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Montana Medicaid
Provider Information

What's New on the Website This Week

Web Postings

A list of the documents posted to the website for the current week.


Proposed Resource-Based Relative Value Scale (RBRVS)

Resource-Based Relative Value Scale (RBRVS)

Important Information Regarding CMS-1500
As of April 1, 2014, the CMS-1500 (08/05) is no longer a valid form for the submission of professional claims. Providers must use the CMS-1500 (02/12) claim form for submission of Medicaid claims for payment.  

Completing the CMS-1500 (02/12)

Montana Medicaid has received claims using the CMS-1500 (02/12); however, there are issues on how the claims are being completed:

  • Providers are billing with the CMS 1500 (02/12) forms but are using the CMS-1500  (08/05) format. This does not work.
    • The diagnosis codes for Box 21 end up in the wrong location, and the Claims Unit will not key them to make them fit. 
    • Claims must follow the CMS-1500 (02/12) format. This could affect the payment of your claims.  Please work with your software vendor to correct this issue.
  • In conjunction with the incorrect formatting of claims, the boxes for diagnosis code pointers are not being completed correctly.
    • Box 24E: The diagnosis pointers must be in alphabetic format, not numeric format.
  • As a reminder we are currently only accepting diagnosis codes A–D on the CMS-1500 (02/12); on the 837P X12 5010 electronic claim this equate to 1–4. Anything submitted above A–D on the CMS-1500 (02/12) or 1–4 on the 837P X12 5010 electronic claim could cause denial of line or claim.

See the April 2014 issue of the Claim Jumper and watch upcoming issues for information about billing with the 02/12 version and reference the guideline developed by the National Uniform Claim Committee at www.nucc.org.

2014 Spring Provider Fair
Plan to attend the 2014 Spring Provider Fair hosted by DPHHS and Xerox on May 20–21, 2014 in Helena at the Great Northern Hotel.

For information and to register, visit the Training page. Check back often for updated information.

Retroactive Eligibility
Effective January 1, 2014, providers must use the Notice of Retroactive Eligibility (160-M) if a member has been determined retroactively eligible. The FA-455 and FA-454 will no longer be accepted.

Providers should attach the Notice of Retroactive Eligibility (160-M) when submitting claims for retroactively eligible member for which the date of service is more than 12 months earlier than the date the claim is submitted. Claims without the Form 160-M will not be paid.

Contact the member’s local Office of Public Assistance to request the form. See http://www.dphhs.mt.gov/contactus/humancommunityservices.shtml.

Medicaid and G-Codes
Beginning January 1, 2014, Medicare changed to a single code (G0463) for the facility fee on clinic visits and Medicaid will follow suit per ARM.

Provider-based clinics will use G0463 (which will group to APC 0634) for the facility fee portion of the outpatient clinic visits. The change applies only to the hospital or facility portion of clinic visit codes 99201–99205 and 99211–99215. 

The physician services claim will remain the same and continue to bill the appropriate procedure code in code ranges 99201–99205 and 99211–99215.

Using Medicaid Card ID for Billing and Checking Eligibility
Providers should use the Medicaid member ID number, not the member’s Social Security number (SSN), for billing purposes and checking eligibility.

This ensures the expenditures are applied to the correct member and any query information is for the correct member. Errors can occur using the SSN for either billing or requesting eligibility information.

If you only have the member’s SSN, have questions, or need assistance, contact Provider Relations at 1.800.624.3958 or via e-mail at MTPRHelpdesk@xerox.com.

Update on EFT and Electronic RA Requirements
All Montana Health Care Programs providers (Medicaid/HMK Plus, CHIP/HMK, and Mental Health Services Plan) will be moved to EFT (direct deposit) and ERA by March 2014.

In order to accomplish this transition, Xerox will eliminate the paper remittance advice option and eliminate payment via paper warrant. Providers may be affected as early as January 1, 2014. 

Providers must complete the paperwork for both ERA/EFT below but will receive a paper warrant until the transition is complete.

To avoid disruption in receipt of remittance advices, providers should initiate the change to ERA as soon as possible. All providers must be registered for the web portal and submit their paperwork to Provider Relations to be eligible for payment and receive applicable ERAs in 2014.

If you are enrolled in EFT, receive ERAs, have already registered for the Montana Access to Health (MATH) web portal, and completed a Trading Partner Agreement (TPA) you meet the requirements of the policy and no additional documentation is needed.

Providers who currently receive paper checks and/or paper RAs must follow the process below to transition to EFT and electronic RAs.

Forms Needed
To sign up for electronic funds transfer (direct deposit) and register for the web portal, providers need to complete the forms below and mail or fax them to Provider Relations. A letter from your financial institution verifying legitimacy of the account is also required.

P.O. Box 4936
Helena, MT 59604
1.800.624.3958 or 406.442.1837 (Tel)
406.442.4402 (Fax)

EFT Instructions

To enroll in EFT, a provider must complete the Montana Medicaid EFT and ERA Authorization Agreement.

  1. The provider completes and signs the EFT and ERA Authorization Agreement.

  2. The provider faxes or mails the EFT and ERA Authorization Agreement to Provider Relations.

  3. Upon receipt of the form, Provider Relations adds the EFT information to the provider's profile. This process takes up to 10 business days. Once completed, the provider will get paid via EFT on the next payment cycle.

ERA Instructions

To receive ERA, a provider must complete the Trading Partner Agreement (TPA) for electronic claims submission and register on the Montana Access to Health web portal so that he/she can view the ERAs.

  1. The provider prints, completes, and signs the TPA. The provider must include his/her NPI/API on the last page of the TPA.

  2. The provider faxes or mails the TPA to Provider Relations.

  3. Once Xerox receives the TPA, the provider is given access to the web portal. This process takes up to 10 business days.

  4. Xerox mails the Welcome Packet to the provider. This packet contains the user ID and password for the web portal and the provider's submitter ID.

  5. Providers can then register online using the information provided in the Welcome Packet or call Provider Relations for assistance. Note: Upon registering, providers are notified via e-mail that they must change their password and have 24 hours to do so.

  6. Once registered, the provider clicks on Retrievals >> View e!SOR Reports to access an RA (in PDF format).

Medicare/Medicaid Remittance Advice Reminder and Adjustments
If you need to do an adjustment, and you are using a Medicare Remittance Advice Template to print your Medicaid Remittance advice, be aware that not all templates will  accommodate the necessary Medicaid information to allow your adjustment to process. 

The issue is the length of the ICN that appears on the Medicare Remittance Advice Template.

The Medicare ICN is formatted for 15 digits but the Medicaid ICN length is 17 digits. This will truncate the Medicaid ICN by 2 digits.

Please check this field and make any necessary corrections. If this is not corrected, we will return your adjustment to you for correction.

Drug and Pharmacy News

EOB Reason and Remark Crosswalk
An updated version of the EOB Reason and Remark crosswalk, which matches the HIPAA standard R&R codes to the Medicaid EOB codes, is posted under Other Resources in PDF and Excel format on each provider page.

Eligible Drug Manufacturers
Montana Medicaid reimburses only for drugs that are manufactured by companies that have a signed rebate agreement with CMS. An updated list of these manufacturers is available at the link and on appropriate provider pages. To determine if a manufacturer has signed a rebate agreement, check the first 5 digits of the National Drug Code (NDC) against the list. If there is no match, the drug is not reimbursable.

The list will be updated quarterly, so please check regularly to assure coverage. In addition, the valid NDC must be recorded on the claim (no spaces, no punctuation) as an 11-digit series of numbers. Claims will be denied for drugs billed without a valid 11-digit NDC. Providers also must be careful when entering the NDC quantity (the administered amount). A list of the most commonly used NDCs is available for providers. For more information on billing with NDCs on a CMS-1500, refer to the provider notice dated April 10, 2008. For more information on billing with NDCs on a UB-04, refer to the provider notice dated September 1, 2009.

Medicare Part D Prescription Drug Benefit News
Introduction to Medicare Part D Drug Benefits

Need help with picking the right Part D plan for you or your member?

Stand-Alone Prescription Drug Plans Eligible to Receive Auto-Enrolled Beneficiaries in Montana

The WellPoint Point of Sale system for dual-eligible Medicare and Medicaid eligible individuals:

  • Point of Sale Facilitated Enrollment of Dual Beneficiaries for Pharmacists
  • Point of Sale Facilitated Enrollment of Dual Beneficiaries Tip Sheet

Learn About the Medicare Prescription Drug Plan

  • Medicare Prescription Drug Coverage Personal Information Worksheet for People with Medicare and Medicaid
  • Choosing a Medicare Drug Plan for People with Medicare and Medicaid
  • People with Medicare and Medicaid: Medicare will enroll you in a plan automatically. How do you find out which plan?
  • Request for Prescription Information or Change. This is a standard form for exceptions or prior authorizations.

Medicaid Program Information Handbook insert. Learn more about Medicaid coverage of prescription drugs for members who are dual eligible for both Medicare and Medicaid.


Tamper-Resistant Prescription Pad Vendors

Get the Most Recent Montana Medicaid Preferred Drug Information!
Visit the Pharmacy provider page for a list of preferred drugs and upcoming Montana Medicaid and Medicaid Mental Health Drug Use Review Board/Formulary Committee Meetings.

For more information on Montana Prescription Drug Assistance Programs, including help with Medicare Rx premiums, visit Big Sky Rx.

Electronic Billing

Electronic Billing Website Links Updated
The Xerox EDI Solutions website (formerly ACS EDI Gateway) has changed. For Montana Medicaid, click on the EDI Solutions Clients tab and choose Montana Department of Public Health and Human Services.

WINASAP5010 software can be found under the WINASAP tab. In addition, EDI enrollment information is available on the EDI Enrollment page.

If you are having trouble finding information, contact Provider Relations 1.800.624.3958.

Health Improvement Program (HIP)

Montana Medicaid Health Improvement Program
The Health Improvement Program for Medicaid and HMK Plus members with chronic illnesses or risks of developing serious health conditions. HIP is operated through a regional network of 14 community and tribal health centers. Medicaid and HMK Plus members eligible for the Passport Program are enrolled and assigned to a health center for possible care management.

Instructions and Provider Referral Form (08/2013)

ICD-10 Information

Montana Medicaid ICD-10 Readiness Survey III
Click to take the survey: ICD-10 Readiness III Survey

Important ICD-10 information and the survey link are on the ICD-10 Information page of the Montana Medicaid Provider Information website.

Meeting Timelines for ICD-10

For detailed timelines of activities that providers, payers, and vendors need to undertake to prepare for ICD-10, download the timeline widget to your desktop or mobile device.

Printer-friendly versions of the ICD-10 widget compliance timeline is available for large providers, small providers, payers and vendors.

The widget and timelines are public domain. CMS encourages organizations to distribute them widely through posting to websites and other channels.

Navigation Assistance

Adobe Reader
Most documents on this website require Adobe Acrobat Reader. Click the image below to download Adobe Reader for free.

Website Tips
For tips on using this website or to download frequently requested resources (such as how to verify member eligibility, Medicaid covered services, important contacts, and more), see the Medicaid Information option in the menu on left.

Professional Claim Issues

Crossover Claims
Xerox recently corrected an issue where the parent or spouse was found instead of the subscriber when the Medicare ID was sent as the subscriber ID in Loop 2010BA, data element NM09 on COBA claims.

The change was implemented on 02/23/2012, so the correct member will be found when the Medicare ID is submitted on any 837P COBA files received on or after this day.

We apologize for any inconvenience and ask providers to resubmit any claims that denied due to this issue. If you are submitting the claim directly to Xerox, the subscriber must be the 7-digit card ID or the 9-digit SSN; the Medicare ID will only be used to find the correct member when the claim comes directly from COBA.

This issue did not affect 837I COBA crossover claims.

EPSDT Indicator Issue
We recently corrected an issue where the EPSDT indicator sent on the 837P in Loop 2400, data element SV111 was not always captured.

This change was implemented on 02/23/2012, and the EPSDT indicator will be captured on any lines sent in 837P files on or after this day.

We apologize for any inconvenience and ask that providers resubmit any claims that denied or adjust any paid claims with denied lines or that had cost share taken incorrectly due to this issue.

Provider File and NPI Information

Provider File Updates
Providers who have already completed their re-enrollment with Montana Health Care Programs in conjunction with the implementation of NPI do not need to complete a new enrollment if their information changes. If a re-enrolled provider needs to update their provider file (e.g., change of practice location, billing address, tax information), they should mail the new information to Provider Relations, P.O. Box 4936, Helena, MT 59604 or fax to 406.442.4402, Attention: Provider File Updates. Health care providers who have not yet re-enrolled with their NPI, or atypical providers for a new proprietary ID, should do so immediately.

NPI Required for Eligibility Verification
Providers must use their NPI when inquiring about member eligibility using FaxBack, the Voice Response system or the MATH web portal. If you are not yet enrolled with your NPI, please call Provider Relations at 1.800.624.3958.

Tribal, Urban, and Indian Health Services

Montana Medicaid strives to provide programs and improve billing capacity within our Tribal, Urban, and Indian Health Service clinics.

DPHHS is committed to improving the health of Montana’s Indian population. Every third Wednesday of the month, Tribal, Urban and IHS clinics discuss billing issues for Indian country with Medicaid staff for distinct sets of billings instructions and claims issues.

Everyone is welcome. Staff from the Montana Medicaid Program and Xerox State Healthcare, LLC, will all be available to answer questions and streamline the billing process.

Our goal for these calls is to improve communication and keep an ongoing conversation revolved around billing, so everyone has the correct information.

For Tribal, Urban, or Indian Health Service billing questions contact:
John Hein, Medicaid Program Officer, 406.444.4349 or JHein@mt.gov
Lesa Evers, Tribal Relations Manager, 406.444.1813 or LEvers@mt.gov

Additional resources are available on the IHS page.