Volume XX Issue November by MontanaDocs


                                 claim jumper
                                                                                    Volume XX, Issue 11, November 2005

            In This Issue                             Prescription Drug Program, have         programs. These rule changes in-
                                                      an income of no more than $19,140       cluded new language that requires
Good News for Clients on                              (single) or $25,660 (couple) and if     outpatient mental health services
Medicare: The Big Sky RX                              income is at or below 150% of the       provided in conjunction with CSCT
Program . . . . . . . . . . . . . . . . . . . . . 1   FPL, applicants must have applied       services be prior authorized. This
Outpatient Therapy Changes . . . 1                    for the Federal Social Security         new procedure will alleviate dupli-
                                                      Extra Help Program. People should       cation of services as well as assure
Split Billing for Hospitals . . . . . . 1             apply for Big Sky Rx even if they       that additional services can be
                                                      think their income exceeds these        provided outside CSCT if they are
Medicaid Drug Coverage for                            limits because some income is not       medically necessary. Concurrent
Duals ends Dec. 31. . . . . . . . . . . . 2           counted in determining eligibility.     services need to be coordinated
Web Portal Training Results. . . . 2                  Assets will NOT be counted for the      amongst providers.
                                                      Big Sky Rx Program. If the Extra
Advanced Medicaid Training . . 2                      Help Program pays part of their         Until new forms are developed, pro-
                                                      premium Big Sky Rx may be able to       viders should use the First Health
Cost Share and TPL . . . . . . . . . . . 3            pay the rest.                           form for continuation of outpatient
Recent Publications . . . . . . . . . . . 3                                                   services. All sessions must be prior
                                                      Our eligibility specialists will be     approved. Forms and instructions
Key Contacts . . . . . . . . . . . . . . . . . 4      able to answer any questions and        are available through the Children’s
                                                      will be available to assist individu-   Mental Health Bureau web page.
                                                      als with the application process.
                                                      You can contact us at:                      Submi�ed by Mary Jane Fox, DPHHS
Good News for Clients
on Medicare: The Big                                           Toll Free In State
                                                                                              Split Claims for
Sky RX Program                                                  (866)369-1233                 Outpatient Hospital
Last month in the article entitled,                                                           Billing
“Helping With the Medicare Pre-                               From Out Of State,              Outpatient hospital claims are
scription Drug Benefit”, Mary                                   and Helena Area                billed on a UB92 and can contain
Noel discussed the topic of clients                             (406)-444-1233                an infinite number of lines. While
with dual Medicare and Medicaid                                                               it is best to submit no more than 40
eligibility. What about Medicare                                    Email:                    lines on a paper claim, claims can
clients, not eligible for Medicaid?                            bigskyrx@mt.gov                be submi�ed on more than one
                                                                                              page and should be labeled ‘page 1
The Big Sky Rx Program may be                            Visit Our Big Sky Rx Website         of 2’ and ‘page 2 of 2’.’ Claims that
able to help. The Big Sky Rx Pro-                           www.bigskyrx.mt.gov               contain more than 40 lines, how-
gram is a state program to assist                                                             ever, will be split for processing in
with drug coverage premiums                              Submi�ed by Margaret Souza, DPHHS    our system. Paper claims are split
for eligible Montana residents                                                                manually and electronic claims are
enrolled in a prescription drug                       Outpatient Therapy                      split by the system.
plan under Medicare Part D. The                       Changes
program was created by the 2005                                                               Based on the line level dates (box
Legislature and is funded from the                    Outpatient therapists, who serve        45), your outpatient claim will be
Tobacco tax (I-149 Funds).                            children, need to be aware of new       broken down into two or more
                                                      requirements. On September 12,          parts, each with 40 lines or less, and
A person enrolled with Big Sky                        2005 new rules were adopted             the header level span will be bro-
Rx must be a Montana resident,                        for Comprehensive School and            ken down to encompass only those
be enrolled in a Medicare Part D                      Community Treatment (CSCT)              dates which are on each part. Each
Montana Medicaid Claim Jumper                                                                             November

part is then processed as a unique People who have Medicaid only (no           a HIPAA compliant data element on the
claim, and paid accordingly.          Medicare) will see no changes to         claim status transactoin. You will still
                                      their prescription drug coverage.        need to look at your remi�ance advice
Example: You submit a claim for                                                notice that you receive.
the month of September, 09/01/05- Information about prescription
09/30/05, with a total of 60 lines of drug plans and Medicare Advan-           Q: Why doesn’t the TPL informa-
service with two line charges for tage plans available in Montana can          tion show the name of the insured?
each date. The claim would then be be found at h�p://www.cms.hhs.              A: HIPAA’s privacy regulation states
split into two equal parts, each with gov/map/map.asp.                         that this information can not be shown.
30 lines. The header level date spans
would be 09/01/05-09/15/05 and For more information on Medicare                Q: Why can we enter only one date
09/16/05-09/30/05. Each claim would Part D, especially how dual eligible       of service for eligibility?
contain the line charges that cor- individuals will be affected, please
respond to their respective header contact Mary Noel at the Depart-            A: When you enter the date of service
level dates.                          ment of Public Health and Human          and view the eligibility screen it will
                                      Services, manoel@mt.gov or 444-          show the eligibility span that contains
If an inpatient claim comes in and 2584.                                       the date requested. Eligibility can be re-
there are more than 40 lines of                                                quested back 365 days.
service, lines will be combined as            Submi�ed by Mary Noel, DPHHS
necessary to produce a claim with                                            Q. How many payments can we
40 lines or less.                     Questions Asked at the                 view in provider payment summa-
                                         Web Portal Trainings                ry?
If you have any questions about                                              A: You will be able to view the last ten
split billing, please contact our Pro-   During the recent web portal train- provider payments.
vider Relations unit at (800)624-3958    ing sessions many questions were
or (406)442-1837.                        asked. We have included several                            Submi�ed by ACS
                                         of the most frequently asked ques-
                      Submi�ed by ACS    tions.
                                                                               Advanced Medicaid
Medicaid Drug Coverage               Q: Why is MEPS being replaced by          Training
for Duals Ends Dec. 31               the web portal?
                                     A: MEPS is being replaced because it is   There is still time to register for the
                                                                               Advanced Medicaid Training to be
                                     not HIPAA compliant. MEPS will be         held in Missoula on November 10.
People who have both Medicaid taken off-line in January 2006.                   The training will be held at St Pat-
and Medicare will begin receiving                                              rick’s Hospital from 8:30 a.m. until
prescription drug coverage through Q: Does everyone in the office need           5:00 p.m.. Subjects that will be cov-
their Medicare prescription drug a separate e-mail to receive their            ered include:
plans on Jan. 1, 2006. Medicaid will passwords?
no longer pay for prescription drugs A: No, we need only one valid e-mail      • CHIP
for people who are “dual-eligible.”  address. We recommend the office ad-        • PASSPORT
                                     ministrator because he/she will be the
As with all rules, this one has                                                • Team Care
exceptions. If a Medicaid benefi- person responsible for rese�ing and cre-
ciary needs a Part D excluded drug ating new users. Everyone will need a       • CSCT
(prescription drug plans are not re- unique user ID, but you may use one e-
quired by CMS to provide excluded mail address for everyone. Also, if your     • Medicare Part D
drugs), Medicaid may continue to e-mail address starts with numbers you        • CMH
cover the drug. Excluded drugs will need to contact EDI or Provider Re-
that Medicaid may provide include lations to work this issue out.              • Physicians/Midlevel Practitioners
benzodiazepines, barbiturates, and
limited over-the-counter drugs that Q: Can we use screen prints of             • Outpatient Hospital
Medicaid currently covers.           claims on the web portal in submit-
                                     ting our claims for adjustment?           If you are interested in a�ending,
Pharmacies will submit all drug A: Yes, you can use screen prints and          please contact ACS Provider Relations
claims to a beneficiary’s Medicare send them in with your adjustment            at (800)624-3958 or (406)442-1837. You
drug plan first. If the drug is an form.                                        can also register by sending email to
excluded drug that Medicaid will                                               M T PR Helpdesk @ acs -i nc.com.
cover, and if the Medicare drug plan Q: Why don’t the reason and re-
denies coverage, Medicaid will pay mark codes and messages appear on                                   Submi�ed by ACS
for the drug.                        the claim inquiry return (277)?
                                     A: The reason and remark codes are not

Montana Medicaid Claim Jumper                                                                                       November

 Cost Share and TPL                            assessed on claims for clients on          share will be taken. However, if a
                                               which a third party payment ex-            Medicare payment is not reflected
 Cost share is the process in which a          ists. However, a payment must              on that same institutional cross-
 client is assessed a fee for services         actually be made by the third party        over, the claim will process but a
 that is the client’s responsibility.          and reflected on the claim for this         cost share will be charged.
                                               to apply. For example, if an institu-
 While cost share generally affects             tional crossover comes in showing                                    Submi�ed by AC
 clients over the age of 21, it is not         the Medicare payment, no cost

                                              Recent Publications
 The following are brief summaries of recently published Medicaid information and updates. For details and
 further instructions, download the complete document from the Provider Information website at www.mtmed-
 icaid.org. Select Resources by Provider Type for a list of resources specific to your provider type. If you cannot
 access the information, contact Provider Relations at (800) 624-3958 or (406) 442-1837 in Helena or out-of-state.

                            Recent Publications Available on Website
  Date                 Provider Type                      Description
  09/22/05   Physician, Mid-Level Practitioner,          Blood draws
             Public Health Clinic, Podiatrist, IDTF,
             Laboratory/X-ray, Psychiatrist
  09/22/05   Physician, Mid-Level Practitioner, Public   Telemedicine
             Health Clinic, IDTF, Social Worker,
             Licensed Clinical Professional Counselor,
             Psychologist, Psychiatrist
  09/26/05   Physician, Mid-Level Practitioner,          Blood Draws (Cpt 36415 and 36416)
             Public Health Clinic, Podiatrist, IDTF,
             Laboratory/X-ray, Psychiatrist
  09/27/05   Hospice                                     Rate Increase

  Manuals/Replacement Pages
  09/09/05   Physical, Occupational & Speech Therapy     Manual replacement pages on revised levels of supervision, new places of
                                                         service codes
  09/09/05   Eyeglasses, Optometry, Ophthalmology        Manual replacement pages for eyeglass services modifiers and new place of
                                                         service codes
  09/12/05   PASSPORT                                    Manual replacement pages with addition of Medicaid Covered Services
  Other Resources
  09/06/05   All Provider Types                          Updated home page
  09/07/05   All Provider Types                          Updated carrier ID list
  09/07/05   School-Based Services                       Revised MAC time study training slide show
                                                         Revised participant training quiz and answers
  09/07/05   All Provider Types                          Revised individual adjustment request
  09/12/05   All Provider types                          Updated home page
  09/19/05   PASSPORT                                    Summer 2005 PASSPORT to Health newsle�er
  09/20/05   All Provider Types                          Updated home page
  09/20/05   PASSPORT                                    Updated caption on Havre photo
  09/21/05   PASSPORT                                    September PASSPORT Summit update
  09/27/05   All Provider Types                          Fall Provider Training: Advanced Medicaid
  09/27/05   School-Based Services                       CSCT Contract Boilerplate
  09/28/05   All Provider Types                          October Claim Jumper

Montana Medicaid Claim Jumper                                                         November

Montana Medicaid
ACS                                                                              PRSRT STD
P.O. Box 8000                                                                    U.S. Postage
Helena, MT 59604                                                                    PAID
                                                                                 Helena, MT
                                                                                Permit No. 154

                                        Key Contacts

 Provider Information website: h�p://www.mtmedicaid.org
 ACS EDI Gateway website: h�p://www.acs-gcro.com
                                                                     Provider Relations
 ACS EDI Help Desk (800) 624-3958                                    P.O. Box 4936
 Provider Relations                                                  Helena, MT 59604
        (800) 624-3958 (In and out-of-state)
        (406) 442-1837 (Helena)
        (406) 442-4402 Fax
        Email: MTPRHelpdesk@ACS-inc.com
 TPL (800) 624-3958 (In and out-of-state)
        (406) 443-1365 (Helena)                                      Claims Processing
                                                                     P.O. Box 8000
        (406) 442-0357 Fax                                           Helena, MT 59604
 Direct Deposit Arrangements (406) 444-5283
 Verify Client Eligibility
        FAXBACK (800) 714-0075
        Automated Voice Response (AVR) (800) 714-0060
        Point-of-Sale Help Desk for Pharmacy Claims (800) 365-4944
 PASSPORT (800) 624-3958                                             Third Party Liability
 Prior Authorization                                                 P.O. Box 5838
                                                                     Helena, MT 59604
        DMEPOS (406) 444-0190
        Mountain-Pacific Quality Health Foundation (800) 262-1545
        First Health (800) 770-3084
        Transportation (800) 292-7114
        Prescriptions (800) 395-7961


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