to use a series of screening and diagnostic procedures designed to detect diseases, disabilities, and abnormalities in the early stages. Some services are covered for children that are not covered for adults, such as the following:
- Nutritionist services
- Private duty nursing
- Respiratory therapy
- Therapeutic family and group home care
- School-based services
All prior authorization and Passport approval requirements must be followed. For more information about the recommended well-child screen and other components of EPSDT, see the EPSDT Well-Child chapter in the General Information for Providers Manual.
Coverage of Specific Services
Montana Healthcare Programs covers the same services for members who are enrolled in Montana Healthcare Programs and Tribal 638 as those members who are enrolled in Montana Healthcare Programs only. All requirements for Montana Healthcare Programs services (such as prior authorization, Passport and others) also apply to Montana Healthcare Programs enrolled members who qualify for Tribal 638 services.
Noncovered Services (ARM 37.85.207 and ARM 37.86.3002)
Some services are not covered by Montana Healthcare Programs. Some of these services may be covered under the EPSDT program for children aged 20 and under based on medical necessity for individuals covered under the Qualified Medicare Beneficiary program. Refer to Member Eligibility in the General Information for Providers manual.
Importance of Fee Schedules
The easiest way to verify coverage for a specific service is to check the Department’s fee schedule for your provider type (the majority of the services operating under 638 authorities are under the Tribal 638 Fee Schedule). In addition to being listed on the fee schedule, all services provided must also meet the coverage criteria listed in the Provider Requirements chapter of the General Information for Providers Manual and in this chapter.
Use the fee schedule in conjunction with the more detailed coding descriptions listed in the current CPT and HCPCS coding books. Take care to use the fee schedule and coding books that pertain to the date of service. Fee schedules are also available on the Provider Information website.
End of Covered Services Chapter
Passport to Health Program
What Is Passport to Health? (ARM 37.86.5101–5120)
Passport to Health is the managed care program for Montana Medicaid members. The Passport programs encourage and support Montana Medicaid members and providers in establishing a medical home and in ensuring the appropriate use of Montana Medicaid services:
• Passport
• Team Care
• Tribal-Health Improvement Program
Passport and Tribal 638
Members who are eligible for both Tribal 638 Services and Montana Medicaid may choose a Tribal 638 provider or another provider as their Passport provider. Members who are eligible for Tribal 638 Services do not need a referral from their Passport provider to obtain services from Tribal 638 Facilities. If a Tribal 638 provider refers the member to a non-Tribal 638 provider or specialist, a Passport or Team Care referral is not needed.
Refer to Passport to Health Provider Manual for additional information.
End of Passport to Health Program Chapter
Prior Authorization
Prior authorization (PA) refers to a list of services that require approval prior to the service being rendered. If a service requires PA, the requirement exists for all members. When PA is granted, the provider is issued a PA number, which must be included on the claim.
When seeking PA request, keep in mind:
- Always refer to the current Medicaid fee schedule to verify if the PA is required for specific services.
- The Prior Authorization Criteria for Specific Services table on the Provider Information website; lists services that require PA, who to contact, and specific documentation requirements. For details on services, call the PA contact listed.
- PA criteria for most services are available on the Provider Information website.
- If a service requires prior PA, the requirements exist for all members. PA is usually obtained through the Department or a PA contractor.
- For prior authorization criteria for prescription drugs, see the Prescription Drug Program Manual on the Provider Information website.
Services will not be reimbursed when PA requirements are not met. See the Prior Authorization Information link in the left menu on the Provider Information website.
End of Prior Authorization Chapter
Coordination of Benefits (COB)
End of Coordination of Benefits Chapter
Billing Procedures
Claim Forms
Services provided by the healthcare professionals covered in this manual must be billed either electronically or on a UB-04 claim form. UB-04 forms are available from various publishing companies; they are not available from the Department or Provider Relations.
Member Copayment (ARM 37.85.204 and 37.85.402)
Effective for all claims paid on or after January 1, 2020 co-payment will not be assessed.
Tribal 638 Revenue Codes
Tribal 638 providers may bill with the revenue codes shown in the current fee schedule.
Billing for Specific Services
Prior authorization (PA) is required for some services. Passport and PA are different, and some services may require both. Different numbers are issued for each type of approval and must be included on the claim form. (See the Submitting a Claim section in the General Information for Providers Manual.)
Some services provided by a Tribal 638 provider are billed with the Tribal 638 provider number and codes specific to Tribal 638. Other services require the Tribal 638 provider to enroll as a Montana Healthcare Programs provider for the type of services provided (e.g., ambulance services, personal care services, home health) and are billed using the provider number assigned to that provider. All providers must be enrolled with Montana Healthcare Programs before billing for services.
Every claim for services must indicate the provider of service. Claims for services rendered in Tribal 638 facilities are submitted using the Tribal 638 facility’s provider number.
Medicaid Specific Services
Provider manuals are available on the Provider Information website.
| Service | Billing Method | Provider Enrollment Type |
| Ambulance | Refer to the instructions in the Ambulance Services Manual. | Ambulance Provider |
| Audiology | Refer to the current Tribal 638 fee schedule. | Tribal 638 Provider |
| Chiropractor (children aged 20 and under) | Refer to the instructions in the Children’s Chiropractic Services Manual. | Chiropractic Provider |
| CT Scan | Refer to the current Tribal 638 fee schedule. | Tribal 638 Provider |
| Dental | Refer to the current Tribal 638 fee schedule. | Tribal 638 Provider |
| Dialysis Clinic | Refer to the instructions in the Dialysis Clinic Services Manual. | Dialysis Clinic Provider * Tribes who have 638 approval for Dialysis services receive reimbursement at the current all-inclusive rate. |
| Durable Medical Equipment, Prosthetics, Orthotics, and Medical Supplies (DMEPOS) | Refer to the current Tribal 638 fee schedule. | Tribal 638 Provider |
| EPSDT (children aged 20 and under) | Refer to the current Tribal 638 fee schedule. | Tribal 638 Provider |
| Eyeglasses Dispensing | Refer to the current Tribal 638 fee schedule. | Tribal 638 Provider |
| Home and Community Services (HCBS) | Refer to the instructions in the Home- and Community- Based Services Manual. |
HCBS Provider |
| Home Infusion Therapy | Refer to the instructions in the Home Infusion Therapy Services Manual. | Home Infusion Therapy Provider |
| Inpatient Hospital | Refer to the current Tribal 638 fee schedule. | Tribal 638 Provider |
| Laboratory | Refer to the current Tribal 638 fee schedule. | Tribal 638 Provider |
|
Licensed Professional Counselor |
Refer to the current Tribal 638 fee schedule. | Tribal 638 Provider |
| Medical/Surgical Supplies | Refer to the current Tribal 638 fee schedule. | Tribal 638 Provider |
| Nursing Facility | Refer to the instructions in the Nursing Facility and Swing Bed Service Manual | Nursing Facility or Swing Bed Provider |
| Occupational Therapy | Refer to the current Tribal 638 fee schedule. | Tribal 638 Provider |
| Optical Exam | Refer to the current Tribal 638 fee schedule. | Tribal 638 Provider |
| Outpatient Clinic | Refer to the current Tribal 638 fee schedule. | Tribal 638 Provider |
| Outpatient Surgery | Refer to the current Tribal 638 fee schedule. | Tribal 638 Provider |
| Personal Assistance | Refer to the instructions in the Personal Assistance Manual. | Personal Assistance Provider |
| Pharmacy | Refer to the instructions in the Pharmacy Provider Manual. | Pharmacy Provider |
| Physical Therapy | Refer to the current Tribal 638 fee schedule. | Tribal 638 Provider |
| Podiatry | Refer to the current Tribal 638 fee schedule. | Tribal 638 Provider |
| Radiology | Refer to the current Tribal 638 fee schedule. | Tribal 638 Provider |
| Radiology, Diagnostic | Refer to the current Tribal 638 fee schedule. | Tribal 638 Provider |
| Speech Therapy | Refer to the current Tribal 638 fee schedule. | Tribal 638 Provider |
| Telemedicine | Refer to the current Tribal 638 fee schedule. | Tribal 638 Provider |
| Transportation | Refer to the instructions in the Commercial and Specialized Non-Emergency Transportation Services manual | Transportation Provider |
End of Billing Procedures Chapter
Remittance Advices and Adjustments
For information on remittance advices and adjustments, see the General Information for Providers Manual, available on the website. (Link once Provider Type 81 page is active)
End of Remittance Advices and Adjustments Chapter
How Payment Is Calculated
Tribal 638 Rates
Although providers do not need the information in this chapter to submit claims, the information allows providers to understand how payment is calculated and to predict approximate payment for particular claims.
Tribal 638 facilities are operated according to the Medicaid State Plan and reflected in the current fee schedule. Unless otherwise stated, the payment methodology follows IHS facility reimbursement which is paid with federal funds according to rates prescribed by the Centers for Medicare and Medicaid Services (CMS) and established by the U.S. Public Health Services as set forth in the Federal Register. Payment adjustments are made pursuant to changes published in the Federal Register.
End of How Payment is Calculated Chapter
Appendix A: Forms
- Individual Adjustment Request
- Paperwork Attachment Cover Sheet
End of Appendix A: Forms Chapter
Appendix B: Definitions and Acronyms
End of Definitions and Acronyms Chapter
Appendix C: Search Options
This manual has three search options;
1. Search the whole manual.
Open the Complete Manual pane. From your keyboard press the Ctrl and F keys at the same time. A search box will appear. Type in a descriptive or key word (for example "Denials"). The search box will show all locations where denials are discussed in the manual.
2. Search by chapter.
Open any Chapter tab (for example the "Billing Procedures" tab). From your keyboard press the Ctrl and F keys at the same time. A search box will appear. Type in a descriptive or key word (for example "Denials"). The search box will show where denials are discussed in just that chapter.
3. Site search.
Search the manual as well as other documents related to a particular search term on the Medicaid Site Specific Search page.
End of Search Options Chapter
End of Tribal 638 Provider Manual
Durable Medical Equipment, Prosthetics, Orthotics, and Medical Supplies (DMEPOS) Manual
To print this manual, right click your mouse and choose "print". Printing the manual material found at this website for long-term use is not advisable. Department Policy material is updated periodically, and it is the responsibility of the users to check and make sure that the policy they are researching or applying has the correct effective date for their circumstances.
Update Log
Publication History
This publication supersedes all previous Durable Medical Equipment, Orthotics, Prosthetics and Supplies (DMEOPS) handbooks. Published by the Montana Department of Public Health & Human Services, January 2005.
Updated January 2005, April 2005, September 2007, June 2008, July 2012, October 2013, November 2014, April 2015, August 2015, January 2016, July 2016, January 2017, May 2017, October 2017, January 2020, March 2020, December 2020, December 2021, May 2023, and July 2023.
CPT codes, descriptions and other data only are copyright 1999 American Medical Association (or such other date of publication of CPT). All Rights Reserved. Applicable FARS/DFARS Apply.
Update Log
07/14/2023
Updated the following sections of Covered Services Chapter.
- Covered Services, Wheelchairs, Wheelchairs in Nursing Facilities
- Covered Services, Bariatric Equipment in Nursing Facilities
05/02/2023
Updated the following sections of Covered Services Chapter.- Removed section: Therapeutic Continuous Glucose Monitor (CGM) Devices and Sensors – K0554 & K0553
- Removed section: Supplies for Therapeutic CGM Devices, Non-Therapeutic CGM Devices, Codes A9278, A9277, and A9276
- Removed section: Non-Therapeutic CGM Criteria
- Added section: Omnipod Coverage (HCBCS Code A9274)
12/27/2021
Updated the following sections of Covered Services Chapter.- Therapeutic Continuous Glucose Monitors (CGM) Devices and Sensors - K0554 & K0553
- Diapers, Underpads, Liners/Shields
- Sterile and Non-Sterile Gloves
- E0470 and E0471 Respiratory Assist Devices (RAD)
- Home Ventilators E0465, E0466, and E0467
12/09/2020
- Cranial Remolding Orthotics/Helmets, Code S1040 added to the Covered Services chapter.
- DME Prescription Requirements updated.
- Covered Services chapter was divided into two chapters: the Covered Services chapter and the Non-Covered Services chapter.
- Removed obsolete fax numbers from the Prior Authorization chapter and added a link to the Qualitrac portal for DME prior authorization requests.
- Removed obsolete form for DMEPOS Medical review from Appendix A: Forms.
03/25/2020
- Updated the Prior Authorization chapter with current prior authorization contractor information and policy.
- Updated the Covered Services chapter with updated requirements for most devices covered and alphabetized the covered items under both the general list and the EPSDT list.
01/01/2020
- Cost Sharing removed from the How Payment is Calculated chapter.
- Medicaid replaced with "Montana Healthcare Programs" in all chapters.
10/16/2017
Durable Medical Equipment, Prosthetics, Orthotics, and Medical Supplies (DMEPOS) Manual converted to an HTML format and adapted to 508 Accessibility Standards.
07/28/2016
DMEPOS, July 2016: In summary, the Hospital Grade Breast Pump section was updated in the Covered Services chapter, and the Table of Contents and Index was changed to reflect impacted page numbers.
06/20/2016
DMEPOS, July 2016: In summary, date only was amended on the cover, and the How Payment is Calculated section was updated to reflect the current cost share amount.
12/31/2015
DMEPOS, January 2016: HELP plan-related updates and others
09/01/2015
DMEPOS, August 2015: URL Updates and Covered Services
04/24/2015
DMEPOS, April 2015: Covered Services, Billing Procedures, and Appendix A: Forms
11/19/2014
DMEPOS, November 2014: Entire Manual
The entire manual has been streamlined; sections that include text changes are noted with black bar in margin.
11/15/2013
DMEPOS, October 2013: Entire Manual
These replacement pages also include a terminology change (client to member). Unless a paragraph also included content changes, it is not marked as a change but is included in this document.
07/26/2012
DMEPOS, July 2012: Appendix A: Forms
06/14/2010
DMEPOS, June 2010: Covered Services
11/26/2008
DMEPOS, June 2008: Covered Services
03/05/2008
DMEPOS, September 2007: Covered Services and Submitting a Claim
04/07/2005
DMEPOS, April 2005: Removed CPAP CMN
01/21/2005
DMEPOS, January 2005: Apnea Monitor PA Requirements
End of Update Log Chapter
Table of Contents
Prior Authorization
Covered Services
Non-Covered Services
Billing Procedures
How Payment Is Calculated
Appendix A: Forms
End of Table of Contents Chapter
Introduction
Thank you for your willingness to serve members of the Montana Healthcare Programs and other medical assistance programs administered by the Department of Public Health and Human Services.
This manual provides information specifically for providers of Durable Medical Equipment, Prosthetics, Orthotics, and Medical Supplies (DMEPOS). Other essential information for providers is contained in the separate General Information for Providers Manual. Providers are responsible for reviewing both manuals.
Rule References
Providers must be familiar with all current Montana Healthcare Programs rules and regulations governing the Montana Healthcare Programs. Provider manuals are to assist providers in billing Montana Healthcare Programs; they do not contain all Montana Healthcare Programs rules and regulations. Rule citations in the text are a reference tool; they are not a summary of the entire rule. In the event that a manual conflicts with a rule, the rule prevails. Links to rules are available on the Provider Information website. Paper copies of rules are available through the Secretary of State’s office. Choose the Contact Us option under the ARM menu on the Secretary of State website.
Providers are responsible for knowing and following current Montana Healthcare Programs rules and regulations.
The following rules and regulations are specific to the DMEPOS program.
- Administrative Rules of Montana (ARM)
- ARM 37.86.1801 – ARM 37.86.1807 Prosthetic Devices, Durable Medical Equipment and Medical Supplies
End of Introduction Chapter
Prior Authorization
What Is Prior Authorization?
To ensure federal funding requirements are met, certain items/services are reviewed before delivery to a Montana Healthcare Programs member. These items/services are reviewed for appropriateness based on the member’s medical need. In determining medical appropriateness of an item/service, the Department or designated review organization may consider the type or nature of the service, the provider of the service, the setting in which the service is provided and any additional requirements applicable to the specific service or category of service.
Prior authorization will be required if the item/service has a reimbursement amount equal to or greater than $1,000.00 or the Manufacturers Suggested Retail Price (MSRP) is greater than $1,334.00.
When requesting prior authorization, remember:
- Only Montana Healthcare Programs enrolled DMEPOS providers may request prior authorization for items/services.
- In circumstances where another insurance carrier is primary and payment has been made, prior authorization is not required unless reimbursement is equal to or greater than $1,000.00 or the MSRP is equal to or greater than $1,334.00.
- Documentation must support medical necessity.
- Documentation must coincide with other documentation provided by those involved with the member.
- Documentation must be complete, including appropriate signatures and dates.
- Member must be eligible for Montana Healthcare Programs.
- Use the correct CMN for the item/service (if required).
- Use current correct coding.
- Use the appropriate place of service, 12 (Home) or 32 (Nursing Facility). See the Place of Service Code Set on the CMS website: https://www.cms.gov/Medicare/Coding/place-of-service-codes/Place_of_Service_Code_Set.html
Montana Healthcare Programs does not pay for services when prior authorization requirements are not met.
Do not submit a prior authorization request solely for denial in order to receive payment from another source. Instead, provide the requesting payer with documentation supporting noncoverage of the item (e.g., provider manuals, provider notices, newsletters). You may request the documentation from Provider Relations.
To request prior authorization for an item/service:
- Submit prior authorization requests to Mountain-Pacific Quality Health, the Department's utilization review contractor,through the Qualitrac web portal at the following link: https://www.mpqhf.org/corporate/medicaid-portal-home/medicaid-portal-document-library/.
- Include appropriate supporting documentation with the request.
Granting of prior authorization does not guarantee payment for the item/service.
Upon completion of the review, the member and requesting provider are notified. The provider receives an authorization number that must be included on the claim. If the requesting provider does not receive the authorization number within 10 business days of being notified of the review approval, the requesting provider may call Mountain-Pacific Quality Health (MPQH) at (877) 443-4021.
Prior Authorization Information
Durable Medical Equipment (DME) Prior Auth Contact:
MPQH
(406) 457-3060 Helena
(877) 443-4021 Long-distance
Documentation Requirements:
Medical necessity documentation must include all of the following:
- Completed DMEPOS Prior Authorization Request through the Qualitrac Portal.
- Supporting documentation, which must include at a minimum:
- Prescription
- Certificate of medical need (if required for the item)
- Narrative summary from the prescribing authority detailing the need for the item
- A manufacturers retail price sheet and product warranty information
For members being treated by a licensed therapist, a copy of the member’s plan of care in relation to the item/service is required; video if possible.
End of Prior Authorization Chapter
Covered Services
General Coverage Principles
This chapter provides covered services information that applies specifically to services and supplies provided by Durable Medical Equipment, Prosthetic, Orthotic and Medical Supply (DMEPOS) providers. Like all healthcare services received by Montana Healthcare Programs members, services rendered by these providers must also meet the general requirements listed in the Provider Requirements chapter of the General Information for Providers Manual.
Montana Healthcare Programs follows Medicare’s coverage requirements for most items. A Medicare manual is available from the Durable Medical Equipment Regional Carriers (DMERC) website, https://med.noridianmedicare.com/web/jddme. Montana Healthcare Programs considers Medicare Region D DMERC medical review policies as the minimum DMEPOS industry standard. This manual covers criteria for certain items/services which are either in addition to Medicare requirements or are services Medicare does not cover.
Montana Healthcare Programs coverage determinations are a combination of Medicare Region D DMERC policies, Centers for Medicare and Medicaid Services (CMS), national coverage decisions (NCDs), local coverage determinations (LCDs), and Department designated medical review decisions. DMEPOS providers are required to follow specific Montana Healthcare Programs policy or applicable Medicare policy when Montana Healthcare Programs policy does not exist. When Medicare makes a determination of medical necessity, that determination is applicable to the Montana Healthcare Programs.
Provision of Services (ARM 37.86.1802)
Federal regulations require that items/services covered by the Department are reasonable and necessary in amount, duration, and scope to achieve their purpose. DMEPOS items/supplies must be medically necessary, prescribed in writing, and delivered in the most appropriate and cost-effective manner, and may not be excluded by any other state or federal rules or regulations.
Supplier Documentation (ARM 37.86.1802)
All covered DMEPOS items for members with Montana Healthcare Programs as the primary payer, must be prescribed by a physician or other licensed practitioner of the healing arts within the scope of the provider’s practice as defined by state law. A prescription or order must include the member's name or Medicaid identification number; order date; general description of the item or HCPCS code or HCPCS code narrative, or a brand name and model number; quantity to be dispensed, if applicable; treating practitioner's name or national provider identifier; and treating practitioner's signature. Prescriptions for oxygen must also include the liter flow per minute, hours of use per day and the member’s PO2 or oxygen saturation blood test results. If applicable, an order for durable medical equipment must list separately all concurrently ordered options, accessories, or additional features that are separately billed or require an upgrade code. If applicable, an order for medical supplies must include all concurrently ordered supplies that are separately billed, listing each separately.
DMEPOS suppliers must obtain a written prescription in accordance with ARM 37.86.1802. Suppliers should also maintain documentation showing the member meets the Medicare coverage criteria.
ARM 37.86.1802 describes how prescriptions/orders can be transmitted. The rule refers providers to the Medicare guidelines. Prescriptions can be oral, faxed, or hard copy. For items that are dispensed based on a verbal order, the supplier must obtain a written order that meets the requirements in Chapter 3 of the Medicare Supplier Manual. The rule refers to current Medicare rules and regulations in the Region D Medicare Supplier Manual (including the most current LCDs). Chapters 3 and 4 of the Medicare Suppliers Manual outline the documentation requirements for suppliers.
Although a prescription is required, coverage decisions are not based solely on the prescription. Coverage decisions are based on objective, supporting information about the member’s condition in relation to the item/service prescribed. Supporting documentation may include but is not limited to (if applicable) a Certificate of Medical Necessity (CMN), DME Information Form (DIF), and/or a physician’s, therapist’s or specialist’s written opinion/attestation for an item/service based on unique individual need.
The member’s medical record must contain sufficient documentation of the member's medical condition to substantiate the necessity for the prescribed item/service. The member’s medical record is not limited to the physician’s office records. It may include hospital, nursing home, or home health agency records and records from other professionals including, but not limited to, nurses, physical and occupational therapists, prosthetists, and orthotists. It is recommended that suppliers obtain (for their files) sufficient medical records to determine whether the member meets Montana Healthcare Programs coverage and payment rules for the particular item.
Proof of delivery is required in order to verify that the member received the DMEPOS item. Proof of delivery documentation must be made available to the Department upon request. Montana Healthcare Programs does not pay for delivery, mailing or shipping fees or other costs of transporting the item to the member’s residence.
The effective date of an order/script is the date in which it was signed.
Providers must retain the original prescription, supporting medical need documentation and proof of delivery. For additional documentation requirements, see the General Information for Providers Manual, Provider Requirements chapter, and Chapters 3 and 4 of the Medicare Supplier Manual.
Certificate of Medical Necessity
For a number of DMEPOS items, a certificate of medical necessity (CMN) is required to provide supporting documentation for the member’s medical indications. Montana Healthcare Programs adopts the CMNs used by Medicare DMERCs, approved by the Office of Management and Budget (OMB), and required by CMS.
These forms are available on the websites listed below:
- Provider Information website, https://medicaidprovider.mt.gov/forms
- CMS website, http://www.cms.gov
- Noridian website, https://med.noridianmedicare.com/web/jddme
The following is a list of items that require a CMN and the corresponding form. This reference list will be updated as changes are made. If any discrepancies exist between these referenced forms and what is published by CMS and Medicare, the CMS and Medicare policy shall take precedence. See Chapter 4 of the Medicare Supplier Manual.
Certificate of Medical Necessity (CMN) Forms
Item: Lymphedema Pumps (Pneumatic Compression Devices)
Form: CMS-846 Form Date: 06/2019
Item: Osteogenesis Stimulators
Form: CMS-847 Form Date: 06/2019
Item: Oxygen
Form: CMS-484 Form Date: 12/2018
Item: Seat Lift Mechanisms
Form: CMS-849 Form Date: 06/2019
Item: Section C Continuation Form
Form: CMS-854 Form Date: 06/2019
Item: Transcutaneous Electrical Nerve Stimulators (TENS)
Form: CMS-848 Form Date: 06/2019
DME Information Forms
Item: External Infusion Pumps
Form: CMS-10125 Form Date: 06/2019
Item: Enteral and Parental Nutrition
Form: CMS-10126 Form Date: 06/2019
Rental/Purchase (ARM 37.86.1801–1806)
The rental period for items identified by Medicare as capped, routine, or inexpensive are limited to 13 months of rental reimbursement. After 13 months of continuous rental, the item is considered owned by the member and the provider must transfer ownership to the member. Total Montana Healthcare Programs rental reimbursement for items listed in Medicare’s capped rental program or classified by Medicare as routine and inexpensive rental are limited to the purchase price for that item listed on the Montana Healthcare Programs fee schedule. If purchasing the rental item is cost effective, the Department may cover the purchase of the item. See Chapter 5 of the Medicare Supplier Manual.
A statement of medical necessity for rental of DME equipment must indicate the length of time the equipment is needed, and all prescriptions must be signed and dated.
Servicing
During the 13-month rental period, Montana Healthcare Programs rental payment includes all supplies, maintenance, repair, components, adjustments, and services related to the item during the rental month. Separately billable supply items identified and allowed by Medicare are also separately billable to Montana Healthcare Programs under the same limitations. No additional amounts related to the item may be billed or reimbursed for the item during the 13-month period. During the rental period, the supplier providing the rental equipment is responsible for all maintenance and service. After the 13-month rental period when ownership of the item is transferred to the member, the provider may bill Montana Healthcare Programs for the supplies, maintenance, repair components, adjustment and services related to the items. Montana Healthcare Programs does not cover repair charges during the manufacturer’s warranty period.
Items classified by Medicare as needing frequent and substantial servicing are covered on a monthly rental basis only. The 13-month rental limit does not apply, and rental payment may continue as long as the item is medically necessary.
Interruptions in rental period
Interruptions in the rental period of less than 60 days will not result in the start of a new 13-month period or new purchase price limit. Periods in which service is interrupted do not count toward the 13-month rental limit.
Change in supplier
A change in supplier during the 13-month rental period will not result in the start of a new 13-month period or new purchase price limit. Providers are responsible for investigating whether another supplier has been providing the item to the member; Montana Healthcare Programs does not notify suppliers of this information. The provider may rely upon a separate written member statement that another supplier has not been providing the item, unless the provider has knowledge of other facts or information indicating that another supplier has been providing the item. The supplier providing the item in the 13th month of the rental period is responsible for transferring ownership to the member.
Change in equipment
If rental equipment is changed to different but similar equipment, the change will result in the start of a new 13-month period or new purchase price limit only when all of the following are met:
- The change in equipment is medically necessary as a result of a substantial change in the member’s medical condition.
- A new certification of medical necessity for the new equipment is completed and signed by a physician.
No more than one month’s medical supplies may be provided to a member at one time.
Coverage of Specific Services
The simplest way to verify coverage for a specific service is to check the Department’s fee schedule for your provider type. Fee schedules are available on the Provider Information website.
In addition to being listed on the fee schedule, all services provided must also meet the coverage criteria listed in the Provider Requirements chapter of the General Information for Providers Manual and in this chapter. Use the fee schedule in conjunction with the detailed coding descriptions in the CPT and HCPCS coding books that pertain to the date of service.
The following are specific criteria for certain items/services which are either in addition to Medicare requirements or are services Medicare does not cover.
Billing of Miscellaneous Code B9998
Supplies listed below that are included in the daily kits but billed with B9998 will be denied. Providers should review supplies being billed with the miscellaneous code and bill according to the following guidelines.
Medicare Coding Guidelines
The codes for enteral feeding supplies (B4034–B4036) include all supplies, other than the feeding tube itself, required for the administration of enteral nutrients to the member for one day.
Codes B4034–B4036 describes a daily supply fee rather than a specifically defined kit. Some items are changed daily; others may be used for multiple days. Items included in these codes are not limited to prepackaged kits bundled by manufacturers or distributors.
These supplies include, but are not limited to, feeding bag/container, flushing solution bag/container, administration set tubing, extension tubing, feeding/flushing syringes, gastrostomy tube holder, dressings (any type) used for gastrostomy tube site, tape (to secure tube or dressings), Y connector, adapter, gastric pressure relief valve, declogging device, etc.
These items must not be separately billed using the miscellaneous code (B9998) or by using specific codes for dressings or tape. The use of member items may differ from member-to-member and from day-to-day.
Blood Glucose Monitors and Related Supplies
For blood glucose monitors and related supplies, the Department will follow the criteria set forth in the LCD for glucose monitors (L33822):
- The member has diabetes mellitus or gestational diabetes; and
- The physician has provided the member (or the member’s caregiver) with adequate training for the device prescribed.
Montana Healthcare programs will allow the following for test strips and lancets:
Members who are not insulin dependent are allowed up to 100 test strips and up to 100 lancets every 3 months if the above criteria have been met.
Members who are insulin dependent are allowed up to 300 test strips and up to 300 lancets every 3 months if the above criteria have been met.
High Utilization
For both members who are not insulin dependent or insulin dependent and require more than the allowed number of test strips and lancets every 3 months, high utilization will be covered if the criteria (a)-(c) below have been met.
- Basic coverage criteria (1)-(2) listed above are met; and
- The treating physician has seen the member, evaluated their diabetes control within 6 months prior to ordering quantities of strips and lancets that exceed the utilization guidelines, and has documented in the member's medical record the specific reason for the additional materials for that particular member; and
- If refills of quantities of supplies that exceed the utilization guidelines are dispensed, there must be documentation in the physician's records (e.g., a specific narrative statement that adequately documents the frequency at which the member is actually testing or a copy of the member’s log) that the member is actually testing at a frequency that corroborates the quantity of supplies that have been dispensed. If the member is regularly using quantities of supplies that exceed the utilization guidelines, new documentation must be present at least every six months.
Providers submitting claims with units considered high utilization must ensure all of the above requirements for high utilization are met. To process claims for high utilization members, the procedure below shall be followed:
- Indicate any associated insulin use in the appropriate field using ICD-10 code Z79.4. If this code is not present, the claim will be denied.
- If the high utilization claim is for a child age birth through 20, a "1" must be entered in column H (EPSDT) on the CMS-1500 paper claim form or a "Y" must be entered in the SV-111 field within the 837 electronic. claim format. This will enable the claim to bypass the edit for over the usual allowable units without rejection or denying the claim first.
Insulin Pumps E0784
Insulin pumps do not require prior authorization. DME providers are reminded before providing insulin pumps to covered Montana Healthcare Programs members, the member must meet the Medicare coverage criteria. The coverage criteria are outlined in the External Infusion Pumps local coverage determination (LCD) located on the Noridian website. https://med.noridianmedicare.com/documents/2230703/7218263/External+Infusion+Pumps+LCD+and+PA.
For enrolled members ages 0-20 only, the criteria for insulin pumps and supplies is not subject to Medicare's criteria outlined above. The criteria for this age group is that the member is insulin dependent.
Breast Pumps
Double Electric Breast Pumps for Purchase E0603
Double electric breast pumps are covered for all eligible Montana Healthcare Programs members who are at least 28 weeks gestation, or currently breastfeeding. Montana Healthcare Programs has a sole source provider, Healthy Babies, Happy Moms.
The ordering process is a two-part process.
- Member must go online and order their breast pump online at Montana Medicaid Breast Pumps — Healthy Babies, Happy Moms Inc.
- Providers must send prescriptions to Healthy Babies, Happy Moms Inc. via fax to (844) 276-5457. The prescription template is available on the Healthy Babies, Happy Moms website.
Providers are reminded that prescriptions must include the following:
- Member name
- Member ID
- Date of birth
- Order date
- Printed name and signature of authorized provider
- Valid diagnosis code for a pregnant member or for a nursing member
- Estimated due date or gestational age
- Medical necessity
- Projected length of need
- Member's mailing address
- Member's phone number
All orders will be delivered within 5 business days from the receipt of a fully completed order, which includes prescription from authorized provider and patient's online order. Pumps can only be provided to a member who is at least 28 weeks pregnant or is breastfeeding.
Please note:
- Only one breast pump will be provided per pregnancy and no more than one breast pump will be provided per year.
Hospital Grade Electric Breast Pump Rentals E0604 RR:
Hospital grade electric breast pump rentals are a covered service if at least one of the following criteria has been met:
- Member has a preterm infant of 39 weeks or less gestation
- Infant has feeding difficulties due to a neurological or physical condition that impairs adequate suckling
- Illness of member and/or infant that results in their separation
- Member is on a mediation that compromises her milk supply; or
- Member has multiple infants.
Hospital grade electric breast pump rental is limited for 2 months, unless additional months are prior authorized by Mountain-Pacific Quality Health through the Qualitrac portal. https://www.mpqhf.org/corporate/medicaid-portal-home/medicaid-portal-document-library/. Montana Healthcare Programs payment may not be provided through the infant’s eligibility.
Combination Shower Commode Chairs and Accessories, Screening Criteria
Use HCPCS Code E0240 when submitting prior authorization request and/or when billing for the shower commode chair. This code does require prior authorization and must meet the criteria listed below:
Description
A combination shower commode chair is used to meet a member's toileting and hygiene needs.
Indications for coverage of the shower commode chair
All of the following criteria must be met:
- Unable to use a standard conventional toilet.
- Unable to get in/out of the shower independently and is unable to sit or stand in the bath/shower independently.
- Home assessment determines that shower/tub access is possible for the requested equipment.
- Home assessment determines that once the equipment is in the shower/tub enclosure caregiver access to the member is adequate.
- Documentation to support that a less costly system will not meet the needs of the member.
Indications for coverage of the tilt/recline feature
Documentation to support the medically necessity for the member to be in a tilt/recline position for toileting or showering.
Indications for coverage of a non-standard seating system
- Current decubitus that is a stage 3 or 4; and
- Shower/commode chair needed for a minimum of 30 minutes or longer; or
- No decubitus and use of the shower/commode chair for a minimum of 2 hours or longer per toileting session.
Indications for coverage of foot plates
No functional use of the lower limbs.
Indications for coverage of elevating leg rests
Musculoskeletal condition which prevents 90-degree flexion of the knee or meets medical necessity for the tilt/recline feature on the shower/commode chair.
Indications for coverage of a heavy-duty shower/commode chair
Documentation from a medical resource of the member's weight to determine justification for the requested chair.
Compression Garments for the Legs
Inflatable compression garments, non-elastic binders, or personally fitted prescription gradient compression stockings are considered medically necessary for members who have any of the following medical conditions:
- Treatment of any of the following complications of chronic venous insufficiency:
- Lipodermatosclerosis
- Stasis dermatitis (venous eczema)
- Varicose veins (except spider veins)
- Venous edema
- Venous ulcers (stasis ulcers)
- Edema accompanying paraplegia, quadriplegia
- Edema following surgery, fracture, burns, or other trauma
- Members with lymphedema
- Post sclerotherapy (applies only to pre-made or custom-made pressure gradient support stockings)
- Post-thrombotic syndrome (post-phlebetic syndrome)
- Postural hypotension
- Prevention of thrombosis in immobilized members (e.g., immobilization due to surgery, trauma, general debilitation)
- Severe edema in pregnancy
Compression garments for the legs are considered experimental and investigational for all other indications (e.g., management of spasticity following stroke) and will not be covered.
Replacements
Are considered medically necessary when the compression garment cannot be repaired or when required due to a change in the member’s physical condition. For pressure gradient support stockings, no more than 4 replacements per year are considered medically necessary for wear.
Two pairs of compression stockings are considered medically necessary in the initial purchase. The second pair is for use while the first pair is in the laundry. For a list of covered compression stocking codes, see the fee schedule on the Provider Information website.
Custom-Made Equipment, Prosthetics, or Orthotics
DME must be billed using the date of service the member receives the equipment or item.
The only exception is in the case of custom-made equipment, prosthetics, or orthotics. In these instances, the date when the item is casted, molded, and/or fitted may be used. Before a provider can bill for any custom-made equipment, prosthetic or orthotic, the work on the item must be complete and the member must have signed the delivery ticket.
Because Montana Healthcare Programs eligibility is determined on a month-to-month basis, providers must check eligibility before an item is ordered or work has begun and document the member’s eligibility in their file.
Only one unit of service may be billed for any one day. Units of service in excess of one per day will be rejected as incorrect coding.
Gastrostomy/Jejunostomy Tube, Code B4088
This code has been incorrectly profiled in the HCPCS coding book. The code is described as just a tube, when in fact it is a complete kit. The manufacturer will not supply the tube separate from the kit. Medicare currently reimburses code B4088 as a tube, but suppliers are billed by the manufacturer for the complete kit. Therefore, the reimbursement to the suppliers is not adequate in comparison to the cost for the complete kit.
Montana Healthcare Programs recognizes the constraints this has put on suppliers when providing this item to members. Effective immediately, Montana Healthcare Programs will reimburse code B4088 at 75% of the Manufacturer’s Suggested Retail Price (MSRP) in accordance with ARM 37.86.1807.
Incontinence Supplies
Diapers, Underpads, Liners/Shields
- Diapers, underpads, and liners/shields are covered for members who have a medical need for the items based on their diagnosis.
- These items are not covered for members under 3 years of age or members in long-term care (nursing facility) settings.
- Montana Healthcare Programs limits the number of incontinent products distributed by product type:
- Disposable diapers are limited to 180 diapers per month.
- Disposable under pads liners/shields are limited to 240 per month.
- Reusable diapers, under pads, liner/shields are limited to 36 units each per year (3 per month).
Sterile and Non-Sterile Gloves
Both sterile and non-sterile gloves are considered incontinence supplies only.
- Gloves are covered for members who have a medical need for the items based on their diagnosis (i.e., diagnosis is incontinence).
- Sterile gloves (A4930) are billed per pair.
- Non-sterile gloves (A4927) are billed per box.
- Gloves are reimbursed at 75% of the Manufacturers Suggested Retail Price (MSRP).
- For gloves without MSRP, providers may submit their Usual and Customary (U&C) charge as long as it does not exceed 50% of their acquisition cost.
The T codes listed below are more specific to the type of incontinence products being distributed by Montana Healthcare Programs DME providers:
Incontinence Products HCPCS Codes
Code: T4521 Description: Adult sized disposable incontinence product, brief/diaper, small, each
Code: T4522 Description: Adult sized disposable incontinence product, brief/diaper, medium, each
Code: T4523 Description: Adult sized disposable incontinence product, brief/diaper, large, each
Code: T4524 Description: Adult sized disposable incontinence product, brief/diaper, extra-large, each
Code: T4525 Description: Adult sized disposable incontinence product, protective underwear/pull-on, small, each
Code: T4526 Description: Adult sized disposable incontinence product, protective underwear/pull-on, medium, each
Code: T4527 Description: Adult sized disposable incontinence product, protective underwear/pull-on, large, each
Code: T4528 Description: Adult sized disposable incontinence product, protective underwear/pull-on, extra-large, each
Code: T4529 Description: Pediatric sized disposable incontinence product, brief/diaper, small/medium size, each
Code: T4530 Description: Pediatric sized disposable incontinence product, brief/diaper, large size, each
Code: T4531 Description: Pediatric sized disposable incontinence product, protective underwear/pull-on, small/medium size, each
Code: T4532 Description: Pediatric sized disposable incontinence product, protective underwear/pull-on, large size, each
Code: T4533 Description: Youth sized disposable incontinence product, brief/diaper, each
Code: T4534 Description: Youth sized disposable incontinence product, protective underwear/pull-on, each
Code: T4535 Description: Disposable liner/shield/guard/pad/ undergarment, for incontinence, each
Code: T4536 Description: Incontinence product, protective underwear/pull-on, reusable, any size, each
Code: T4537 Description: Incontinence product, protective underpad, reusable, bed size, each
Code: T4539 Description: Incontinence product, diaper/brief, reusable, any size, each
Code: T4540 Description: Incontinence product, protective underpad, reusable, chair size, each
Code: T4541 Description: Incontinence product, disposable underpad, large, each
Code: T4542 Description: Incontinence product, disposable underpad, small size, each
Code: T4543 Description: Disposable incontinence product, brief/diaper, bariatric, each
Prosthetic Devices
HCPCS codes L5000-L7520, L8040-L8515, and L8630-L8670 no longer require prior authorization.
In accordance with Administrative Rules of Montana (ARM) 37.86.1802, Montana Medicaid has adopted Medicare coverage criteria for Medicare covered durable medical equipment as outlined in the Region D Supplier Manual, local coverage determinations (LCDs) and national coverage determinations (NCDs).
Providers are reminded that members must meet the Medicare coverage criteria. The criteria can be found at the following documentation checklists and at the following Noridian website: https://med.noridianmedicare.com/web/jddme/policies/lcd/active.
Lower Limb Prostheses - LCD 33787 Documentation Checklist: https://med.noridianmedicare.com/documents/2230703/6750839/Documentation+Checklist+-+Lower+Limb+Prostheses
Facial Prostheses - LCD 33738
Eye Prostheses - LCD 33737
External Breast Prostheses - LCD 33317 Documentation Checklist: https://med.noridianmedicare.com/documents/2230703/6750839/Documentation+Checklist+-+External+Breast+Prostheses
Upper Extremity Prostheses - Criteria can be found in Section 120 of the Medicare Benefit Policy Manual, Chapter 15: https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/bp102c15.pdf.
Respiratory Devices
Apnea Monitors - Infants
See the Respiratory Devices section under Children’s (EPSDT) Coverage Criteria for Specified DME of this chapter below.
Bi-level Positive Airway Pressure Devices (Bi-Pap) E0470 – E0471
Bi-level positive airway pressure device with back-up rate, does not require prior authorization. Providers are reminded of the following Medicare LCD L33718 medically necessary criteria that must be met in order for Medicaid reimbursement to include:
E0470 Obstructive Sleep Apnea:
A. The member must have a face-to-face clinical evaluation by the treating practitioner prior to the sleep test to assess the member for obstructive sleep apnea.
B. The member must have a sleep test (as defined below) that meets either of the following criteria (1 or 2):
- The Apnea-Hypopnea Index (AHI) or Respiratory Disturbance Index (RDI) is greater than or equal to 15 events per hour with a minimum of 30 events;
OR - The AHI or RDI is greater than or equal to 5 and less than or equal to 14 events per hour with a minimum of 10 events and documentation of:
- Excessive daytime sleepiness, impaired cognition, mood disorders, or insomnia; or
- Hypertension, ischemic heart disease, or history of stroke.
C. The member and/or their caregiver has received instruction from the supplier of the device in the proper use and care of the equipment.
D. A single-level continuous positive airway pressure device (E0601) has been tried and proven ineffective based on a therapeutic trial conducted in ether a facility or in a home setting.
E0470 and E0471 Respiratory Assist Devices (RAD):
For an E0470 or an E0471 RAD to be covered, the treating physician must fully document in the member's medical record symptoms characteristic of sleep-associated hypoventilation, such as daytime hypersomnolence, excessive fatigue, morning headache, cognitive dysfunction, dyspnea, etc.
A RAD (E0470 or E0471) is covered for those beneficiaries with one of the following clinical disorders:
- Restrictive thoracic disorders (i.e., neuromuscular diseases or severe thoracic cage abnormalities)
- Severe chronic obstructive pulmonary disease (COPD)
- CSA or CompSA
- Hypoventilation syndrome
Items coded as E0470 and E0471 do not require prior authorization if the coverage criteria are met.
Home Oxygen Therapy for Members Residing in Skilled Nursing Facility
In accordance with ARM 37.86.1802, Montana Healthcare Programs has adopted Medicare coverage criteria for Medicare covered durable medical equipment as outlined in the Region D Supplier Manual, Medicare Supplier Manual, and local and national coverage determinations (LCDs and NCDs).
For prosthetic devices, durable medical equipment, and medical supplies not covered by Medicare, coverage will be determined by the Department and published on the Department’s fee schedule in accordance with ARM 37.86.1807.
The Department will follow criteria set forth in the LCD for Oxygen and Oxygen Equipment (L11457) for members residing in a skilled nursing facility. The only exception is that the Department will allow oximetry tests ordered by a physician and performed by qualified nursing personnel at the skilled nursing facility as an acceptable blood gas study. To be reimbursed for this service, DME providers shall follow all other criteria set forth in L11457.
Montana Healthcare Programs Policy on 36-Month Oxygen Cap
To preserve member access, Montana Healthcare Programs will not be following the Medicare 36-month cap policy on oxygen for Montana Healthcare Programs-only members. This policy will include eligible Montana Healthcare Programs nursing home dual-eligible (both Medicare and Montana Healthcare Programs coverage) members for Medicare non-covered oxygen. Montana Healthcare Programs pays only Medicare co-insurance and deductibles up to the Montana Healthcare Programs allowable for QMB-only members. The Department will follow established policy for this member group. For example, once the 36-month cap starts, Medicare rules apply, and the Department will follow.
Dual-eligible members will follow the 36-month cap as outlined by Medicare rules. Montana Healthcare Programs members with QMB and SLMB do not have Montana Healthcare Programs oxygen coverage. Montana Healthcare Programs will follow all of the Medicare oxygen changes outlined in the Medicare Improvements for Patients and Providers Act (MIPPA) of 2008 except for the 36-month cap as stated above.
Home Ventilators E0465, E0466, and E0467
The following documentation requirements apply for both invasive and non-invasive home ventilators and should be submitted with each prior authorization request.
Requirements for initial home ventilator requests:
- Ordering Health Care Provider/Prescriber (HCP) notes detailing the diagnosis for which the ventilator is required. This is to include diagnoses such as progressive neuromuscular disease, thoracic restrictive conditions, cardiac conditions, COPD, upper airway conditions, and other causes of respiratory failure.
- The HCP’s notes must document why less costly alternatives such as simple oxygen therapy, maximal medical management, bilevel and/or other respiratory assistive devices, etc., are not suitable. This might be because they were tried and failed, they are inappropriate for the patient's condition with an explanation as to why, or some other specific reason why less costly alternatives will not meet the patient’s needs.
- The notes must include objective data such as blood gas measurements, Pulmonary Function Test (PFT), oximetry, sleep study interpretations, and any other laboratory and diagnostic imaging that supports the need for home ventilation. This does not mean that absolute lab or test values will be used for authorization. It means that the ordering HCP’s judgment, informed by the objective data will be the ultimate determinant of need.
- The original prescription from the ordering HCP.
- A Detailed Written Order (DWO)* must also be provided: This includes:
- Estimated length of need – this may be undetermined but might also vary in the case of convalescence from an exacerbation of a condition
- Hours of use
- Ventilator settings
*A prescription alone that does not include this information will not be sufficient.
After initial approval:
Prescribers shall determine the frequency of follow-up assessments. Providers must document all updated orders and/or information regarding treatment in the medical record. Providers are reminded, in accordance with 42 CFR 440.70, the need for medical supplies, equipment, and appliances should be identified by the prescriber and reviewed at least annually. Face-to-face assessments of the patient by the prescriber can be performed using telemedicine. Telemedicine guidance can be found in the General Information for Providers Manual.
To renew a prior authorization:
For ongoing ventilator usage, in addition to information described above that justifies the initial provision of the ventilator, there must be information in the member’s medical record to support that the item continues to remain reasonable and necessary. Information used to justify continued medical need must be timely for the date of service under review. Any of the following may serve as documentation justifying continued medical need:- A recent order by the treating physician/practitioner for refills; or
- A recent change in prescription; or
- Timely documentation in the member's medical record showing usage of the item.
- Timely documentation in the member’s medical record showing usage of the item.
- Supplier records such as compliance logs or service plans.
- Supplier records documenting member confirmation of continued use.
Ventilators are not subject to the 13-month rental period. Ventilators are reimbursed as a rental only.
Wheelchairs
In addition to the Medicare Region D DMERC Medical Review Policies for wheelchairs, to meet the needs of a particular member, various wheelchair options or accessories are typically selected. The addition of options or accessories does not deem the wheelchair as a custom wheelchair.
Wheelchairs in Nursing Facilities
Standard wheelchairs (K0001) are included in the nursing facility per diem and are not covered under the DME program. All other wheelchairs (including tilt-in-space) will be considered for purchase. Wheelchairs must be used primarily for mobility. All wheelchairs purchased are considered owned by the member.
Roll-about chairs which cannot be self-propelled are specifically designed to meet the needs of ill, injured, or otherwise impaired members and are considered similar to wheelchairs. Roll-about chairs may be called by other names such as transport or mobile geriatric chairs (geri chairs). Roll-about chairs are not wheelchairs; however, many of the same options and accessories can be found for use on them. Like standard wheelchairs, roll-about chairs are expected to be available to Members by the nursing facility.
Wheelchair Seating in the Nursing Facility
Indications and limitations for a wheelchair seating system for an existing wheelchair such as a facility wheelchair, member owned wheelchair or a donated wheelchair. The seating system would be the least costly alternative that is able to be adapted to meet the positioning needs of a member in a nursing home and will be covered if there is a comprehensive written evaluation by a licensed clinician who is not an employee of or otherwise paid by a supplier.
Included in the evaluation referenced above are the following:
- Seating systems for increased independence
- Documentation must support all of the following:
- The member must be able to self-propel to specific destinations (e.g., to and from the dining room, to and from the activity room).
- Be able to do a functionally independent task as a result of the seating system such as feed self.
- The member must be evaluated to determine that he/she is able to safely self-propel and does not have the potential cause harm.
- Be alert and oriented and capable of being completely independent in use of the wheelchair after adapted seating system is placed.
OR
- Seating systems for positioning purposes
- Seating for positioning purposes will be reviewed on a case-by-case basis.
- Documentation must support that all other less costly alternatives have been ruled out, to include but not be limited to use of the following:
- Use of mobile geriatric chairs (geri chairs) provided by nursing home and use of standard off-the-shelf seating products have been tried and ruled out; and
- Use of rolled towels, blankets, pillows, wedges, or similar devices by facility caregivers to reasonably position and reposition member; and
- Documentation that has determined that nursing staff is unable to accomplish repositioning by any other means while the member is up and out of bed; and member is not incapacitated to the point that he/she is bedridden.
Bariatric Equipment in Nursing Facilities
Children’s (EPSDT) Coverage Criteria for Specified DME
ARM 37.86.2201 allows for coverage of a durable medical equipment (DME) item/service that is typically considered non-covered, does not meet coverage criteria, or is over the Montana Healthcare Programs allowable units if the item/service is determined medically necessary for an eligible child under 21.
Bowel Management Program Supplies for EPSDT Children Ages 0-20
For the Enema Bowel Program, the child must:
Have failed a trial of oral medications for chronic constipation AND has ONE or more of the following:
- History of excessive stool retention
- History of painful or hard bowel movements
- Presence of a large fecal mass in the rectum
Supplies covered:
- Foley catheters with 30cc balloon
- Medline enema bags/gravity bags
- Lubricant, non-sterile
- 30-60cc luer lock syringes
For the Appendicostomy/Cecostomy Supplies, the child must:
Have had an appendicostomy/cecostomy.
Supplies covered:
- Chait trapdoor
- Chait access adapter tube
- Enema bags/gravity bags
- 60cc catheter tip syringes
Gait Trainers - EPSDT Only
A gait trainer (GT) is a device used to support a member during ambulation. Criteria for coverage of GT include:
- The member's age is 0-20.
- The member is unable to ambulate independently with a standard front or reverse walker because of the need for postural support, due to a chronic neurological condition including abnormal movement patterns, poor balance, poor endurance, or other clearly documented reasons.
- The anticipated functional benefits of walking are not attainable with the use of a walker.
- Must demonstrate tolerance for standing and weight bearing through the lower extremities.
- Potential benefits to the member of assisted walking must be clearly documented as follows:
- The member must be involved in a therapy program established by a physical therapist. The program must include measurable documented objectives and functional goals related to the member and equipment that includes a written carry over plan to be utilized by the member and/or caregiver. The equipment must match the user’s needs and ability level.
- The member has had a trial of the requested GT and the member shows compliance, willingness, and ability to use the GT in the home.
- Video of member using the requested GT home demonstrating ability to use GT by showing potential for progress to meet goals and objectives.
Ketone Test Strips, Codes A4250 and A4252
The following HCPCS codes will be covered for Montana Healthcare Programs children ages 0-20 only, who are at immediate risk for diabetic ketoacidosis:
- A4250, Urine test or reagent strips or tablets (100 tablets or strips)
- A4252, Blood ketone test or reagent strip, each
The member must have a diabetes mellitus or gestational diabetes diagnosis code.
MDI Spacers (EPSDT), Code A4627
A spacer device will be allowed for a child if he/she is using metered dose inhalers prescribed by his/her physician for medication delivery, and the spacer is medically necessary.
If the above criteria are met, the item does not require prior authorization. Montana Healthcare Programs will reimburse this code at 75% of the Manufacturer’s Suggested Retail Price (MSRP), in accordance with ARM 37.86.1807.
Nebulizers/Nebulizer Kit (EPSDT), Codes E0570 RR and A7005
Nebulizers and supplies should be considered for in-home treatment of children when prescribed by their medical provider and when the child has been diagnosed with acute bronchiolitis or respiratory syncytial virus (RSV).
The nebulizer and supplies should be considered for a rental of prescribed length of need as indicated by the provider; typically, 1–3 months.
If the above criteria are met, the item does not require prior authorization.
Omnipod Coverage (HCPCS Code A9274)
Omnipod and related supplies will no longer require prior authorization. Omnipod and related supplies will now be billed under a pharmacy’s Point of Sale (POS) system only, effective September 18, 2022. Therefore, any claims billed via the medical benefit after September 18, 2022, will be denied for payment.
This device and supplies are covered under Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) benefit, which means they are only covered for members under 21 years of age. Anyone 21 years of age and older will not be covered.
Omnipod and related supplies are covered when all of the following coverage criteria below (1-7) are met:
1. The member is under 21 years of age, but at or over the FDA approved age.
2. The member has a diagnosis of Type 1 diabetes.
3. The member has a prescription from their medical practitioner.
4. There is clinically documented compliance with the diabetes management plan, with current clinical
notes dates within the previous 90 days.
5. Patient and/or parent education has been provided on the proper use of the device.
6. The patient and/or parent have determined that this type of device would be a good fit for the member.
7. The LCD-related standard documentation requirements are met.
For the continuation of supplies the following criteria must be met:
1. There is clinically documented compliance with diabetes management plan.
2. There is continued use of Omnipod.
Orthotics (EPSDT), Codes L3002, L3010, L3020, and L3040
Devices and instruments to help a child maintain his/her level of mobility, correct physical issues, or decrease pain should be considered when prescribed by their medical provider and the following conditions apply. This list is not all-inclusive, and each case is determined on a case-by-case review of medical necessity:
- Knee or hip subluxation, dislocation
- Spastic movement
- Correct, limit or prevent deformities
- Low-tone pronation (fallen arches, outward-turned foot due to muscle weakness)
- High-tone pronation (high arch, outward-turned foot due to increased muscle tone)
- Swing-phase inconsistency (erratic movements in the foot)
- Drop-foot (drop of the front of the foot due to weakness)
- Eversion (outward turn)
- Inversion (inward turn)
If the child is not having symptoms or pain associated with the above conditions, foot orthotics are not considered medically necessary.
If the above criteria are met, the item does not require prior authorization.
Phototherapy (Bilirubin) Light with Photometer, Code E0202 RR
The E0202 RR will be reimbursed for infants ages 0-1. One unit of service is billed for each day and units billed are not to exceed a 5-day limit. To assure correct coding, providers are encouraged to refer to the current HCPCS coding manual. DMEPOS suppliers must obtain a written prescription in accordance with ARM 37.86.1802. Suppliers should also maintain supporting documentation showing the member meets the Montana Healthcare Programs coverage criteria.
Respiratory Devices for Children (EPSDT)
Apnea Monitors - Infants
The rental of an apnea monitor will be covered initially for a six-month period from the date of the physician’s order. Apnea monitors are covered under at least one of the following conditions:
- A sibling has died from SIDS.
- Infant has symptomatic apnea.
- Observation of apparent life-threatening events (ALTE).
- Infant is on oxygen.
- Symptomatic apnea due to neurological impairment.
For coverage after the initial six-month period, additional months coverage must be prior authorized by the Department and the following conditions must exist and be documented by the physician:
- Infant continues to have significant alarms. (Log must be kept on file.)
- Unresolved symptomatic apnea.
Pulse Oximetry for Children Age 0-20
The capped rental of a Pulse Oximetry Meter (E0445) will no longer require prior authorization for children age 0-20 when all of the following criteria are met:
- The member has a chronic, progressive respiratory or cardiovascular condition that requires continuous or frequent oxygen therapy.
- Oxygen need varies from day to day or per activity (e.g., feeding, sleeping, movement), and a medical need exists to maintain oxygen saturation within a very narrow range in which unpredictable, sub therapeutic fluctuations of oxygen saturation levels occur that cannot be clinically determined and have an adverse effect if not treated.
- A trained caregiver is available to respond to changes in oxygen saturation.
- Montana Healthcare Programs will only reimburse for a capped rental if the above criteria are met. Therefore, the purchase of a pulse oximeter will not be approved for reimbursement.
Continuous read oximetry meters and any meter used for diagnostic purposes are not covered.
Pulse Oximeter Probes (EPSDT), Code A4606
If a child has a pulse oximeter that was paid for by Montana Healthcare Programs, a replacement probe (A4606) will be covered if the pulse oximeter is still medically necessary and prescribed by their medical provider.
If above criteria are met, the item does not require prior authorization. Montana Healthcare Programs will reimburse this code at 75% of the Manufacturer’s Suggested Retail Price (MSRP), in accordance with ARM 37.86.1807.
Oral Nutrition
Montana Healthcare Programs may cover oral nutritional products for members under the age of 21 who have had an EPSDT screen resulting in a diagnosed medical condition that impairs absorption of a specific nutrient. The member must also have a measurable nutrition plan developed by a nutritionist and the member’s primary care provider (PCP). Use modifier -BO when nutrition is orally administered, not by a feeding tube (only for members under age 21).
Oral Food Thickener (EPSDT), Code B4100
The addition of a thickening agent should be considered medically necessary when prescribed by his/her medical provider and the following diagnosis applies:
- Oropharyngeal dysphagia;
- Reflux disease; or
- Any diagnosis that indicates child is at risk for life threatening aspiration.
If the criteria are met, the item does not require prior authorization. Montana Healthcare Programs will reimburse this code at 75% of the Manufacturer’s Suggested Retail Price (MSRP), in accordance with ARM 37.86.1807.
Cranial Remolding Orthotics/Helmets (EPSDT), Code S1040
Prior authorization is not required for cranial remolding orthotics if the following criteria has been met:
For Members 0-6 Months Old
- Documented moderate to severe deformational or positional plagiocephaly by physical examination or imaging.
- Continued deformity after at least two months of parent or caregiver education and at least two months of physical therapy or occupational therapy.
For Members 6-18 Months Old
- Documented moderate to severe deformational or positional plagiocephaly by physical examination or imaging.
If a member has had craniosynostosis surgery, then S1040 is approved for all age groups without the trial conservative therapies.
End of Covered Services Chapter
Non-Covered Services (ARM 37.86.1802)
Below are items and/or categories of items that are not covered through the DMEPOS program. All coverage decisions are based on federal and state mandates for program funding by CMS, including the Medicare program or the Department’s designated review organization.
- Adaptive items for daily living
- Environmental control items
- Building modifications
- Automobile modifications
- Convenience/comfort items
- Disposable incontinence wipes
- Sexual aids or devices
- Member personal care items
- Member personal computers
- Alarms/alert items
- Institutional items
- Exercise/therapeutic items
- Educational items
- Items/services provided to a member in a nursing facility setting. (See the Nursing Facility and Swing Bed Services Manual for details.)
- Furniture associated with the use of a seat lift mechanism.
- Scales
- Backup equipment
- Items included in the nursing home per diem
Requesting an Item/Code Be Added to the Fee Schedule
DME providers and suppliers can request that the Department consider adding non-covered supplies and equipment to the DME plan of benefits or to modify existing coverage criteria. The procedure must allow the Department to make a well-informed decision in regard to considering coverage based primarily on medical necessity. The policy is not a guarantee of coverage.
Requester/Supplier Responsibility
Requester must submit a written request to the DPHHS DME program officer. The request must include the following:
- HCPCS code and a detailed description of the item.
- Clear and concise statement of why the item is needed. This could include a letter of medical necessity (LMN) if available.
- Supporting information documenting the medical necessity for the requested item from peer reviewed national compendia or publication. Evidence must support the need for this equipment to meet the intended medical need.
- A statement addressing if there is a least costly alternative and why it cannot be used.
- Recommended coverage criteria of the requested item.
- Recommended limits. This would include any limits that could apply such as lifetime, units per month, age limits, weight.
- Estimated (per unit) cost of the requested item.
- Estimated number of people that would utilize the item.
- Expected medical outcome.
- Estimated overall cost/cost savings (if any).
The request may include any other pertinent information the requester would like the Department to consider.
Department’s Responsibility and Process
Upon receipt of a request for coverage of a non-covered item, the Department:
- Submits the request and associated documentation to the Department’s DME Utilization Review contractor for evaluation of the request.
- Upon completion of the review, the contractor makes a coverage recommendation to the Department.
- May forward the request to the State Medical Director (SMD) for review.
- If SMD recommends coverage denial, the Department sends letter to the requester explaining why.
- If SMD recommends coverage, the Department determines whether the current budget can fulfill the expense of the item’s expected utilization.
- An adverse budget impact results in a letter to the requester explaining why the item cannot be added.
- Department approval of the request initiates the Administrative Rule and State Plan Amendment process. These are required steps for new items to be added to the DME fee schedule allowing for public comment.
- The Department is responsible for preparing a written response within a reasonable time period to inform all applicable parties of the decision.
- The process could take up to six months. The Department provides quarterly progress reports to the DME workgroup.
End of Non-Covered Services Chapter
Billing Procedures
Using the Montana Healthcare Programs Fee Schedule
When billing Montana Healthcare Programs, it is important to use the Department’s fee schedule for your provider type in conjunction with the detailed coding descriptions listed in the current CPT and HCPCS coding books. In addition to covered services and payment rates, fee schedules often contain helpful information such as appropriate modifiers. Fee schedules are available on the Provider Information website.
Place of Service
Place of service must be entered correctly on each line. Montana Healthcare Programs typically reduces payment for services provided in hospitals and ambulatory surgical centers since these facilities typically bill Montana Healthcare Programs separately for facility charges.
Date of Service
The date of service for custom molded or fitted items is the date upon which the provider completes the mold or fitting and either orders the equipment from another party or makes an irrevocable commitment to the production of the item.
Rental
Payment includes the entire initial month of rental even if actual days of use are less than the full month. Payment for second or subsequent months is allowed only if the item is used at least 15 days in such months.
End of Billing Procedures Chapter
How Payment Is Calculated
Overview
Although providers do not need the information in this chapter in order to submit claims to Montana Healthcare Programs, the information allows providers to understand how payment is calculated and to predict approximate payment for particular claims.
Usual and Customary Charge (ARM 37.85.406 and ARM 37.86.1806)
Providers should bill Montana Healthcare Programs their usual and customary charge for each service; that is, the same charge that is made to other payers for that service. The amount of the provider’s usual and customary charge may not exceed the reasonable charge usually and customarily charged by the provider to all payers. For DMEPOS providers, a charge is considered reasonable if it is less than or equal to the manufacturer’s suggested list price.
For items without a manufacturer’s suggested list price, the charge is considered reasonable if the provider’s acquisition cost from the manufacturer is at least 50% of the charge amount. For items that are custom fabricated at the place of service, the amount charged will be considered reasonable if it does not exceed the average charge of all Montana Healthcare Programs providers by more than 20%.
Payment for DMEPOS Items/Services (ARM 37.86.1807)
Payment for DMEPOS is equal to the lowest of either the provider’s usual and customary charge for the item or the Montana Healthcare Programs fee schedule amount in effect for the date of service.
Montana Healthcare Programs payment is equal to 100% of Medicare Region D fee schedule for current procedure codes where a Medicare fee is available, less applicable incurment and/or other applicable fees. Generic or miscellaneous procedure codes are excluded from the Medicare fee schedule. Payment for such excluded procedure codes is 75% of the provider’s submitted charge. For all other procedure codes where no Medicare fee is available, payment is 75% of the submitted charge.
Rental Items
If the purchase of a rental item is cost effective in relation to the member’s need of the item, the purchase may be negotiated. The purchase price would be the amount indicated on the applicable fee schedule less previous payments made to the provider of the item.
Total Montana Healthcare Programs rental reimbursement for items listed in Medicare’s capped rental program or classified by Medicare as routine and inexpensive rental is limited to the purchase price for that item. Monthly rental fees are limited to 10% of the purchase for the item, limited to 13 monthly payments. Interruptions in the rental period of less than 60 days do not result in the start of a new 13-month period or new purchase price limit, but periods during which service is interrupted will not count toward the 13-month limit.
How Payment Is Calculated on TPL Claims
When a member has coverage from both Montana Healthcare Programs and another insurance company, the other insurance company is often referred to as third party liability or TPL. In these cases, the other insurance is the primary payer (as described in the Member Eligibility and Responsibilities chapter of the General Information for Providers Manual), and Montana Healthcare Programs makes a payment as the secondary payer.
How Payment is Calculated on Medicare Crossover Claims
When a member has coverage from both Montana Healthcare Programs and Medicare, Medicare is the primary payer as described in the Member Eligibility and Responsibilities chapter of the General Information for Providers Manual. Montana Healthcare Programs then makes a payment as the secondary payer. For the provider types covered in this manual, the Montana Healthcare Programs payment is calculated so that the total payment to the provider is either the Montana Healthcare Programs allowed amount less the Medicare paid amount or the sum of the Medicare coinsurance and deductible, whichever is lower. This method is sometimes called “lower of” pricing.
End of How Payment Is Calculated Chapter
Appendix A: Forms
See the Forms page of the Provider Information website for the forms listed below.
Certificates of Medical Necessity
- Lymphedema Pumps (Pneumatic Compression Devices) (CMS-846)
- Osteogenesis Stimulators (CMS-847)
- Oxygen (CMS-484)
- Seat Lift Mechanisms (CMS-849)
- Section C Continuation Form (CMS-854)
- Transcutaneous Electrical Nerve Stimulators (TENS) (CMS-848)
DME Information Forms
- External Infusion Pumps DME 09.03 (CMS-10125)
- Enteral and Parenteral Nutrition DME 10.03 (CMS-10126)
End of Appendix A: Forms Chapter
End of Durable Medical Equipment, Prosthetics, Orthotics, and Medical Supplies (DMEPOS) Manual
Prescription Drug Program Manual
To print this manual, right click your mouse and choose "print". Printing the manual material found at this website for long-term use is not advisable. Department Policy material is updated periodically, and it is the responsibility of the users to check and make sure that the policy they are researching or applying has the correct effective date for their circumstances.
Update Log
Publication History
This publication supersedes all previous Prescription Drug Program Manuals. Published by the Montana Department of Public Health & Human Services, July 2001.
Updated October 2001, December 2001, May 2002, June 2002, September 2002, January 2003, August 2003, July 2004, November 2004, May 2011, August 2011, October 2011, December 2011, January 2013, March 2013, July 2013, September 2013, March 2015, June 2015, January 2016, July 2016, October 2016, December 2016, August 2017, February 2018, July 2018, November 2018, July 2019, January 2020, July 2020, April 2021, October 2021, July 2022, and July 2023.
CPT codes, descriptions and other data only are copyright 2014 American Medical Association (or such other date of publication of CPT). All Rights reserved. Applicable FARS/DFARS Apply.
Update Log
07/05/2023
- Revised Covered Products chapter
07/21/2022
- Updated Key Contacts, Dispensing Limitations, Prior Authorization, Reimbursement, and Billing Procedures chapters.
- Updated Index to Search Options
10/26/2021
Updated Montana Healthcare Programs Covered Products and Reimbursement chapters.
04/13/2021
Added the COVID-19 vaccine administration rates to the Reimbursement chapter.
07/01/2020
Updated dispensing fees and the vaccine administration fee.
01/01/2020
- Cost Share references removed, and Cost Share section changed to Co-Payments section.
- Term "Medicaid" replaced with "Montana Healthcare Programs" throughout the manual.
- Terms "client", "recipient" and "patient" replaced with "member".
07/08/2019
References to the MA-5 were replaced with references to the Universal Claim Form Version 1.2-02/2013 throughout the manual. Instructions for the Universal Claim Form replaced instructions for the MA-5 form. Seasonale® removed from the 34-day supply exception list. Vasopressors-midodrine removed from the drug classes considered for maintenance medications list.
11/27/2018
Reimbursement Chapter was updated with current rates.
07/31/2018
How to Bill Pharmacy Claims was added to the Billing Procedures chapter and obsolete language was removed from the Drug Program chapter.
07/10/2018
Dispensing Limitations was updated.
02/9/2018
Reimbursement rates were updated in the Reimbursement chapter.
09/26/2017
A portion of the Federal Maximum Allowable Cost section in the Reimbursement chapter was eliminated.
08/08/2017
Mental Health Services - Adult Manual converted to an HTML format and adapted to 508 Accessibility Standards.
06/15/2016
Prescription Drug Program, July 2016: Cost Share Updates
12/31/2015
Prescription Drug Program, January 2016: HELP Plan-Related Updates and Others
07/21/2015
Prescription Drug Program, Prior Authorization, Reimbursement, and Billing Procedures
03/25/2015
Prescription Drug Program, Entire Manual
09/27/2013
Prescription Drug Program, Reimbursement
09/05/2013
Prescription Drug Program, Entire Manual Including the New Passport Chapter. This set of replacement pages contains a terminology change ("client" to "member"); however, only content changes are marked with a change bar (black line).
04/17/2013
Prescription Drug Program, Key Contacts and Reimbursement
02/04/2013
Prescription Drug Program, Medicaid Covered Products
02/01/2012
Prescription Drug Program, Multiple Chapters
09/01/2011
Prescription Drug Program, Medicaid Covered Services and Reimbursement (Dispensing Fee) and MHSP Covered Products (Formulary Drugs)
06/17/2011
Prescription Drug Program; Entire manual has changed from last posted version.
11/16/2004
Prescription Drug Program, Updated Prescription Drug Prior Authorization Criteria
06/16/2004
Prescription Drug Program, Prior Authorization and HIPAA Updates
06/10/2004
Prior Authorization Additions
End of Update Log Chapter
Table of Contents
Key Contacts
Drug Program
Montana Healthcare Programs Covered Products
MHSP Covered Products
Dispensing
Generic Drugs
Compounding
Signature Requirements
Prior Authorization
Prior Authorization for Retroactively Eligible Members
Reimbursement
Billing Procedures
Third Party Payer – Negative Payment Amounts
Psychiatric Residential Treatment Facility (PRTF) Non-Psychotropic Medications
Point-of-Sale
Billing a Paper Claim
Appendix A: Forms
Definitions and Acronyms
Search Options
End of Table of Contents Chapter
Key Contacts
Drug Prior Authorization
For all questions regarding drug prior authorization:
(800) 395-7961
(406) 443-6002 (Helena)
8 a.m. to 5 p.m., Monday–Friday
Mountain Time
Mail or fax backup documentation to:
Mountain-Pacific Quality Health
P.O. Box 5119
Helena, MT 59604
(800) 294-1350 Fax
(406) 513-1928 Fax Helena
Point-of-Sale (POS) Help Desk
For assistance with online POS claims adjudication:
Conduent, Atlanta
Technical POS Help Desk
(800) 365-4944
6 a.m. to midnight, Monday–Saturday;
10 a.m. to 9 p.m., Sunday
Eastern Time
Program Policy
For program policy questions:
(406) 444-2738 Phone
(406) 444-1861 Fax
Allied Health Services Bureau
1400 Broadway
P.O. Box 202951
Helena, MT 59620
End of Key Contacts Chapter
Drug Program
Thank you for your willingness to serve members of the Montana Healthcare Programs administered by the Department of Public Health and Human Services.
Manual Organization
This manual provides information specifically for Prescription Drug Program providers. Other essential information for providers is contained in the separate General Information for Providers Manual. Providers are responsible for reviewing both manuals.
There is a list of Key Contacts at the beginning of this manual, and additional contacts are on the Contact Us link in the left menu on the Provider Information website.
Manual Maintenance
Notification of manual updates are provided through the weekly web postings under “Recent Website Posts” on the Home page of the Provider website. Older versions of the manual may be found through the Archive page on the Provider Information website. Printing the manual material found at this website for long-term use is not advisable. Department Policy material is updated periodically, and it is the responsibility of the users to make sure that the policy they are researching or applying has the correct effective date for their circumstances.
Rule References
Providers must be familiar with all current rules and regulations governing the Montana Healthcare Programs. Provider manuals are to assist providers in billing Montana Healthcare Programs; they do not contain all Montana Healthcare Programs rules and regulations. Rule citations in the text are a reference tool; they are not a summary of the entire rule. If a manual conflicts with a rule, the rule prevails. Links to rules are available on the Provider Information website. Paper copies of rules are available through the Secretary of State’s office. In addition to the general Montana Healthcare Programs rules outlined in the General Information for Providers Manual, the following rules and regulations are also applicable to the Prescription Drug Program:
- Code of Federal Regulations (CFR)
- 42 USC 1396r-8, Payment for Covered Outpatient Drugs
- Montana Codes Annotated (MCA)
- MCA 37-7-101 – MCA 37-7-1408, Pharmacy
- Administrative Rules of Montana (ARM)
- ARM 37.86.1101 – ARM 37.86.1105, Outpatient Drug Services
Claims Review (MCA 53-6-111, ARM 37.85.406)
The Department is committed to paying Montana Healthcare Programs providers’ claims as quickly as possible. Montana Healthcare Programs claims are electronically processed and usually are not reviewed by medical experts prior to payment to determine if the services provided were appropriately billed. Although the computerized system can detect and deny some erroneous claims, there are many erroneous claims which it cannot detect. For this reason, payment of a claim does not mean that the service was correctly billed, or the payment made to the provider was correct. Periodic retrospective reviews are performed which may lead to the discovery of incorrect billing or incorrect payment. If a claim is paid and the Department later discovers that the service was incorrectly billed or paid or the claim was erroneous in some other way, the Department is required by federal regulation to recover any overpayment, regardless of whether the incorrect payment was the result of Department or provider error or other cause.
Getting Questions Answered
The provider manuals are designed to answer most questions; however, questions may arise that require a call to a specific group (such as a program officer, Provider Relations, or a prior authorization unit). The Key Contacts chapter and the Contact Us link on the Provider Information website have important phone numbers and addresses. Montana Healthcare Programs manuals, provider notices, fee schedules, forms, and more are available on the Provider Information website.
Drug Program Goal
The Prescription Drug Program covers pharmaceuticals and pharmacist services to members served by the Department in the Montana Healthcare Programs and the Mental Health Services Plan (MHSP).
Who May Prescribe, Administer, or Dispense Legend Drugs and Controlled Substances?
Primary authority for the prescribing of legend drugs and controlled substances comes from individual professional practice acts, usually in the section of the act which defines the scope of practice for the profession. The definition of scope of practice is the responsibility of the board that licenses the professional. Only those providers not excluded by federal programs are eligible.
DUR Board
The Drug Use Review (DUR) Board performs drug utilization review and educational interventions. Five pharmacists and four physicians comprise the DUR Board which is coordinated by a full-time registered Montana pharmacist. The DUR Board meets monthly to review utilization and advise the Department.
Drug Use Review (DUR) Board meetings are posted on the Provider website. On the Pharmacy page, click on the Drug Use Review (DUR) Board pane.
The DUR Board and The University of Montana Skaggs School of Pharmacy also advise the Department on its outpatient drug formulary. Drugs are evaluated for safety, effectiveness, and clinical outcome. Drugs recommended for formulary exclusion have no significant, clinically meaningful therapeutic advantage over drugs recommended for inclusion.
End of Drug Program Chapter
Montana Healthcare Programs Covered Products
What Drugs and Pharmaceutical Supplies Are Covered?
Drug coverage is limited to those products where the pharmaceutical manufacturer has signed a rebate agreement with the federal government. Federal regulations further allow states to impose restrictions on payment of prescription drugs through prior authorization and preferred drug lists (PDL).
The Montana Healthcare Programs Prescription Drug Program covers the following:
- Legend drugs, subject to the PDL and prior authorization requirements.
- Selective non-prescription (over the counter (OTC)) medications. See the OTC Coverage tab on the Pharmacy page of the website. Nursing facilities are responsible for providing OTC antacids, aspirin, and laxatives to their residents.
- Compounded prescriptions
- Contraceptive supplies and devices
- Federal law allows states the discretion to cover certain medications listed in 42 USC 1396r-8. Montana Healthcare Programs has opted to cover the following medications for all members, including Medicare Part D members:
- Prescription cough and cold medications
- Selective non-prescription (over the counter (OTC)) medications. See the OTC Coverage tab on the Pharmacy page of the website. Montana Healthcare Programs does not cover proton pump inhibitors or non-sedating antihistamines for Part D members when the member’s prescription drug plan covers these classes of drugs.
- Vitamins and minerals may be granted prior authorization when indicated for the treatment of an appropriate diagnosis.
What Drugs and Pharmaceutical Supplies Are Not Covered?
The Montana Healthcare Programs Prescription Drug Program does not reimburse for the following items or services:
- Drugs supplied by drug manufacturers who have not entered into a federal drug rebate agreement.
- Drugs supplied by other public agencies such as the United States Veterans Administration, United States Department of Health and Human Services, local health departments, etc.
- Drugs for Medicare Part D dual eligible members, except for drugs covered in #5 in the What Drugs and Pharmaceutical Supplies Are Covered? section above.
- Drugs prescribed:
- To promote fertility
- For erectile dysfunction
- For weight reduction
- For cosmetic purposes or hair growth
- For an indication that is not medically accepted as determined by the Department in consultation with federal guidelines, the DUR Board, or the Department medical and pharmacy consultants.
- Drugs designated as less-than-effective (DESI drugs) or drugs that are identical, similar, or related to such drugs.
- Drugs that are experimental, investigational, or of unproven efficacy or safety.
- Free pharmaceutical samples.
- Obsolete National Drug Code (NDC).
- Terminated drug products.
- Any drug, biological product, or insulin provided as part of, or incident to and in the same setting as, any of the following:
- Inpatient hospital setting
- Hospice services
- Outpatient hospital services emergency room visit
- Other laboratory and x-ray services
- Renal dialysis
- Incarceration
- Any of the following drugs:
- Outpatient nonprescription drugs (except those OTC products previously listed)
- Covered outpatient drugs for which the manufacturer seeks to require as a condition of sale that associated tests or monitoring services be purchased exclusively from the manufacturer or its designee.
- Medical supplies (non-drug items) are not covered under the Prescription Drug Program.
a. Exception: Contraceptive supplies and devices
The Montana Preferred Drug List
To address the rising costs of prescription drugs, Montana Healthcare Programs implemented a preferred drug list (PDL) in 2005. The Department of Public Health and Human Services uses this program to provide clinically effective and safe drugs to its members at the best available price.
The PDL addresses certain classes of medications and provides a selection of therapeutically effective products for which the Montana Healthcare Programs will allow payment without restriction in those targeted classes. The Department, through its Formulary Committee, designates this listing of preferred drugs as “preferred” based primarily on clinical efficacy. In the designated classes, drug products that are non-preferred on the PDL will require prior authorization.
The Department updates the PDL annually and periodically as new drugs and information become available.
The current Montana PDL can be found on the Preferred Drug Information tab on the Pharmacy Page of the Provider Information website. Providers may address questions regarding the PDL and requests for prior authorization to the Drug Prior Authorization Unit. (See the Key Contacts chapter) The PDL/Prior Authorization Help Line is for providers only. Montana Healthcare Programs members with questions can ask their providers or call the Member Help Line, (800) 362-8312.
Medicare Part B and Part D Drug Claims
Part D
Medicare added prescription drug coverage for its beneficiaries under the Medicare Modernization Act, 42 USC 1302 Sec. 1395. Members enrolled in Medicare Part A and/or Part B are eligible for Medicare Part D and are required to receive their drug benefits through a Medicare Prescription Drug Plan (PDP). Members enrolled in both Montana Healthcare Programs and Medicare are considered “dual eligible” and are auto-enrolled in a Medicare PDP if they do not choose a plan. The Montana Healthcare Programs reimbursement for outpatient drugs provided to a full-benefit dual eligible member will be limited to the excluded drugs identified in this chapter and the Part B drugs described in the following paragraph.
Part B
Claims cross over automatically if the provider’s NPI/API is on file with Montana Healthcare Programs. The taxonomy code for the pharmacy is required on the claim.
To bill paper claims:
- Submit your claims on a CMS-1500 form.
- Attach the Medicare EOMB.
- Use your NPI/API.
- Mail to the Claims Processing Unit, P.O. Box 8000, Helena, MT 59604.
- Providers using paper claims must wait 45 days after Medicare paid date to submit claims.
Part B Crossover Claims
Part B crossover claims will be reimbursed using the following “lower of” pricing methodology:
- Montana Healthcare Programs allowed minus the Medicare paid; or
- Medicare coinsurance plus Medicare deductible.
Montana Healthcare Programs allowed for the pharmacy supplying and dispensing fee is $4.94.
For an updated list of covered Part B drugs, visit the CMS website, https://www.cms.gov.
End of Montana Healthcare Programs Covered Products Chapter
MHSP Covered Products
The Mental Health Services Plan (MHSP)
- The Mental Health Services Plan (MHSP) formulary is limited to specific psychotropic and adjunct legend drugs. The formulary is available in the MHSP Information tab on the Pharmacy page of the Provider Information website.
- The Department has rebate agreements with pharmaceutical manufacturers for many of the drugs on the formulary. Providers are asked to use preferred products to the extent possible. See the Provider Information website.
- Effective for all claims paid on or after January 1, 2020, co-payment will not be assessed. For members with MHSP coverage, there is a $425 pharmacy cap. The MHSP program pays for the first $425 in prescriptions for the member each month, and the member must pay privately for any amounts over that cap.
- Drug claims for the MHSP are processed through the same system used for Montana Healthcare Programs claims. To avoid confusion and claim denials, follow the instructions below:
- Point-of-Sale: To submit MHSP claims, use Group Number 0064206420.
- Paper Claims: Clearly write MHSP ONLY on the face of each paper claim.
MHSP Formulary
The MHSP formulary includes the following types of drugs:
- Adrenergic blocking agents
- Antianxiety drugs
- Anticonvulsants for adjunct therapy
- Antidepressants
- Antihyperkinesis/Adrenergic agents
- Antimania drugs
- Antipsychotics (limited to 15-day initial fill)
- Anti-cholinergics
- MAO inhibitors
- Miscellaneous psychotherapeutic agents
- Nonbarbituate sedatives, hypnotics
- SSRIs
Refer to the MHSP formulary on the Pharmacy page of the Provider Information website.
End of MHSP Covered Products Chapter
Dispensing
Dispensing Limitations
Prescription Quantity (ARM 37.86.1102)
Medications may not be dispensed in quantities greater than a 34-day supply except where manufacturer packing cannot be reduced to a smaller quantity.
1. The following drug classes are considered maintenance medications and may be dispensed up to a 90-day supply.
Drug Classes Considered for Maintenance Medications
Cardiovascular (Heart Health)
- Antiarrhythmics — digoxin, amiodarone
- Antihypertensives (Blood Pressure)
- Angiotensin Modulators and Combinations — benazepril, lisinopril, irbesartan, losartan, valsartan, losartan/HCTZ, valsartan/HCTZ, lisinopril/HCTZ, enalapril/HCTZ
- Calcium Channel Blockers and Combinations — amlodipine, nifedipine, verapamil, diltiazem, amlodipine/valsartan, amlodipine/benazepril, Exforge HCT
- Beta Blockers and Alpha Blockers — atenolol, propranolol, metoprolol, prazosin, doxazosin, terazosin, carvedilol
- Alpha Agonists — clonidine, guanfacine, methyldopa
- Vasodilators — hydralazine, minoxidil, isosorbide
- Diuretics — furosemide, bumetanide, torsemide, HCTZ, metolazone, chlorothiazide, indapamide, spironolactone, amiloride, triamterene/HCTZ, spironolactone/HCTZ, amiloride/HCTZ
- Antihyperlipidemics (Cholesterol) — atorvastatin, lovastatin, pravastatin, rosuvastatin, simvastatin, gemfibrozil, fenofibrate, ezetimibe
- Platelet Aggregation inhibitors and hemorrhelogic agents (Blood Thinners) — Aggrenox, aspirin, clopidogrel, dipyridamole, Effient, Brillinta, pentoxifylline
Diabetes
- Antihyperglycemic — glimepiride, glipizide, glyburide, metformin, acarbose, Glyset, glyburide/metformin
Central Nervous System
- Anticonvulsants (exclusions apply) — divalproex, ethosuximide, phenytoin, lamotrigine, levetiracetam, topiramate, zonisamide, carbamazepine, oxcarbazepine
- Anti-Parkinson's and Other Movement Disorders — carbidopa, amantadine, pramipexole, ropinirole, carbidopa-levodopa
- Skeletal Muscle Relaxants — baclofen, chlorzoxazone, cyclobenzaprine, methocarbamol, orphenadrine, tizanidine
Gastrointestinal
- Antacids — Tums, Maalox
- Anti-Ulcer — sucralfate, misoprostol
- H2-Inhibitors — famotidine, ranitidine
- Bile Salts — ursodiol
Renal System
- Incontinence — oxybutynin, Toviaz
- Electrolyte Depleters/Replacers — calcium acetate, Renagel, potassium chloride, Phos-Nak, potassium citrate
- Hyperuricemia (Gout) — allopurinol, probenecid
Respiratory
- Antihistamines — cetirizine, loratadine, levocetirizine
- Leukotriene Receptor Antagonist (Asthma/Allergies) — montelukast
- Other — theophylline
Men and Women’s Health
- Contraceptives (oral, transdermal, intravaginal)
- Prostate — alfuzosin, tamsulosin, finasteride, dutasteride
- Breast Cancer — tamoxifen
- Vitamin Supplementation (restrictions apply) — prenatal vitamins, vitamin B, vitamin D, folic acid
Other Body Systems
- Bone Strength — alendronate, raloxifene
- Thyroid/Antithyroid — levothyroxine, methimazole, propylthiouracil
- NSAIDs (Pain/Inflammation) — diclofenac, ibuprofen, indomethacin, meloxicam, naproxen, sulindac, celecoxib
2. No more than two prescriptions of the same drug may be dispensed in a calendar month except for the following:
- Antibiotics
- Schedule II through V drugs
- Antineoplastic agents
- Compounded prescriptions
- Prescriptions for suicidal members or members at risk for drug abuse
- Topical preparations
The DUR Board has set monthly limits on certain drugs. Use over these amounts requires prior authorization.
Prescription Refills
Prescriptions for non-controlled substances may be refilled after 75% of the estimated therapy days have elapsed. Prescriptions for controlled substances (CII-CV), Ultram (tramadol), Ultracet (tramadol/acetaminophen), carisoprodol, and gabapentin may be refilled after 90% of the estimated therapy days have elapsed. The POS system will deny a claim for “refill to soon” based on prescriptions dispensed on month-to-month usage.
A prescription may be refilled early only if the prescriber changes the dosage, or if the member was admitted to a nursing facility. The pharmacist must document any dosage change. In any circumstance, the provider must contact the Drug Prior Authorization Unit to receive approval. (See Key Contacts.)
Pharmacists who identify members who experience difficulties in managing their drug therapy may consider unit dose prescriptions (see below).
Generic Drugs
The Department has a mandatory generic edit in the claims processing system. The edit is enabled once there are two rebateable AB-rated generic drugs available in the marketplace. Typically, the first generic labeler will have a six-month period of market exclusivity. To maximize value to the State, the Department recommends dispensing the brand name drug over the generic during this period of market exclusivity. Brands may be preferred over generics in other instances where there is a net cost benefit to the Department. Brand over generic preferences are listed on the PDL. When there are “preferred brands” on the Department’s PDL, generic equivalent drugs will require a prior authorization.
For drugs not subject to PDL restrictions and for those drugs listed in the Dispense As Written (DAW) section of the Billing Procedures chapter, if the brand name drug is prescribed instead of a generic equivalent, the prescriber must get prior authorization.
Authorization is based on medical need such as adverse reactions or therapeutic failures (clinically demonstrated, observed and documented) which have occurred when the generic drug has been used.
Unit Dose Prescriptions
Pharmacy-packaged unit dose medications may be used to supply drugs to members in nursing facilities, group homes, and other institutional settings.
Members who are not in one of the above facilities may also be considered high-risk and eligible for unit dose packaging if they:
- Have one or more of the following representative disease conditions: Alzheimer’s disease, blood clotting disorders, cardiac arrhythmia, congestive heart failure, depression, bipolar, cancer, diabetes, epilepsy, HIV/AIDS, hypertension, schizophrenia, or tuberculosis; and
- Consume two or more prescribed concurrent chronic medications which are dosed at three or more intervals per day; or
- Have demonstrated a pattern of noncompliance that is potentially harmful to their health.
Unit dose prescriptions may not exceed the 34-day supply limit.
Compounding
The Department shall reimburse pharmacies for compounding drugs only if the member’s drug therapy needs cannot be met by commercially available dosage strengths and/or forms of the therapy.
Prescription claims for compound drugs shall be billed and reimbursed using the National Drug Code (NDC) number and quantity for each compensable ingredient in the compound. No more than 25 ingredients may be reimbursed in any compound. Reimbursement for each drug component shall be determined in accordance with ARM 37.86.1101. Prior authorization requirements for individual components of a compound must be met for reimbursement purposes. The Department does not consider reconstitution to be compounding.
The Department may reimburse for compounded non-rebateable API bulk powders and excipients on the Department’s drug formulary maintained in accordance with ARM 37.86.1102.
Counseling Requirements
Pharmacies must comply with Montana Board of Pharmacy patient counseling requirements specified in Administrative Rules of Montana (ARM) 24.174.903.
Pharmacies must also comply with all record retention requirements outlined in Administrative Rules of Montana (ARM) 37.85.414.
Signature Requirements
As specified in Administrative Rules of Montana (ARM) 37.86.1102(10), “a provider must maintain a signature log to act as proof that the dispensed medication has been received by the member or an individual acting on behalf of the member. The member, or an individual acting on behalf of the member, must sign the log each time that they receive a prescription drug from a pharmacy provider. For prescription drugs delivered to a nursing facility, the individual charged with ensuring the security of pharmaceutical supplies may sign the log after verifying delivery of all prescription drugs.”
Pharmacies must also comply with all record retention requirements outlined in Administrative Rules of Montana (ARM) 37.85.414.
End of Dispensing Limitations Chapter
Prior Authorization
Prior Authorization for Covered Drugs
Many drug products require prior authorization before the pharmacist provides them to the member. Requests are reviewed for medical necessity.
- To request prior authorization, providers must submit the information requested on the Request for Drug Prior Authorization form to the Drug Prior Authorization Unit. See the Forms link in the site index in the left menu on the Provider Information website.
- The prescriber (e.g., physician) or pharmacy may submit requests by mail, telephone, or fax to:
Drug Prior Authorization Unit
Mountain-Pacific Quality Health
P.O. Box 5119
Helena, MT 59604
(406) 443-6002 or 800-395-7961 (Phone)
(406) 513-1928 or 800-294-1350 (Fax)
- Requests are reviewed and decisions made immediately in most cases. Decisions on requests with special circumstances that require further peer review are made within 24 hours. Requests received after the Drug Prior Authorization Unit’s regular working hours of 8 a.m. to 5 p.m., Monday through Friday, or on weekends or holidays, are considered received at the start of the next working day.
- An emergency 72-hour supply may be dispensed for emergency, after-hours, weekend, and holiday requests. Payment will be authorized by using a “3” in the Days Supply field and a value of “8” in the Prior Authorization Type Code field.
Prior Authorization for Retroactively Eligible Members
All prior authorization requirements must be met for retroactively eligible members.
When a member is determined retroactively eligible for Montana Healthcare Programs, the member should give the provider a Notice of Retroactive Eligibility (160-M).
The provider has 12 months from the date retroactive eligibility was determined to bill for those services.
Retroactive Montana Healthcare Programs eligibility does not allow a provider to bypass prior authorization requirements.
When a member becomes retroactively eligible for Montana Healthcare Programs, the provider may:
- Accept the member as a Montana Healthcare Programs member from the current date.
- Accept the member as a Montana Healthcare Programs member from the date retroactive eligibility was effective.
- Require the member to continue as a private-pay member.
Providers may choose whether to accept retroactive eligibility. (See the General Information for Providers Manual, Member Eligibility and Responsibilities chapter.) All prior authorization requirements must be met to receive Montana Healthcare Programs payment.
When submitting claims for retroactively eligible members, attach a copy of the Notice of Retroactive Eligibility (Form 160-M) to the claim if the date of service is more than 12 months earlier than the date the claim is submitted.
MHSP Prior Authorization Criteria
For a list of drugs requiring prior authorization, contact the Drug Prior Authorization Unit. (See Key Contacts.)
End of Prior Authorization Chapter
Reimbursement
Reimbursement for Covered Drugs
Reimbursement for covered brand and generic preferred drugs shall not exceed the lowest of:
- The provider’s usual and customary charge of the drug to the general public; or
- The allowed ingredient cost plus a professional dispensing fee. Where allowed ingredient cost is defined as the lower of:
- The Average Acquisition Cost (AAC); or
- Submitted ingredient cost.
- If an AAC rate is not available, drug reimbursement is determined at the lower of:
- Wholesale Acquisition Cost (WAC);
- Affordable Care Act Federal Upper Limit (ACA FUL); or
- Submitted ingredient cost.
Average Acquisition Cost
Average acquisition cost (AAC) is the calculated average drug ingredient cost per drug determined by direct pharmacy survey, wholesale survey, and other relevant cost information. The AAC rates are published online under the Pharmacy Provider webpage.
Submitted Ingredient Cost
Submitted Ingredient is a pharmacy’s actual ingredient cost. For drugs purchased under the 340B Drug Pricing Program, submitted ingredient cost means the actual 340B purchase price. For drugs purchased under the Federal Supply Schedule (FSS), submitted ingredient cost means the actual FSS purchase price.
Usual and Customary
The usual and customary charge is the price the provider most frequently charges the general public for the same drug. In determining “usual and customary” prices, the Department:
- Does not include prescriptions paid by third party payers, including health insurers, governmental entities, and Montana Healthcare Programs, in the general public.
- Includes discounts advertised or given (including but not limited to cash rebate, monetary price discount, coupon of value) to any segment of the general public.
- Uses the lower of the two pricing policies if a provider uses different pricing for “cash” and “charge” members.
- Will use the median price if during an audit, the most frequent price cannot be determined from pharmacy records.
Federal Maximum Allowable Cost (MAC)
- The Federal Upper Limit pricing set by the U.S. Department of Health and Human Services Centers for Medicare and Medicaid (CMS).
Dispensing Fee
- The dispensing fee assigned shall range between:
- The minimum of $4.32 and the maximum of $15.73 for pharmacies with an annual prescription volume between 0 and 39,999
- The minimum of $4.32 and the maximum of $13.62 for pharmacies with an annual prescription volume between 40,000 and 69,999; or
- The minimum is $4.32 and the maximum is $11.52 for pharmacies with an annual prescription volume greater than 70,000.
- The dispensing fee for each compounded drug shall be $12.50, $17.50, or $22.50 based on the level of effort required by the pharmacist.
- New pharmacy providers are assigned the maximum dispensing fee. Failure to comply with the six-month dispensing fee questionnaire requirement will result in assignment of a dispensing fee of the lowest calculated cost to dispense that year.
- Pharmacies may receive an additional $0.75 for dispensing pharmacy-packaged unit dose prescriptions.
- Dispensing fee surveys are available from the Department of Public Health and Human Services Prescription Drug Program. (See Key Contacts.)
Vaccine Administration Fee
Pharmacies can receive a vaccine administration fee. This fee is in lieu of the standard dispensing fee. The fee for the first vaccine administered will be $21.32; the fee for each additional vaccine administered will be $15.65.
For the COVID-19 vaccine, Montana Healthcare Programs will follow the Medicare established rates for the administration fee, which are different from the above rates.
The Remittance Advice
The remittance advice is the best tool providers have to determine the status of a claim. Remittance advices accompany payment for services rendered. The remittance advice provides details of all transactions that have occurred during the previous remittance advice cycle. Each line of the remittance advice represents all or part of a claim and explains whether the claim or service has been paid, denied, or suspended (also referred to as pending). If the claim was suspended or denied, the remittance advice also shows the reason. See the General Information for Providers manual for more information on the remittance advice.
As of July 2013, all new providers were required to enroll in electronic funds transfer (EFT) and receive electronic remittance advices. Providers who enrolled prior to July 2013 who received paper checks or paper remittance advices were transitioned to the electronic-only system over time.
Credit Balances
Credit balances occur when claim adjustments reduce original payments causing the provider to owe money to the Department. These claims are considered in process and continue to appear on the remittance advice until the credit has been satisfied. Credit balances can be resolved in two ways:
- By working off the credit balance. Remaining credit balances can be deducted from future claims. These claims will continue to appear on consecutive remittance advices until the credit has been paid.
- By sending a check payable to DPHHS for the amount owed. This method is required for providers who no longer submit claims to Montana Healthcare Programs. Attach a note stating that the check is to pay off a credit balance and include your provider number. Send the check to Third Party Liability
Rebilling and Adjustments
Rebillings and adjustments are important steps in correcting any billing problems you may experience. Knowing when to use the rebilling process versus the adjustment process is important. When submitting a reversal (void) use a B2 NCPDP transaction and when submitting a rebilled claim or an adjustment use a B3 NCPDP transaction (void & rebill).
Timeframe for Rebilling or Adjusting a Claim
- Providers may resubmit or adjust any initial claim within the timely filing limits described in the Billing Procedures chapter of this manual. Depending on switch-vendor requirements, some point-of-sale adjustments must be completed within three months. In this case, adjustments may be submitted on paper within the timely filing limits.
- These time periods do not apply to overpayments that the provider must refund to the Department. After the 12-month time period, a provider may not refund overpayments to the Department by completing a claim adjustment. The provider may refund overpayments by issuing a check or asking the Third-Party Liability Unit to complete a gross adjustment.
Rebilling Montana Healthcare Programs
Rebilling is when a provider submits a claim or claim line to Montana Healthcare Programs that was previously submitted for payment but was either returned or denied. Pharmacy providers can rebill Montana Healthcare Programs via point-of-sale or on paper. Paper claims are often returned to providers before processing because information such as the NPI or authorized signature/date are missing or unreadable. See the Billing Procedures chapter for tips on preventing returned or denied claims.
When to Rebill Montana Healthcare Programs
- Claim Denied. Providers can rebill Montana Healthcare Programs when a claim is denied in full, as long as the claim was denied for reasons that can be corrected. When the entire claim is denied, check the Explanation of Benefits (EOB) code, make the appropriate corrections, and resubmit the claim (not an adjustment).
- Line Denied. When an individual line is denied on a multiple-line claim, correct any errors and rebill Montana Healthcare Programs. Either submit the denied service on a new Universal Claim Form Version 1.2-02/2013, or cross out paid lines and resubmit the form, or submit via point-of-sale. Do not use an adjustment form.
- Claim Returned. Rebill Montana Healthcare Programs when the claim is returned under separate cover. Occasionally, Montana Healthcare Programs is unable to process the claim and will return it to the provider with a letter stating that additional information is needed to process the claim. Correct the information as directed and resubmit your claim. Paper pharmacy claims should be billed on a Universal Claim Form Version 1.2-02/2013.
How to Rebill
- Check any EOB code listed and make your corrections on a copy of the claim, or produce a new claim with the correct information, or rebill using point-of-sale.
- When making corrections on a copy of the claim, remember to cross out or omit all lines that have already been paid. The claim must be neat and legible for processing.
- Enter any insurance (third party liability) information on the corrected claim, or attach insurance denial information to the corrected claim, and send it to Claims Processing.
Adjustments
If a provider believes that a claim has been paid incorrectly, the provider may call Provider Relations. Once an incorrect payment has been verified, the provider may submit an Individual Adjustment Request form to Provider Relations or submit an adjustment through point-of-sale. If incorrect payment was the result of a Conduent keying error, the provider should contact Provider Relations.
When adjustments are made to previously paid claims, the Department recovers the original payment and issues appropriate repayment. The result of the adjustment appears on the provider’s RA as two transactions. The original payment will appear as a credit transaction. The replacement claim reflecting the corrections will be listed as a separate transaction and may or may not appear on the same remittance advice as the credit transaction. The replacement transaction will have nearly the same ICN number as the credit transaction, except the 12th digit will be a 2, indicating an adjustment. Adjustments are processed in the same time frame as claims.
When to Request an Adjustment
- • Request an adjustment when a claim was overpaid or underpaid.
• Request an adjustment when a claim was paid but the information on the claim was incorrect (e.g., member ID, NPI, date of service, NDC, prescribing provider, units).
How to Request an Adjustment
To request an adjustment, use the Individual Adjustment Request form. Adjustments may also be made using point-of-sale. The requirements for adjusting a claim are as follows:
- Claims Processing must receive individual claim adjustment requests within 12 months of the date of service. (See Timely Filing Limits in the Billing Procedures chapter.) After this time, gross adjustments are required.
- Use a separate adjustment request form for each TCN.
- If you are correcting more than one error per TCN, use only one adjustment request form, and include each error on the form.
- If more than one line of the claim needs adjusting, indicate which lines and items need to be adjusted in the Remarks section of the adjustment form.
Completing an Adjustment Request Form
- You may download the Individual Adjustment Request form from the Provider Information website. Complete Section A first with provider and member information and the claim’s TCN.
- Complete Section B with information about the claim. Complete only the items that need to be corrected. (See the table on next page.)
- Enter the date of service or the line number in the Date of Service or Line Number column.
- Enter the information from the claim that was incorrect in the Information on Statement column.
- Enter the correct information in the Corrected Information column.
- Attach copies of the remittance advice and a corrected claim if necessary.
- If the original claim was billed electronically, a copy of the remittance advice will suffice.
- If the remittance advice is electronic, attach a screen print of it.
- Verify the adjustment request has been signed and dated.
- Send the adjustment request to Claims Processing.
- If an original payment was an underpayment by Montana Healthcare Programs, the adjustment will result in the provider receiving the additional payment amount allowed.
- If an original payment was an overpayment by Montana Healthcare Programs, the adjustment will result in recovery of the overpaid amount through a credit balance or a check from the provider. (See Credit Balances earlier in this chapter.)
- Any questions regarding claims or adjustments must be directed to Provider Relations.
Completing an Individual Adjustment Request Form
Section A
Field: 1. Provider Name and Address
Description: Provider’s name and address (and mailing address if different).
Field: 2. Member Name
Description: The member’s name.
Field: 3.* Internal Control Number (ICN)
Description: There can be only one TCN per Adjustment Request form. When adjusting a claim that has been previously adjusted, use the TCN of the most recent claim.
Field: 4*. Provider NPI/API
Description: The provider’s NPI/API
Field: 5*. Member's Montana Healthcare Programs Number
Description: Member's Montana Healthcare Programs ID number.
Field: 6. Date of Payment
Description: Date claim was paid found on Remittance Advice Field 5 (see the sample RA earlier in this chapter).
Field: 7. Amount of Payment
Description: The amount of payment from the Remittance Advice Field 19 (see the sample RA earlier in this chapter.).
Section B
Field: 1. Units of Service
Description: If a payment error was caused by an incorrect number of units, complete this line.
Field: 2. Procedure Code/NDC/Revenue Code
Description: If the procedure code, NDC, or revenue code are incorrect, complete this line.
Field: 3. Dates of Service (DOS)
Description: If the date of service is incorrect, complete this line.
Field: 4. Billed Amount
Description: If the billed amount is incorrect, complete this line.
Field: 5. Personal Resource (Nursing Facility)
Description: If the member's personal resource amount is incorrect, complete this line.
Field: 6. Insurance Credit Amount
Description: If the member’s insurance credit amount is incorrect, complete this line.
Field: 7. Net (Billed - TPL or Medicare Paid)
Description: If the payment error was caused by a missing or incorrect insurance credit, complete this line. Net is billed amount minus the amount TPL or Medicare paid.
Field: 8. Other/Remarks
Description: If none of the above items apply, or if you are unsure what caused the payment error, complete this line.
*Indicates a required field
Mass Adjustments
Mass adjustments are done when it is necessary to reprocess multiple claims. They generally occur when:
- Montana Healthcare Programs has a change of policy or fees that is retroactive. In this case federal laws require claims affected by the changes to be mass adjusted.
- A system error that affected claims processing is identified.
Providers are informed of mass adjustments by a provider notice or on the first page of the remittance advice. Mass adjustment claims shown on the RA have an ICN that begins with a 4.
Payment and the Remittance Advice
Providers receive their Montana Healthcare Programs payment and remittance advices weekly. To sign up for EFT (direct deposit) and register for the web portal to view or download remittance advices, providers need to complete the EFT and ERA Authorization Agreement and the EDI Trading Partner Agreement and mail or fax them to Provider Relations. See the Provider Enrollment page for those documents.
A letter from your financial institution verifying legitimacy of the account is also required. The letter must include the name and contact information of the bank representative and be signed by the bank representative. Do not send voided checks or deposit slips.
Once enrolled in EFT and registered for the MATH web portal, providers are able to receive their electronic remittance advices. Due to space limitations, each remittance advice is available on the web portal for 90 days.
For assistance on enrolling in EFT, completing the EDI Trading Partner Agreement, and registering for the MATH web portal, contact Provider Relations.
End of Reimbursement Chapter
Billing Procedures
How to Bill Pharmacy Claims
- The Department supports NCPDP X2 Version D.0 electronic transactions.
- If a claim must be billed on paper, the Department supports the Universal Claim Form Version 1.2 - 02/2013.
- Pharmacies are eligible to receive five free Universal Claim Forms per year through NCPDP. To obtain a copy, please call (480) 477-1000.
- If a pharmacy needs more paper forms, they can be ordered through CommuniForm LLC via phone (877) 817-3676 or fax at (866) 308-2036. Providers may also request online login access from CommuniForm LLC by calling (877) 817-3676 to order forms online by logging in at https://www.asbaces.com/NEWACES/(S(exhfqdwrar3yfin0ozystqw0))/storefront.aspx.
- Pharmacies are eligible to receive five free Universal Claim Forms per year through NCPDP. To obtain a copy, please call (480) 477-1000.
Provider Number
- The Department uses the pharmacy’s NPI as the provider number for billing purposes.
- The Department-assigned provider number is used for payment and reporting purposes.
- Changes in pharmacy ownership or NABP (NCPDP) number must be reported immediately to ensure that payments are received by the billing owner. Contact Provider Relations to report all ownership changes.
Provider Enrollment
P.O. Box 4936
Helena, MT 59604
(800) 624-3958
(406) 442-1837
Tamper-Resistant Pads
Written prescriptions must contain all of the following.
- One or more industry-recognized features designed to prevent unauthorized copying of a completed or blank prescription form;
- One of more industry-recognized features designed to prevent the erasure or modification of information written on the prescription by the prescriber; and
- On or more industry-recognized features designed to prevent the use of counterfeit prescription forms.
Outpatient pharmacy claims for Montana Healthcare Programs and MHSP require the prescription origin code to indicate the source of the prescription. Valid values for prescription origin code are:
- 0 – Not specified
- 1 – Written prescription
- 2 – Telephone
- 3 – Electronic
- 4 – Facsimile
How Long Do I Have to Bill?
Providers are required to submit a clean claim no later than 365 days from:
- The date of service;
- The date retroactive eligibility is determined;
- The date disability is determined; or
- Within 6 months of the date Medicare pays, whichever is later.
A clean claim is one that can be adjudicated without correction or additional information or documentation from the provider.
Prescription Tracking and Claim Reversals
For purposes of billing for prescribed drugs, the date of service means the date a prescription is filled. If the drug has not been received by the member or the member’s representative within 15 days after the prescription is filled, the pharmacy must reverse the claim and refund the payment to the Department.
Tips to Avoid Timely Billing Denials
- Correct and resubmit denied claims promptly. (See the Reimbursement chapter, Remittance Advices and Adjustments section in this manual.)
- If a claim submitted to Montana Healthcare Programs does not appear on the remittance advice within 30 days, contact Provider Relations for claim status.
When to Bill Montana Healthcare Programs Members (ARM 37.85.406)
In most circumstances, providers may not bill Montana Healthcare Programs members for services covered under Montana Healthcare Programs. More specifically, providers cannot bill members directly:
- For the difference between charges and the amount Montana Healthcare Programs paid.
- For a covered service provided to a Montana Healthcare Programs-enrolled member who was accepted as a Montana Healthcare Programs member by the provider, even if the claim was denied.
Under certain circumstances, providers may need a signed agreement in order to bill a Montana Healthcare Programs member (see the following table).
Routine Agreement: This may be a routine agreement between the provider and member which states that the member is not accepted as a Montana Healthcare Programs member, and that he/she must pay for the services received.
Custom Agreement: This agreement lists the service the member will receive and states that the service is not covered by Montana Healthcare Programs and that the member will pay for the services received.
Billing for Retroactively Eligible Members
When the provider accepts the member’s retroactive eligibility, the provider has 12-months from the date retroactive eligibility was determined to bill for those services.
When submitting claims for retroactively eligible members in which the date of service is more than 12 months earlier than the date the claim is submitted, attach a copy of the Provider Notice of Eligibility (Form 160-M). The provider must request the form from the member’s local Office of Public Assistance.
See https://dphhs.mt.gov/hcsd/OfficeofPublicAssistance. For more information on retroactive eligibility, see the Member Eligibility and Responsibilities chapter in the General Information for Providers Manual.
Usual and Customary Charge (ARM 37.85.406)
Providers should bill Montana Healthcare Programs their usual and customary charge for each service; that is, the same charge that is made to other payers for that service.
Member Co-Payment (ARM 37.85.204)
Effective for all claims paid on or after January 1, 2020 co-payment will not be assessed. For members with Mental Health Services Plan (MHSP) coverage, there is a $425 pharmacy cap. The MHSP program pays for the first $425 in prescriptions for the member each month, and the member must pay privately for any amounts over that cap.
The provider must always use the complete 11-digit NDC from the dispensing container.
National Drug Codes (NDC)
All outpatient prescription drugs are billed using the drug’s NDC, the 11-digit code assigned to all prescription drug products by the labeler or distributor of the product under FDA regulations.
The Department accepts only the 5-4-2 NDC format. All 11 digits, including zeros, must be entered. The three segments of the NDC are:
SAMPLE NDC: 12345-6789-10
12345 = labeler code
6789 = product code
10 = package size
Claims must accurately report the NDC dispensed, the number of units dispensed, days supply, and the date of dispensing. Use of an incorrect NDC or inaccurate reporting of a drug quantity will cause the Department to report false data to drug manufacturers billed for drug rebates.
The Department will recover payments made on erroneous claims discovered during dispute resolution with drug manufacturers. Pharmacies are required to document purchase for quantities of brands of drugs reimbursed by the Department if disputes occur.
Dispense As Written (DAW)
Prescribers and pharmacies must prescribe and dispense the generic form of a drug whenever possible. Except for those drugs listed below, prior authorization is required when a brand name drug is prescribed instead of a generic equivalent. Please use the following DAW codes for these situations:
- DAW 1 may only be used if authorized by the Drug Prior Authorization Unit. In addition to prior authorization requirements, brand name drugs with a generic equivalent (except those required by the PDL) may be billed only when the prescriber has handwritten “brand necessary” or “brand required” on the prescription. The pharmacy must retain brand certifications as documentation.
- DAW 5 may be used in instances where the drug dispensed is generic but is listed as a brand (branded generics) and some cases a prior authorization is required.
- DAW 7 may be used for seizure medications with an appropriate diagnosis without prior authorization. Based on DUR Board recommendations only antiepileptic medications being used for a seizure diagnosis, and anti-hemophilic factors will continue to be considered narrow therapeutic index (NTI) drugs. A DAW 7 override will be allowed on these drugs only. See the 2009 provider notice on the Pharmacy page of the website for additional information.
- DAW 9 is used when a brand name multisource drug is preferred and pharmacy is dispensing the brand name drug, this exempts the pharmacy from using the generic and allows reimbursement at the brand name rate.
Abuse and Misutilization
The following practices constitute abuse and misutilization:
- Excessive Fees: Commonly known as prescription splitting or incorrect or excessive dispensing fees. Billing inappropriately in order to obtain dispensing fees in excess of those allowed by:
- Supplying medication in amounts less than necessary to cover the period of the prescription.
- Supplying multiple medications in strengths or quantities less than those prescribed to gain more than one dispensing fee.
- Excessive Filling: Billing for an amount of a drug or supply greater than the prescribed quantity.
- Prescription Shorting: Billing for drug or supply greater than the quantity actually dispensed.
- Substitution to Achieve a Higher Price: Billing for a higher priced drug than prescribed even though the prescribed lower priced drug was available.
Third Party Payer – Negative Payment Amounts
Montana Healthcare Programs will not approve a claim with a negative payment amount (from click fees or PBM clawbacks) or allow pharmacies to bypass the primary insurance to eliminate the negative payment amount. If a pharmacy receives a negative amount from the primary insurance and a member has Montana Healthcare Programs as secondary, the pharmacy must bill with the following to receive payment from the Department:
- Other Coverage Code = 4, defined as Other Coverage exists – payment not collected – NCPDP field (308-C8)
- Other Payer Amount – NCPDP field (431-DV) = $0.00
In addition, providers are reminded that aside from a member copayment, if there is one, payment from Montana Healthcare Programs is payment in full. Negative payment amounts may not be passed on to members.
Psychiatric Residential Treatment Facility (PRTF) Non-Psychotropic Medications
Pharmacies who fill medications for PRTFs are able to bill for non-psychotropic medications for members currently in an all-inclusive PRTF by submitting the claim with a submission clarification code (SCC) of 10 in NCPDP field (420-DK). If these pharmacies receive a claim rejection of “member enrolled in all-inclusive program, contact facility for payment” despite submitting with a SCC code of 10, this indicates the medication being billed is classified as a psychotropic medication and can’t be reimburse through the pharmacy benefit. Psychotropic medications are included in the all-inclusive payment and must be billed to the facility. However, if the medication is on the psychotropic list but is being used for a non-psychiatric diagnosis, a prior authorization may be obtained by calling the Drug Prior Authorization Unit at (406) 443-6002 or (800) 395-7961.
If pharmacies are trying to bill prescriptions for a member that has been released from an all-inclusive facility but are still getting denied claims with the same rejection referenced above, please contact the Pharmacy Program Officer or the Montana Healthcare Programs Pharmacist.
End of Billing Procedures Chapter
Point-of-Sale
What Is the Pharmacy Point-of-Sale (POS)?
The point-of-sale (POS) system finalizes claims at the point of entry as either paid or denied. Pharmacies arrange their own telecommunications switch services to accept Montana Healthcare Programs point of sale and are responsible for any charges imposed by these vendors. Hard copy (paper) billing is still accepted when billed on a Universal Claim Form Version 1.2-02/2013. All claims are processed and edited through the POS system regardless of how the claim was originally submitted.
If the claim continues to deny for eligibility past 3 working days, call Provider Relations at (800) 624-3958.
Possession of a Montana Access to Health (MATH) Montana Healthcare Programs ID card is not proof of eligibility.
Member eligibility may change monthly, so providers should verify eligibility each month. Both the 7-digit member number and the member’s Social Security number are billable numbers. If a claim is rejected online, a provider should verify eligibility by one of the methods (MATH web portal, IVR, FaxBack, calling Provider Relations) described in the General Information for Providers Manual.
Pro-DUR
The POS system performs all major prospective drug utilization review (Pro-DUR) edits. In some circumstances, the Pro-DUR edits result in denied claims. When a Pro-DUR denied claim needs to be overridden, pharmacy providers may enter one Reason for Service Code (formerly DUR Conflict Code) from each category in the following order, as long as the indicated situations exist and the pharmacy retains documentation in its files:
- Two-byte alpha Reason for Service Code, followed by...
- Two-byte alphanumeric Professional Service Code, followed by...
- Two-byte alphanumeric Result of Service Code
By placing codes into the claim, the provider is certifying that the indicated DUR code is true and documentation is on file. For questions regarding DUR codes, contact the Drug Prior Authorization Unit.
NCPDP DUR Codes
End of Point-of-Sale Chapter
Billing a Paper Claim
Completing a Universal Claim Form
Providers may also request online login access from CommuniForm LLC by calling (877) 817-3676. Forms can be ordered online by logging in at https://www.asbaces.com/NEWACES/(S(exhfqdwrar3yfin0ozystqw0))/storefront.aspx.
For MHSP claims, clearly write MHSP ONLY on the face of each paper claim.
Paper claims must be mailed to the following address:
Claims Processing Unit
P.O. Box 8000
Helena, MT 59604
Universal Claim Form Instructions
| Field Number | Field Title | Instructions |
|---|---|---|
| 1 | ID-Insurance | Enter the Member ID. |
| 2 | Group ID-Insurance | Enter the insurance Group ID. |
| 3 | Last-Insurance | Enter the last name of the member |
| 4 | First-Insurance | Enter the first name of the member. |
| 5 | Plan Name-Insurance | Enter the plan name for the member. |
| 6 | BIN #-Insurance | Enter the BIN number from the member ID Card. |
| 7 | Processor Control #-Insurance | Enter the PCN number from the member ID card. |
| 8 | CMS Part D Defined Qualified Facility | Enter a "Y" or "N" if the pharmacy is a CMS Part D Defined Qualified Facility. |
| 9 | Last-Member | Enter the member last name. |
| 10 | First-Member | Enter the member first name. |
| 11 | Person Code-Member | Enter the three digit person code. |
| 12 | D.O.B.-Member | Enter the member date of birth in MM-DD-CCYY format. |
| 13 | Gender-Member | Enter the member gender code. |
| 14 | Relationship-Member | Enter the relationship code between the member and cardholder. |
| 15 | Member Residence-member | Enter the member residence code. |
| 16 | DO NOT USE | Leave this field blank. |
| 17 | Service Provider ID-Pharmacy | Enter the pharmacy ID. |
| 18 | Qualifier-Pharmacy | Enter the service provider ID qualifier code. |
| 19 | Name-Pharmacy | Enter the name of the pharmacy. |
| 20 | Telephone #-Pharmacy | Enter the telephone number for the pharmacy. |
| 21 | Address-Pharmacy | Enter the address of the pharmacy. |
| 22 | City-Pharmacy | Enter the city of the pharmacy. |
| 23 | State-Pharmacy | Enter the State of the Pharmacy. |
| 24 | Zip-Pharmacy | Enter the zip code for the pharmacy. |
| 25 | Signature of Provider | The provider must sign this field. |
| 26 | Date | Enter the date in which the provider signed the paper claim. |
| 27 | ID-Prescriber | Enter the ID for the prescribing provider. |
| 28 | Qualifier-Prescriber | Enter the the prescriber ID qualifier. |
| 29 | Last Name-Prescriber | Enter the prescriber's last name. |
| 30 | ID-Pharmacist | Enter the pharmacist's ID number. |
| 31 | Qualifier-Pharmacist | Enter the pharmacist's ID qualifier. |
| 32 | Prescription/Service Ref. #-Claim | Enter the Prescription or reference number. |
| 33 | Qual-Claim | Enter the prescription or service ID qualifier. |
| 34 | Fill #- Claim | Enter the fill number. |
| 35 | Date Written-Claim | Enter the date the prescription was written. |
| 36 | Date of Service-Claim | Enter the date of service. |
| 37 | Submission Clarification-Claim | Enter the submission clarification code. |
| 38 | Prescription Origin-Claim | Enter the prescription origin code. |
| 39 | Pharmacy Service Type-Claim | Enter the pharmacy service type code. |
| 40 | Special Packaging Indicator-Claim | Enter the special packaging indicator code. |
| 41 | Product/Service ID-Claim | Enter the product/service ID. |
| 42 | Qual-Claim | Enter the product/service ID qualifier. |
| 43 | Product Description-Claim | Enter the product description. |
| 44 | Quantity Dispensed-Claim | Enter the quantity dispensed. |
| 45 | Days Supply-Claim | Enter the days supply dispensed. |
| 46 | DAW Code- Claim | Enter the appropriate DAW code. |
| 47 | Prior Auth # Submitted-Claim | Enter the prior authorization number submitted. |
| 48 | PA Type-Claim | Enter the prior authorization type code. |
| 49 | Other Coverage-Claim | Enter the appropriate other coverage code, if applicable. |
| 50 | Delay Reason-Claim | Enter the appropriate delay reason code. |
| 51 | Level of Service-Claim | Enter the level of service. |
| 52 | Place of Service-Claim | Enter the place of service. |
| 53 | Quantity Prescribed-Claim | Enter the total quantity prescribed. |
| 54 | Diagnosis Code-Clinical | Enter the appropriate diagnosis code. |
| 55 | Qual-Clinical | Enter the diagnosis code qualifier. |
| 56 | DUR/PPS Codes- Reason-DUR | Enter the DUR/PPS reason for service code. |
| 57 | DUR/PPS Codes-Service-DUR | Enter the DUR/PPS service code. |
| 58 | DUR/PPS Codes-Result-DUR | Enter the DUR/PPS result of service code. |
| 59 | Level of Effort-DUR | Enter the level of effort-required when billing a compound. |
| 60 | Procedure Modifier-DUR | Enter the procedure modifier. |
| 61 | Other Payer ID-COB 1 | Enter the other payer ID when COB is present. |
| 62 | Qual-COB 1 | Enter the other payer ID qualifier. |
| 63 | Other Payer Date-COB 1 | Enter the date in which the other payer paid the claim. |
| 64 | Other Payer Rejects-COB 1 | Enter the other payer reject codes (maximum of 3). |
| 65 | Other Payer ID-COB 2 | Enter the other payer ID when COB is present. |
| 66 | Qual-COB 2 | Enter the other payer ID qualifier. |
| 67 | Other Payer Date-COB 2 | Enter the date in which the other payer paid the claim. |
| 68 | Other Payer Rejects-COB 2 | Enter the other payer reject codes (maximum of 3). |
| 69 | Dosage Form Description Code-Compound | Enter the dosage form description code. |
| 70 | Dispensing Unit Form Indicator-Compound | Enter the dispensing unit form indicator. |
| 71 | Route of Administration | Enter the SNOMED route of administration code. |
| 72 | Ingredient Component Count-Compound | Enter the ingredient component count code. |
| 73 | Product Name-Compound | Enter the product name (maximum of 25). |
| 74 | Product ID-Compound | Enter the product ID (maximum of 25). |
| 75 | Qual-Compound | Enter the product ID number qualifier (maximum of 25). |
| 76 | Ingredient QTY-Compound | Enter the ingredient quantity. |
| 77 | Ingredient Drug Cost-Compound | Enter the ingredient drug cost associated with the product ID. |
| 78 | Basis of Cost-Compound | Enter the basis of cost code. |
| 79 | Usual & Customary Charge-Pricing | Enter the usual and customary charge. |
| 80 | Basis of Cost Det.-Pricing | Enter the basis of cost determination. |
| 81 | Ingredient Cost Submitted Enter | Enter the submitted ingredient cost. |
| 82 | Dispensing Fee Submitted-Pricing | Enter the submitted dispensing fee. |
| 83 | Prof Service Fee Submitted-Pricing | Enter the submitted professional service fee. |
| 84 | Incentive Amount Submitted-Pricing | Enter the submitted incentive amount. |
| 85 | Other Amount Submitted-Pricing | Enter the submitted other amount. |
| 86 | Sales tax Submitted-Pricing | Enter the submitted sales tax. |
| 87 | Gross Amount Due (submitted)-Pricing | Enter the submitted gross amount due. |
| 88 | Member Paid Amount | Enter the amount paid by the member. |
| 89 | Other Payer Amount Paid #1-Pricing | Enter the other payer amount paid by the first other payer (if present). |
| 90 | Other Payer Amount Paid #2 | Enter the other payer amount paid by the second other payer (if present). |
| 91 | Other Payer Member Resp. Amount #1-Pricing | Enter the other payer member responsibility amount from the first other Payer (if present). |
| 92 | Payer Member Resp. Amount #2-Pricing | Enter the other payer member responsibility amount from the second other Payer (if present). |
| 93 | Net Amount Due-Pricing | Enter the net amount due. |
End of Billing a Paper Claim Chapter
Appendix A: Forms
The forms below and others are available on the Forms page of the Provider Information website:
- Drug Prior Authorization Form
- Individual Adjustment Request
- Link Request, Montana Access to Health Web Portal
- Prescription Claim Form UCF (Universal Claim Form Version 1.2-02/2013)
End of Appendix A: Forms Chapter
Definitions and Acronyms
End of Definitions and Acronyms Chapter
Search Options
This edition has three search options.
- Search the whole manual. Open the Complete Manual pane. From your keyboard press the Ctrl and F keys at the same time. A search box will appear. Type in a descriptive or key word (for example "Denials"). The search box will show all locations where denials discussed in the manual.
- Search by Chapter. Open any Chapter tab (for example the "Billing Procedures" tab). From your keyboard press the Ctrl and F keys at the same time. A search box will appear. Type in a descriptive or key word (for example "Denials"). The search box will show where denials discussed in just that chapter.
- Site Search. Search the manual as well as other documents related to a particular search term on the Montana Healthcare Programs Site Specific Search page.