Provider Manual
Provider Manual
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 the 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.
This section outlines the following for all MHCP providers:
Please also review the following billing policies for all providers:
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 providers must coordinate the services and document in the recipient's record how the services were coordinated. MHCP will not inform providers of services the recipient is receiving from other providers.
For dates of service before Dec. 15, 2014, MHCP takes into account all resources available to recipients, including free services. CMS’ “free-care” policy does not reimburse providers for services they give to Medicaid recipients if the same services are offered for free to non-Medicaid patients.
For dates of service on or after Dec. 15, 2014, MHCP pays for covered services even when the provider offers the same service for free to any other patient. Services must still meet all other MHCP coverage criteria to be eligible for reimbursement.
MHCP providers who render or supervise services are responsible for claims submitted to MHCP:
Follow these requirements for timely billing:
Use applicable HIPAA-compliant codes and follow the most current guidelines. Providers are not required to purchase all of the manuals. Determine which of these manuals are appropriate for the services you provide:
Use appropriate HCPCS 2-digit alpha, numeric and alphanumeric modifiers to identify one of the following:
HCPCS developed 13 U modifiers for state definition. See Minnesota-defined U Modifiers.
Bill unlisted procedure codes only when a specific code is not available to define a service or procedure. When billing an unlisted code, include a description defining the service or procedure on electronic claims or send an attachment with a written description or documentation defining the service or procedure (see Electronic Claim Attachments).
MN–ITS is MHCP’s free, web-based, HIPAA-compliant system for claim submission, inquiry and other health care transactions. Submit claims through the following:
Providers must register for MN–ITS to perform any of the following functions:
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.
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.
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.
Eligibility responses include the following information for each recipient:
Review your provider type web page for information about claim submissions specific to the services you provide.
MHCP FFS does not accept the AUC appeals form that corresponds to the AUC Best Practice due to regulatory requirements (42 CFR 447). Follow this process for reconsideration:
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.
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:
Claims that have been underpaid must be replaced within 12 months of the date of service or six months from the date of payment. Claims that have been overpaid can be replaced or refunded (voided) electronically.
Replacement claim process
If |
Then |
|---|---|
The claim is within 12 months from the date of service or six 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 six 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 six 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 |
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:
Follow these steps to void a claim for any of the situations noted above:
After the void is completed, MHCP will report RA01 on your RA in the reversal section.
For a lead agency void request for adjusting service authorizations or agreements, see Void Waiver and Alternative Care (AC) Service Claims.
Assertive Community Treatment (ACT), adult rehabilitative mentail health services (ARMHS), or day treatment: see Billing in the ACT section (just before chart) for reversal requests due to denial.
The start and 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. Refer to the MN–ITS Mailbox user guide in the MHCP MN–ITS User Manual for more information and instructions on using the mailbox feature.
Providers must keep appropriate records according to state and federal retention requirements.
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 following 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.
MHCP-enrolled providers receive their RAs in one of the following formats:
For reading PDF file RA information, review How to Read Your RA and Remittance Advice (RA) Guide Chart (DHS-7400) (PDF).
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).
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 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:
MHCP is required to pay or deny clean claims within 30 days and complex claims within 90 days of receipt. Clean claims are MHCP primary claims without attachments. Complex claims are replacement claims, Medicare crossovers, third-party liability claims, claims with information in the notes or comment fields,or claims with attachments.
Refer to the following sections for additional Billing Policy requirements and resources:
Minnesota Statutes 62Q.75 Prompt Payment Required
Minnesota Statues 256B.0915, subd 3a(c) Elderly waiver cost limits
Minnesota Statues 256b.0913, subd 4 (7) Alternative Care Program- Eligibility for funding for services for nonmedical assistance recipients
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
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