Determine MHCP Rates for Incarcerated Individuals

Overview

Effective July 1, 2011, Legislation limits the amount counties pay for medical services provided to incarcerated individuals in a county jail to the maximum allowed MHCP payment rate for the services, whether or not they have Minnesota Health Care Programs (MHCP) eligibility.

DHS established the following new process for counties and the Department of Corrections (DOC) to determine the maximum allowed MHCP payment rate. This process changes the current process for some counties and DOC that previously phoned or submitted requests directly to DHS. This process will improve the consistency of the MHCP rates determination process.

Medical Provider Requirements

If an incarcerated individual is covered by other health insurance, the health care provider must bill that insurance before submitting the bill to the appropriate county or DOC for reimbursement. If the individual is enrolled in an MHCP managed care organization (MCO) during the month services are received, bill the MCO. DHS-contracted MCOs are required to cover out-of-network emergency or urgent care. Other health care services must meet MCO guidelines for network and service authorizations.

After all other payment sources have paid, or when the individual is not covered by other insurance or enrolled in an MCO, the health care provider, to be reimbursed by a county or DOC, must:

• Submit to the county or DOC a completed paper claim form (ADA , CMS-1500, UB-04) for service(s) provided that includes:

• CDT, CPT, HCPCS or revenue codes

• Appropriate modifiers

• Usual and customary amount charged for each service

• If applicable, provide an explanation of benefits from all other payment sources

• Provide invoice(s) for medical equipment or services that may be subject to pricing

County and DOC Requirements

Counties and DOC must first use the MHCP fee schedule to determine MHCP total allowed amounts following the steps below:

1.	Select MHCP Fee Schedule
2.	Accept the End User License Agreement
3.	Select the MHCP Fee Schedule in PDF
4.	Determine type of claim form • ADA contains CDT codes which always begin with a ‘D’ • CMS-1500 contains CPT or HCPCS codes and may contain modifiers • UB-04 contains revenue codes and may contain CPT, HCPCS or CDT codes
5.	Enter the procedure/service code in the ‘Find’ search option on your Web page or scroll to find the service code Look at the FACT CODE to determine if the service is allowed, non-covered, or requires pricing or a report. Some service codes may have multiple fact codes; review all fact codes before determining payment. If the fact code is one of the following, proceed as indicated:
	D, H, L, P, 4, 8:	MHCP does not cover this service
	9:	Code is discontinued, send the claim back to the provider and have provider resubmit with a current code
	C, G, K, O, S, T, 3, 7:	Fax the claim with an invoice or other description of service to MHCP for pricing
	Q:	Refer to the ‘Dental Exams and X-rays for children under age 21’ section of the fee schedule for pricing, if ‘by report,’ fax the claim with an invoice or other description of service to MHCP for pricing

Determine MHCP Rate

If the service code does not have a fact code listed above, use the following as a guideline to determine the MHCP rate.

Claim Type	Use price under column name	Process to determine county/DOC payment
ADA claims	TOTAL ALLOW
CMS-1500	TOTAL ALLOW
	If a code is followed by a modifier, you may need to use a different column to determine the rate:
	ANESTH BASE VALUE + appropriate anesthesia formula	For anesthesia modifiers, use the formula under ‘Anesthesia Formulas’ that applies to the listed modifier For example, the modifier AA formula is: ((Base Units + (Time Units / 15)) X 18.00. If a provider billed code 36471 with modifier AA for 38 units, you would calculate ((3 + (38/15)) X 18.00 = (3 + 2.5) X18 = 5.5 X18 = 99.00
	PROF COMPONENT	For professional components, modifier 26, use the PROF COMPONENT column to price the service
	TECH COMPONENT	For technical components, modifier TC, use the TECH COMPONENT column to price the service
	RENTAL ALLOW	For equipment rental, KH, KI, KJ, KR, LL and RR modifier, use the RENTAL ALLOW column to price the service
UB-04	APC/ASC ALLOW	For claims with type of bill 013X, 014X, 07XX, 083X, or 085X, review the information under ‘PSI’ and ‘Facility Component Pricing Hierarchy (APC/ASC Allow or TECH Component).’The payment rate is the: 1) APC rate. If no APC rate, see 2). 2) TC rate. If no TC rate (factor code E), see 3). 3) System calculates a facility charge allowable. If a rate is not listed, fax the claim and any invoice or additional description to MHCP For UB-04 claims that have a type of bill other than those listed above, fax the claim and any invoice or additional description to MHCP

When the MHCP allowed amount is not available on the MHCP fee schedule, follow the process below.

Submit the following to MHCP to determine the allowable rates:

• Service (CDT, CPT or HCPCS) codes without MHCP allowed amounts (Fact Codes: C, G, K, O, S, T, 3, 7)

• Inpatient claims (DRG)) (hospital/facility claims when the individual is admitted)

• Outpatient claims without APC/ASC or technical component rates

• Pharmacy claims, include the National Drug Code (NDC), date of service, number of units and total charge

Fax:

651-431-7439

Use secure fax to send a cover sheet that includes your first and last name, phone number and your fax number with the provider’s completed paper claim and any corresponding invoices. Allow seven business days for processing. DHS will respond by secure fax with a cover sheet that includes your original paper claim and corresponding documentation that displays the MHCP allowed amount.

DHS PR Training

Direct questions/disputes about the MHCP fee schedule

Definitions

ADA 2006	American Dental Association dental paper claim form
CDT	Current Dental Terminology: an alpha-numeric code set used to report dental procedures and services
CMS-1500	Centers for Medicare and Medicaid Services professional paper claim form
CPT	Current Procedural Terminology: a numeric code set used to report medical procedures and services
HCPCS	Healthcare Common Procedure Coding System: an alpha-numeric code used to identify products, supplies, and services not included in CPT
Modifier	2-digit alpha, numeric, or alphanumeric code used to indicate a service or procedure that is altered without changing the procedure’s definition or code
Revenue codes	Codes that identify accommodations, ancillary services or billing calculations or arrangements
UB-04	Uniform Bill 2004 institutional (inpatient/outpatient) paper claim form
Unlisted/Pricing	Codes that do not have an MHCP allowed amount on the fee schedule require a description

Legal References

MS 241.021, subd. 4 Health Care

MS 641.15, subd. 2 Medical Aid

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