Topics:
NPI
Reenrollment
Eligibility
Medicaid Policy
MATH/Faxback/AVRS
Billing Medicaid Clients
Passport
Cost-Sharing
Passport Approval Denied
Other/Miscellaneous Policy
TPL/Medicare
Medicaid Services
Claims Processing
Fraud and Abuse
Prior Authorization
Other/Miscellaneous
Adjustments
Team Care
Q. Should our office test submitting claims
using NPI with our clearinghouse?
A. Yes, if you are using a clearinghouse, you still will need to follow
the Montana’s Healthcare Programs NPI billing requirements.
Q. I received an error report (824) back
from my clearinghouse or ACS saying our NPI and/or taxonomy is not on
file. What could be the cause?
A. There could be several reasons for this:
Again, if any of these do not match, a report will be generated and the
claims will not process.
Q. I have submitted all the required paperwork
but still have not been notified that my enrollment is complete. How long
should I wait before contacting ACS?
A. If you haven’t received your welcome letter three weeks after
you have submitted all of your completed and signed paperwork, contact
ACS.
Q. Why do I need a taxonomy code?
A. Taxonomy is required as one of several data elements to match the enrollment
in the 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.
Q. Why do my claims deny when I bill with
my NPI and enter my legacy as rendering/attending (and vice versa)?
A. The claims processing system does not recognize that the legacy number
and NPI are the same entity. To the MMIS it appears as if these are different
providers and the claims will deny if the pay-to/billing provider does
not require a rendering/attending, or the rendering/attending is not a
provider type that can be a rendering/attending.
Q. Which provider types require a rendering/attending
NPI and taxonomy?
A.
Q. What if I have more than one rendering
provider on a professional claim?
A. The Montana Healthcare claims system can only process 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.
Q. What is the difference between enrolling
as an individual and enrolling as an organization?
A. 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 pay-to/billing provider
with another provider as the rendering/attending.
Q. I have two NPIs, one for myself and one
for my clinic. Which one do I use when I am billing for services I rendered?
A. If you own the clinic and the clinic’s regular practice is to
bill with the clinic as the pay-to/billing provider, you should continue
to use the clinic NPI and taxonomy as the pay-to/billing provider and
your individual NPI and taxonomy as the rendering/attending provider.
Q. I am told that I need to use a clinic
taxonomy. Do I use the one from ACS or do I need to get another one from
NPPES?
A. Providers are not bound to use the taxonomy given to them by NPPES.
The list of taxonomies used by Montana’s Healthcare Programs can
be found on www.mtmedicaid.org.
Q. I am a one-person office. Do I need
to have more than one NPI or taxonomy?
A. You need only one NPI and taxonomy if you will be both the pay-to/billing
and rendering/attending provider. You will need an additional NPI and
taxonomy if you plan on having your practice or clinic bill as a clinic
for the services of other rendering/attending providers.
Q. I decide to add another person to my
practice and I want to bill and get paid for all services. What do I need
to do?
A. You will need to obtain an NPI for the clinic from NPPES and reenroll
with Montana’s Healthcare Programs as a clinic. Then submit your
claims with the clinic NPI and taxonomy as the pay-to/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.
Q. I decided to add another person to my
practice but we want to bill our own services. What do we need to do?
A. Each provider should use his or her own NPI and taxonomy as the pay-to/billing
provider.
Q. I have several claims that have been
denied because of NPI issues. What do I do with them?
A. Please refer to the NPI billing instructions available on www.mtmedicaid.org
to determine the reason your claims are denying, then correct and resubmit
them within the 365-day timely filing limit. If you have questions, please
call Provider Relations at (800) 624-3958.
Q. What number do I use for a clinic that
is part of a provider-based entity?
A. 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 for a clinic as the pay-to/billing
provider. The professional portion of the provider-based service billed
on a CMS-1500 must use the NPI and the appropriate taxonomy for which
they enrolled. The NPI and taxonomy of the professional performing the
provider-based service should be entered as the rendering provider on
the CMS-1500 and the pay-to/billing should be the enrolled organization
whether they chose the clinic NPI or they chose to use the hospital NPI
with the appropriate taxonomy for a clinic. They must use the one they
enrolled as. The facility portion of the providerbased service billed
on a UB-04 should use the hospital NPI and the appropriate taxonomy for
an acute care hospital. The NPI and taxonomy of the professional performing
the provider-based service should be entered as the attending provider
on the UB-04.
Q. What about crossover claims? Do I need
to include my taxonomy code on claims I’m sending to Medicare?
A. Yes, claims for dually-eligible clients cross over from Medicare automatically,
so you must include your taxonomy on the claim being sent to Medicare
so that it will appear on your Medicaid claim when it crosses over to
the Montana’s Healthcare Programs. Claims sent to Medicare must
contain the appropriate pay-to/billing NPI and taxonomy as well as the
rendering/attending NPI and taxonomy. Currently, Medicare is not sending
both taxonomies. If your claim denies because of this, you can directly
rebill Montana’s Healthcare Programs for these crossovers electronically
or through your clearinghouse. Nursing facility claims do not automatically
cross over from Medicare, so nursing facility claims must be submitted
directly to Medicaid.
Q. How do I resubmit my claim that was
denied prior to NPI being required?
A. If you submitted an institutional claim prior to January 1, or a professional
claim prior to March 1, please resubmit the claim to Montana’s Healthcare
Programs electronically. If the claim was submitted to Medicare, include
the Medicare information in the proper loop and segment (please refer
to the Implementation and Companion Guides, available at www.mtmedicaid.org
by clicking on Electronic Billing Implementation Guide or Electronic Billing
Companion Guide in the left column navigation bar).
Q. What changes does my clearinghouse need
to make in submitting my claims?
A. Clearinghouses should be submitting the claims to Medicaid following
the same Medicaid rules as individual providers.
Q. Why am I not getting my 835s?
A. If your 835 is not being delivered to the expected submitter for pickup,
you should verify the submitter number sent on your enrollment for the
835 delivery point. Providers can call Provider Relations at (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.
Q. What if I’ve received my EFT but
no remittance advice?
A. You should contact Provider Relations to verify your 835 delivery point.
If your NPI doesn’t appear in the web portal drop-down menu, contact
Provider Relations for assistance. If possible, have your web portal submitter
number ready when you call.
Q. Why are my direct deposits not showing
up on my bank statements?
A. It’s likely that we received incomplete or incorrect account
information. Please call Provider Relations to verify your banking information
and your tax reporting information.
Q. What if I need to adjust a claim that was submitted using my old provider
ID number?
A. If you need to adjust a claim that was submitted using your old provider
ID number, submit the adjustment with the provider number under which
it was originally submitted. Adjustments are subject to the 365-day timely
filing rule, so once a full year has passed after complete NPI implementation,
Montana’s Healthcare Programs will no longer be using the legacy
number. If you have a paid claim with a denied line(s), you may submit
an adjustment to correct the denied lines, rather than resubmitting the
denied line(s) on a new claim. If you resubmit the denied line(s) on a
new claim it may result in another cost share for each version of the
claim. Paid claims with denied lines may be credited and completely resubmitted
using NPI and taxonomy to prevent this situation. Keep in mind if the
claim denied and had no paid lines, you cannot adjust that claim, and
it must be resubmitted as a new claim.
Q. Do I need to be using my NPI and taxonomy
now?
A. If you have already obtained your NPI and reenrolled with Montana’s
Healthcare Programs, you should be billing with your NPI and taxonomy
immediately. Institutional providers (UB-04 or 837I) were required to
begin using their NPI and taxonomy on January 1, 2008. Professional providers
(CMS-1500 or 837P) were encouraged to begin using their NPI and taxonomy
beginning March 1, 2008. Pharmacies and professional providers will be
required to use their NPI and taxonomy by May 23, 2008.
Q. We’re a nursing facility. How
do we bill for contracted therapists?
A. Nursing facilities may reenroll with ACS using their nursing facility
NPI for multiple disciplines. These disciplines may include therapies
or pharmacy. If a facility chooses to use the same NPI for multiple disciplines,
then a separate reenrollment will need to be completed for each discipline.
Q. How should mental health centers bill?
A. Mental health centers will need to reenroll for each type of provider
and service—such as case management, therapeutic group home, and
therapeutic foster care—for which they now bill. Centers must reenroll
each of the service types using their clinic NPI and choosing the provider
type for each.
Q. What qualifier do I use to reflect taxonomy
on the professional claim?
A. Use the ZZ qualifier.
Q. Why do I have to reenroll
with Montana Medicaid, Children’s
Health Insurance Plan (CHIP)—dental/eyeglasses, and Mental Health
Services Plan (MHSP)?
A. The Department of Public Health and Human Services is requiring
a complete reenrollment of all providers participating in Montana’s Healthcare
Programs (Medicaid, MHSP, and CHIP—dental/eyeglasses) as recommended
by the Office of Inspector General (OIG). This will provide the opportunity
to coordinate reenrollment with the collection of National Provider Identifier
(NPI) related information. To participate in Montana’s Healthcare
Programs after September 30, 2007, healthcare providers will reenroll
with their NPI and atypical providers will reenroll to obtain a new proprietary
number. Prior to September 30, 2007, providers will continue to use their
current Medicaid, MHSP and CHIP provider numbers to bill claims.
Q. How do I reenroll?
A. After March 1, 2007, all reenrollments must be completed online, unless
extenuating circumstances exist. Online enrollments process more efficiently
and the web editing capabilities will assist you in completing all of
the required information. Paper enrollments often need to be returned
for corrections.
If extenuating circumstances exist that prevent you from accessing the
web portal, you may call Provider Relations at 800-624-3958 or send an
email
to mtprhelpdesk@acs-inc.com to request a paper application.
Q. Do I need a National Provider Identifier (NPI) to reenroll?
A. All healthcare providers, both individuals and organizations such
as clinic or hospitals, must obtain a National Provider Identifier (NPI)
and supply
it in their reenrollment information. For more information on how to
obtain an NPI, go to www.nppes.cms.hhs.gov or call (800) 465-3203. Providers
that
do not provide healthcare services, such as personal care and non-emergency
transportation providers, are considered atypical and are not eligible
for NPIs but still need to reenroll to participate in Montana’s
Healthcare Programs.
Q. I don’t have an NPI. Do I need to
reenroll?
A. If you are a healthcare provider, you must obtain an NPI. However,
providers that do not provide healthcare services (atypical), such as
personal care
and non-emergency transportation providers, are not eligible for NPIs
but still need to reenroll. You will be assigned another proprietary number
to bill for services.
Q. I just enrolled with one of Montana’s
Healthcare Programs. Do I have to enroll again?
A. Yes, if you have enrolled as a new provider to bill services prior
to September 30, 2007, you will need to reenroll to bill on and after October
1, 2007.
Q. Will I receive a new proprietary number to bill for services?
A. If you have a National Provider Identifier (NPI), you will be required
to use the NPI on your Montana’s Healthcare Programs claims after
September 30, 2007. Organizations such as clinics will use their clinic
NPI as the billing provider and the NPI for the individual providing
the services as the rendering provider. If you are an atypical provider
that
does not require an NPI, you will be assigned a new proprietary number
for billing and web-based transactions.
Q. I am a clinic and could not previously enroll as a clinic type. How
do I enroll?
A. A significant policy and billing change is being made with the implementation
of NPI. Currently, clinics/groups are typically not permitted to enroll
and each individual that renders service is required to enroll separately
for each clinic or group in which he or she works. This policy is being
changed to align Montana’s Healthcare Programs billing with the rest
of the industry. Clinics and groups are now permitted to enroll and will
be the billing provider on claims received on and after October 1, 2007.
The individual providing the service will be indicated on the claim as
the rendering provider. The exceptions to this rule are Mental Health Centers
and Chemical Dependency Clinics, as rendering providers will not be required
on these claims. Individuals may only enroll one time, regardless of
the
number of clinics or groups in which they work. Therefore, it is critical
that you work with the individuals in your organization to ensure that
duplicate enrollments are not submitted for them. More information on the
billing
changes will be provided via separate notices.
Q. How do I know which taxonomy code to use for reenrollment?
A. The confirmation letter or email you received from NPPES will contain
the taxonomy you need to use for reenrollment. Taxonomy codes are listed
on
the website under the appropriate provider type.
Q. What is a Preferred Out-of-State Hospital?
A. A Preferred Out-of-State Hospital is a hospital located more than
100 miles outside the Montana border that has signed an agreement with
the Department
to provide specialized services that require prior approval by the Department
or its designated utilization review organization. By agreeing to become
a “Preferred Hospital,” the facility will be reimbursed at the
hospital-specific cost-to-charge ratio and will be cost settled annually.
Reimbursement without authorization will be reimbursed at the in-state
DRG payment rates and will not be eligible for cost settlement.
Q. Where do I find my four-digit ZIP code extension?
A. http://zip4.usps.com/zip4/welcome.jsp
Q. How do I fill out the tax reporting information?
A. 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 reenrollment.
Q. Do I need to fill out the ownership/control information?
A. Yes. CMS requires that ownership information be collected for all
healthcare providers that provide services that are publicly funded so
states can qualify
for federal funds. Refer to CFR 42 455.100, 455.101, 455.102, 455.103,
455.104, 455.105, and 455.106. There is no distinction between for-profit
and not-for-profit.
Enrollments will be denied if ownership information is not provided.
Q. What is the beginning and end date of my previous provider numbers?
A.
If you do not know the exact enrollment dates of your previous provider
number, leave the effective and end dates blank.
Q. Why am I required to sign up for Electronic Funds Transfer (direct deposit)?
A. The Department realizes a significant cost savings with Electronic
Funds Transfer (EFT). EFT also makes funds available to you more quickly
than
paper checks. 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 Department will
mandate EFT for all Montana’s Healthcare Programs providers within the next
two years. At that time, providers not currently receiving their Montana’s
Healthcare Programs payment electronically will be notified and be required
to provide electronic payment information. The electronic payment option
allows Montana’s Healthcare Programs providers to receive their payments
on Monday of the payment week. In addition, by choosing EFT and electronic
remittance advices, providers are able to receive weekly payments and
remittance advices which are available for download from the provider web
portal.
Q. How do I know if I am a Provider-Based Facility?
A. Provider-based status means the relationship between a hospital as
the main provider and one of the following as defined by rule:
All providers who are provider-based facilities are required to send the CMS letter received designating them as a provider-based facility.
Q. What is the government agency name and address on the direct deposit
form?
A. The government agency name on the direct deposit form is DPHHS. The
address is P.O. Box 4210, Helena, MT 59635.
Q. Why does the bank have to sign my direct deposit form?
A. Section 3 requires a bank representative signature to guarantee that
the bank account belongs to the provider. Please send back the completed
direct
deposit form with the provider ’s enrollment.
Q. What number goes in Section 1, Box C of the direct deposit?
A. The provider’s National Provider Identifier (NPI). If you are an
atypical provider you may leave this field blank.
Q. How will I know if my enrollment is complete?
A. You will receive a welcome letter from ACS informing you that your
enrollment is active. The welcome letter will contain either your NPI
for healthcare
providers or your new proprietary number for atypical providers and can
be used for transactions or claims submitted on or after October 1, 2007.
Q. Where can applicants receive an application for Medicaid?
A. From any Local Office of Public Assistance.
Q. If a client is entering a nursing home, what kind of asset resource transfer
can they do to qualify for Medicaid? Can they gift a home to a child or must
they sell it?
A. If the client does not sell the home for Fair Market Value, an asset
transfer penalty (ineligibility period) will be assigned to the person that
runs from the date of transfer forward.
Q. Do infants automatically get coverage too?
A. If the mother is eligible for and receiving Medicaid at the time
of birth, then the baby is enrolled in the Automatic Newborn program. This
provides coverage for up to one year for the infant, as long as the baby
is living with the mother in Montana, and the household countable resources
are under $3,000.
Q. Can a provider sign the Medicaid application if the applicant is not
capable?
A. 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 patient’s behalf if the patient is not willing to apply for Medicaid.
Q. How does eligibility information come from the Local County Office of
Public Assistance to ACS? How long does this take?
A. OPA workers enter client information into TEAMS. This gets uploaded
and passed to ACS every night. Nursing Home spans take longer because of
the additional check to verify the initial span. If you are having specific
questions or problem clients, call Kathe Quittenton to resolve. Another option
is to call the PR staff to help facilitate this.
Q. Can you tell me a little bit about incurment amounts and how providers
get caught up in this?
A. Incurment is for patients who don’t meet financial eligibility until
they spend down their income on medical services. On a certain day they are
eligible for everything except a specific provider with whom they meet their
incurment. Ideally, the client should receive a copy of their incurment at
the OPA and should give it to you.
Q. How far back can medical bills go and still be counted for incurment?
A. Paid bills can be counted for three months prior to the current
month. Unpaid bills can be counted as long as the patient is still financially
responsible for them (that is, as long as the provider has not written
the bill off).
Q. What is the difference between QMB, QMB only, and Medicare/Medicaid?
A. QMB only clients receive a Medicaid hard card. Under this program,
Medicaid pays the client’s Medicare Part A and Part B premiums, Medicaid’s
portion of the Medicare coinsurance and deductibles up to the qualified
amount. Clients are only covered 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, 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
only pays for services allowed by Medicare. The client is responsible for
their Medicare premiums.
Q. What does SLMB stand for?
A. Special Low-Income Medicare Beneficiary – in this program Medicaid
pays the premium for Medicare but no services.
Q. If a client has SLMB only, who
is responsible for the Medicare coinsurance and deductibles?
A. The client is responsible for the coinsurance and deductible.
Q. If you call a claim up in MATH,
and it has denied for invalid diagnosis code, is it possible to go further
to find out why?
A. No, since the site is secure and contains no medical information,
you must review your remittance advice and call Provider Relations.
Q. When you use MATH and the only
information you can receive is your own, how do you 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?
A. Call Provider Relations at ACS, they can look up prior authorization
limits.
Q. Where on the CMS-1500 form do you put the Passport provider approval
number?
A. You need to put the Passport provider number in box 17A (ID number
of the referring physician). You don’t have to have the name of the
provider, only the provider’s number.
Q. What services do not need Passport approval?
A. If you are a Passport provider, you should have a Passport Provider
Handbook which covers Passport approval. The manual Medicaid General Information
for Providers II, Appendix A lists the services that require approval from
the Passport provider.
Q. Every time you call for Passport approval do you have to speak to the
doctor?
A. No, the office staff can relay the information, but the doctor has
to actually give the approval.
Q. Is it the client’s responsibility
to get approval before they visit another provider?
A. No. The Passport provider usually initiates the referral process
by contacting another provider. If a client requests to be seen by another
provider, it is the provider's responsibility to get approval from the
Passport provider prior to seeing the client.
Q. Are Passport providers assigned without
the client’s
knowledge? We have trouble getting approval from the primary care
provider.
A. We are required to assign a Passport provider to a client if the
client does not select a Passport provider for themselves. The client is
notified that they have been assigned a provider. It is the provider’s
responsibility to manage the patient’s care. You can ask the patient
to choose you as the Passport provider if the patient is new to you. Providers
and patients can disenroll. Certain circumstances will allow a patient to
be exempt from managed care.
Q. Which Passport number do we give
if a provider calls for a Passport referral for a visit that occured
three months prior to the request and our Passport number has changed?
A. You will give the Passport number that was effective on the day of
service. If you did not make the referral, you do not have to give your
approval after the fact just to allow the provider the ability to receive
payment.
Q. We have a patient that we referred to a specialist and that specialist
referred to another specialist but we have no record.
A. This is piggy backing and shouldn’t happen, but if it does, if you
feel you are still managing the patient’s care you can give the approval
for the second specialist. No referral has to be written, but must be noted
in the record.
Q. If the Passport provider sends a referral does that qualify or does the
provider still need to call?
A. If the Passport number is on the referral that is all you need.
Q. Are all clients Passport except for those in nursing home?
A. Most clients are required to be on Passport. Clients who are not
eligible to participate in Passport are those clients living in a nursing
home or other institution, clients receiving Medicare and Medicaid, clients
classified as medically needy and have an incurment, clients receiving
Medicaid for less than three months, subsidized adoption, eligibility is
only retroactive, and client receiving Home and Community Based Waiver
Program Services. Some clients may also apply for a medical hardship. For
example, clients in a residential treatment arrangement, like those kids
in the School for Deaf and Blind. Exemptions can be requested for other
situations as needed.
Q. Can you use the hospital’s Passport
approval for the physician on call?
A. It is up to the Passport provider to outline what the referral is
for when he/she is called for the Passport facility approval. It cannot be
assumed that a hospital facility approval is an approval for any and all
services.
Q. Is there a mechanism to change the Passport provider when a patient moves?
A. No. When a client moves, and does not change his or her Passport
provider due to that move, he or she remains with the same Passport
provider until the client calls Provider Relations requesting a Passport
provider change.
Q. On Passport, is the Passport approval
the same thing as the provider’s
Medicaid ID number?
A. No. As of February 1, 2003, the Passport number is not the provider’s
Medicaid number.
Q. Why are clients allowed to change Passport providers so often?
A. This is determined by the state – some states have a lock-in period.
Our state allows clients to change Passport providers every month if they
desire. Less than 4 % of Medicaid clients change providers each month. Less
than 2% change providers more than 3 times a year.
Q. Who is responsible for getting the Passport
approval – the
provider or the client? What do we do when clients come with no referral?
A. It is ultimately the provider’s responsibility to contact the Passport
provider for approval for the client to be seen in the other provider’s
office. When you ask the client what insurance they have, if they say Medicaid
tell them you cannot meet with them until you get Passport approval.
Q. If Passport approval was denied by provider for having not seen the patient
previously, what can you do?
A. Refuse to treat the client or encourage the client to see their
PCP, explaining why that is important. The Passport provider has the right
to deny their approval of any service.
Q. We have a walk-in clinic and since they sometimes come in on the weekend,
obtaining Passport is difficult. We advise them that if they cannot get Passport
approval that they can either be responsible for the charges or wait and
see their Passport provider.
A. You either need to accept them as Medicaid, including Passport,
or take them as private pay at that time. It cannot be a “you may be
responsible” situation – it either has to be, you accept them
as private pay right away and take their money, and then try to get approval,
and then refund the money. Or accept them as Medicaid and just try and get
approval.
Q. Is there some way that if a Passport provider will not authorize a service,
can the patient go to Medicaid and get that?
A. If the Passport provider does not authorize the service, they can
ask to have their Passport provider changed, but we do not override the Passport
provider’s decision.
Q. You mentioned before about working the
enrollee list – can they
drop a patient or is the patient the only one who can change?
A. Give 30 days notice – send letter to client and to Passport. Currently
there are four reasons providers can disenroll client, and that is
in the contract.
Q. Do you have to send a claim to the other payer if the provider knows
the insurance is going to deny?
A. 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 two years.
Q. What about when a client has Medicare/Medicaid
coverage, and the service is denied by Medicare for not being medically
necessary?
A. 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. Procedures that Medicare does
not cover do not post the Medicare edit, so they would not be denied
for this reason.
Q. What about those cases where Medicaid
shows a TPL, but the provider can’t
get any information from either the client or the other carrier?
A. Turn over to the TPL unit. They will contact the insurance company
to verify coverage and update our records as appropriate.
Q. If you give us a denial, and we have
to resubmit a particular line and it’s Medicare/Medicaid, when
we resubmit that line, do we need to resubmit the Medicare EOB?
A. The answer is yes, we need the Medicare EOB every time.
Q. What happens if the message says it
crossed over, but the client ID wasn’t
correct? If we send it on paper to get paid, will it, or will it be
denied?
A. You must wait 45 days after the Medicare payment date to submit
the claim to ACS on paper or the claim will be returned to you. If the client
ID # was incorrect, you should send the paper claim with corrected client
ID to ACS after waiting the 45 day period.
Q. What if the TPL doesn’t pay, what
documentation do we need to submit to Medicaid?
A. If the TPL hasn’t paid within 90 days, you can submit documentation
of when you filed the claim with the private insurance company with the TPL
unit at ACS. ACS will then pay the claim, and then chase the TPL for you.
Q. When a patient is currently on Workers Compensation, and they come to
you for a complaint unrelated to the Workers Comp. Is a denial required and
do we need to submit that bill in hard copy?
A. A denial is not required but there must be some indication that it
is not related to the Workers Compensation injury. For electronically
submitted claims, staff will check to determine whether the diagnosis
codes could be related to the Workers Compensation injury. If it cannot
be adequately determined, the claim will be denied and the provider
will be asked to send a hard copy. The provider needs to indicate on
the claim form the injury is not workers comp related (field 19 on HCFA-1500;
field 64 on the UB). Those claims need to be submitted directly to the
TPL unit at P.O. Box 5838, Helena, MT 59604.
Q. There are some patients that have cancer policies, but the patient is
not being seen for cancer related illness.
A. Get a blanket denial from our TPL unit, call (406) 443-1365 or (800)
624-3958.
Q. Can you get an override form for services
not customarily covered by an insurance company, so that you don’t
have to send the claim to the TPL first and have it denied before
Medicaid can pay?
A. Yes. It’s called a blanket denial letter, and when you send your
Medicaid claim in, the TPL unit will verify that the blanket denial letter
is accurate for that service before overriding the TPL insurance.
Q. If I have an EOB from private insurance listing a paid amount, do I need
to attach the EOB to the claim?
A. No. You only need to record the actual payment from the TPL. If
the claim was denied by the TPL, then you would need to attach a TPL EOB
along with the explanation or reason code for why it denied, or if the allowed
amount went towards the person’s deductible.
Q. Is it true that UB providers (including Rural Health Centers, Federally
Qualified Health Centers and Home Health) do not have to include a Medicare
EOB?
A. Yes. The Medicare payment needs to be in Field 54 with the coinsurance
and deductibles in Fields 39-41 with the appropriate value code.
Q. What happens when the insurance company sends the payment for a claim
to the patient rather than the provider? Can we bill the patient the entire
amount?
A. No. You can only bill the patient for the amount listed on the insurance
company’s EOB.
Q. What fields on the UB-04 should
be used to indicate Medicare coinsurance and deductible if the Form
Locator 39 is used by the provider for something else?
A. The provider may also use Form Locator 40-41 to report that information.
Q. We are not a Medicare provider, but we have a client that we send in
to Medicaid and it denied from Medicaid because there was no Medicare EOB.
A. If you are not a Medicare provider, we cannot process that without
a letter stating that you are not a Medicare provider.
Q. With Medicare when you adjust a
claim you can’t just adjust a line, you have to adjust the whole
claim, then the deductible amount changes and you have to adjust Medicaid
adjustment form. Is there a simple way?
A. No, but what you can do is send us an adjustment that indicates that
Medicare information has changed on the face of adjustment and we will
review the coinsurance and deductible. Adjustments do not come to us
electronically from Medicare. Also you need to attach a new EOMB.
Q. What is considered proof of billing the private insurance for pay and
chase to begin?
A. If you send a letter indicating the date you billed, which insurance
company and sign it, we will accept that as proof of billing.
Q. When we file claims electronically, how long do we keep EOBs?
A. 6 years and 3 months
Q. Do you ever send the actual claim back?
A. Yes, if one of the basics is missing (provider number, bill date,
signature) we will return the entire claim to the provider with a letter
stating what problems were found.
Q. Do you only process clinic claims one week, and then hospital claims
the next week?
A. No. We are constantly processing all the claims that come into the
office, regardless of claim type.
Q. How long does it take to get payment?
A. It can take anywhere from one to four weeks, depending on the backlog
of your claim type and whether your claim is paper or sent in electronically.
Q. Do you not pay for claims under five dollars?
A. 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 over $5. However, two times a year,
we reduce the payment threshold to one cent to release all small checks.
Q. Is the FA-455 sent to PR or Claims?
A. For electronic claims, the FA-455 can either be faxed to (406) 442-4402
with the appropriate Paperwork
Attachment Coversheet or mailed to Paperwork Attachment at P.O.
Box 8000 with the same coversheet. For paper claims, providers can either
attach the paperwork to the claim or submit the paperwork separately
with a Paperwork Attachment Coversheet as described above. Instructions
can be found at the bottom of the coversheet.
Q. Do all diagnosis codes get keyed?
A. Yes, up to four diagnosis codes per claim on a CMS-1500 and nine
on a UB-04.
Q. What if there is a child who comes in for immunizations, and there are
more immunizations than spaces for diagnosis?
A. You can make the diagnosis pointer point to whichever diagnosis
you’d like for child immunizations- the diagnosis doesn’t have
to match the procedure in this case only. ACS can still only enter four diagnosis
codes for the claim.
Q. What do we do if ACS says a claim was paid, but I am unable to find it
on the remittance advice statement?
A. If you call Provider Relations they can give you the date of the
statement. If you are still unable to find it, someone in PR can pull your
statement for that time and send it to you. There is a dollar per page charge
for this service.
Q. If a provider has done a sterilization, and the client gets retroactive
eligibility, can the provider bill Medicaid without the sterilization form?
A. No. You cannot bill Medicaid without the correct form. If the provider
suspects that the client may become eligible for Medicaid, the provider should
have the client sign the form prior to the sterilization. However, for a
medically necessary sterilization, you can send the claim and supporting
documentation, including operative notes and the physician’s statement
to the Department for review.
Q. A client became retroactively eligible during their hospital stay. They
were in the hospital on 5/30/01, but they were eligible for Medicaid on 6/01/01.
Medicare requires dates of service from 5/30/01. How can the provider bill
this?
A. They will have to prorate the stay for Medicaid eligibility both
on the Medicare EOB and on the Medicaid claim.
Q. What is the receipt date for electronic claims, is the date received
the same as the date sent?
A. The receipt date is the date the claim is actually uploaded onto
the mainframe. This ordinarily is the day after it is received, except for
weekends and holidays.
Q. How do you submit a claim for a recently born child without an ID?
A. You cannot submit the claim until you get some sort of ID number
from the county – either their original ID number from the county
or their SSN. Our system cannot pay a claim without an ID. Clients or providers
can call the client’s local Office of Public Assistance. The OPA
will assign an original ID number to the baby so claims may be paid.
Q. When you get denials while the provider is in the process of changing
their provider number, is the provider responsible for adjusting claims?
A. These claims are not paid, so the provider is responsible for resubmitting
the claim with the proper Montana's Healthcare Programs provider number
to ACS.
Q. Can you bill for fewer units than are authorized?
A. Yes, less is fine, more is not.
Q. What about a Prior Authorization
that has multiple lines, since a CMS-1500 claim can only have six lines?
A. As long as the separate claims have the appropriate Prior Authorization
number and match the information on the Prior Authorization on it they
will process.
Q. Will my claim process if the dates
on the claim overlap the date spans on a prior authorization?
A. The dates of service on the claim must be contained within one date
span on the prior authorization or the claim will deny.
Q. If I have an error can I submit a corrected claim at the same time that
I send the claim credit?
A. Yes. However, please make it clear that you would like the corrected
claim submitted after the claim credit is processed.
Q. When adjusting a claim, do you need a copy of the original bill?
A. No, you don’t have to send a copy of the claim. If you want, please
send a copy of the corrected claim. There is an exception for UB billers – if
you are combining an inpatient and outpatient claim, please send an updated,
corrected claim.
Q. What happens if you get paid for clients
that aren’t
yours?
A. If this happens, please call Provider Relations and we will take
care of this by doing the appropriate adjustment.
Q. If you are sending an adjustment
to add a TPL payment, do you need to send the EOB?
A. No – just put the information in the correct box in part B of the
adjustment form.
Q. Can we bill the client for a code that you do not pay on?
A. If it is a non-covered service, and the client is told prior to
the services being rendered you can bill the client.
Q. If you have one service that is non-covered at the same time as other
services provided that are covered, does the fact that I establish private
pay for the non-covered service mean that I could not bill Medicaid for the
other services?
A. No, it does not mean that you cannot bill Medicaid for the other
services.
Q. If a patient is not eligible, but we
do not know they aren’t eligible
until after the treatment because they do not provide a card, we cannot
charge them?
A. You can tell a patient who does not present a card that you are not
willing to accept Medicaid for them until you have seen their Medicaid
card and verify their eligibility. You can take them as a private pay
patient until they verify eligibility. If you do not set up private
pay with the patient and Medicaid denies payment you will be responsible
for the patient's charges. If the patient brings in his or her card
and eligibility can be verified within timely filing requirements, you
can opt to bill Medicaid or continue as private pay.
Q. What can an Emergency Department do with a client who continues to present
to the ED with non-emergent symptoms? If we determine they have Medicaid
can we arrange for private payment?
A. EMTALA prohibits a delay in providing the required screening or
stabilization treatment in order to inquire about payment methods or insurance
status. You are okay to ask what insurance the client has and to ask to get
the card to make a copy of it as long as in doing so, you do not delay giving
the screening/stabilization. You might have a script, which you follow, stating
to 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 examination and at that time it could be decided that you
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.
Q. On our form for the patient to sign,
determining their insurance, can we add a line that states the patient
will be
responsible if Medicaid won’t
cover the service or if the client is not eligible?
A. For a non-covered service, you cannot have a blanket form—it has
to be specific as to the service that is not covered and what the patient
will be expected to pay. You could create a blanket form stating that if
the client is not eligible for Medicaid that they will be responsible for
the bill. This is the case even if you do not have a form signed by the client.
Q. Can we bill for no shows for Montana's
Healthcare Programs clients?
A. You cannot bill Montana's Healthcare Programs or the Montana's Healthcare
Programs client for no show.
Q. If we have it posted in our office that after three no shows we will
not accept you any more, is that ok?
A. Yes, as long as you treat private pay and Montana's Healthcare Programs
patients the same.
Q. We bill someone as private pay and then when they go to collections they
tell us they have Medicaid, what can we do?
A. 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 provider manual). If you had
established private pay with that client, then you can continue that
process and turn them over to collection.
Q. Is a pregnant woman still exempt from paying cost sharing if the services
are not related to her pregnancy?
A. 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 goes
to the end of that month.
Q. Is there a rule that you can refuse
service if a client won’t pay
their cost-share?
A. You cannot refuse service outright to Medicaid clients who will
not pay their cost-share. However, if your office policy is not to 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, Medicare, or private pay clients.
Q. Can you have a policy that states that cost-share must be paid in advance?
A. No, you cannot. The goal is not to deny service to patients just
because they cannot pay their cost-share at that time.
Q. When you say no balance billing, are we required to receive that cost-sharing
from the patient, or can we write it off if they are unable to pay? Is that
part of their spend down?
A. No, you do not have to collect cost-sharing from a client – you
may choose to write off that amount if you’d 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.
Q. If a provider has a problem with a particular client not showing up for
appointments, does the office have to give a reason for refusing to see the
patient anymore?
A. No, the provider can tell the client over the phone that the provider
is severing the relationship. The provider should also follow-up in writing
to keep as written documentation in the client’s file. Make sure not
to treat Medicaid clients differently than private pay, and often you need
to treat them better.
Q. Do you consider urgent care facilities the same as an Emergency Room?
A. No, they are not considered emergency.
Q. If we have a visitor from another state, do we have to enroll as a provider
for another state?
A. No, enrolling as a Medicaid provider is voluntary enrollment, so
you can make the choice whether to enroll with that state’s Medicaid
program or arrange for the client to be private pay.
Q. What do you consider a new patient, a patient leaves for three to four
years then comes back, are they new or established?
A. There is a three-year guideline – after three years the patient
is considered new.
Q. I work in a public health clinic,
and I get claims back saying that the client has MHSP, and you are not
a mental health provider and can’t give them shots.
A. Because the Mental Health Services Plan (MHSP) is 100 percent state
funded, these clients can only get mental health related services. They
are not Medicaid clients, they are MHSP clients.
Q. What happens when a patient is ordered to get a walker? The client wants
the fancy walker, but Medicaid will only pay for standard walker. Both walkers
have the same procedure code. Could we bill the patient for the difference
between the fancy walker that is not covered and the standard walker that
is?
A. If they want the fancy walker, and only require the standard walker
then the fancy walker is considered a non-covered service. The patient should
pay for the full amount of the non-covered service. Put it in writing that
this is a non-covered service.
Q. Who do I call to report provider or client fraud or abuse?
A. The following hotlines and phone numbers are available to you in
matters regarding suspected fraud and abuse:
Q. If SURS comes back and takes the
money, can we bill the Montana's Healthcare Programs client?
A. If the provider made an error that resulted in overpayment or Montana's
Healthcare Programs made an error in processing, no you cannot bill
the patient.
Q. Where can I find the Administrative
Rules of Montana?
A. They can be found at http://www.dphhs.mt.gov/legalresources/administrativerules/index.shtml.
Most of the Medicaid rules are in section 37.
Q. What is the Provider Information Web site address?
A. http://www.mtmedicaid.org
Q. Where can you find the Montana Code?
A. On the Internet: Go to http://data.opi.state.mt.us/bills/mca_toc/index.htm
Q. How do I get a new fee schedule?
A. Provider Information web site at www.mtmedicaid.org