Claim Instructions

 

Claims System Modernization - New Montana Healthcare Programs Claims System Coming in 2027

The Department of Public Health and Human Services is pleased to announce we have contracted with Gainwell Technologies to implement a new system for processing and paying Montana healthcare claims. The claims project kicked off in October 2024, with plans to roll out the new system in 2027. For more information and to subscribe to receive updates to your inbox, please visit Claims Modernization on the DPHHS website.

New Provider Services Portal for Enrollment, Maintenance and Claims Entry available 12/13/2021.

Montana Healthcare Programs is excited to introduce a new Provider Services Module. Beginning December 13, 2021, you will notice a change to the online enrollment links. All providers seeking to enroll with Montana Healthcare Programs will be directed to the new MPATH online application offering a more efficient way to enroll, update information and easily submit claims!

MPATH Claims Entry Solution - The claims entry solution is an online tool allowing providers to manually enter claims. Available options include:

  • Claim form templates - The system allows users to create and save templates for common claim submissions. No need to start from scratch every time.
  • Diagnosis and Procedure code look up - The system has code look up features to assist with entering correct information.
  • Ability to submit multiple claim types - including Professional, Facility and Dental claims.
  • Great alternative to WinASAP5010 - The claims entry solution is a free, simple to use and providers can enter claims without converting and uploading files.
  • Electronic Claim Adjustments - Paper adjustment forms are no longer required. The provider service module allows for online claim adjustments.

 

Provider Services Portal

 

There are two ways to submit claims to the Montana Healthcare Programs: Electronic and paper.  Electronic claims are processed an average of 14 days faster than paper claims. Paper claims submitted via mail are processed an average of 12 days faster than paper claims submitted by fax. The information below is intended to support claim submission in both formats. 

Whether you submit one claim a month or hundreds, any provider can benefit from switching from paper to electronic billing. Whether by using the free Provider Services Portal or by using a clearinghouse to submit claims, electronic billing is faster, more accurate, and more secure.

See Electronic Submission Setup below to begin the process.

For information about HIPAA 5010,visit the HIPAA5010 page on this website

Follow the steps below to submit your Medicaid claims electronically.

STEP 1

Download the electronic billing enrollment forms and instructions below. Complete and submit the forms to the address/fax number listed on the EDI enrollment form.

Clearinghouses or Billing Agents

EDI Submitter Enrollment Packet for X12N Transaction
All forms must be completed. To print individual sections, access the links below.

Individual Providers

EDI Submitter Enrollment Packet for X12N Transaction
Providers may omit sections 4a, 7b, and 8 Of the EDI Provider Enrollment Form. To print individual sections, access the links below.

STEP 2

Follow the steps in chapter 2 of the Provider Services Portal User Guide to register and set up your user access for the Provider Services Portal.

  • You must have completed the enrollment packet and received your welcome letter before using the Provider Services Portal for claims.

  • For technical support, please contact Provider Relations at (800) 624-3958.

STEP 3

Login to the Provider Services Portal.

Under myMenu, without clicking, place your curser on Claims.

A side menu with submission options will appear.

Select the claims submission option you wish to use to submit claims using the free Provider Services Portal.

To bill claims electronically, a provider must enroll with EDI Solutions following the steps in the Electronic Submission Setup tab. 

The Provider Services Portal is a web-based program hosted by MPATH and allows providers to submit directly to Medicaid without a software download.

If you have questions regarding the Provider Services Portal, please contact Provider Relations at (800) 624-3958.

Provider Services Portal User Guide

Instructions for Billing Electronically

Paper Claim Instructions

Providers bill using their NPI and their taxonomy code or their atypical provider ID number.

CMS-1500 Claim Form Sample and Instructions

Instructions for Completing the UB-04

UB-04 Using NPI and Taxonomy

Instructions for Completing the 2019 Dental Claim Form

Sample ADA Dental 2019 Claim Form 10/2021

Electronic Claim Adjustments

Electronic Adjustments are now accepted by Montana Medicaid. There will be 2 options for submitting an electronic adjustment, depending on how the claim was originally submitted.

Acceptable frequency codes:

1 Indicates the claim is an original claim.
7 Indicates the new claim is a replacement or corrected claim – the information present on this claim represents a complete replacement of the previously issued claim.
8 Indicates the claim is a voided/canceled claim

Instructions for a Clearing House or Other Direct Submission Software

Create a new claim with the corrected information. If you are voiding the claim, claim information must match original claim.

All claim types

Loop 2300 - (CLM05-3) is the Claim Frequency Code. Enter 7 or 8.
REF*F8* - Enter the original ICN.

MPATH Claims Solutions

Create a new claim with the corrected information. If you are voiding the claim, claim information must match original claim.

Professional Claims (CMS-1500) & Dental Claims

Answer YES, to the first question at the bottom of the claim entry screen. The next two fields are now visible.

Select either Replacement of prior claim or Void of prior claim from the Medicaid Resubmission drop down.

Enter the Paid ICN of the claim being adjusted in the Original Reference Number field.

Institutional Claims (UB-04)

When recreating the claim, change the last digit of the Type of Bill code to either 7 for replacement or 8 for void.

The Original Reference Number filed is now visible. Enter the Paid ICN of the claim being adjusted in the Original Reference Number field.

November 2023 Billing 101 Training

Electronic Claim Adjustments

MPATH Provider Services Portal Claims Training Presentation

This is a portion of the January 2022 Provider Services Module training presentation. To view the entire training presentation, please see the Training Page.

Common Billing Errors

Paper claims are often returned to the provider before they can be processed, and many other claims, both paper and electronic, are denied. To avoid unnecessary returns and denials, double check each claim to confirm the following items are included and accurate.

Common Billing Errors
Reasons for Return or Denial How to Prevent Returned or Denied Claims
Provider’s NPI and/or Taxonomy is missing or invalid The provider NPI is a 10-digit number assigned to the provider by the national plan and provider enumerator system. Verify the correct NPI and Taxonomy are on the claim.
Authorized signature missing Each claim must have an authorized signature belonging to the provider, billing clerk, or office personnel. The signature may be typed, stamped, hand-written, or computer-generated.
Signature date missing Each claim must have a signature date.
Incorrect claim form used The claim must be the correct form for the provider type.
Information on claim form not legible Information on the claim form must be legible. Use dark ink and center the information in the form locator. Information must not be obscured by lines.
Member ID number not on file, or member was not eligible on date of service Before providing services to the member, verify member eligibility by using one of the methods described in the Member Eligibility and Responsibilities chapter of this manual. Montana Healthcare Programs eligibility may change monthly.
Passport provider number is missing or invalid A Passport provider number must be on the claim form when a referral is required. Passport approval is different from prior authorization. See the Passport to Health provider manual.
Prior authorization number is missing Prior authorization is required for certain services, and the prior authorization number must be on the claim form. Prior authorization is different from Passport. See the Prior Authorization chapter in this manual.
Prior authorization does not match current information Claims must be billed, and services performed during the prior authorization span. The claim will be denied if it is not billed according to the spans on the authorization.
Duplicate claim Check all remittance advices for previously submitted claims before resubmitting.
When making changes to previously paid claims, submit an adjustment form rather than a new claim form. (See Remittance Advices and Adjustments in this manual.)
TPL on file and no credit amount on claim If the member has any other insurance (or Medicare), bill the other carrier before Montana Healthcare Programs.
If the member’s TPL coverage has changed, providers must notify the TPL unit before submitting a claim.
Claim past 365-day filing limit The Claims Processing unit must receive all clean claims and adjustments within the timely filing limits described in this chapter.
To ensure timely processing, claims and adjustments must be mailed to Claims Processing.
Missing Medicare EOMB All denied Medicare crossover claims must have an Explanation of Medicare Benefits (EOMB) with denial reason codes attached and be billed to Montana Healthcare Programs on paper.
Provider is not eligible during dates of services, enrollment has lapsed due to licensing requirements, or provider number terminated Out-of-state providers must update licensure for Montana Healthcare Programs enrollment early to avoid denials. If enrollment has lapsed due to expired licensure, claims submitted with a date of service after the expiration date will be denied until the provider updates his or her enrollment.
New providers cannot bill for services provided before Montana Healthcare Programs enrollment begins.
If a provider is terminated from the Montana Healthcare Programs program, claims submitted with a date of service after the termination date will be denied.
After updating his/her license, the claims that have been denied must be resubmitted by the provider.
Procedure is not allowed for provider type Provider is not allowed to perform the service.
Verify the procedure code is correct using current HCPCS and CPT coding books.
Check the appropriate Montana Healthcare Programs fee schedule to verify the procedure code is valid for your provider type.

Montana Medicaid reimburses only for drugs that are manufactured by companies that have a signed rebate agreement with CMS. An updated list of these manufacturers has been posted on the Site Index under Rebateable Manufacturers.

To determine if a manufacturer has signed a rebate agreement, check the first five digits of the National Drug Code (NDC) against the list. If there is no match, the drug is not reimbursable.

The list will be updated quarterly, so check regularly to assure coverage.

In addition, the valid NDC must be recorded on the claim (no spaces, no punctuation) as an 11-digit series of numbers. Claims will be denied for drugs billed without a valid 11-digit NDC. Providers also must be careful when entering the NDC quantity (the administered amount).