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Ancillary Services Claim and Rate Information for Counties and Tribes

Revised: 07-01-2016

  • Overview
  • Claim Information
  • Ancillary Access Service Procedure Codes, Modifiers and Payment Rates
  • Overview

    County and tribal requests for MHCP reimbursement for access service, transportation and related ancillary services must be billed electronically through MN–ITS interactive or batch.

    Access transportation and the related ancillary service claim submissions require a number of fields to be completed with correct and accurate information for the claim to process and pay. This section has general information for basic claim submission. Additional requirements may be necessary for the access transportation and the related ancillary services claims to be billed and reimbursed correctly.

    Claim Information

    Basic claim information includes:

  • Pay-to provider number: Local agency (county or tribe) provider number
  • Individual subscriber ID: MHCP ID (MA ID) number of the MHCP eligible individual who received the covered medical service for which the ATS transport or ancillary service(s) were provided or reimbursed
  • • Diagnosis code:
  • • V68.9 – unspecified administrative purpose. Valid for dates-of-service on or prior to 9-30-2015.
  • • Z02.9 – Encounter for Administrative Examinations; Unspecified” for dates of service on or after October 1, 2015.
  • Claim submission will require each service provided (each code) to be billed on a separate service line. Proper claim submission requires entry of the following:

  • • Date(s) of service (DOS)
  • • Dates on claim limited to one calendar month
  • • Enter single date when service is provided on one date only
  • • Enter “From-To” date span for multiple consecutive dates of the same service. A date span does not include a date the service was not provided
  • • Service (procedure) code: Reflects the access transportation service provided or reimbursed as indicated in the tables below in this section
  • • Enter a separate claim line for each distinct service code submitted
  • • Multiple services within same calendar month can be included on claim
  • • Modifier: Indicates the level of service provided when the service includes more than one level or type of transport as indicated in the tables below in this section
  • • Service unit count: Reflects the total number of units of service provided for the date(s) and service type entered
  • • Example: A0190 (meals) = client only = breakfast = 1 unit
  • • Example: A0190 (meals) = client only = breakfast and lunch = 2 units
  • • Line item charge amount: Reflects the total reimbursement amount requested for the service units billed on the line
  • • Example: A0190 (meals) = client only = breakfast = 1 unit X $5.50 (breakfast rate) = $5.50 total line item charge amount
  • • Example: A0190 (meals) = client only = breakfast and lunch = 2 units = 1 unit X $5.50 + 1 unit X $6.50 (lunch rate) = $12.00 total line item charge amount
  • Submit claims for the appropriate transportation base and mileage rates for transport of the MHCP member with the service code and modifier(s) combinations listed on the table.

    Ancillary Access Service Procedure Codes, Modifiers and Payment Rates

    Parking, Lodging and Meals

    Procedure codes and payment rates

    Procedure Code

    NEMT Service Description

    Service Modifier

    Payment Rate

    A0170

    Parking- Least costly transport meeting the needs of the client must be utilized

    None

    At cost; receipts required except for meters that do not provide receipts

    A0180*

    Lodging

    None

    $50 per night maximum unless prior approved by local agency for a higher rate

    A0190*

    Meals

    None

    Maximum rate for each approved meal – combine total meal costs – combine total number of meal units

    Breakfast

    Must be in transit to, from or at medical appointment before 6:00 a.m.

    None

    $5.50 maximum

    Lunch

    Must be in transit to, from or at medical appointment between 11:00 a.m. and 1:00 p.m.

    None

    $6.50 maximum

    Dinner

    Must be in transit to, from or at medical appointment between after 7:00 p.m.

    None

    $8.00 maximum

    * For consideration of lodging and meal reimbursements, travel time does not include time taken to stop and eat the meal.

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    © 2017 Minnesota Department of Human Services Updated: 7/5/16 10:51 AM | Accessibility | Terms/Policy | Contact DHS | Top of Page | Updated: 7/5/16 10:51 AM