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’DHS image
  • • CMS-1500 contains CPT or HCPCS codes and may contain modifiersDHS image
  • • UB-04 contains revenue codes and may contain CPT, HCPCS or CDT codesDHS image

  • 5.

    Enter the procedure/service code in the ‘Find’ search option on your Web page or scroll to find the service code

    DHS image

    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.

    DHS image

    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

    Rate/Report this page Report/Rate this page