Mont. Admin. R. 37.85.406 - BILLING, REIMBURSEMENT, CLAIMS PROCESSING, AND PAYMENT
(1) Providers must submit clean claims to
Medicaid within the latest of:
(a) 12 months
from the latest of:
(i) the date of
service;
(ii) the date retroactive
eligibility is determined; or
(iii)
the date disability was determined;
(b) six months from the date on the Medicare
explanation of benefits approving the service, if the Medicare claim was timely
filed and the member was Medicare eligible at the time the Medicare claim was
filed; or
(c) six months from the
date on an adjustment notice from a third party payor, where the third party
payor has previously processed the claim for the same service and the
adjustment notice is dated after the periods described in (1)(a) and
(b).
(2) For purposes of
this rule:
(a) "Clean claim" means a claim
that can be processed without additional information or documentation from or
action by the provider of the service;
(b) For inpatient hospital services, date of
service is the date of discharge;
(c) The date of submission to the Medicaid
program is the date the claim is stamped "received" by the department or its
designee; and
(d) The claim
submission deadline specified in (1) through (1)(c) applies regardless of
whether or not a third party has allowed or denied a provider's claim. If a
third party has not allowed or denied a provider's claim, the provider may
submit a claim to Medicaid according to the requirements of ARM
37.85.407(6)(c)
and subject to the claim submission deadline
specified in (1) through (1)(c).
(3) Claims must be submitted in accordance
with this rule to be valid. In processing claims, the department or its agent
may deny payment of or pend a claim upon determining that a basis exists for
denial of payment or pending the claim. No further review or processing of a
denied claim is required until resubmission of the claim by the provider. The
department or its agent is not required to list or identify all possible
grounds for denial or pending of the claim. The fact that a particular basis
for denial or pending of a claim for a service or item was not identified on an
earlier statement of remittance or other similar statement does not preclude
denial or pending of the claim on that basis on a later submission of the
claim.
(4) Except as provided in
(7), all Medicaid claims submitted to the department are to be submitted on a
state claim form which is:
(a) personally
signed by that provider;
(b)
personally signed by a person who has actual written authority to bind and
represent the provider for this purpose. The department may require a provider
to furnish this written authorization; or
(c) signed by the use of a facsimile
signature stamp or a computer generated, typed or block letter signature.
Providers submitting or causing to be submitted a claim using a facsimile,
computer generated, typed or block letter signature shall bear full
responsibility for submission of the claim as though the claim were personally
signed by the provider or the provider's authorized agent.
(5) All Medicaid claims submitted to the
department by a hospital for services provided by a physician who is required
to relinquish fees to the hospital are to be submitted on a state claim form
which is:
(a) personally signed by the
physician provider;
(b) personally
signed by a person who has actual written authority to bind and represent the
physician provider for this purpose. The department may require a provider to
furnish this written authorization; or
(c) signed by the use of a facsimile
signature stamp or a computer generated, typed or block letter signature.
Providers submitting or causing to be submitted a claim using a facsimile,
computer-generated, typed or block letter signature shall bear full
responsibility for submission of the claim as though the claim were personally
signed by the provider or the provider's authorized agent.
(6) The department may require a hospital
provider to obtain on the claim form the signature of a physician providing
services for which fees are relinquished to the hospital.
(7) Electronic media claims may be submitted
by a provider who enters into an agreement with the department for this purpose
and who meets the department's requirements for documentation, record retention
and signature requirements.
(8)
Claims submitted for the professional component of electrodiagnostic procedures
which do not involve direct personal care on the part of the physician and
performed by physicians on contract to the hospital may be submitted on state
approved claim forms signed by the person with authority to bind the hospital
under (5)(b).
(a) Electrodiagnostic
procedures include echocardiology studies, electroencephalography studies,
electrocardiology studies, evoked potential studies, holter monitors,
telephonic or teletrace checks and pulmonary function tests.
(b) If, after review, the department
determines that claims for hospital-based physician services are not submitted
by a hospital provider in accordance with this rule, the department may require
the hospital provider to obtain the signature of the physician providing the
service on the claim form.
(9) If the department pays a claim but
subsequently discovers that the provider was not entitled to payment for any
reason, the department is entitled to recover the resulting overpayment as
provided in (10).
(10) The
department is entitled to recover from the provider and the provider is
obligated to repay to the department all Medicaid payments made to which the
provider was not entitled under applicable state and federal laws, regulations
and rules. At the option of the department, recoveries may be accomplished by a
direct payment to the department or by automatic deductions from future
payments due the provider. Notice of overpayment must be made in accordance
with ARM
37.85.512.
(a) The department is entitled to recover
under (10) any payment to which the provider was not entitled, regardless of
whether the payment was the result of department or provider error, or other
cause, and without proving that the provider submitted an improper or erroneous
claim knowingly, intentionally, or with intent to defraud.
(b) The department is entitled to recover an
overpayment from the provider in whose name the erroneous or improper claim was
submitted, even if the provider was an employee of another individual or entity
and was required as a condition of the provider's employment to turn over all
fees received by the provider to the employer.
(11) Providers are required to accept, as
payment in full, the amount paid by the Montana Medicaid program for a service
or item provided to an eligible Medicaid member in accordance with the rules of
the department. Providers must not seek any payment in addition to or in lieu
of the amount paid by the Montana Medicaid program from a member or his
representative, except as provided in these rules. A provider may bill a member
for the copayments specified in ARM
37.83.826
and
37.85.204
and may bill certain members for amounts above the Medicare deductibles and
coinsurance as allowed in ARM
37.83.825.
(a) A provider may bill a member for
noncovered services if the provider has informed the member in advance of
providing the services that Medicaid will not cover the services and that the
member will be required to pay privately for the services, and if the member
has agreed to pay privately for the services. For purposes of (11)(a),
noncovered services are services that may not be reimbursed for the particular
member by the Montana Medicaid program under any circumstances and covered
services are services that may be reimbursed by the Montana Medicaid program
for the particular member if all applicable requirements, including medical
necessity, are met.
(b) Except as
provided in this rule, a provider may not bill a member after Medicaid has
denied payment for covered services because the services are not medically
necessary for the member.
(i) A provider may
bill a member for covered but medically unnecessary services, including
services for which Medicaid has denied payment for lack of medical necessity,
if the provider specifically informed the member in advance of providing the
services that the services are not considered medically necessary under
Medicaid criteria, that Medicaid will not pay for the services and that the
member will be required to pay privately for the services, and the member has
agreed to pay privately for the services. The agreement to pay privately must
be based upon definite and specific information given by the provider to the
member indicating that the service will not be paid by Medicaid. The provider
may not bill the member under this exception when the provider has informed the
member only that Medicaid may not pay or where the agreement is contained in a
form that the provider routinely requires members to sign.
(ii) An ambulance service provider may bill a
member after Medicaid has denied payment for lack of medical
necessity.
(c) A
provider may not bill a member for services as a private pay patient if, prior
to provision of the services, the member informed the provider of Medicaid
eligibility, unless, prior to provision of the services, the provider informed
the member of its refusal to accept Medicaid and the member agreed to pay
privately for the services.
(d) In
service settings where the individual is accepted as a Medicaid member by an
arranging provider including, but not limited to, a facility, institution, or
other entity that arranges for provision of services by other providers, all
other providers performing services for the individual in conjunction with the
arranging provider will be deemed to have accepted the individual as a Medicaid
member.
(i) The only exception to (d) is if
the other provider, prior to providing services, informed the individual of
their refusal to accept Medicaid and the individual agreed to pay privately for
the services. The other provider may then bill the individual for
services.
(e) The
provider may not bill a member for services when Medicaid does not pay as a
result of the provider's failure to comply with applicable enrollment, prior
authorization, billing, or other requirements necessary to obtain
payment.
(f) Acceptance of an
individual as a Medicaid member applies to all services provided by the
provider to the member, except as provided in (11)(a) or (b). A provider may
not accept Medicaid payment for some covered services but refuse to accept
Medicaid for other covered services. Subject to the requirements of ARM
37.85.402(4),
a provider may terminate acceptance of Medicaid for a member in accordance with
the provider's professional responsibility, by informing the member of the
termination and the effect of the termination on provision of and payment for
any further services.
(g) If an
individual has agreed prior to receipt of services that payment will be made
from a source other than Medicaid but later is determined retroactively
eligible for Medicaid, the provider may choose to accept the individual as a
Medicaid member with respect to the services or to seek payment in accordance
with the original payment agreement.
(h) A provider that bills Medicaid for
services rendered will be deemed to have accepted the individual as a Medicaid
member.
(i) Nothing in this rule is
intended to permit a provider to refuse to accept an individual as a Medicaid
member where the provider is otherwise required by law to accept an individual
as a Medicaid member.
(12) In the event that a provider of services
is entitled to a retroactive increase of payment for services rendered, the
provider must submit a claim within 180 days of the written notification of the
retroactive increase or the provider forfeits any rights to the retroactive
increase.
(13) The Montana Medicaid
program will make payments directly to the individual provider of service
unless the individual provider is required, as a condition of his employment,
to turn his fees over to his employer.
(a)
Exceptions to the above requirement may, at the discretion of the department,
be made for transportation and/or per diem costs incurred to enable a member to
obtain medically appropriate services.
(14) The method of determining payment rates
for out-of-state providers will be the same as for in-state providers except as
otherwise provided in the rules of the department.
(15) A government agency may bill the
Medicaid program for covered medical services under the following
circumstances:
(a) The government agency has
complied with all federal and state law governing the Medicaid program, and
assures that the provider has complied with all state and federal law governing
the Medicaid program, including reimbursement levels.
(b) The government agency accepts assignment
from an eligible Medicaid provider for services provided prior to eligibility
determination.
(16) A
person enrolled as an individual provider may not submit a claim for services
that the provider did not personally provide, inclusive of services provided by
another person under the provider's supervision, unless authorization to bill
for and receive reimbursement for services the provider did not personally
provide is stated in administrative rule or a Montana Medicaid program manual
and is in compliance with any supervision requirements in state law or rule
governing the provider's professional practice and the practice of assistants
and aides. Other providers, including but not limited to hospitals, nursing
facilities, and home health agencies, may bill for and receive reimbursement
for services provided by supervised persons in accordance with the Medicaid
rules and manual and any supervision requirements in state law or rule
governing professional practice.
(17) Medicaid coverage and reimbursement is
available only for services or items that are provided in accordance with all
applicable Medicaid requirements and within the scope of practice permitted
under state licensure laws and other mandatory standards applicable to the
provider.
(18) Except as otherwise
provided in the rules of the department which pertain to the method of
determining payment rates for claims of recipients members who have Medicare
and Medicaid coverage (cross-over claims), the Medicaid allowed amount for
Medicare covered services is:
(a) for
facility based providers who generally bill on the UB-04 billing form, for
covered medical services the full Medicare coinsurance and deductible as
defined by the Medicare carrier;
(i) there is
an exception for inpatient ancillary services with Medicare Part B coverage
only (no Medicare Part A) or FQHCs: Medicare payments for these services are
treated as third party payments and are offset against the Medicaid
payment;
(b) for medical
providers who generally bill on the HCFA-1500 billing form, for covered medical
services the lower of:
(i) the Medicare
coinsurance and deductible (if not met); or
(ii) the Medicaid fee less the amount paid by
Medicare for the same service, not to exceed the Medicaid fee for that
service;
(c) for mental
health services that are subject to the Medicare psychiatric reduction, the
lower of:
(i) the Medicaid allowed amount;
or
(ii) the Medicare allowed
amount, less the Medicare paid amount;
(d) for services to members eligible to
receive both Medicare and Medicaid benefits, an amount not to exceed the
Medicare allowed amount in instances where the Medicaid fee is higher than the
Medicare allowable.
(19)
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.
(20) Reimbursement from
Medicaid may not exceed an amount which would cause total payment to the
provider from both Medicaid and all other payers to exceed the Medicaid fee.
(21) Montana Medicaid does not
reimburse for the facility component of a Provider Based entity
service.
Notes
AUTH: 53-2-201, 53-6-113, MCA; IMP: 53-2-201, 53-6-101, 53-6-111, 53-6-113, 53-6-131, 53-6-149, MCA
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