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, eligibility verification requests, referral authorizations and coordination of benefits).

Review Covered and Noncovered IEP Health-Related Services under Individualized Education Program Services (IEP) in the Minnesota Health Care Programs (MHCP) Provider Manual for coverage criteria and the service specific section for detailed billing information for that service.

Authorization and Orders

The 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.

Parents, legal guardians, or the school must obtain written orders or prescriptions for certain nursing services from a physician, advanced practice registered nurse (APRN), nurse practitioner, or physician assistant working within their scope of practice. Review IEP Nursing Services under Individualized Education Program Services in the MHCP Provider Manual for nursing services that require written orders. The need for the service must be identified in the child’s IEP or IFSP, maintained in the child’s file, and updated based on the child’s needs or annually. Schools may not bill MHCP until the required written orders are in place.

The IEP team will approve the need for all other covered IEP health-related services (such as physical therapy, assistive technology, mental health, transportation, and so forth).

Review MHCP Eligible Children for more information about eligibility and consent.

Billing Requirements

ICD Codes

Federal law requires 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 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

The Minnesota Department of Human Services (DHS) pays claims every two weeks. Refer to the MHCP billing resources webpage under the Calendars and reading the PCN section for online MHCP payment and claim cut-off calendars for payment dates and cut-off dates for submitting claims. Adhere to the following 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 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

Families are required to report changes to private health care coverage, including termination, to the county or state. District staff should not report these changes on behalf of the family.

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 (through U.S. Postal Service) a copy of the termination notice or denial with termination dates, or fax or mail (through U.S. Postal Service) 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

Mail: DHS Benefit Recovery Section
PO Box 64994
St. Paul, MN 55164-0994

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 Personal Care Assistance (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 the Minnesota Department of Education (MDE) for information about determining coverage for a child who has both Medical Assistance (MA) 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 Billing for IEP Services in the MN–ITS User Manual 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 following information.

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

Electronic Claim Attachments

State law mandates 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.

Instructions for Electronic Claim Attachments can be found on the MHCP billing resources webpage. Review the Billing for IEP Services in the MN–ITS User Manual for instructions about which fields on the claim information are required for claim attachments.

A suggested method for creating a unique attachment control number (ACN) 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, and so forth, claim with an attachment for that day.

ACN Example: 0035-00000001-06082019-2
In this example, 0035 is the district number; 00000001 is the child’s MHCP number; 06082019 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 Place of Service, 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, then 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 1 unit of PT service. 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 1 unit of evaluation. Document the time for the service and the evaluation as the total direct service time. Schools must use the following billing requirements when submitting claims.

Place of Service (POS)
Use the following table to identify where the child received the IEP health-related services.

POS Code	Description
02	Telehealth provided other than in the child’s home. The child is not located in their home when receiving health services or health-related services through telecommunication technology.
10	Telehealth provided in the child’s home. The child is located in their home (which is a location other than a hospital or other facility where the patient receives care in a private residence) when receiving health services or health-related services through telecommunication technology.
03	Child is receiving in-person, face-to-face IEP health-related services in a school.
12	Child is receiving in-person, face-to-face health-related services in their home, or location other than a hospital or other facility, where the child receives care in a private residence.

IEP Evaluation and Reevaluation
Use the following table 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 Evaluation	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

Health-related services coding schemes

Service	Procedure Code	Modifier	Units Limits
Physical Therapy	T1018	U1 and TM	1 per day
Occupational Therapy	T1018	U2 and TM	1 per day
Speech or Audiology	T1018	U3 and TM	1 per day
Children’s Therapeutic Services and Supports (CTSS) services: IEP or IFSP services provided in schools	T1018	U4 and HE Only use the HE modifier for billing for CTSS services.	1 per day
Mental Health Services in Special Education (MH-SPED)	T1018	U4 and TM	1 per day
Nursing	T1018	U5 and TM	1 per day
PCA	T1018	U6 and TM XP when appropriate	1 per day
Assistive Technology	T1018	U7, TM add additional modifier 1. NU for purchase of new item 2. RR for rented item 3. RB for repair of item 4. RA for replacement of item	1 per item
Special Transportation	T1018	U8 and TM – first trip of the day U8, TM and XE – (use modifier XE to identify each additional trip per day)	1 per trip 1 for each additional trip per day
Interpreter Services	T1013	No modifier	1 per day

Additional Modifiers for IEP Health Related Services:

· Use modifier XE to identify each additional trip per day for special transportation.

· Use modifier XP to identify that another school or school district with a different NPI will be billing for the same service on the same day as the date of service on the claim.

Using a Date Span

Districts may use a date span when billing services for consecutive dates to reduce line item entries. The 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 XE for dates of service beyond November 1, 2018 for each additional trip per day. For dates of service November 1, 2018, and beyond, use XE 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 Billing for IEP Services in the MN–ITS User Manual for complete step-by-step instructions for submitting claims through MN–ITS.

For batch submissions, refer to the Batch Submission User Guides, in the MN–ITS User Manual.

Legal References

Minnesota Statutes, 125A.21 (Third-Party Payment)
Minnesota Statutes, 125A.74 (Medical Assistance Payments to School Districts)
Minnesota Statutes, 256B.0625, subdivision 3b (Covered Services – Telehealth services)
Code of Federal Regulations, title 34, section 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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