- Should our office test submitting claims with our clearinghouse?
- We received an error report (824) from our clearinghouse or Xerox saying our NPI and/or taxonomy is not on file. What could be the cause?
Yes, if you are using a new clearinghouse, it is important to ensure claims will be accepted by Montana Health Care Programs following all billing requirements.
There could be several reasons for this:
- We do not have you enrolled with your NPI number. Make sure you have enrolled with Xerox State Healthcare, LLC (Xerox) and have received the acknowledgement letter that your NPI and taxonomy have been approved to bill claims.
- The claims processing system completes several checks of the NPI being billed to ensure that it is valid. Listed are the most common edits questions that would prevent your claims from processing.
- Is it a valid NPI number?
- Is the taxonomy code correct? The taxonomy code billed on your claims has to match the taxonomy you had indicated during enrollment and is on your provider file established at that time.
- Is the billing provider's ZIP+4 correct? If this is different from what IS on file, the claims will not process.
- For schools billing CSCT, is the correct team number being billed and is it in the correct location on the claim?
Again, if any of these do not match, a report will be generated and the claims will not process.
Taxonomy is required as one of several data elements to match the enrollment in MMIS. If an entity has more than one enrollment under an NPI, the taxonomy is the first match the claims processing system makes to determine the line of business.
Podiatry clinics, physical therapist clinics, speech therapist clinics, occupational therapist clinics, dental clinics, physician clinics, dedicated emergency departments, general groups or clinics, family planning clinics, provider based clinics, rural health clinics (RHCs), federally qualified health centers (FQHCs), and hospitals require a rendering/attending NPI and taxonomy. If rendering/attending provider NPI and taxonomy are not sent or the rendering/attending provider information sent is the same as the billing provider information, your claims will deny.
For providers billing professional claims (CMS-1500, 837P or 2006 ADA dental claim form), the rendering/attending provider taxonomy is not required if the rendering/attending and billing provider are the same. Do not include a rendering NPI.
If you are a provider type that does not require a rendering/attending NPI and taxonomy, your claims will deny if the rendering/attending NPI and taxonomy on the claim are different than the billing NPI and taxonomy on the claim.
If you are an ambulance provider, durable medical equipment provider, or ambulatory surgical center who are billing only for your services and not the physician's, leave the rendering/attending provider fields blank.
If you are an RHC or FQHC, you can now bill professional services administered in a hospital setting on a CMS-1500. Enter the RHC or FQHC NPI and taxonomy as the billing provider and the physician's NPI and taxonomy as the rendering/attending provider. Any claims that denied because of this recent system change are re-billed.
Providers enrolled as individuals cannot be the billing provider for other individuals. Only providers enrolled as a clinic or with a clinic specialty can bill for someone else's services.
The Montana Health Care Programs claims processing system can process only one rendering provider per professional claim. If a provider enters more than one rendering provider on a paper professional claim, the system will choose the rendering that appears on the first line and complete adjudication using that rendering number. Additional rendering providers billed on the claim will not be processed. Professional claims submitted electronically with multiple rendering providers will be split into separate claims.
If you own the clinic and the clinic's regular practice is to bill with the clinic as the billing provider, continue to use the clinic NPI and taxonomy as the billing provider and your individual NPI and taxonomy as the rendering/attending provider.
Providers are not bound to use the taxonomy given to them by NPPES.
- Billing providers use the taxonomy with which they enrolled in Montana Health Care Programs
- Clinic enrollment, providers choose either the taxonomy that matches what they received from NPPES or the one that best fits their practice.
- The list of taxonomies used by Montana Health Care Programs are on the Provider Information website on the appropriate provider type page.
Obtain an NPI for the clinic from NPPES and enroll with Montana Health Care Programs as a clinic. Then submit your claims with the clinic NPI and taxonomy as the billing provider and the NPI and taxonomy of the provider who rendered the service as the rendering/attending provider. Individual providers cannot bill for services rendered by another provider.
Each provider uses his/her own NPI and taxonomy as the billing provider.
Refer to the NPI claims instructions on the Provider Information website to determine the reason your claims are denying, then correct and resubmit them within the 365-day timely filing limit.
If you have questions, contact Provider Relations at 1.800.624.3958 or 406.442.1837, by fax at 406.442.4402, firstname.lastname@example.org, or through the Ask Provider Relations function on the Montana Access to Health (MATH) web portal at https://mtaccesstohealth.acs-shc.com/. Most inquiries will be responded to within 3 days.
Facilities that are CMS-designated provider-based entities may choose to enroll as a clinic with a clinic taxonomy or they may choose to use the hospital NPI and appropriate taxonomy as the billing provider. The professional portion of the provider-based service billed on a CMS-1500/837P use the NPI and the appropriate taxonomy for which they enrolled.
The NPI and taxonomy of the professional performing the provider-based service is entered as the rendering provider on the CMS-1500/837P and the billing provider is the enrolled organization whether they chose the clinic NPI or they chose to use the hospital NPI with the corresponding taxonomy.
They use the NPI with which they enrolled. The facility portion of the provider-based service billed on a UB-04/837I uses the hospital NPI and the appropriate taxonomy for an acute care hospital. The NPI and taxonomy of the professional performing the provider-based service is entered as the attending provider on the UB-04/837I.
No, Medicare does not include taxonomy codes on claims transmitted to Medicaid. If your claim rejects, does not reach the claims processing system or denies because of this, you can directly bill Montana Health Care Programs for these crossovers electronically or through your clearinghouse.
Mental health centers enroll for each type of provider and service – such as case management, therapeutic group home, and therapeutic family care/foster care – for which they now bill. Centers enroll each of the service types using their clinic NPI and choosing the provider type and taxonomy for each.
- For example, enroll for case management by choosing case management- mental health in the Provider Type drop-down box and enter the center's NPI.
- When the mental health center bills for these services, they will bill with the center's NPI and the taxonomy for the type of service being provided.
- Services currently being billed using the community mental health center provider number will be billed using the mental health center NPI and taxonomy.
- The mental health center enrolls for practitioner services using the mental health center NPI and the appropriate taxonomy for the practitioner enrolling.
- For crossovers, Medicare requires the mental health center to bill using the facility NPI and taxonomy as billing and each individual as a rendering/attending provider. Claims billed with the mental health center NPI and taxonomy of an individual practitioner (e.g., social worker, licensed professional counselor) as a billing provider will deny.
HIPAA is the acronym for the Health Care Portability and Accountability Act. In October 2003, it was mandated that all electronic health care transactions be submitted in a standard format, regardless of the payer to which they were submitted. These standard formats have been reviewed and updated to meet changes which have taken place in health care since 2003; the new required format is Version 5, Release 1, Sub-Release 0, also known as 005010.
The deadline for all trading partners to use the 5010 electronic transactions is January 1, 2012. No transactions in the HIPAA 4010 format will be accepted by Montana Health Care Programs as of this date.
Providers can contact their clearinghouse, electronic claim software vendor and/or submitter to make sure they will be ready to submit and receive electronic transactions in the 5010 format by the January 1, 2012 deadline. The affected transactions include:
- 837P (Health Care Claim: Professional)
- 837D (Health Care Claim: Dental)
- 837 (Health Care Claim: Institutional)
- 835 (Health Care Claim: Payment/Advice)
- 270/271 (Eligibility Inquiry and Response)
- 276/277 (Claim Status Inquiry and Response)
Also, two current 4010 transactions will be replaced with new and different transactions under 5010 for Montana Health Care Programs. The current 997 (Functional Acknowledgement) will be replaced with the 999 (Implementation Acknowledgement for Health Care Insurance) and the 824 (Application Advice) will be replaced with the 277CA (Health Care Claim Acknowledgement).
Use the ZZ qualifier until the implementation of HIPAA Version 5010 electronic transactions. After 5010 implementation, effective January 1, 2012, the qualifier for taxonomy will be PXC for electronic claims. You will still utilize the ZZ qualifier on the paper professional claim.
- What is the difference between enrolling as an individual and enrolling as an organization?
- Only providers who are enrolled as an organization can bill for the services of other providers.
- Providers enrolled as individuals cannot bill for services rendered by another provider.
- Only providers enrolled as a clinic or with a clinic specialty can bill as a billing provider with another provider as the rendering/attending.
If you have not received your welcome letter 3 weeks after you have submitted all of your completed and signed paperwork, contact Xerox at 1.800.624.3958 or 406.442.1837.
The confirmation letter or e-mail you received from NPPES will contain the taxonomy you use for enrollment. Taxonomy codes are listed on the website under the appropriate provider type. For billing purposes, use the taxonomy code noted in your welcome letter sent by Xerox.
Providers are not bound to use the taxonomy given to them by NPPES.
- For billing, providers use the taxonomy with which they enrolled in Montana Health Care Programs.
- For clinic enrollment, providers choose from the drop-down list either the taxonomy that matches what they received from NPPES or the one that best fits their practice.
You can find this information by typing in your address on the U.S. Postal Service website, http://zip4.usps.com/zip4/welcome.jsp.
The tax reporting information is needed for generating 1099 tax information. Use the tax-reporting information from your W-9 to complete the tax-reporting section of the enrollment.
Yes. CMS requires that ownership information be collected for all health care providers who provide services that are publicly funded so states can qualify for federal funds.
Refer to CFR 42 455.100–106. There is no distinction between for-profit and not for profit. Enrollments will be denied if ownership information is not provided.
Provider-based status means a relationship exists between a hospital as the main provider and one of the following as defined by rule:
- A provider-based entity is a health care provider “that is either created by, or acquired by, a main provider for the purpose of furnishing health care services of a different type from those of the main provider under the name, ownership, administrative and financial control of the main provider.”
- A department of a provider is a “facility or organization or a physician office that is either created by, or acquired by, a main provider for the purpose of furnishing health care services of the same type as those furnished by the main provider under the name, ownership, financial and administrative control of the main provider.”
- A department cannot be licensed to provide health care services in its own right or be qualified on its own to participate in Medicare. The definition does not include a rural health clinic (RHC) or a federally qualified health center (FQHC) except in limited circumstances.
- A remote location of a hospital is defined as “a facility or organization that is either created by, or acquired by, a hospital that is a main provider for purposes of furnishing inpatient hospital services under the name, ownership, and financial and administrative control of the main provider.” The remote location is not licensed in its own right or separately certified as a Medicare provider.
- A satellite facility is a hospital unit or part of a hospital unit that provides inpatient services in a building also used by another hospital or in one or more buildings on the same campus as buildings used by another hospital. “Campus” is defined as the area immediately adjacent to the main buildings and other areas and buildings not strictly contiguous but that are located within 250 yards of the main buildings.
- All providers who are provider-based facilities are required to send the CMS letter received designating them as a provider-based facility.
Electronic funds transfer (EFT) makes funds available to you more quickly than paper checks. The electronic payment option allows Montana Health Care Programs providers to receive their payments on Monday of the payment week. If you feel you have extenuating circumstances that prohibit you from receiving payment via EFT, request a waiver by including a signed letter explaining why paper checks are required.
The government agency name on the direct deposit form is “DPHHS.” The address is DPHHS, P.O. Box 4210, Helena, MT 59604-4210
Section 3 requires a bank representative signature to guarantee that the bank account belongs to the provider. This may also avoid fraudulent banking information from being attached to your Montana Health Care Programs enrollment. Return the completed direct deposit form with the provider’s enrollment to Provider Enrollment, Xerox State Healthcare, LLC, P.O. Box 4936, Helena, MT 59604.
The provider’s National Provider Identifier (NPI). If you are an atypical provider you may leave this field blank.
You will receive a welcome letter from Xerox informing you that your enrollment is active. The welcome letter will contain either your NPI for health care providers or your Atypical Provider Identifier (API) for atypical providers.
- What provider number do we use when verifying
Utilize your NPI or your new Montana Health Care Programs provider number.
- If a client is entering a nursing home, can he/she transfer assets in order to qualify for Medicaid?
- Do infants automatically get coverage too?
- Can a provider sign the Medicaid application if the applicant is not capable?
- How does eligibility information come from the local Office of Public Assistance to Xerox? How long does this take?
- Can you tell me a little bit about incurment amounts and how it applies to providers?
- How far back can medical bills go and still be counted for incurment?
- What is the difference between QMB, QMB only, and Medicare/Medicaid?
- What does SLMB stand for?
- If a client has SLMB only, who is responsible for the Medicare coinsurance and deductibles?
- What is the difference between HMK and HMK Plus?
- Where can applicants receive an application for Medicaid?
- Where can applicants receive an application for Healthy Montana Kids?
Can he/she gift a home to a child or is he/she required to sell it? Nursing home residents cannot have given away assets within the 60 months prior to applying for Medicaid as a nursing home resident. If they have given away assets or sold them for less than fair market value, an asset transfer penalty (ineligibility period) may be assigned to the person. The penalty will run from the date the person otherwise qualified for and had applied for Medicaid as a nursing home resident. There are exceptions to this rule; direct questions to the local Office of Public Assistance (OPA).
If the mother is eligible for and receiving non-medically needy Medicaid at the time of birth, then the baby is eligible for the Medicaid Newborn program. This provides coverage for up to one year for the infant, as long as the baby continues to live in Montana.
Yes, if the applicant is not able to complete the application, another party, including a provider, may assist. However, the provider cannot apply on a client’s behalf if the client is not willing to apply for Medicaid.
OPA workers enter client information into the eligibility system. This is uploaded and passed to Xerox every night. Nursing home spans take longer because of the additional check to verify the initial span. If you have specific questions, call Xerox Provider Relations at 1.800.624.3958 or 406.442.1837 for assistance.
Incurments apply to clients who do not meet Medicaid financial eligibility until they spend down (incur) some of their income on medical services. On a certain day, they may be eligible for everything except a specific provider or portion of a specific provider’s services with which they meet their incurment. Ideally, if this happens, you, as a provider will get a form (HCS-454) from the OPA notifying you to bill Medicaid for some or all services provided to the client on the date the incurment was met. The date the incurment is met will be the day prior to the start date of Medicaid eligibility appearing on the eligibility verification systems.
Paid and unpaid bills may be applied toward the incurment for up to 3 months after the month in which they are incurred. Current payments made on outstanding bills that were incurred more than 3 months prior to the benefit month may be applied toward the incurment if the bills have not already been applied to an incurment in the past, and the provider has not written off the bill.
Qualified Medicare Beneficiary (QMB) only clients receive a Medicaid hard card. Under this program, Medicaid pays the client’s Medicare Part A and Part B premiums and Medicaid’s portion of the Medicare coinsurance and deductibles up to the qualified amount. Clients are covered only for Medicare allowed services.
QMB Medicaid clients are eligible for Medicare, Medicaid, and QMB. A client who has QMB and Medicaid receives a Medicaid card. Under this program, Medicaid pays the client’s Medicare part A and B premiums and Medicaid’s portion of the Medicare coinsurance and deductibles up to the qualified amount. Clients are covered for Medicare allowed services, as well as services that only Medicaid allows. If however, Medicare denies a service for medical necessity, Medicaid will also deny for the same reason. Clients are responsible to make Medicaid cost shares for services only paid for by Medicaid.
Medicare/Medicaid – For clients that are dually eligible, Medicaid pays for services allowed by Medicaid according to a lower-of pricing formula as well as those allowed by Medicare.
SLMB stands for Specified Low-Income Medicare Beneficiary. For clients who are SLMB only, Medicaid pays the Medicare premium only. Medicaid does not provide reimbursement for coinsurance, deductible or medical services.
The client is responsible for the coinsurance and deductible.
Healthy Montana Kids Plus (HMK Plus) was formerly Children’s Medicaid. HMK Plus is health care coverage for low-income children and youth up to age 19 in Montana who are at or below 133% of the federal poverty level (FPL) guidelines. To be eligible for HMK Plus, applicants must meet income limits. HMK was formerly the Children’s Health Insurance Plan (CHIP). It is a free or low-cost health coverage plan also run through the HMK program of DPHHS. The plan provides health coverage to eligible Montana children and teenagers up to age 19 with income between 133%–250% FPL. A child qualifies for HMK based on family size and income. There are no pre-existing condition limitations. A small copayment not to exceed $215 per family per year may apply.
You can get an application from any local Office of Public Assistance or online at https://app.mt.gov/mtc/apply/index.html.
Applications for HMK are available online or through the mail.
- Online at:
- By mail:
- Call 1-877-KIDS-NOW (1-877-543-7669), and an application will be sent.
- In Montana communities at several locations, including but not limited
- County Offices of Public Assistance Health departments
- Health care facilities
- WIC offices
- Head Start facilities
- Indian Health Service (IHS)
- If we call a claim up in MATH, and it has denied for invalid diagnosis code, is it possible to go further to find out why?
- When we use MATH, the only information we can receive is our own. How do we find out how many units have been used for a service that has limits, such as prior authorized limits, or limits for mental health service plan?
No. The claim status on the web portal is an ANSI X12 276 transaction. The 276 does not allow for reason and remark code display. Review your remittance advice for denial reasons.
Call Xerox Provider Relations at 1.800.624.3958 or 406.442.1837. They can look up prior authorization limits.
- Where on the CMS-1500 form is the Passport referral number placed?
On an electronic claim: Loop 2300, reference segment, data element 02, with the qualifier 9F in Loop 2300, reference segment, data element 01. On a paper claim: Box 17A.
- Which services do not need Passport referrals?
The Physician-Related Services Manual lists services that do not need Passport referrals. Also, see the "Medicaid Covered Services" chapter in the General Information for Providers manual.
- Do we speak to the Passport primary care provider (PCP) to get a Passport referral?
Office staff can relay the referral, but the PCP provides and documents the referral.
- Is it the client's responsibility to get a referral before visiting a provider who is not the client’s PCP?
No. If a client visits a provider who is not the client's PCP, the non-PCP provider gets a referral from the PCP.
- How are Passport providers assigned?
The Passport client either chooses the PCP or is assigned to a PCP by Medicaid if the client does not select. Assignment is made as described in the Passport to Health Provider Handbook. When assigned, the client is notified of the Passport provider assignment. When checking Medicaid eligibility, a provider who is not the client’s PCP also checks the identity of the Passport provider and contacts the Passport provider for a referral.
- Our Passport number has changed. Which Passport number do we give if a provider calls for a Passport referral for a visit that occurred on a date our old Passport number was effective?
Provide the Passport number that was effective on the date of service. However, if you did not make the referral, you are not obligated to provide a referral after the fact.
- We have a client that we referred to a specialist, and that specialist referred the client to another specialist, but we have no record.
Once a Passport provider gives a referral, the provider who requested the referral cannot refer the client to a third provider. The Passport provider refers the client to the third provider.
- What if my Passport number is being used without me giving a referral?
If a Passport provider suspects that his/her Passport number is being used without a referral, the provider is encouraged to contact Provider Relations at 1.800.624.3958 or 406.442.1837.
- If the Passport provider sends a written referral, does that qualify, or is the provider still required to call?
A written referral that includes the Passport number is sufficient. No phone call is required.
- Are all Medicaid clients Passport-eligible except those residing in nursing homes?
Approximately 70% of Medicaid enrolled individuals are eligible for Passport. Clients not eligible for Passport include those who: live in a nursing home or other institution; are covered by both Medicare and Medicaid (dual-eligible); are enrolled as medically needy; are covered by Medicaid for less than 3 months; are eligible under subsidized adoption; have only retroactive Medicaid eligibility; receive Home- and Community-Based Waiver services. Exemptions from Passport may be granted for other situations on a case-by-case basis.
- Can we use a Passport referral received by the hospital for the physician on call?
The Passport PCP will outline the purpose of the referral when giving a referral to a facility. The referral to the facility cannot be assumed to be a referral for all services.
- Is there a mechanism to change the Passport provider when a client moves?
When a client moves, the client can select a new Passport PCP on the website or by calling the Client Help Line. Until the client selects a new PCP, the client will remain with the current PCP in the Passport system.
- Is the Passport approval number the same as the provider’s Medicaid ID number?
No. The Passport number is a 7-digit number and is not the provider’s Medicaid (NPI or API) number.
- Why are clients allowed to change Passport providers monthly?
Passport allows clients to change Passport providers every month if they desire, through the State’s agreement with the Federal government. Each month, less than 4% of Medicaid clients change providers. Less than 2% change providers more than 3 times a year.
- What do we do when clients come with no referral?
It is the provider’s responsibility to get a Passport referral. After confirming that the client is Medicaid eligible, contact the Passport provider for a referral. If you are unable to get a Passport referral at that time, you may still provide services and pursue Passport approval after services are rendered, or you may ask the client to sign a private pay agreement. If you pursue a private pay agreement, the agreement will clearly state that the client will be responsible for the bill, not that they may be responsible. If you accept the client as private pay and the client pays you, you may still try to get Passport approval after the service and then refund the client’s money.
- If Passport referral was denied by a PCP because the PCP has not seen the client, what can we do?
Options are to encourage the client to see the client’s Passport PCP, ask the client to sign a private pay agreement, or refuse to see the client. The Passport provider has the right to not give a referral.
- If a Passport provider will not give a referral, can the client go to Medicaid to get a referral?
Medicaid does not override a Passport provider’s decision.
- Can a provider disenroll a client, or is the client the only one who can make this change?
A provider may disenroll a client based on the 4 approved disenrollment reasons detailed in the Passport provider agreement. A provider gives a client 30-days’ notice by sending a letter to the client and to Passport.
- How are clients auto-assigned to a provider?
- Prior Passport enrollment
- Most recent claims history
- Family (Child/Adult) history
- American Indians assigned to IHS/Tribal Health if one is within 50 miles of address
- Random within the geographic area
Clients are auto-assigned a provider if they do not choose one. In auto-assigning a client, the Passport program seeks to preserve existing provider-client relationships. Clients are assigned based on the following criteria, in this order:
- Do claims have to be sent to the other payer if the provider knows the insurance is going to deny?
- What about when a client has Medicare/Medicaid coverage and the service is denied by Medicare for not being medically necessary?
- What about those cases where Medicaid shows a TPL, but the provider cannot get any information from either the client or the other carrier?
- If you give us a denial, and we have to resubmit a particular line and it is Medicare/Medicaid, when we resubmit that line, do we resubmit the Medicare EOB?
- What happens if the message says the claim crossed over, but the client ID was not correct?
- What if the TPL does not pay? What documentation needs to be submitted to Medicaid?
- What if the TPL does not respond after being billed? What documentation is submitted to Medicaid?
- When a client is currently on workers’ compensation, and he/she comes in for a complaint unrelated to the workers’ compensation, is a denial required, and do we submit that bill in hard copy?
- There are some clients who have cancer policies. What do we do when the client is not being seen for cancer-related illness?
- Can we get an override form for services
not customarily covered by an insurance company, so that we do not have to
send the claim to the TPL first and have it denied before Medicaid can pay?
Yes. Fax a Blanket Denial Request for TPL form, available on the Forms page of the Provider Information website along with a copy of an EOB indicating the insurance company does not pay for the service, to 406.442.0357 or call 406.443.1365 or 1.800.624.3958. When you send your Medicaid claim for processing, the claims processing unit will verify that the blanket denial letter is accurate for that service before overriding the TPL insurance. For a blanket denial request, send a copy of the EOB from the other payer reflecting the denial from the other insurance as non-covered.
- If we have an EOB from private insurance
listing a paid amount, do we attach the EOB to the claim?
No. You only record the actual payment from the TPL. If the claim was denied by the TPL, then you would attach a TPL EOB along with the explanation or reason code for why it denied, or if the allowed amount went toward the client’s deductible.
- Is it true that UB providers (including RHCs,
FQHCs, and home health) do not have to include a Medicare EOB?
Yes. The Medicare payment needs to be in form locator 54. The coinsurance and deductibles go in form locator 39–41, with the appropriate value code. On the electronic claims transaction, the coinsurance and deductible are reported in Loop 2430, CAS segment.
- What happens when the insurance company sends
the payment for a claim to the client rather than the provider? Can we bill
the client the entire amount?
No. You can only bill the client for the amount listed on the insurance company’s EOB.
- Which fields on the UB-04 are used to indicate
Medicare coinsurance and deductible if form locator (FL) 39 is used by the
provider for something else?
The provider may also use FL 40–41 to report that information.
- We are not a Medicare provider. What can
we do when a claim that we sent to Medicaid denied because there was no Medicare
If you are not a Medicare provider, you send your claim to the Department with a letter of explanation.
- With Medicare, when you adjust a claim you
are not able to adjust only one line, you have to adjust the whole claim.
Then the deductible amount changes and then you have to complete a Medicaid
adjustment form. Is there a simpler way?
No, but you can send an adjustment with the new Medicare EOB that indicates on the face that Medicare information has changed. We will review the coinsurance and deductible. Adjustments do not come to us electronically from Medicare.
- What is considered proof of billing the private
insurance for pay and chase to begin?
If you send a signed letter indicating the date you billed and which insurance company, we accept that as proof of billing.
- How do we bill for a client who is eligible
for Medicare Part D but is not enrolled in a prescription drug plan yet?
The Limited Income Newly Eligible Transition (LI NET) Program, administered by Humana, is designed to eliminate any gaps in coverage for low-income individuals transitioning to Medicare Part D drug coverage. The 4-step LI NET billing process can be found at the LI NET pharmacy website http://www.humana.com/pharmacists/pharmacy_resources/information.aspx or by calling 1.800.783.1307.
- What drugs will Medicaid pay for a client
eligible for Medicare Part D?
Beginning January 1, 2006, Medicare added prescription drug coverage for its beneficiaries under the Medicare Modernization Act, 42 USC 1302 Sec. 1395.
Clients eligible for Medicare Part A and/or Part B are deemed eligible for Medicare Part D and are required to receive their drug benefits through a Medicare Prescription Drug Plan (PDP). Clients enrolled in both Medicaid and Medicare are considered “dual eligible” and are auto-enrolled in a Medicare PDP if they do not choose a plan. Montana Medicaid’s reimbursement for outpatient drugs provided to a full-benefit dual eligible recipient will be limited to the “excluded” drugs and the Part B drugs. Federal law allows states the discretion to cover certain medications listed in 42 USC 1396r-8. Montana Medicaid has opted to cover the following “excluded” medications for all recipients, including Medicare Part D recipients:
Yes, we may not know that the claim will be denied. You can get a blanket denial to attach to your claims that we will accept for 2 years.
Medicaid follows Medicare's determination of medical necessity. Therefore, if the Medicare EOB indicates the service was denied for medical necessity, Medicaid would also deny the service.
Request assistance from the Xerox TPL Unit. They will contact the insurance company to verify coverage and update the client’s records as appropriate.
Yes, we need the Medicare EOB every time.
If we send it on paper, will it get paid, or will it be denied? If the client ID number was incorrect, either submit the claim electronically with the Medicare data in the appropriate loops and segments or send the paper claim with the corrected client ID to Xerox with the appropriate Medicare EOB.
Submit the TPL explanation of benefits, ensuring the header information and the verbiage identifying the reason for denial are present.
If the TPL has not paid within 90 days, submit documentation showing when you filed the claim with the private insurance company. Xerox will pay the claim and chase the TPL for you.
A denial is not required but some indication that the claim is not related to the workers’ compensation injury is required. For electronic claims, documentation that the service is unrelated to workers’ compensation is sent as a paperwork attachment with the PWK indicator in the appropriate loop and segment. If the relationship cannot be adequately determined, the claim will be denied and the provider will be asked to send a hard copy. The provider indicates on the claim form the injury is not workers’ compensation-related (Field 19 on CMS 1500; Field 64 on the UB-04). These claims are submitted directly to TPL, P.O. Box 5838, Helena, MT 59604.
Get a blanket denial from the TPL Unit. Fax a Blanket Denial Request for TPL form, which is available on the Forms page of the Provider Information website, to 406.442.0357 or call 406.443.1365 or 1.800.624.3958. When you send your Medicaid claim for processing, the TPL Unit will verify that the blanket denial letter is accurate for that service before overriding the TPL insurance. For a blanket denial request, send a copy of the EOB from the other payer reflecting the denial from the other insurance as non-covered.
- Prescription cough and cold medications
- OTC medications listed above. Medicaid does not cover proton pump inhibitors or non-sedating antihistamines for Part D recipients when the client’s prescription drug plan covers these classes of drugs.
- Prescription vitamins and minerals will be granted prior authorization when indicated for the treatment of an appropriate diagnosis. For an updated list of covered Part B drugs, visit the CMS website, www.cms.gov/.
- When we file claims electronically, how long
are we required to keep EOBs?
Keep EOBs for 6 years and 3 months.
- Do you ever send the actual claim back?
Yes. If one of the basic required information is missing (provider number, bill date, signature), we will return the entire paper claim to the provider with a letter stating what problems were found.
- Do you only process clinic claims one week,
and then hospital claims the next week?
No. All claims that are received at Xerox are processed each week, regardless of claim type.
- How long does it take to get payment?
It can take anywhere from one to 4 weeks, depending on the backlog of claims and whether your claim is paper or sent electronically.
- Do you pay for claims under $5?
If only one claim is submitted for payment, and the payment is under $5, then we will wait until the next time a claim is submitted and add those claims together for a payment of more than $5. However, twice a year, we reduce the payment threshold to $.01 to release all small checks.
- Is the FA-455 sent to Provider Relations
or to Claims?
For electronic claims, the FA-455 can either be faxed to 406.442.4402 with the appropriate Paperwork Attachment Cover Sheet or mailed to Paperwork Attachment at P.O. Box 8000, Helena, MT, 59604, with the same cover sheet. For paper claims, providers can either attach the paperwork to the claim or submit the paperwork separately with a Paperwork Attachment Cover Sheet as described above. Instructions can be found at the bottom of the cover sheet.
- Do all diagnosis codes get keyed?
Yes, up to 4 diagnosis codes per claim on a paper CMS-1500 and up to 18 on a paper UB-04. For electronic claims, all diagnosis codes are accepted on the transaction, but only four are used in processing the 837P and eighteen for the 837I are used for processing.
- What if there is a child who comes in for
immunizations, and there are more immunizations than spaces for diagnosis?
You can make the diagnosis pointer point to whichever diagnosis you would like for child immunizations. The diagnosis does not have to match the procedure in this case only. Only 4 diagnosis codes are allowed on the CMS-1500 claim.
- What do we do if Xerox says a claim was paid,
but we are unable to find it on the remittance advice statement?
If you call Provider Relations at 1.800.624.3958, they can give you the date of the statement. If you are still unable to find it, a PR representative can pull your statement for that time and send it to you. There is a $1 per page charge for this service. Xerox can also fax your remittance advice or burn it to a CD free of charge.
- If a provider has performed a sterilization,
and the client gets retroactive eligibility, can the provider bill Medicaid
without the sterilization form?
No. You cannot bill Medicaid without the correct form. If the provider suspects that the client may become eligible for Medicaid, the provider has the client sign the form 30 days prior to the sterilization. However, for a medically necessary sterilization, the provider can send the claim and supporting documentation, including operative notes and the physician’s statement to the Department for review.
- A client became retroactively eligible during
his hospital stay. He was in the hospital on 05/30/11, but he was eligible
for Medicaid on 06/01/11. Medicare requires dates of service from 05/30/11.
How can the provider bill this?
The provider will have to prorate the stay for Medicaid eligibility both on the Medicare EOB and on the Medicaid claim.
- What is the receipt date for electronic claims?
Is the date received the same as the date sent?
The receipt date is the date the claim is actually uploaded onto the mainframe. This is usually the day after it is received, except for weekends and holidays.
- How do we submit a claim for a recently born
child without an ID?
Our system cannot pay a claim without an ID. You cannot submit the claim until you get an ID number from the local Office of Public Assistance (OPA). The OPA may assign an original ID number or use the newborn’s Social Security number. Clients or providers can call the client’s local Office of Public Assistance.
- Can we bill for fewer units than are authorized?
Yes, fewer is fine; more is not.
- If a prior authorization has multiple lines
on the authorization, can multiple claims be submitted since the CMS-1500
claim form has only 6 lines?
As long as the separate claims have the appropriate prior authorization number and match the information on the prior authorization, they will process.
- Will my claim process if the dates on the
claim overlap the date spans on a prior authorization?
The dates of service on the claim must be within the date span on the prior authorization or the claim will deny.
- If we have an error, can we submit a corrected
claim at the same time that we send the claim credit?
Yes. However, make it clear that you would like the corrected claim submitted after the claim credit is processed.
- When adjusting a claim, do you need a copy
of the original bill?
No. You do not have to send a copy of the claim. However, if you prefer, you may send a copy of the corrected claim. There is an exception for UB billers: If you are combining an inpatient and outpatient claim, send an updated, corrected claim.
- What happens if we get paid for clients that
are not ours?
If this happens, call Provider Relations at 1.800.624.3958, and we will complete the appropriate adjustments.
- If we are sending an adjustment to add a
TPL payment, do we send the EOB?
No. Put the information in the correct box in Section B of the Individual Adjustment Request form. The Individual Adjustment Request form is available at https://medicaidprovider.hhs.mt.gov/providerpages/forms.shtml.
Billing Medicaid Clients
- Can we bill the client for a code that Medicaid
does not cover?
If it is a non-covered service, the provider must inform the client, in advance, that the service being rendered is not covered. Have the client sign a statement specific to the service to be rendered, and that the client understands he/she is responsible for payment. The provider can bill the client if these steps have been followed.
- If a non-covered service is provided at the
same time as another, covered service, can Medicaid be billed for the covered
service if private pay is established for the non-covered service?
Yes. You can bill Medicaid for the covered service.
- If a client is not eligible, but we do not
know he is not eligible until after the treatment because he does not provide
a card, can we charge him?
A provider can use one of several methods to check Medicaid eligibility—the Montana Access to Health web portal, FaxBack, Automated Voice Response, or the Xerox Provider Relations line. These methods are described in provider manuals and notices. If a provider cannot verify Medicaid eligibility, the provider can accept the client as a private-pay client until eligibility is verified. If the provider later verifies Medicaid eligibility for a client accepted as private-pay, the provider can opt to bill Medicaid (within timely filing rules) or to continue the private-pay arrangement with the client.
- What can an emergency department (ED) do
with a client who continues to present to the ED with non-emergent symptoms?
If the provider determines he/she has Medicaid, can the provider arrange for
The Emergency Medical Treatment and Active Labor Act (EMTALA) prohibit a delay in providing the required screening or stabilization treatment in order to inquire about payment methods or insurance status. It is acceptable to ask what insurance the client has and to ask to make a copy of the card as long as in doing so you do not delay giving the screening/ stabilization. You might follow a script, that states to the clients that seeing them for the medical screening examination and stabilization treatment (if an emergency does indeed exist) does not in any way imply that you have accepted their method of payment (whether it be private insurance, Medicaid or Medicare). Payment will be discussed after completion of the medical screening exam and at that time it could be decided that the client will be required to pay privately. EMTALA prohibits making the “private pay arrangement” prior to initiating the medical screening examination. As soon as it is initiated, payment conversations can take place.
- On our form for the client to sign determining
their insurance, can we add a line that states the client will be responsible
if Medicaid does not cover the service or if the client is not eligible?
For a non-covered service, you cannot have a blanket form; it has to be specific as to which service is not covered and what the client will be expected to pay. You could create a blanket form stating that if the client is not eligible for Medicaid that he/she will be responsible for the bill, as long as you apply this policy for all payment types. This is the case even if you do not have a form signed by the client.
- Can we bill for no-shows for Montana Health
Care Programs clients?
You cannot bill Montana Health Care Programs or the Montana Health Care Programs client for no shows.
- Is it okay to post a sign in our office that
after 3 no-shows we will not accept the client anymore?
Yes, as long as you treat private pay and Montana Health Care Programs clients the same. If you are the client’s Passport Provider, follow the process for disenrolling a Passport client outlined in your Passport Provider Handbook.
- Sometimes we bill someone as private pay
and then when the claims go to collections, the client tells us they have
Medicaid. What are our options at this point?
If you had established private pay with that client, then you can continue that process and turn them over to collection. You may bill Medicaid if within timely filling (see your provider manual).
- Is a pregnant woman still exempt from paying
cost sharing if the services are not related to her pregnancy?
Yes. Pregnant women are exempt from paying any cost sharing. Montana considers pregnancy lasting through the postpartum period. The postpartum period begins on the last day of pregnancy and extends 60 days and then to the end of that month.
- Is there a rule that we can refuse service
if a client will not pay his cost share?
You cannot refuse service outright to Medicaid clients who will not pay his cost share. However, if it is your office policy to not serve people who have an outstanding balance, and all clients are notified of this at the beginning of their treatment, you can follow your office policy with Medicaid clients as well. You cannot treat Medicaid clients any differently than you treat clients with private insurance or Medicare, or private pay clients.
- Can you have a policy that states that cost
share is paid in advance?
No. The goal is not to deny service to clients just because they cannot pay their cost share at that time.
- When you say no balance billing, are providers
required to receive that cost sharing from the client, or can we write it
off if they are unable to pay?
Is that part of their spend down? No. You do not have to collect cost sharing from a client; you may choose to write off that amount if you would like. Cost share is included in spend down provided the Medicaid client actually paid it. The provider can give the client a receipt which is needed to verify payment.
- Why are we not getting my 835s?
If your 835 is not being delivered to the expected submitter for pickup, verify the submitter number sent on your enrollment for the 835 delivery point. Providers can call Provider Relations at 1.800.624.3958 to verify the submitter number. Remember that 835s are available for review for 60 days from when they are posted, and they can’t be regenerated. If you miss the deadline, your remittance advice is available on the web portal.
- What if we have received our EFT but no remittance
Contact Provider Relations to verify your 835 delivery point. If your NPI does not appear in the web portal drop-down menu for the ESOR! (the printable version of the remittance advice), contact Provider Relations for assistance. If possible, have your web portal submitter number ready when you call. Your web portal submitter number may be different than the submitter number for transmitting claims.
- Why are our direct deposits not showing up
on our bank statements?
It is likely that we received incomplete or incorrect account information. Call Provider Relations to verify your banking information and your tax reporting information.
- If a provider has a problem with a particular
client not showing up for appointments, does the provider have to give a reason
for refusing to see the client anymore?
No. The provider can tell the client over the phone that he/she is severing the relationship. The provider follows up in writing to keep as documentation in the client’s file. Do not treat Medicaid clients differently than private pay clients. However, if the provider is the client’s Passport Provider, follow the process for disenrolling a Passport client outlined in the Passport Provider Handbook.
- Do you consider urgent care facilities the
same as an emergency room?
No. They are not considered emergency.
- If we have a visitor from another state,
do we have to enroll as a provider for that state?
No. Enrolling as a Medicaid provider is voluntary, so you can make the choice whether to enroll with that state’s Medicaid program or arrange for the client to be private pay.
- What do you consider a new client? If a client
leaves for 3 to 4 years then comes back, would he be a new or established
A new patient is one who has not received any professional services from a physician or another physician of the same specialty who belongs to the same group practice within the past three years. Refer to the Evaluation and Management guidelines section of the CPT-4.
- We work in a public health clinic, and we
get claims returned saying that the client has MHSP, and since we are not
a mental health provider, we cannot give them shots. Why is this not covered?
Because the Mental Health Services Plan (MHSP) is 100% state funded, these clients can only get mental health related services. They are not Medicaid clients; they are MHSP clients.
- What happens when a client is ordered to get
The client wants the deluxe walker, but Medicaid will only pay for standard walker. Both walkers have the same procedure code. Could we bill the client for the difference between the deluxe walker that is not covered and the standard walker that is? If the client wants the deluxe walker, but only requires the standard walker then the deluxe walker is considered a non-covered service. The client pays for the full amount of the non-covered service. Document that this is a non-covered service.
- If I receive payment for a service, but the
payment is later recovered by SURS, can we bill the Montana Health Care Programs
client for that service?
If the provider made an error that resulted in overpayment or Montana Health Care Programs made an error in processing, the provider cannot bill the client.
- Where can we find the Administrative Rules of Montana?
- What is the Provider Information website address?
- Where can we find Montana Code Annotated?
On the Internet at http://data.opi.mt.gov/bills/mca_toc/index.htm.
- How do we get a new fee schedule?
Fee schedules are available on the Provider Information website by following the Resources by Provider link to your specific provider page
- Who do we call to report provider or client fraud or abuse?
The following hotlines and phone numbers are available to you in matters regarding suspected fraud and abuse:
- Provider Fraud or Abuse: 1.800.376.1115 (MFCU: Medicaid Fraud Control Unit); or 406.444.4586 (SURS: Surveillance and Utilization Review)
- Client Eligibility Fraud: 1.800.201.6308
- Client Abuse: 1.800.362.8312 (Team Care)