Medicaid provicer manual

For eligibility and coordination of benefit information, see the Member Eligibility and Responsibilities chapter in this manual. Provider-specific information is in provider type manuals. Contact Provider Relations at with questions. Older versions of the manual may be found through the Archive page on the Provider website. Other resources are also available. See the menu for links. The monthly Montana Healthcare Programs online newsletter, the Claim Jumper , covers Montana Healthcare Programs program changes and includes a list of documents posted to the Provider Information website during that time frame.

Montana Healthcare Programs offers a variety of training opportunities that are announced on the Provider Information website and in the Claim Jumper newsletter. Recorded training sessions are available on the Training page of the website.

Montana Healthcare Programs works with various contractors who represent Montana Healthcare Programs through the services they provide. While it is not necessary for providers to know contractor duties, the information below is provided as informational. Covered services include, but are not limited to, audiology services, clinic services, community health centers services, dental services, doctor visits, hospital services, immunizations, Indian Health Services, laboratory services, mental health services, Nurse First services, nursing facility, occupational therapy, pharmacy, public health clinic services, substance dependency services, tobacco cessation, transportation, vision services, well-child checkups, and x-rays.

Members covered under this waiver receive Standard Montana Healthcare Programs benefits. In addition to those listed below, other subsidized health insurance plans may be available from programs funded by the federal government or private organizations.

Planning efforts toward family reunification are the primary objective, with transition planning essential for youth in out-of-home care. Children must be uninsured U. Plan First If a member loses Montana Healthcare Programs, family planning services may be paid by Plan First, which is a separate Montana Healthcare Programs program that covers family planning services for eligible women. Some of the services covered include office visits, contraceptive supplies, laboratory services, and testing and treatment of sexually transmitted diseases STDs.

Providers must complete a Montana Healthcare Programs Provider Enrollment Form, which is a contract between the provider and the Department. Providers must enroll for each type of service they provide. Enrollment Materials Each newly enrolled provider is sent an enrollment letter confirming enrollment.

The letter includes instructions for obtaining additional information from the Provider Information website. Montana Healthcare Programs-related forms are available on the Provider Information website. Out-of-state providers can avoid denials and late payments by renewing Montana Healthcare Programs enrollment early. Montana Healthcare Programs Renewal For continued Montana Healthcare Programs participation, providers must maintain a valid license or certificate.

For Montana providers, licensure or certification is automatically verified and enrollment renewed each year. If licensure or certification cannot be confirmed, the provider is contacted. Out-of-state providers are notified when Montana Healthcare Programs enrollment is about to expire. To renew enrollment, providers should mail or fax a copy of their license or certificate to Provider Relations.

See the Contact Us link on the Provider Information website. For change of address, providers can use the form on the website; for a physical address change, providers must include a completed W-9 form. To avoid payment delays, notify Provider Relations of an address change in advance. Change of Ownership When ownership changes, the new owner must re-enroll in Montana Healthcare Programs. For income tax reporting purposes, the provider must notify Provider Relations at least 30 days in advance about any changes to a tax identification number.

Early notification helps avoid payment delays and claim denials. Electronic Claims Providers who submit claims electronically experience fewer errors and quicker payment. For more information on electronic claims submission options, see the Electronic Claims section in the Billing Procedures chapter in this manual. Terminating Montana Healthcare Programs Enrollment Montana Healthcare Programs enrollment may be terminated by writing to Provider Relations; however, some provider types have additional requirements.

Providers should include their NPI healthcare providers or API atypical providers and the termination date in the letter. All correspondence and claim forms submitted to Montana Healthcare Programs must have an NPI healthcare providers or API atypical providers and an authorized signature.

The signature may belong to the provider, billing clerk, or office personnel, and may be handwritten, typed, stamped, or computer-generated. When a signature is from someone other than the provider, that person must have written authority to bind and represent the provider for this purpose. The request must be addressed to the division that issued the decision and delivered or mailed to the Department.

Providers may request extensions in writing within this 30 days. If the provider is not satisfied with the administrative review results, a fair hearing may be requested. This document must be signed and received by the Fair Hearings Office within 30 days from the date the Department mailed the administrative review determination. A copy must be delivered or mailed to the division that issued the determination within 3 working days of filing the request.

By enrolling in the Montana Healthcare Programs program, providers must comply with all applicable state and federal statutes, rules, and regulations, including but not limited to, federal regulations and statutes found in Title 42 of the Code of Federal Regulations and the United States Code governing the Montana Healthcare Programs program and all applicable Montana statutes and rules governing licensure and certification.

Institutional providers include nursing facilities, skilled care nursing facilities, intermediate care facilities, hospitals, institutions for mental disease, inpatient psychiatric hospitals, and residential treatment facilities. Other providers may limit the number of Montana Healthcare Programs members.

They may also stop serving private-pay members who become eligible for Montana Healthcare Programs. Any such decisions must follow these principles:. Non-Discrimination ARM Providers are entitled to Montana Healthcare Programs payment for diagnostic, therapeutic, rehabilitative or palliative services when the following conditions are met:. For all purposes of this rule, the amount of the provider's usual and customary charge may not exceed the reasonable charge usually and customarily charged to all payers.

Zero paid claims are considered paid. Payment Return ARM Confidentiality ARM Providers are responsible for maintaining confidentiality of healthcare information subject to applicable laws. Record Keeping ARM The provider must furnish these records to the Department or its designee upon request. The Department or its designee may audit any Montana Healthcare Programs-related records and services at any time.

Such records may include but are not limited to:. Compliance with Applicable Laws, Regulations, and Policies All providers must follow all applicable rules of the Department and all applicable state and federal laws, regulations, and policies. Provider manuals are to assist providers in billing Montana Healthcare Programs; they do not contain all Montana Healthcare Programs rules and regulations. The following are references for some of the rules that apply to Montana Healthcare Programs.

The provider manual for each individual program contains rule references specific to that program. Links to rules are available on the provider type pages of the Provider Information website. Providers are responsible for keeping informed about applicable laws, regulations, and policies.

It helps families get early identification and treatment of medical, dental, vision, mental health, and developmental problems for their children.

All Montana Healthcare Programs families are encouraged to use these services. See ARM By following the Bright Futures schedule of well child visits, parents can ensure their children receive the full benefit of their comprehensive health care coverage.

In addition to well child visits, EPSDT includes inter-periodic sick visits, or other visits as needed by the individual child. Immunization Schedule - The American Academy of Pediatrics Bright Futures recommended immunization schedule for children through the age of Additional Services Under EPSDT If a child up to the age of 21 , needs medically necessary services, outside the normal realm of covered services non-covered, over the limit, does not meet criteria, etc , these can be approved on a case by case basis.

These requests are reviewed and decision determinations completed within 2 weeks of receipt of all required documentation. The well-child screens are based on a periodicity schedule established by medical, dental, and other healthcare experts, including the American Academy of Pediatrics.

Every infant should have a newborn evaluation after birth. If a child comes under care for the first time at any point on the schedule, or if any items are not accomplished at the suggested age, the schedule should be brought up-to-date at the earliest possible time. Developmental, psychosocial, and chronic disease issues for children and adolescents may require frequent counseling and treatment visits separate from preventive care visits. Using an evidence-based screening tool, a caregiver depression screening is covered under an enrolled child's Montana Healthcare Programs benefit, during their first year of life.

This includes anyone that is considered a child's primary care provider. Positive screenings must be appropriately referred. The service is directed at treating the health and well-being of the child, with a goal of providing a healthy start to their life. Once it is done, it only needs to be updated at subsequent visits. The history should include the following:. Developmental Assessments Appropriate Developmental Surveillance.

Providers should administer an age-appropriate developmental screen at each well-child visit. Any concerns raised during the surveillance should be promptly addressed with standardized developmental screening tests. Appropriate Developmental Screening. Providers should administer an age appropriate developmental screen at age 9, 18, and 30 months.

Results should be considered in combination with other information gained through the history, physical examination, observation, and reports of behavior. Speech and language screens identify delays in development. The most important readiness period for speech is 9 to 24 months. Parents should be urged to talk to their children early and frequently.

Refer the child for speech and language evaluation as indicated. PLUK is an organization designed to provide support, training, and assistance to children with disabilities and their parents.

Depression Screening. Signs and symptoms of emotional disturbances represent deviations from or limitations in healthy development. These problems usually will not warrant a psychiatric referral but can be handled by the provider. If a psychiatric referral is warranted, the provider should refer the child to an appropriate provider. Alcohol and Drug Use Screen. The provider should screen for risky behaviors e. In most instances, indications of such behavior will not warrant a referral but can be handled by the provider, who should discuss the problems with the member and the parents and give advice.

If a referral is warranted, the provider should refer to an appropriate provider. Recommended screening tool can be found on the Bright Futures website. Nutritional Screen Providers should assess the nutritional status at each well-child screen. Children with nutritional problems may be referred to a licensed nutritionist or dietician for further assessment or counseling.

Unclothed Physical Inspection At each visit, a complete physical examination is essential. Infants should be totally unclothed and older children undressed and suitably draped.

Vision Screen A vision screen appropriate to the age of the child should be conducted at each well-child screen. If the child is uncooperative, rescreen within six months.

Hearing Screen A hearing screen appropriate to the age of the child should be conducted at each well-child screen. All newborns should be screened. Autism Screen Autism screenings are recommended at age 18 and 24 months, and a recommended tool is provided on the Bright Futures website.

Critical Congenital Heart Defect Screen Screening using pulse oximetry should be performed in newborns, after 24 hours old and before discharge. Laboratory Tests Providers who conduct well-child screens must use their medical judgment in determining applicability of performing specific laboratory tests.

Appropriate tests should be performed on children determined at risk through screening and assessment. Hematocrit and Hemoglobin. Hematocrit or hemoglobin tests should be done for at-risk premature and low birth weight infants at ages newborn and 2 months.

For children who are not at risk, follow the recommended schedule. Blood Lead Level. All children in Montana Healthcare Programs are at risk of lead poisoning. To ensure their good health, the federal government requires that all Montana Healthcare Programs-enrolled children be tested for lead poisoning.

Testing is recommended at 12 and 24 months of age. Children up to age 6 years who have not been checked for lead poisoning before should also be tested. A blood lead level test should be performed on all children at 12 and 24 months of age. All Montana Healthcare Programs children at other ages should be screened. If the answer to all questions is no , a child is considered at low risk for high doses of lead exposure. Children at low risk for lead exposure should receive a blood test at 12 and 24 months.

Tuberculin Screening. Tuberculin testing should be done on individuals in high-risk populations or if historical findings, physical examination, or other risk factors so indicate.

Dyslipidemia Screening. Screening should be considered based on risk factors and family history at 24 months, 4, 6, 8, 12, 13, 14, 15, 16, and 17 years, and is indicated at or around 10 and 20 years of age. All adolescent members should be screened for sexually transmitted infections STIs and HIV based on risk assessment starting at age 11 and reassessed annually with at least one assessment occurring between the ages of 16—18 years old. Cervical Dysplasia Screening. Adolescents are not routinely screened for cervical dysplasia until age Immunizations The immunization status of each child should be reviewed at each well-child screen.

This includes interviewing parents or caretakers, reviewing immunization records, and reviewing risk factors. Annual dental screens include an oral inspection, fluoride varnish as available and making a referral to a dentist for any of the following reasons:.

Age-appropriate discussion and counseling should be an integral part of each visit. Allow sufficient time for unhurried discussions. At each screening visit, provide age-appropriate anticipatory guidance concerning such topics as the following:. Prior authorization refers to a list of services that require Department authorization before they are performed. Some services may require both Passport referral and prior authorization.

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

Montana Healthcare Programs does not pay for services when prior authorization, Passport, or Team Care requirements are not met. In practice, providers will often encounter members who are enrolled in Passport. Services are only covered when they are provided or approved by the designated Passport provider or Team Care pharmacy shown in the eligibility information. If a service requires prior authorization, the requirement exists for all Montana Healthcare Programs members.

Prior authorization is usually obtained through the Department or a prior authorization contractor. When both Passport and prior authorization are required, they must be recorded in different places on the claim.

If both Passport referral and prior authorization are required for a service, then both numbers must be recorded in different fields on the Montana Healthcare Programs claim form. See the Submitting a Claim section in this manual.

Most Montana Healthcare Programs fee schedules indicate when prior authorization is required for a service. Telemedicine is the use of interactive audio-video equipment to link practitioners and members located at different sites. The Montana Healthcare Programs Program reimburses providers for medically necessary telemedicine services furnished to eligible members.

Telemedicine is not itself a unique service but a means of providing selected services approved by Montana Healthcare Programs.

Telemedicine involves two collaborating providers, an originating provider and a distance provider. The provider where the member is located is the originating provider or originating site. In most cases, the distant provider is a clinician who acts as a consultant to the originating provider. However, in some cases the distant provider may be the only provider involved in the service.

Providers must be enrolled as Montana Healthcare Programs providers and be licensed in the State of Montana in order to:. Montana Healthcare Programs considers the primary purposes of telemedicine are to bring providers to people living in rural areas, and to allow members access to care that is not available within their community. Providers should weigh these advantages against quality of care and member safety considerations. Members may choose which is more convenient for them when providers make telemedicine available.

Telemedicine should not be selected when face-to-face services are medically necessary. Members should establish relationships with primary care providers who are available on a face-to-face basis. All Montana Healthcare Programs providers using telemedicine to deliver Montana Healthcare Programs services must employ existing quality-of-care protocols and member confidentiality guidelines when providing telemedicine services.

Health benefits provided through telemedicine must meet the same standard of care as in-person care. Transmissions must be performed on dedicated secure lines or must utilize an acceptable method of encryption adequate to protect the confidentiality and integrity of the transmission.

Transmissions must employ acceptable authentication and identification procedures by both the sender and receiver. Providers may only bill procedure codes for which they are already eligible to bill. Services not otherwise covered by Montana Healthcare Programs are not covered when delivered via telemedicine. The use of telecommunication equipment does not change prior authorization or any other Montana Healthcare Programs requirements established for the services being provided.

The availability of services through telemedicine in no way alters the scope of practice of any health care provider; or authorizes the delivery of health care services in a setting or manner not otherwise authorized by law. The originating and distant providers may not be within the same facility or community. The same provider may not be the pay to for both the originating and distance provider. The originating site provider must have secure and appropriate equipment to ensure confidentiality, including camera s , lighting, transmission and other needed electronics.

Originating providers bill using procedure code Q telemedicine originating site fee for the use of a room and telecommunication equipment. The telehealth place of service code 02 does not apply to originating site facilities billing a facility fee.

Originating provider claims must include a specific diagnosis code to indicate why a member is being seen by the distance provider. The originating site must request the diagnosis code s from the distance site prior to billing the telemedicine appointment.

The originating provider may also, as appropriate; bill for clinical services provided on-site the same day that a telemedicine originating site service is provided. This originating site may not bill for assisting the distant provider with an examination, this includes any services that would be normally included in a face-to-face visit.

Distance providers should submit claims for telehealth services using the appropriate CPT or HCPCS code for the professional service along with the GT modifier interactive communication. Effective January 1, , providers must also use the telehealth place of service of 02 for claims submitted on a CMS claim. By coding with the GT modifier and the 02 place of service, the provider is certifying that the service was a face-to-face visit provided via interactive audio-video telemedicine.

Any out of state distance providers must be licensed in the State of Montana and enrolled in Montana Healthcare Programs in order to provide telemedicine services to Montana Healthcare Programs members. Providers must contact the Montana Department of Labor and Industry to find out details on licensing requirements for their applicable professional licensure. Members must never throw away the card, even if their Montana Healthcare Programs eligibility ends.

The member number may be used for checking eligibility and for billing Montana Healthcare Programs. Since eligibility information is not on the card, providers must verify eligibility before providing services. See the Verifying Member Eligibility section below.

Providers should verify eligibility before providing services. Member eligibility may change monthly. Providers should verify eligibility at each visit using any of the methods described in the following table.

Hours are Mountain Time. Providers may use whichever method they find most convenient. Before using FaxBack, your fax number must be on file with Provider Relations. When prompted, ask for the audit number or the transaction will not be completed. Verify eligibility for up to 5 members in one call. Program benefit limits not available here. Contact Provider Relations for limits. If the member is not currently eligible, any managed care or third party liability information will not be displayed.

Provider Relations P. Box Helena, MT To become a provider who determines presumptive eligibility, call Using the Overview, you will be able to identify the chapters most relevant to you and your activities. We believe you will find the format and search capabilities of this Manual to be user-friendly and having all policies in a single document very convenient.

Keeping your web browser up to date is very important. Newer web browsers let you use more features and new technologies resulting in a better browsing experience. It is easiest to navigate the manual using bookmarks. Enabling bookmarks depends on which web browser you are using. Click on Three dots symbol that is at the top right corner of the browser and click on Settings. MDHHS discourages printing of the manual because of the cost and loss of functionality e.

The manual chapter is intended to make available to Medicaid providers of FQHC services a ready reference for information and procedural material needed for the prompt and accurate filing of claims for services furnished to Medicaid recipients.

Free Standing Birthing Centers. Description : Free-standing birthing centers FSBCs provide delivery services to eligible Medicaid recipients not requiring hospitalization and which the expected duration of services would not exceed 24 hours following an admission. Description : The purpose of this chapter is to present useful information and guidance to providers participating in the Louisiana Medicaid program. Policies and information applicable to provider requirements, recipient eligibility, program integrity and claims filing are provided in this reference guide.

Home Health. Description: Provides information on coverage, procedures, and claims filing requirements applicable to home health agencies. Description : Provides information on coverage, procedures, and claims filing requirements related to hospice services. Hospital Services. Description : This manual chapter provides information relative to coverage policies for inpatient and outpatient hospital services. Information on provider requirements and claims related information are also included. Independent Laboratories.

Description : Outlines the conditions and requirements that independent laboratories must meet in order to qualify for reimbursement under the Louisiana Medicaid program.

This chapter is a ready reference for information and procedural material needed for the prompt and accurate filing of claims for services furnished to Medicaid recipients. Description : Federal regulations and applicable state laws require that third-party resources be used before Medicaid is billed.

Medical Transportation. Description : This chapter specifies the requirements of providing Non-Emergency Medical Transportation NEMT , a non-ambulance transportation provided to Medicaid recipients to and from Medicaid covered services.

New Opportunities Waiver. Description : Provides a NOW provider the information needed to fulfill its vendor agreement with the State of Louisiana, and is the basis for federal and state reviews of the program. Description : Provides information to aid the provider in understanding and implementing federal and state Program of All-inclusive Care for the Elderly PACE policies and procedures. Pediatric Day Health Care. Description : Outlines Pediatric Day Health Care PDHC Program which provides services to meet the medical, social and developmental needs of medically fragile children with complex medical conditions from birth up to 21 years of age.

Description : This chapter outlines the PDHC program which provides services for Medicaid recipients who require assistance with the activities of daily living and are either in a nursing home or at imminent risk of nursing facility placement.

Description : This chapter explains coverage, policies, procedures, and claims filing requirements applicable to the Pharmacy Program. The ADA is a third party beneficiary to this Agreement. The scope of this license is determined by the ADA, the copyright holder. End Users do not act for or on behalf of the CMS. In no event shall CMS be liable for direct, indirect, special, incidental, or consequential damages arising out of the use of such information or material.

The license granted herein is expressly conditioned upon your acceptance of all terms and conditions contained in this agreement. If the foregoing terms and conditions are acceptable to you, please indicate your agreement by clicking below on the button labeled "ACCEPT". If you do not agree to the terms and conditions, you may not access or use the software. Instead, you must exit from this computer screen. The Texas Medicaid Provider Procedures Manual was updated on December 31, , and contains all policy changes through January 1, Claim form examples referenced in the manual can be found on the claim form examples page.

See the release notes for a detailed description of the changes.