Physician

Provider Manuals (Updated May 14, 2012)
Medicaid Rules/Regulations (Updated May 9, 2006)
Fee Schedules (Updated January 30, 2012)
Archived Fee Schedules (Updated February 8, 2010)
Notices and Replacement Pages (Updated May 1, 2012)
Other Resources (Updated May 2, 2012)
Remittance Advice Notice
Key Contacts (Updated April 13, 2012)
Rebateable Manufacturers (Updated March 28, 2012)

Provider Manuals
General Information for Providers Updated April 2012
Medicaid billing manual with general information for all provider types.
04/2012

Physician-Related Services Updated March 2012
This manual has billing instructions specific to your provider type.
05/2012

Mental Health Services – Adult
This manual has billing instructions specific to your provider type.
07/2011

Mental Health Services – Children Updated September 2011
This manual has billing instructions specific to your provider type.
10/2011

Prescription Drug Program Updated August 2011
This manual has information specific to your provider type.
09/2011

Passport to Health Provider Handbook
Everything providers need to know to become a successful Passport provider.
09/2005

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Medicaid Rules/Regulations
Administrative Rules of Montana (ARM)
Montana Code Annotated (MCA)
Code of Federal Regulations (CFR)

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Fee Schedules
Current ATP Fee Schedule in Excel Format
01/2012

Current ATP Fee Schedule in PDF Format
01/2012

Current Fee Schedule in PDF Format
01/2012

Current Fee Schedule in Excel Format
01/2012

Current Fee Schedule for Medicaid Mental Health and MHSP Services for Clients Under 18 Years of Age in PDF Format
09/2011

Previous Fee Schedule in PDF Format Updated November 2011
09/2011

Previous Fee Schedule in Excel Format Updated November 2011
09/2011

Current Fee Schedule for 72-Hour Presumptive Eligibility Program for Crisis Stabilization for Individuals 18 years of Age and Older in PDF Format
09/2011

Previous Fee Schedule in PDF Format
02/2011

Previous Fee Schedule in Excel Format
02/2011

Previous Fee Schedule for Medicaid Mental Health and Mental Health Services Plan for Clients Under 18 years of Age in PDF Format
01/2011

Previous ATP Fees in PDF Format
01/2011

Previous Fee Schedule for 72-Hour Presumptive Eligibility Program for Crisis Stabilization for Individuals 18 years of Age and Older in PDF Format
08/2010

Previous Fee Schedule for Medicaid Mental Health and MHSP Services for Clients Under 18 Years of Age in PDF Format
08/2010

Previous Fee Schedule in PDF Format
07/2010

Previous Fee Schedule in Excel Format
07/2010

Current Fee Schedule for Medicaid Mental Health for Clients 18 Years of Age and Older in PDF Format
07/2010

Current Fee Schedule for MHSP Services for Clients 18 Years of Age and Older in PDF Format
07/2010

Previous Fee Schedule for Medicaid Mental Health for Clients 18 Years of Age and Older in PDF Format
03/2010

Previous Fee Schedule in PDF Format
02/2010

Previous Fee Schedule in Excel Format
02/2010

Previous ATP Fees in PDF Format
02/2010

Previous Fee Schedule for MHSP Services for Clients 18 Years of Age and Older in PDF Format Updated March 16
12/2009

Previous Fee Schedule for 72-Hour Presumptive Eligibility Program for Crisis Stabilization for Individuals 18 Years of Age and Older in PDF Format Updated September 1
08/2009

Previous Fee Schedule in PDF Format Updated July 28
07/2009

Previous Fee Schedule in Excel Format Updated July 28
07/2009

Previous Fee Schedule for MHSP Services for Clients 18 Years of Age and Older in PDF Format
07/2009

Previous Fee Schedule for Medicaid Mental Health for Clients 18 Years of Age and Older in PDF Format Updated January 26
07/2009

Previous ATP Fees in PDF Format Updated March 12
02/2009

Previous Fee Schedule in PDF Format Updated April 27
01/2009

Previous Fee Schedule in Excel Format Updated April 27
01/2009

Previous Fee Schedule for MHSP Services for Clients 18 Years of Age and Older in PDF Format Updated February 11
02/2009

Previous Fee Schedule for 72-Hour Presumptive Eligibility Program for Crisis Stabilization for Individuals 18 Years of Age and Older in PDF Format
07/2008

Previous Fee Schedule for Medicaid Mental Health for Clients 18 Years of Age and Older in PDF Format
07/2008

Previous Fee Schedule for MHSP Services for Clients 18 Years of Age and Older in PDF Format
07/2008

Previous Fee Schedule in PDF Format
07/2008

Previous Fee Schedule in Excel Format
07/2008

Previous Fee Schedule in PDF Format
01/2008

Previous Fee Schedule in Excel Format
01/2008

Previous Fee Schedule in PDF Format
10/2007

Previous Fee Schedule in Excel Format
10/2007

Previous Fee Schedule for Medicaid Mental Health and MHSP Services for Clients 18 Years of Age and Older in PDF Format
10/2007

Previous Fee Schedule in PDF Format
01/2007

Previous Fee Schedule in Excel Format
01/2007

Previous ATP Fees in PDF Format
01/2007

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Notices and Replacement Pages
(for prescription medication notices, see the Pharmacy page)
05/03/2012

05/01/12
Passport and Foster Care

04/13/12
Replacement Pages; General Information for Providers Medicaid Covered Services and Client Eligibility

02/15/2012
Non-Coverage of Artificial Disc

02/13/2012
Emergency Room Services Update

01/06/12
Smoking and Tobacco Use Cessation Counselor Services

01/06/12
Psychiatric Residential Treatment Facility (PRTF) Prior Authorization Start Date Must Match Admission Date

12/12/11
Qualifier for Anesthesia Services on HIPAA 5010 837P Transactions

11/07/11
Provider Information on HIPAA 5010 837 Health Care Claim Transactions

11/04/11
Meeting the Requirements of HIPAA 5010 When Reporting National Drug Codes on Electronic 837I and 837P Transactions Updated November 16

11/02/11
Smart PA® Prior Authorization for Synagis®

10/20/11
Prior Authorization for Children's Vitamins

10/07/11
Influenza Virus Vaccine

09/09/11
HIPAA 5010/OCR Qualifier Changes Effective January 1, 2012

09/09/11
DME Order and Prescription Requirements

09/07/11
Payment Error Rate Measurement (PERM)

07/18/11
Reimbursement Changes for Covered Ancillary Services Provided to Youth in a Psychiatric Residential Treatment Facility (PRTF) and Additional Ancillary Services Are Covered

07/18/11
Prior Authorization Requirements Discontinued for Targeted Case Management (TCM) and Outpatient Therapy Concurrent with Comprehensive School Community Treatment (CSCT)

06/27/11
HIPAA 5010/OCR Qualifier Changes Effective January 1, 2012

06/24/11
PRTF Waiver Site Denial Required

06/01/11
17-AHP and Makena

05/18/2011
Dentist and Denturist Program Manual Updated

05/05/11
Renew Passport Provider Agreement

04/12/11
Request: Claims Submission, Date of Payment by June 30, 2011

03/23/11
Changes to Procedure Code Indicators

02/07/11
Vaccine Administration Code Update

11/17/10
17-AHP

11/17/10
Compound Drugs Billed on a CMS-1500

10/05/10
Changes to NCCI Edits

09/15/10
Unlinking Passport Providers No Longer Part of Group Practice

07/28/10
Provider Record Update Procedures Effective Immediately

07/15/10
Vaccine Update Effective February 23, 2010

Fee Schedule for Mirena
07/07/10

06/23/10
Cost Sharing Exemption under ARRA

06/23/10
Resource Based Relative Value Scale (RBRVS) Information

06/22/10
Electronic Health Records Link

06/04/10
Medicaid Consultation Services

05/28/10
Clinical Laboratory Fee Schedule (CLFS) Instructions for Test Codes 80100, 80101, 80101 QW, G0430, G0430 QW, and G0431 QW

05/25/10
Medicaid Incentive Payment Program for Adopting Electronic Health Records

03/29/10
Implantable Neurostimulators

02/09/10
United States 2010 Census

02/08/10
Medicaid Health Improvement Program

02/03/10
Medicaid Consultation Services

01/21/10
Reimbursement Change for Psychiatric Residential Treatment Facilities and How It Affects Other Montana Medicaid Providers

12/10/09
Billing and Code Clarification for Psychological Testing and Request to Adjust Claims by December 31, 2009

10/08/09
2009 H1N1 Influenza Vaccine and Administration Updated October 15

10/07/09
Quantity Limits on Ostomy Products

10/01/09
Healthy Montana Kids Plan

09/29/09
Update: SmartPA® Prior Authorization for Synagis®

09/22/09
NDC Billing Tools

09/10/09
First DataBank, Medi-Span, and McKesson AWP Litigation
Settlements: Pharmacy Reimbursements May Be Impacted by Upcoming Reporting Change

07/16/09
Coverage of Fluoride Varnish

07/08/09
Anesthesia Providers

06/02/09
Clarification of Required NDC Information for Coverage of
17 Alpha-Hydroxyprogesterone Caproate (17-AHP)

04/27/09
Transplant Program Update Updated April 30

03/16/09
Timely Filing for Medicare Crossovers

03/05/09
Vagus Nerve Stimulation (VNS) Updated March 10

02/26/09
ATP Lab Fees
Updated March 12

02/25/09
Vaccines for Children (VFC) Effective as of October 10, 2008

02/12/09
Reimbursement Change for Psychiatric Residential Treatment Facilities and How It Affects Other Montana Medicaid Providers

10/20/08
Changes in Transplant Coverage Updated October 27

09/03/08
Tamper-Resistant Rx Pad Update: Three Features Required October 1

09/02/08
Introducing SmartPA®

08/12/08
Federal Government May Request Medical Records
Updated September 18

07/22/08
Billing Procedures Regarding Electronic Claims (837P and 837I)

07/11/08
Changes in Mental Health Services Plan for Adults Age 18 and Older

07/10/08
Physician-Related Services Manual Replacement Pages - Revised Key Contacts, Completing a Claim Form, Prior Authorization, Billing for Immunizations

07/10/08
Multiple Conversion Factors for RBRVS Providers

05/29/08
When to Submit an NDC (National Drug Code) If You Are Billing as a 340B Provider

05/22/08
Frequently Asked Questions About NPI Reenrollment and Billing Updated June 17

05/21/08
Maintenance Medications, Pharmacy Dispensing Fee Increase, and Signature Log Requirements

05/01/08
RHC/FQHC Taxonomy on Provider Encounters in Hospitals

04/10/08
Billing Procedures Regarding National Drug Code (NDC) for Providers Using the CMS-1500 and 837-P

04/01/08
Preferred Drug List (PDL): Brand Products No Longer Preferred
Over Generics

03/17/08
Resubmission of Denied Claims Updated March 19

03/11/08
Billing Procedures Regarding National Drug Code (NDC) Updated October 15

03/10/08
NPI Reenrollment and Billing

02/20/08
Changes to Prior Authorization for Circumcision Updated August 5

02/19/08
New HCPCS/CPT Codes

02/13/08
Tamper-Resistant Prescription Pads

02/04/08
Duplicate Issue Updated from January 31

01/29/08
Enhanced Claims Editing—Medicare Correct Coding Initiative Edits (CCI)

01/28/08
Expansion of Provider Types for the Mental Health Services Plan

01/22/08
Passport to Health Caseloads to Increase

01/18/08
Possible Duplicate Claims Processed Through Electronic Data Interchange

01/11/08
Vaccines for Children (VFC)

12/28/07
New Codes for Smoking and Tobacco Use Cessation Counseling

12/26/07
WINASAP Upgrade Required for NDC Data Collection

12/21/07
Compound Prescription Billing Changes Updated January 16

12/18/07
Radiopharmaceutical Pricing 2007 Update

12/17/07
Enhanced Claims Editing—Assistant / Team / Co-Surgeon

12/17/07
Enhanced Claims Editing—Multiple Evaluation and Management Services Provided on the Same Day

12/11/07
Sports Physicals

12/03/07
NPI Requirement for Fee-for-Service Healthcare Provider Claims

11/30/07
NDC Requirement on All Physician-Administered Drugs Updated January 17

11/27/07
Cost Share Changes

11/01/07
Enhanced Claims Editing—Add-on Codes

11/01/07
Enhanced Claims Editing—New Visit Evaluation and Management Codes

11/01/07
Enhanced Claims Editing—Bloodhound ClaimsGuard®

10/03/07
VFC Update

10/03/07
Rendering Provider

10/01/07
Tamper-Resistant Prescription Pads — Postponed

09/28/07
Smoking and Tobacco Use Cessation Counseling

09/20/07
Tamper-Resistant Prescription Pads — Updated

08/27/07
Vaccines for Medicare Part D Participants

08/07/07
Tamper-Resistant Prescription Pad Requirement

08/01/07
Elimination of ESOR

07/06/07
Coverage of 17 Alpha-Hydroxyprogesterone Caproate

06/25/07
NPI on the Web Portal

06/11/07
Ownership and Control Information Required for Reenrollment

06/06/07
NPI Contingency Plan Implemented, Reenrollment Extended

05/31/07
New CMS-1500 to Be Required Beginning July 2, 2007

04/16/07
VFC Update Updated from January 24

04/16/07
Coverage of HPV Vaccine

03/08/07
New and Deleted Codes

03/08/07
Cardiac and Pulmonary Rehabilitation No Longer Require a Prior Authorization for Outpatient Settings

02/01/07
Adjustments to Anesthesia Claims

01/26/07
Mental Health Claims May Have Been Underpaid

01/22/07
ATP Lab Fees

12/22/06
Prior Authorization for DMEPOS and Medical/Surgical Procedures Updated Phone and Fax Lines

11/08/06
Prior Authorization on the Move

10/04/06
Change in Reimbursement of the -QY Modifier

09/22/06
VFC Update

07/27/06
Billing for Clients With Medicare and Medicaid—Revised

07/25/06
Physician Related Services Manual Replacement Pages - Well Child EPSDT Update

04/25/06
Physician Related Services Manual Replacement Pages - Revised Instructions for Completing a Claim, Revised Information on How Cost-Sharing Affects Claim Payment

04/18/06
VFC Update

04/11/06
ATP Lab Fees

03/01/06
VFC Update

02/10/06
New and Deleted Codes

01/05/06
Increased Reimbursement for EPSDT Preventive Services

12/28/05
Montana Medicaid Provider Website Now Offers
Online Medical History


12/12/05
Physician Related Services Manual Replacement Pages - New EPSDT Chapter, Hysterectomy Acknowledgement Form, and Revised Information on Imaging Modifiers, Billing for Immunizations, and ER Visits for Clients Under Age 2

12/02/05
Coverage of Drugs for Sexual and Erectile Dysfunction Eliminated

10/11/05
Wheelchair CMNs - Transition Instructions

09/26/05
Blood Draws (CPT 36415 and 36416)

09/22/05
Telemedicine

07/28/05
Scales - Congestive Heart Failure

07/01/05
Revised Processing for Emergency Room Visits

07/01/05
VFC Update

06/01/05
Medicaid Coverage Update

04/29/05
General Manual Replacement Page - Member Number a Billable Number and Key Contacts Updated

04/04/05
Pricing Logic Changes for Professional (CMS-1500) Claims

03/01/05
Physician Related Services Manual Replacement Pages – Hysterectomy Acknowledgement Update

03/01/05
Hysterectomy Acknowledgement Update

02/04/05
Introduction to Preferred Drug List

01/25/05
Physician Related Services Manual Replacement Pages – Rule References Added, Updates to Covered Services, PA and Modifiers

02/01/05
New and Deleted Codes and New Botox Criteria

12/01/04
Billing for Clients With Medicare and Medicaid

11/16/04
Physician Manual Replacement Pages – Updated Prescription Drug PA Criteria

11/16/04
Pharmacy Manual Replacement Pages – Updated Prescription Drug PA Criteria

11/05/04
General Manual Replacement Pages – References to Medicaid Rules/Regulations Added

10/01/04
Emergency Department Claims Appeal Process

09/16/04
General Manual Replacement Pages – Team Care and Nurse First Information Added

09/15/04
Physician Manual Replacement Pages – Team Care Added

06/16/04
Physician Manual Replacement Pages – Clarification on Sterilizations, Hysterectomies, Abortions and HIPAA and Drug PA Update

06/16/04
Prescription Drug Manual Replacement Pages – PA and HIPAA Updates

06/10/04
Team Care Program – A New Component of the Passport to Health Program

06/01/04
Important Reminder Regarding Sterilizations, Hysterectomies and Abortions

04/27/04
Observation Bed Criteria – Updated

03/16/04
ATP Lab Fees

02/01/04
New and Deleted Codes

01/22/04
Lab and Radiology Services Covered Under MHSP Plan

01/01/04
VFC Changes Updated from December

01/01/04
New and Discontinued Optometric Codes

12/23/03
Manual Replacement Pages for Immunizations, PA Criteria, Family Planning, and Using Modifiers

12/08/03
ED Claim Review Procedure

12/01/03
Bilateral X-ray Reimbursement Update

12/01/03
High Risk Pregnant Women (HRPW) Changes

12/01/03
VFC Changes

12/01/03
Discontinued Local Codes

11/10/03
EMTALA Policy Change

09/16/03
Physician Manual Replacement Pages for Hysterectomies and Prescription Drug PA Update

08/29/03
Passport to Health Implementation in Prairie County

08/29/03
DMEOPS Advisory Workgroup Openings

08/20/03
Submitting HIPAA Compliant Claims – Information for All Providers

08/20/03
Physician Manual Replacement Pages – Includes New Emergency Services Policy and Hard Card Information

08/05/03
ATP Lab Panel Fees

08/05/03
Lab Panel Crosswalk

08/05/03
Observation Bed Criteria

07/31/03
Passport and Emergency Services

07/28/03
Hysterectomy Requirements and Physician Manual Replacement Pages

06/01/03
Discontinued Services That Now Require Prior Authorization

06/01/03
Replacement Pages for Physician Manual - New PA Requirements and Hysterectomy Information

05/28/03
Change in Reimbursement for Interactive Psychotherapy

05/12/03
Provider Rate and Payment Update

05/01/03
Outpatient Hospital Lab Panel Update

04/30/03
Gastric Bypass Surgeries and Circumcisions

03/01/03
New and Deleted HCPCS/CPT Codes

03/01/03
Nutrition Services Require Passport Approval

01/27/03
Optometric Program Update

01/10/03
New Provider Notification Procedure and Medicaid Changes

01/02/03
Prior Authorization Replacement Pages

12/01/02
Program Changes and Updates

10/07/02
Presumptive Eligibility

10/01/02
Billing for Medicare Crossovers After Medicare's 45-Day Response Time

09/26/02
DME Update

09/01/02
Cost Sharing Replacement Page – Physician Related Services

09/01/02
Cost Sharing

07/01/02
2.6% Reduction

07/01/02
Passport Provider Approval Update

06/20/02
Passport to Health 24-Hour Availability

03/21/02
Prior Authorization Reminders: DME, DMEOPS

02/14/02
Weekly Payment Available

10/17/01
Dental Implants

01/26/01
New Definitions for SED and SDMI

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Other Resources
EOB R&R Crosswalk in PDF Format
EOB R&R Crosswalk in Excel Format
With the implementation of HIPAA, Medicaid will discontinue the use of Medicaid EOB codes and begin using HIPAA standard reason and remark (R&R) codes. This document crosswalks the HIPAA standard R&R codes to the Medicaid EOB codes.
02/2011

Service Matrix
Medicaid Mental Health Plan and Mental Health Services Plan (MHSP) for Youth services excluded from simultaneous reimbursement
01/2011

Previous ATP Fees
2010 ATP tests and fee schedule
02/2010

Most Commonly Used NDCs
12/2009

Self Audit Policy and Procedure
04/2009

Carrier ID List
TPL insurance carriers listed by carrier ID
05/2012
Carrier ID List
TPL insurance carriers listed by name
05/2012

Lab Panels 2007
List of codes that make up lab panels for 2004-2007
01/2007

Criteria for Botox
Prior authorization screening criteria for botox injections. See the Physician Related Services manual for instructions on requesting prior authorization.
01/2005

Criteria for Blepharoplasty
Prior authorization screening criteria for blepharoplasty surgery. See the Physician Related Services manual for instructions on requesting prior authorization.
11/2003

Criteria for Circumcision
Screening criteria for circumcision. See the Physician Related Services manual for instructions on requesting prior authorization.
11/2003

Criteria for Excising Excess Skin and Subcutaneous Tissue

Prior authorization screening criteria for excising excessive skin and subcutaneous tissue including lipectomy and abdominoplasty. See the Physician Related Services manual for instructions on requesting prior authorization.
11/2003

Criteria for Contact Lenses
Prior authorization screening criteria for contact lenses. See the Physician Related Services manual for instructions on requesting prior authorization.
11/2003

Criteria for Dermabrasion, Abrasion, and Chemical Peel
Prior authorization screening criteria for dermabrasion, abrasion, and chemical peel. See the Physician Related Services manual for instructions on requesting prior authorization.
11/2003

Criteria for Prophylactic Mastectomy
Prior authorization screening criteria for prophylactic Mastectomy. See the Physician Related Services manual for instructions on requesting prior authorization.
11/2003

Notice for Surgery Following Mastectomy
This notifies providers that all health plans that cover mastectomies must also cover reconstructive surgery.
11/2003

Criteria for Rhinoplasty and Septorhinoplasty
Prior authorization screening criteria for rhinoplasty and septorhinoplasty. See the Physician Related Services manual for instructions on requesting prior authorization.
11/2003

Criteria for Temporomandibular Joint (TMJ) Arthroscopy/Surgery
Prior authorization screening criteria for temporomandibular joint arthroscopy/surgery. See the Physician Related Services manual for instructions on requesting prior authorization.
11/2003

Criteria for Maxillofacial/Cranial Surgery
Prior authorization screening criteria for maxillofacial/cranial surgery. See the Physician Related Services manual for instructions on requesting prior authorization.
11/2003

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Remittance Advice Notice
Your current RA message is as follows:

New 1099 Process
December 14, 2006

Medicaid providers will see a change in the 1099s received for 2006 reporting Medicaid payments. Effective for calendar year 2006 and forward, ACS will no longer be generating and mailing a separate 1099 for Medicaid payments. The Department of Administration will be combining all payments by tax identification number into one 1099 instead of a separate 1099 for each Medicaid provider number. If you have any questions, please contact Roy Hinman at (406) 444-5932 or Susan Austad (406) 444-4060 at the Department of Public Health and Human Services.

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Key Contacts
Physicians
11/2008

Claims
03/2012

Public Assistance Offices
03/2012

Client Eligibility
04/2012

HMK/CHIP
12/2010

Passport
03/2012

Policy Information
03/2012

Prior Authorization
03/2012

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