MHCP Provider Manual - Billing Policy Overview

In a fee-for-service (FFS) delivery system, providers (including billing organizations) bill for each service they provide and receive reimbursement for each covered service based on a predetermined rate. Minnesota Health Care Programs (MHCP) providers and their billing organizations must follow MHCP billing policies as outlined in this section and provider type specific sections of the MHCP Provider Manual for billing services provided to FFS recipients.

MHCP recipients enrolled in a managed care organization (MCO) contracted with MHCP receive their health care services through the MCO. Contact the appropriate MCO to learn about their billing policies for services provided to MCO-enrolled MHCP recipients.

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). Minnesota’s Uniform Electronic Transactions and Implementation Guide Standards require all Minnesota-based health care claims to be submitted electronically.

Coordination of Services

Providers are responsible to ask recipients if they are currently receiving the same health care services from another provider. If the recipient is receiving the same services from another provider, the persons providing services must coordinate the services and document, in the recipient's record, that coordination occurred. MHCP does not make this information available to providers.

Free-care Policy

MHCP takes into account all resources available to recipients, including free services. CMS’ “free-care” policy does not reimburse providers for services given to Medicaid recipients if the same services are offered for free to non-Medicaid patients.

General Billing Requirements

MHCP providers who render or supervise services are responsible for claims submitted to DHS/MHCP:

• Submit claims only after you provide one or more MHCP-covered service

• Bill only for dates of service when services were provided

• Bill the provider's usual and customary charge

• Bill only one calendar month of service per claim

• Submit claims electronically

Timely Billing

• Submit claims correctly, including Medicare crossover and TPL claims, so that MHCP receives them no later than 12 months from the date of service

• Submit replacement claims so that MHCP receives them within 6 months of the date of incorrect payment, or within 12 months from the date of service, whichever is greater

• Submit Medicare crossover claims that do not automatically cross over so that MHCP receives them within 6 months of the Medicare determination/adjudication date or within 12 months of the date of service, whichever is greater

• Resubmit claims MHCP denied erroneously (due to system error or incorrect information from county) within 12 months of the date of service or up to 6 months from date of county correction, whichever is greater

• Submit claims over one year old with appropriate, dated documentation. See Electronic Claim Attachments for instructions. MHCP will review documentation, but does not guarantee payment.

Coding Schemes

Providers must use applicable HIPAA-compliant codes and follow the most current guidelines. Providers are not required to purchase all of the manuals. Determine which manuals are appropriate for the services you provide:

• CDT: (Current Dental Terminology) Order by contacting American Dental Association at 1-800-947-4746 or may be purchased from various medical book sources.

• CPT: (HCPCS Level I: Physicians' Current Procedural Terminology) Contact the American Medical Association at 1-800-621-8335 or may be purchased from various medical book sources.

• HCPCS: (Healthcare Common Procedural Coding System) Available online at CMS Alpha-Numeric HCPCS; may also be purchased from various medical book sources

• ICD-9-CM: (International Classification of Diseases 9th Revision Clinical Modification) May be purchased from medical book sources.. Files also available for download at Classification of Diseases, Functioning, and Disability

• NDC: (National Drug Codes) Review the National Drug Code Directory, search NDC

• UB-04 Data Specifications Manual: Order by contacting NUBC

Use appropriate HCPCS 2-digit alpha, numeric, and alphanumeric modifiers to identify one of the following:

• A service/procedure altered by a specific circumstances, but not changed in its definition or code

• Rental, lease, purchase, repair, or alteration of medical supply

• The origin and destination for medical transportation (1-digit alpha codes)

Bill unlisted procedure codes only when a specific code is not available to define a service/procedure. When billing an unlisted code, include a description defining the service/procedure on electronic claims or send an attachment with a written description/documentation defining the service/procedure (see Electronic Claim Attachments).

MN–ITS and Electronic Billing

MN–ITS is MHCP’s free, Web-based, HIPAA-compliant system for claim submission, inquiry and other health care transactions.

• Submit individual, direct data entry claims through MN–ITS Interactive

• If you use HIPAA-compliant billing software or are a billing organization, submit your transactions through MN–ITS Batch

• Verify active provider enrollment status

• Verify program eligibility for one or more MHCP recipients at one time

• Submit authorization requests for medical/dental services or supplies

• Submit service agreement (SA) requests for home care services

• Retrieve your authorization and service agreement letters

• Submit claims (including claims with Medicare or other insurance)

• Copy previously submitted MN–ITS claims or replace incorrectly submitted paid claims

• Check a claim's paid or denied status

• Submit a Pay-for-Performance Results Payment

• Retrieve your RAs in your MN–ITS Mailbox

Your Welcome Letter includes your Initial User ID and Password. When you register, you must agree to the EDI Trading Partner Addendum. This addendum augments your existing MHCP Provider Agreement and supersedes any existing MHCP EDI Biller Agreements between you and MCHP.

All pay-to providers billing through a billing organization (such as a clearinghouse or billing intermediary) must also register for MN–ITS as the provider organization. Providers may assign their billing organization as their MN–ITS administrator, but providers must retain system access to continue to verify eligibility, check the status of their claims and receive their RAs. Providers are responsible for all claims submitted to MHCP and for reconciling their claims.

Billing Organization/Responsibilities

A provider may not submit claims to MHCP through a factor, which is an individual or entity such as a collection agency or service bureau that advances money to the provider for accounts receivable that the provider has assigned, sold, or transferred to the individual or entity for a fee or for a deduction of a portion of the accounts receivable. Review the Billing Organization/Responsibilities section for additional information.

Eligibility Requests and Responses

MHCP requires providers to verify eligibility before they render services and submit claims. Clearinghouses are out of HIPAA compliance if they conduct eligibility (270) or health claim status (276) inquiries on behalf of provider organizations. Use MN–ITS to request recipient eligibility and receive eligibility responses. Verify ID numbers (up to 50) or dates of service up to one year before date of inquiry.

• Major program

• Prepaid health plan (MCO enrollment) status, if applicable

• Other insurance/TPL/ Medicare coverage, if applicable

• Special transportation, hospice, living arrangement indicators

• Potential copay indicator

• Spenddown

• Waiver program participation indicator

• Restricted recipient indicator*

• Benefit limits (applies to fee-for-service recipients only)

• Elderly waiver obligation

• Eyeglass payment*

MHCP also contracts with an outside vendor who offers other options for verifying eligibility. For more information about their options and rates, contact Emdeon Business Services:

Electronic Claims

Review your provider type Web page for information about claim submissions specific to the services you provide.

Reconsideration of a Claim

MHCP FFS does not accept the AUC appeals form that corresponds to the AUC Best Practice due to regulatory requirements (citation: 42 CFR 447). Providers

• Can be corrected and resubmitted

• Meets the MHCP Attachment Criteria to submit an Electronic Claims Attachment (sent within two days of the electronic claim) that includes medical necessity or other forms of documentation that supports the claim

Original claims submitted via MN–ITS Direct Data Entry (DDE) can be copied or replaced using the Request Status feature in MN–ITS to display the original claim.

Replacement Claims

A replacement claim is a resubmission of an incorrectly paid claim due to a billing error or a third party payment. Submit a replacement claim only in the following circumstances:

• When all or some of a claim (including Medicare claims submitted through MN–ITS) is paid incorrectly due to a billing error

• When you receive a third party payment after you receive MHCP payment

Claims that have been underpaid must be replaced within 12 months of the date of service or 6 months from the date of payment. Claims that have been overpaid can be replaced or refunded (voided) electronically.

Void Claims

If you need to return the entire claim payment to MHCP, use MN–ITS to void the claim. The amount will be deducted from a subsequent remittance advice. Claims that are voided after Timely Billing requirements cannot be resubmitted for payment.

If you need to void a claim because one of the following situations applies, follow the step below:

• A claim was originally paid with an MHCP ID (the provider number you used to bill before the NPI or UMPI)

• It has been more than three years since you received payment for a claim

• The provider to whom the claim was paid is no longer an actively enrolled MHCP provider

• The claim is identified as “claim type: gross adj” on your remittance advice (claims display the recipient name, ID and date of service)

After the void is completed, MHCP will report RA01 on your RA in the reversal section.

ACT/ARMHS/Day treatment: see ACT under Billing (just before chart) for reversal requests due to denial.

MN–ITS Mailbox

Contents in MN–ITS mailbox folders are not available for dates before 09/17/11. The start/end dates in MN–ITS Quick Search span a rolling 30-day period (today minus 30 days). As contents build, providers are able to search and retrieve contents using Quick Search by entering earlier start and end dates. For example, if the current date span is start date 12/25/11 and end date 1/24/12, to retrieve information from two months ago, enter start date 10/17/11 and end date 11/16/11. A broad search (leaving the end date as the current date) may result in a time delay.

Provider must keep appropriate records according to state and federal retention requirements.

Remittance Advice (RA)

HIPAA requires providers and payers to use a standardized electronic RA (X12N 835) transaction. MHCP adopted the HIPAA standards for electronic and paper RAs.

RAs provide detailed payment information about health care claims and, if applicable, describe why the total original charges are not paid in full. The X12 835 is a financial transaction designed to automatically balance financial accounts. The 835 transaction standards and HIPAA-related adjustment code lists are available through the Washington Publishing Company (WPC).

Remittance advice information is listed alphabetically by recipient name, unless you request one of the other remittance sequences upon your initial enrollment with MHCP:

To request a sequence change in your RA, call the Provider Call Center and choose option 5 for provider enrollment.

Taxes and 1099 Forms

MHCP does not withhold taxes, such as Medicare or Social Security, from payments made to providers. IRS 1099 forms are sent to providers by February of the year following payment. DHS sends a 1099 for payments made by paper check. Minnesota Management and Budget (MMB) sends a 1099 for payments made by electronic funds transfer (EFT).

MHCP Reimbursement is Payment in Full

A provider must accept MHCP reimbursement as payment in full for covered services provided to a recipient. A provider may not request or accept payment in addition to the amount allowed under MHCP from a recipient, a recipient's relatives, the local human services agency, or any other source, in addition to the amount allowed under MHCP, unless the request is for one of the following:

• Spenddown

• Copay

• Family deductible

• Insurance payment that was made directly to the recipient. MHCP is liable for the amount payable by MHCP minus the third-party liability amount

Prompt Payment

MHCP is required to pay or deny clean claims within 30 days and complex claims within 90 days of receipt. Clean claims are electronic and paper claims without attachments. Complex claims are replacement claims, Medicare crossovers, third-party liability claims, or paper claims with attachments.

Additional Resources

Refer to the following sections for additional Billing Policy requirements and resources:

Legal References

42 CFR 447.10 Prohibition against reassignment of provider claims
42 CFR 447.15 Acceptance of State payment as payment in full
42 CFR 447.45 Timely claims payment

If	Then
The claim is within 12 months from the date of service or 6 months from the original date of payment	Submit the replacement claim electronically via MN–ITS. Review the Replacement Claim User Guide for instructions
The claim is over 12 months from the date of service or more than 6 months from the original date of payment, and your original claim payment was an overpayment due to a billing error or you received other third party payments	Submit the replacement claim electronically with an ACN and an electronic attachment. See Claim Attachment Criteria sheet
The claim is over 12 months from the date of service or more than 6 months from the original date of payment, and your original claim payment was an underpayment due to a billing error	Your request cannot be processed due to timely filing limitations

1.	Collect the following information:
	• Original payer claim control number • Recipient ID • Date of service • Total charge billed • Total amount paid • Contact name and number
2.	Call the MHCP Provider Call Center; a representative will create a work order to review and complete the void process.

Folder Name	File Type	Retrieve up to:
Mailbox Home	LINKS and ARCHIVE File Types	30 days
Transaction Responses	All file types except 835s (RAs) 835s (RAs)	90 days 12 months
Miscellaneous Received	All file types	90 days