Medi-cal provider billing manual

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 Montana Healthcare Programs are at risk of lead poisoning. To ensure their good health, the federal government requires that all Montana Healthcare Programs-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 Montana Healthcare Programs children at other ages should be screened.

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. 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. 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 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. Annual dental screens include an oral inspection, fluoride varnish as available and making a referral to a dentist for any of the following reasons:.

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:.

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. To be covered by Montana Healthcare Programs, all services must also be provided in accordance with the requirements in the Passport to Health manual and on the Prior Authorization Information page of the Provider Information website, the Montana Healthcare Programs manual for your provider type, and the provider fee schedule.

Montana Healthcare Programs 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. 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 Montana Healthcare Programs 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 Montana Healthcare Programs 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. Telemedicine is the use of interactive audio-video equipment to link practitioners and members located at different sites. The Montana Healthcare Programs 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 Montana Healthcare Programs. 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 Montana Healthcare Programs providers and be licensed in the State of Montana in order to:. Montana Healthcare Programs 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. All Montana Healthcare Programs providers using telemedicine to deliver Montana Healthcare Programs 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.

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.

Providers may only bill procedure codes for which they are already eligible to bill. Services not otherwise covered by Montana Healthcare Programs are not covered when delivered via telemedicine.

The use of telecommunication equipment does not change prior authorization or any other Montana Healthcare Programs 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. 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. 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 Q 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. 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 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, , providers must also use the telehealth place of service of 02 for claims submitted on a CMS 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 Montana Healthcare Programs in order to provide telemedicine services to Montana Healthcare Programs members.

Providers must contact the Montana Department of Labor and Industry to find out details on licensing requirements for their applicable professional licensure. Members must never throw away the card, even if their Montana Healthcare Programs eligibility ends.

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. Member eligibility may change monthly. Providers should verify eligibility at each visit using any of the methods described in the following table. Hours are Mountain Time. Providers may use whichever method they find most convenient. Before using FaxBack, your fax number must be on file with Provider Relations.

When prompted, ask for the audit number or the transaction will not be completed. Verify eligibility for up to 5 members in one call. Program benefit limits not available here. Contact Provider Relations for limits. If the member is not currently eligible, any managed care or third party liability information will not be displayed. Provider Relations P. Box Helena, MT To become a provider who determines presumptive eligibility, call To verify presumptive eligibility, call or 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. Presumptive eligibility is available to hospitals and their affiliated facilities that participate with Montana Healthcare Programs.

Personnel must be trained and certified to make presumptive eligibility determinations for short-term, temporary coverage for the following coverage groups:. To encourage prenatal care, uninsured pregnant women may receive presumptive eligibility for Montana Healthcare Programs.

Presumptive eligibility may be for only part of a month and does not cover inpatient hospital services, but does include other applicable Montana Healthcare Programs services.

For more information about presumptive eligibility training or certification, see the Presumptive Eligibility page of the Provider Information website. When a member is determined retroactively eligible for Montana Healthcare Programs, the member should give the provider a Notice of Retroactive Eligibility 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. See specific provider manuals for requirements. 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 Montana Healthcare Programs for retroactive eligibility services, see the Billing Procedures chapter in this manual.

This coverage is for members who have an income level that is higher than the SSI-eligible Montana Healthcare Programs program standards. The spend down amount is based on the member's countable income.

Providers should verify if medically needy members are covered by Montana Healthcare Programs on the date of service to determine whether to bill the member or Montana Healthcare Programs.

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. 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 Montana Healthcare Programs equal to the spend down amount, instead of making payments to providers, and have Montana Healthcare Programs 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 Montana Healthcare Programs, the Department requires time to process the payment.

Once the payment is processed, the system will provide the Montana Healthcare Programs coverage. The member may choose to submit their payment to Montana Healthcare Programs after medical services have been provided. In that situation, the member's Montana Healthcare Programs 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. Nurse First programs provide disease management and nurse triage services for Montana Healthcare Programs members throughout the state. Nurse First Advice Line, The nurses do not diagnose or provide treatment. Most Montana Healthcare Programs members are eligible to use the Nurse First Advice Line,The program is voluntary though participation is strongly encouraged.

All other policies and procedures in this chapter apply. 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 Montana Healthcare Programs, but there are some exceptions. Medicare is processed differently than other sources of coverage. 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:. Providers should use the same procedures for locating third party sources for Montana Healthcare Programs members as for their non-Montana Healthcare Programs members. Providers cannot refuse service because of a third party payer or potential third party payer. Medicare claims are processed and paid differently than other non-Montana Healthcare Programs claims.

The other sources of coverage are called third party liability or TPL, but Medicare is not. Providers must submit these claims first to Medicare. Providers must tell Medicare that they want their claims sent to Montana Healthcare Programs automatically, and must have their Medicare provider number on file with Montana Healthcare Programs. When a crossover claim is submitted only to Medicare, Medicare will process the claim, submit it to Montana Healthcare Programs, 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 Montana Healthcare Programs for further processing. See the Billing Procedures chapter in this manual. Providers should submit Medicare crossover claims to Montana Healthcare Programs only when:. When submitting electronic claims with paper attachments, see the Billing Electronically with Paper Attachments section of the Billing Procedures chapter.

When a Montana Healthcare Programs 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 Montana Healthcare Programs.

Providers are required to notify their members that any funds the member receives from third party payers when the services were billed to Montana Healthcare Programs must be turned over to the Department. Requesting an Exemption Providers may request to bill Montana Healthcare Programs first under certain circumstances.

In each of these cases, the claim and required information should be sent directly to the Third Party Liability unit. Coordination Between Medicare and Montana Healthcare Programs Coordination of benefits between Medicare and Montana Healthcare Programs is generally accomplished through electronic crossover of claims.

It is important to always bill Medicare prior to Montana Healthcare Programs for healthcare services. After Medicare processes the claim, it will automatically cross over to Montana Healthcare Programs. If a claim does not cross automatically to Montana Healthcare Programs from Medicare, the provider should not submit the claim to Montana Healthcare Programs until Medicare has processed. Montana Healthcare Programs payment is subsequent to Medicare and will only pay up to the Montana Healthcare Programs fee after considering the payment from Medicare.

See the How Payment Is Calculated chapter in the provider type manuals to learn how Montana Healthcare Programs payments are calculated. 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 Montana Healthcare Programs covers. However, other coverage does affect the payment procedures. See the How Payment Is Calculated chapter in your provider type manual.

In these cases, Montana Healthcare Programs may pay the premiums, at which time the private insurance plan becomes the primary insurer. The member also remains eligible for Montana Healthcare Programs. For more information, see the Subsidized Health Insurance Programs in Montana table at the end of this chapter.

This program may provide funding for medical expenses, mental health counseling, lost wages support, funerals, and attorney fees. For more information, see the Subsidized Health Insurance Programs in Montana table later in this chapter. 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.

Montana Healthcare Programs members may see any Montana Healthcare Programs-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. Members should apply for services directly from the state-approved programs.

For a list of these programs, call Services require prior authorization and authorization for continued stay review. If both cards are valid, treat the patient as an HMK patient. 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. Call for more information. Some of the services covered include office visits, contraceptive supplies, laboratory services, and testing and treatment of STDs.

Providers may refer member to the following programs. For Information on Eligibility:. Note: Eligibility rules are complex; members and providers should check with the program administrator for specifics. 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.

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 During an audit, 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. With the approval of the committee, an overpayment letter will be sent to the provider.

Their approval will initiate an overpayment letter to the provider. The following suggestions may help reduce billing errors but are not inclusive of all possible errors and recoupment scenarios. Services provided by the healthcare professionals covered in this manual may be billed electronically or on paper claim forms, which are available from various publishing companies; they are not available from the Department or Provider Relations.

For claims involving Medicare or TPL, if the month time limit has passed, providers must submit clean claims to Montana Healthcare Programs within:. 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 month period.

If a provider bills Montana Healthcare Programs and the claim is denied because the member is not eligible, the provider may bill the member directly. Private-Pay Agreement. 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 Montana Healthcare Programs and the member will pay for them. Effective for claims paid on or after January 1, , members covered under Montana Healthcare Programs or Medicaid Expansion will not be assessed a co-payment, as denied in ARM When completing a claim for members with Medicare and Montana Healthcare Programs , Medicare coinsurance and deductible amounts must correspond with the payer listed.

For example, if the member has Medicare and Montana Healthcare Programs , 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. 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 M. 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:. Please note that the Department does not endorse the products of any particular publisher.

Updated each January and throughout the year. Contact: Available through various publishers and bookstores or from CMS at www. Description: ICD diagnosis and procedure code definitions.

Updated each October. The Montana claims processing system supports 40 lines on a UB claim, 21 lines on a CMS, and 21 lines on a dental claim. 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.

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. All line items must have a valid date of service. 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.

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. 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:. This mandate affects all providers who submit claims for procedure-coded drugs both electronically and manually.

The NDC should be structured in the format. Some manufacturers omit leading zeros in one of the three positions. This results in a 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. Example only: N ML0. Enter the digit NDC numeric code in the format. The Description Field allows for a maximum of 24 total characters. Example only: NML0. 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.

Claims denied for this reason may be re-billed with the proper NDC within one year of the date of service. 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. Clinic services provided by an individual physician or mid-level practitioner in the clinic must be billed on a CMS with place of service POS 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 services must be billed with the national code for partial hospitalization, the appropriate modifier, and the prior authorization code. Montana Healthcare Programs covers elective sterilization for men and women when all of the following requirements are met:. For elective sterilizations, a completed Informed Consent to Sterilization MA form must be attached to the claim for each provider involved or payment will be denied.

This form must be legible, complete, and accurate. 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:.

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. Paper Claims Unless otherwise stated, all paper claims must be mailed to:. The following are accepted codes:. 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.

Providers should be familiar with federal rules and regulations related to electronic claims submission. 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. Contact Provider Relations for general claim questions and questions regarding payments, denials, member eligibility.

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: Provider is not eligible during dates of services, enrollment has lapsed due to licensing requirements, or provider number terminated How to Prevent Returned or Denied Claims:.

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

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. If you have any questions or need clarification regarding a policy or the version date please contact our Provider Relations Department at Provider Manuals. Image Caption.

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