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IEP Billing and Authorization Requirements

Revised: 06-06-2017

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Overview

The federal Health Insurance Portability and Accountability Act of 1996 (HIPAA) requires all health care providers and payers to use universal standards for electronic billing and administrative transactions (health care claims, remittance advice [RA], eligibility verification requests, referral authorizations and coordination of benefits).

Review the Covered and Noncovered service page for coverage criteria and the service specific section for detailed billing information for that service.

Authorization and Orders

The Individualized Education Program (IEP) team authorizes all IEP health-related services documented in the IEP plan or Individualized Family Service Plan (IFSP). Services do not require prior authorization from the MHCP medical review agent.

Orders from a physician, nurse practitioner, or physician assistant are required for nursing service that would require such orders if performed in another setting, such as a hospital, clinic or home. Orders must be obtained annually and can cover a period of up to one year. The orders must be in place at the time the provider bills the service.

All other covered IEP services are ordered by the health care professional within his or her scope of practice.

Review the MHCP Eligible Children section of this guide for more information about eligibility and consent.

Billing Requirements

ICD Codes

For dates of service on or after Oct. 1, 2015, federal law will require schools to report ICD-10-CM codes for IEP health-related services billed to MHCP.

Schools must submit an individual ICD-10-CM code for each specific service provided to a child. ICD-10-M codes are subject to change at any time. Review ICD-10-CM coding lists for updates.

Seek Reimbursement from other payers

Minnesota Statutes require Minnesota public school districts to seek reimbursement from insurers and similar third parties for the cost of services a district provides whenever the services are covered by the child’s other health coverage.

Benefits and Limitations

Note the following benefits and limitations:

  • • Districts may not require parents to sign up for or enroll in public benefits or insurance programs for their child to receive services under an IEP or IFSP.
  • • Districts may not require parents to incur any out of pocket expense, such as payment of a deductible or copay amount.
  • • Districts may not use a child’s benefits if that use would:
  • • Decrease available lifetime coverage or any other insured benefit
  • • Result in the family paying for services that would otherwise be covered by the public benefits or insurance program and that are required for the child outside of the time the child is in school
  • • Increase premiums or lead to the discontinuation of benefits or insurance
  • • Risk loss of eligibility for home and community-based waivers, based on aggregate health-related expenditures
  • Timely Billing

    DHS pays claims every two weeks. See the online MHCP Payment and Cut-Off Calendar for information on payment dates and cut-off dates for submitting claims. Follow these guidelines when submitting claims:

  • • Submit all claims correctly and so that MHCP receives them no later than 12 months from the date of service
  • • Submit claims on a regular basis; at least monthly is recommended. Do not wait until the end of the school year
  • • Submit replacement claims so that MHCP receives them within six months from the date of incorrect payment, or within 12 months from the date of service, whichever is greater
  • MHCP Eligible Children with Private Health Care Plans – Third Party Liability (TPL)

    All providers must comply with third party liability (TPL), including the following:

  • • Obtain payment or a denial of coverage from private health care plans before billing MHCP for covered IEP services
  • • Report payment or denial determination from private health care plan on MHCP claims
  • Reporting a Change in Private Health Insurance Coverage

    Districts may report termination dates to DHS when notified by a health plan that the policy has terminated. Claims will deny if termination dates are not reported.

    Fax or mail a copy of the termination notice or denial with termination dates, or fax or mail a letter on your district letterhead to report a health plan termination. Include all of the following information:

  • • Name of private health plan
  • • Child’s name and MHCP ID number
  • • Termination date
  • • Whether the termination applies to the policy or individual
  • • Name and phone number of the person contacted to obtain the termination information.
  • Fax (preferred method): 651-431-7431
  • or
  • Mail: DHS Benefit Recovery Section
  • PO Box 64994
  • St Paul, MN 55164-0994
  • Families must report changes to private health care coverage to the county or state. District staff cannot report these changes on behalf of the family. Only families can report these changes.

    Coordination of Benefits (COB)

    Coordination of benefits identifies payment information between payers with different payment responsibility. MHCP considers Medicare and private health care plans primary to MHCP coverage. Providers must bill and receive payment from primary coverage to the fullest extent possible, or obtain denial of coverage before billing MHCP.

    Private health care plans do not cover IEP transportation and PCA services; it is not necessary to obtain a denial of coverage for these services before billing MHCP.

    Reporting COB information on a claim
    Contact Minnesota Department of Education (MDE) for information about determining coverage for a child who has both Medical Assistance and a private health care plan. Review the MDE roster of private insurers for information about the private insurance coverage.

    Note: DHS calls private insurance coverage third party liability (TPL); MDE refers to it as third party reimbursement (TPR).

    Response from the TPL
    If the private health plan denies coverage as a noncovered service or refuses to provide information (for example, sends letter back with refusal), submit the claim to MHCP. Complete the required fields in COB section of the claim. Review the MN–ITS User Guide for IEP Services for complete instructions.

    For denial of a noncovered service, a refusal to respond is good for one year. No further attempts are required until the following year.

    No response from the TPL
    The district may bill MHCP when there is no response from the private health plan after three attempts within a 90-day period. Each attempt must be 30 days after the previous attempt. Send an electronic claim attachment with the proper documentation. Do not complete the COB section of the claim. For more information and instructions about electronic claims attachment, review the information below.

    Retain copies of all correspondence with private health plans regarding determinations of coverage for IEP services, including phone conversations, for five years.

    Electronic Claim Attachments

    The 2007 state law mandated that the Minnesota Administrative Uniformity Committee (AUC) work collaboratively with Minnesota’s payers and providers to create uniform, electronic health care billing standards for electronic claims and eligibility requests that were being exchanged on paper. The AUC Companion Guides give providers one set of electronic billing standards to use in Minnesota.

    Follow the instructions on the MHCP Enrolled Providers web page for Electronic Claim Attachments. Review the MN–ITS User Guide for IEP Service for instructions about which fields on the claim are required for claim attachments.

    Creating unique attachment control number
    When creating a unique attachment control number (ACN), a suggested scheme is to combine the four-digit district number, child’s eight-digit MHCP number and the service date (MM/DD/CCYY). To submit attachments for more than one claim for the same service date, add a number at the end to indicate the first, second, third, etc., claim with an attachment for that day.

    ACN Example: 0035-00000001-06082009-2:
    In this example, 0035 is the district number; 00000001 is the child’s MHCP number; 06082009 is the date of service; and, 2 indicates the second claim with an attachment submitted for this service date. You may modify the example AUC scheme or create an entirely different unique numbering scheme.

    Do not use simple numbers like 123 and 107. A number of other providers may use simple numbers causing your attachment to attach to a different claim or be lost completely.

    This process allows the claim specialist to match the attachment control number entered on the claim, with the faxed documentation when reviewing a claim for payment.

    Use the same ACN on the attachment and claim. Enter the ACN on each page of the attachment in the upper right-hand corner and on the MN–ITS claim in the appropriate field.

    IEP Procedure Codes, Modifiers and Units

    Procedure code T1018 identifies the services as school based IEP service. The modifier identifies the specific IEP service and the unit is the “cost based” per diem rate for the district based on information the school reports to MDE and DHS.

    MA will only pay one per diem rate per services provided to a child in a school district. For example, if a child meets individually with a physical therapist (PT) in the morning, and meets with the same PT or a different PT in a group setting in the afternoon, add the time for the two encounters together and bill as a PT service; 1 unit. Document the time for the two encounters as the total direct service time for that date.

    Another example: If a child receives a service on the same day as an evaluation, add the service time to the evaluation time for that specific date and bill as an evaluation; 1 unit. Document the time for the service and the evaluation as the total direct service time.

    Effective for dates of service July 1, 2015, and after: Schools must use the following billing requirements when submitting claims.

    IEP Evaluation and Reevaluation
    Use the table below for evaluations performed by IEP health-related service professionals, working within their scope of practice.

    Evaluation or Assessment

    Procedure Code

    Modifier

    Unit Limits

    Physical Therapy

    T1018

    U1 only

    1 per completed evaluation

    Occupational Therapy

    T1018

    U2 only

    1 per completed evaluation

    Speech or Audiology

    T1018

    U3 only

    1 per completed evaluation

    Mental Health

    T1018

    U4 only

    1 per completed evaluation.
    The limit of four evaluations per year is for IEP mental health evaluations only. One unit includes all parts of the mental health evaluation. (For date of service, use the date the evaluation is completed.)

    Nursing

    T1018

    U5 only

    1 per completed evaluation

    Note: Use the date that the evaluation and all billable hours for the evaluation or assessment have been completed as the date of service on evaluation claims. No other modifiers are allowed on claims for evaluations.

    IEP Health Related Services
    Use this table for services approved by the IEP team and performed or delegated by IEP health-related service professionals working within their scope of practice.

    Service

    Procedure Code

    Modifier

    Units Limits

    Physical Therapy

    T1018

    U1 and TM*

    77* or GT*, or both when appropriate

    1 per day

    Occupational Therapy

    T1018

    U2 and TM*

    77* or GT*, or both when appropriate

    1 per day

    Speech or Audiology

    T1018

    U3 and TM*

    77* or GT*, or both when appropriate

    1 per day

    Mental Health

    T1018

    U4 and HE*

    77* or GT*, or both when appropriate

    1 per day

    Nursing

    T1018

    U5 and TM*

    1 per day

    PCA

    T1018

    U6 and TM*

    1 per day

    * Modifier 77: When two districts provide the same service on the same day to the same child, both districts must use modifier 77 in addition to the modifier assigned to that service to avoid denied claims.

    * Modifier GT: Use modifier GT in addition to the assigned modifiers to identify that the service was provided via telemedicine.

    Use this table for IEP health-related items and services approved by the IEP team and ordered by IEP health-related service professionals working within their scope of practice.

    Service

    Procedure Code

    Modifier

    Units Limits

    Assistive Technology

    T1018

    U7, TM add additional modifier

  • • NU for purchase of new item
  • • RR for rented item
  • • RB for repair of item
  • • RA for replacement of item
  • 1 per item

    Special Transportation

    T1018

    U8 and TM – first trip of the day

    U8, TM and 76 – for additional trips

    1 per trip

    Interpreter Services

    T1013

    No modifier required

    1 per day

    Note: When two districts provide the same service on the same day to the same child, both districts must use modifier 77 in addition to the modifier assigned to that service to avoid denied claims.

    Using a Date Span

    Districts may use a date span when billing service for consecutive dates to reduce line item entries. Maximum number of days in a date span cannot exceed five units. Enter the following:

  • • On one line, enter the from and to date of the date span
  • • Enter the correct procedure code (T1018 or T1013)
  • • Enter the correct modifier to identify the service and any additional modifiers as appropriate for the service. Special transportation will need to use two or more lines: one line for the first trip using modifier U8, and on the next line the modifier U8 and modifier 76 for each additional trip per day
  • • Bill one unit per day for each day identified in the date span for the child. For example, if using a five-day date span, bill five units; if using a three-day date span, bill three units
  • • Multiply the district’s bundled rate for the service by the number of units reported on the claim line to determine the submitted charge for that claim line
  • Note: Do no use a date span for assistive technology devices. For assistive technology device, bill 1 unit for the complete device including any additional mounting components and accessories.

    Submitting a Claim

    It is the provider’s responsibility to verify the child’s eligibility before billing for health-related services. Review the information about MHCP Eligible Children for more details.

    Submit claims to MHCP in the 5010 HIPAA compliant X12, 837P (professional) electronic claim format. Use MN–ITS Direct Data Entry (DDE) or batch files to submit claims for IEP services. Refer to the MN–ITS User Guide for IEP Service for complete step-by-step instructions for submitting claims through MN–ITS. For batch submissions refer to the MN–ITS User Manual for Batch Submission, and HIPAA Implementation Guide and the Minnesota AUC Guide for guidance.

    Legal References

    Minnesota Statutes 125A.21 (Third Party Payment)
    Minnesota Statutes 125A.74
    (Medical Assistance Payment to School Districts)
    Minnesota Statutes 256B.0625, subd 3b
    (Covered Services – Telemedicine Services)
    34CFR 300.154
    (Title 34: Education Part 300 - Assistance to States for the Education of Children with Disabilities - Methods of ensuring services

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