Montana Healthcare Programs Provider Enrollment

 

Individual Providers

Montana Medicaid has three enrollment types for individual providers:

  • Sole Proprietor Provider
  • Rendering Provider
  • Ordering/Referring/Prescribing Provider

These enrollment types have different functions and requirements.

Sole Proprietor Provider

A provider who owns their own business and the associated tax ID.

They will be used as the pay-to provider on a claim, and they are the direct recipient of payment from Montana Healthcare Programs.

This enrollment type is appropriate for individuals who own their own practice and do not employ other individuals. Providers who are sole proprietors can also work part-time at another organization and be used as a rendering provider on the organization’s claims. However, they do not need to add a location to their sole proprietor enrollment for the other organization for whom they are working.

Individual providers who are sole proprietor providers are not allowed to share a tax ID with an organization NPI or another individual NPI. Any individual providers currently enrolled under a shared tax ID with an organization or individual would need to be disenrolled and reenrolled.

The options for re-enrollment would be:

  • As an individual sole proprietor provider under their SSN or a private practice tax ID
  • As a Rendering only provider.
If your individual sole proprietor provider is due for revalidation and shares a tax ID with an organization or another individual NPI, refer to the instructions above.

Revalidations submitted for a sole proprietor under a shared tax ID will be denied. The submitting party will be notified of the denial and provided instructions on how to disenroll and re-enroll.

Rendering Provider

The individual who sees patients directly but works for a group, clinic, hospital, or other organization.

They are only used as a rendering or attending provider on a claim under an organization’s NPI. They do not receive payments directly from Montana Healthcare Programs. Rendering providers are not enrolled under a tax ID as they do not own one. Claims are used to associate the rendering provider to an organization. Rendering providers can practice at multiple locations. This enrollment type is appropriate for individuals who are employed by at least one organization and who are not expecting direct payment from Montana Healthcare Programs.

Ordering/Referring/Prescribing Provider

This provider does not bill for services and is not listed as a rendering provider on a professional claim.

They simply write orders, prescribe medications, and refer members for testing and to other providers. This is the correct enrollment type for individuals who only perform these functions and would be entered on an institutional claim form for Montana Healthcare Programs members.

Organization Providers

Montana Medicaid has two enrollment types for organization providers:

  • Group
  • Facility

There are different taxonomy codes available under these types.

Group

This enrollment type will be a Group/Clinic under one of the taxonomy codes below. A provider enrolled in this type can add additional provider types and taxonomies under the NPI using the subparts feature on the Provider Information tab of the enrollment as needed and appropriate.

The two available taxonomy codes are:

  • 193200000X
  • 193400000X

Facility

This enrollment type encompasses all other taxonomies and provider types for organizations. This includes the other taxonomies that fall under the Group/Clinic provider type beginning with 261Q. This enrollment type will not have access to add the Group enrollment taxonomy codes. This enrollment type also has the option to add additional types using the subparts feature.

Selecting the correct enrollment type on your enrollment application can impact processing time and the amount of supporting documentation required.

If you have questions on which enrollment type is appropriate for you, contact Provider Relations at (800) 624-3958 or email MTEnrollment@conduent.com.

For more information on Medicaid Provider Requirements, refer to the Provider Requirements chapter of the General Information for Providers Manual.

Thank you for your interest in becoming a Montana Healthcare Programs provider.

 

Begin the Enrollment Process

 

If you have further questions about the completing enrollment application, please contact:
Montana Provider Relations
Provider Enrollment
MTEnrollment@conduent.com
(800) 624-3958
(406) 442-1837 (Helena/Local)

 

Enrollment Mailing address:
PO Box 89
Great Falls, MT 59403

Note: If you are mailing enrollment documents, you must use the Montana Provider Services Mail Cover Sheet found in the Enrollment Support Forms tab below.

 

Enrollment Support Information

What is the difference between enrolling as an individual and enrolling as an organization?

Only providers who are enrolled as an organization can bill for the services of other providers. Providers enrolled as individuals cannot bill for services rendered by another provider. Only providers enrolled as a clinic or with a clinic specialty can bill as a billing provider with another provider as the rendering/attending.

 

How do we know which taxonomy code to use for enrollment?

The confirmation letter or e-mail you received from NPPES will contain the taxonomy you use for enrollment. Taxonomy codes are listed on the website under the appropriate provider type. For billing purposes, use the taxonomy code noted in your welcome letter sent by Montana Provider Relations.

We were told to use clinic taxonomy. Do we use the one from Montana Provider Relations or do we get another one from NPPES?

Providers are not bound to use the taxonomy given to them by NPPES. For billing, providers use the taxonomy with which they enrolled in Montana Healthcare Programs. For clinic enrollment, providers choose from the drop-down list either the taxonomy that matches what they received from NPPES or the one that best fits their practice.

Where do we find ZIP+4 extensions?

You can find this information by typing in your address on the U.S. Postal Service website, http://zip4.usps.com/zip4/welcome.jsp.

How do we fill out the tax reporting information?

The tax reporting information is needed for generating 1099 tax information. Use the tax-reporting information from your W-9 to complete the tax-reporting section of the enrollment.

Are we required to fill out the ownership/control information?

Yes. CMS requires that ownership information be collected for all health care providers who provide services that are publicly funded so states can qualify for federal funds.

Refer to CFR 42 455.100–106. There is no distinction between for-profit and not for profit. Enrollments will be denied if ownership information is not provided.

How do we know if we are a provider-based facility?

Provider-based status means a relationship exists between a hospital as the main provider and one of the following as defined by rule:

  • A provider-based entity is a health care provider “that is either created by, or acquired by, a main provider for the purpose of furnishing health care services of a different type from those of the main provider under the name, ownership, administrative and financial control of the main provider.”

  • A department of a provider is a “facility or organization or a physician office that is either created by, or acquired by, a main provider for the purpose of furnishing health care services of the same type as those furnished by the main provider under the name, ownership, financial and administrative control of the main provider.”

  • A department cannot be licensed to provide health care services in its own right or be qualified on its own to participate in Medicare. The definition does not include a rural health clinic (RHC) or a federally qualified health center (FQHC) except in limited circumstances.

  • A remote location of a hospital is defined as “a facility or organization that is either created by, or acquired by, a hospital that is a main provider for purposes of furnishing inpatient hospital services under the name, ownership, and financial and administrative control of the main provider.” The remote location is not licensed in its own right or separately certified as a Medicare provider.

  • A satellite facility is a hospital unit or part of a hospital unit that provides inpatient services in a building also used by another hospital or in one or more buildings on the same campus as buildings used by another hospital. Campus” is defined as the area immediately adjacent to the main buildings and other areas and buildings not strictly contiguous but that are located within 250 yards of the main buildings.

  • All providers who are provider-based facilities are required to send the CMS letter received designating them as a provider-based facility.

Why are we required to sign up for electronic funds transfer (also referred to as direct deposit)?

Electronic funds transfer (EFT) makes funds available to you more quickly than paper checks. The electronic payment option allows Montana Health Care Programs providers to receive their payments on Monday of the payment week. If you feel you have extenuating circumstances that prohibit you from receiving payment via EFT, request a waiver by including a signed letter explaining why paper checks are required.

How will we know if our enrollment is complete?

Once your enrollment is complete, you receive a welcome letter from Montana Provider Relations informing you that your enrollment is active. The welcome letter contains your NPI for health care providers or your Atypical Provider Identifier (API) for atypical providers.

What do we do for ownership Changes?

Any change in business ownership may require updated ownership and tax information prior to being active as a Montana Healthcare provider. Please contact Provider Relations (800) 624-3958 or email: MTenrollment@conduent.com 60 days prior to the active date. The intent is to protect Montana providers from claim denials or duplicate submissions. There may also be critical tax implications if claims are paid to the incorrect provider.

The following general guidelines are here to help you navigate through the enrollment process:

  • Purchasing NPI - If your business is purchasing an active NPI enrolled with Montana Healthcare Programs

    • A new application will be required if tax ID information is changing.

    • Claims cannot be processed until the enrollment is complete.

    • All information on the National Plan & Provider Enumeration System (NPPES) will need to be updated prior to enrollment application submission. This information can be accessed at https://nppes.cms.hhs.gov/#/.

    • Some provider types require state approvals including mandatory site visits which will add to the processing time. 

  • Selling NPI - If you are selling your NPI to either an active or inactive Montana Healthcare Programs Provider

    • Notify Provider Relations in writing 30 days prior to the date of the sale.

    • After the sale is complete, claims submissions must not be submitted with the old provider information. 

    • Please contact Provider Relations (800) 624-3958 or email: MTenrollment@conduent.com to help facilitate the transition.

  • Pharmacy Specific Requirements - Pharmacy business changes can be critical due to the high-volume nature of pharmacy claims. The following should be updated prior to enrolling.

    • NCPDP number needs to be current. If purchasing a NCPDP number, the purchase agreement documentation will need to be made available to Provider Relations. 

    • DEA number needs to be updated.  

  • Changing ownership - Transition between Individual and Organization owners

    • The same rules apply if transitioning between individuals and organizational ownership. Because tax information is changing, a new application will need to be submitted.

    • Please contact Provider Relations to help facilitate the change.

Welcome New Providers and Billers!

Now that you have enrolled as a Montana Healthcare Programs provider, there are a few things you will need to know about how to get claims submitted and paid.

Please follow these steps for successful claim submission:

  1. Go to the provider type page on the provider website.

    1. Choose and click on your provider type.
    2. Bookmark your provider type page.
      The provider type page contains manuals, provider notices, fee schedules, and resources specific to your provider type. Be aware of your specific provider type requirements regarding all documents. Documents such as fee schedules and manuals change constantly, and provider notices can be issued at any time.
    3. When reviewing documents such as the manuals, fee schedules, and provider notices, take notice of requirements necessary PRIOR to providing services. For example, look for age limits, dollar limits, prior authorization, and passport referral requirement. Re-check the fee schedule prior to delivering a service.
    4. Read the general manual, the manual specific to your provider type, and any additional manuals in the Manuals panel of the provider type page.
      Note: Providers and billers do not need to print out the manual. Manuals are updated regularly as Federal and State laws and procedures change. Always reference the current manual online.

  2. Register for the Provider Services Portal.

    1. The Provider Services Portal is where you can check the status of a claim, eligibility, download remittance advices, and update provider file information.
    2. To access the portal, click the link on the left-hand menu. Follow the instructions in the User Guide to set up your access and link your providers.

  3. Sign up to bill electronically.

    1. Find out how on the Claims Instructions page.

  4. Montana Healthcare Programs recommends providers check the general eligibility of any member before rendering services. This can be done through:

    1. Provider Services Portal
    2. Calling Integrated Voice Response (IVR): (800) 714-0060
    3. Receive Faxback: (800) 714-0075
    4. Call Provider Relations Monday - Friday 8am - 5pm at (800) 624-3958

  5. The majority of members are also Passport members.

    1. When checking eligibility, also check to see if the member is a Passport member. If so, contact the assigned Passport Provider PRIOR to rendering services to obtain a Passport referral number. A Passport referral number is required if the member is enrolled in the Passport program and the service requires a Passport referral.
    2. Learn more about the Passport program and how to obtain Passport provider approval on the Passport page of the provider website.

  6. Read recent Announcements and Claim Jumper Newsletters.

    1. Register to receive monthly Claim Jumper Newsletters with important updates.
    2. The most recent announcements are on the home page.
    3. Other archived announcements are found on the Announcements page.
    4. Prior issues of the Claim Jumper are on the Claim Jumper Newsletters page.

  7. Register for Trainings and Webinars.

    1. Access the Training and Events page from the button on the home page of the Provider Website or from the Site Index.

  8. Ensure your CMS and Montana State Level Registry is current.

    1. The Electronic Healthcare Record (EHR) provides incentive monies to eligible providers and hospitals.
    2. Learn about the program and how to register and apply by visiting the Montana EHR page of the DPHHS website.

A Provider Relations Field Rep is always available to answer questions and help you navigate the claims process. Email the Field Rep at mtprhelpdesk@conduent.com.

Correspondence, claims processing, and provider file updates are handled by Conduent on behalf of Montana DPHHS. If you cannot access the website, have any questions, or if you have problems with billing or claims, please contact Provider Relations at (800) 624-3958.