Ancillary Services Claim and Rate Information for Counties and Tribes

Revised: January 29, 2019

· Overview

· Claim Information

· Ancillary Access Service Procedure Codes, Modifiers and Payment Rates

Overview

County and tribal requests for MHCP reimbursement for access service, transportation and related ancillary services must be billed electronically through MN–ITS interactive or batch.

Access transportation and the related ancillary service claim submissions require a number of fields to be completed with correct and accurate information for the claim to process and pay. This section has general information for basic claim submission. Additional requirements may be necessary for the access transportation and the related ancillary services claims to be billed and reimbursed correctly.

Claim Information

Basic claim information includes:

· Pay-to provider number: Local agency (county or tribe) provider number

· Individual subscriber ID: MHCP ID (MA ID) number of the MHCP eligible individual who received the covered medical service for which the ancillary service(s) were provided or reimbursed

· Diagnosis code Z02.9 – Encounter for Administrative Examinations; Unspecified

Claim submission will require each service provided (each code) to be billed on a separate service line. Proper claim submission requires entry of the following:

· Date(s) of service (DOS)

· Dates on claim limited to one calendar month

· Enter single date when service is provided on one date only

· Enter “From-To” date span for multiple consecutive dates of the same service. A date span does not include a date the service was not provided

· Service (procedure) code: Reflects the access transportation service provided or reimbursed as indicated in the tables below in this section

· Enter a separate claim line for each distinct service code submitted

· Multiple services within same calendar month can be included on claim

· Service unit count: Reflects the total number of units of service provided for the date(s) and service type entered

· Example: A0190 (meals) = client only = breakfast = 1 unit

· Example: A0190 (meals) = client only = breakfast and lunch = 2 units

· Line item charge amount: Reflects the total reimbursement amount requested for the service units billed on the line

· Example: A0190 (meals) = client only = breakfast = 1 unit X $5.50 (breakfast rate) = $5.50 total line item charge amount

· Example: A0190 (meals) = client only = breakfast and lunch = 2 units = 1 unit X $5.50 + 1 unit X $6.50 (lunch rate) = $12.00 total line item charge amount

Submit claims for the appropriate transportation base and mileage rates for transport of the MHCP member with the service code and modifier(s) combinations listed on the table.

Ancillary Access Service Procedure Codes, Modifiers and Payment Rates

Parking, Lodging and Meals

Procedure codes and payment rates

Procedure Code	NEMT Service Description	Service Modifier	Payment Rate
A0170	Parking- Least costly, meeting the needs of the client must be utilized	None	At cost; receipts required except for meters that do not provide receipts
A0180*	Lodging	None	$50 per night maximum unless prior approved by local agency for a higher rate
A0190*	Meals	None	Maximum rate for each approved meal – combine total meal costs – combine total number of meal units
Breakfast	Must be in transit to, from or at medical appointment before 6:00 a.m.	None	$5.50 maximum
Lunch	Must be in transit to, from or at medical appointment between 11:00 a.m. and 1:00 p.m.	None	$6.50 maximum
Dinner	Must be in transit to, from or at medical appointment between after 7:00 p.m.	None	$8.00 maximum

* For consideration of lodging and meal reimbursements, travel time does not include time taken to stop and eat the meal.