Help Plan Provider Manual

HELP PLAN
PROVIDER MANUAL
January 2018
This project is funded in whole or in part under a contract with the Montana Department of Public Health and Human Services.
The statements herein do not necessarily reflect the opinion of the Department.
Blue Cross and Blue Shield of Montana, a Division of Health Care Service Corporation, a Mutual Legal Reserve Company,
an Independent Licensee of the Blue Cross and Blue Shield Association 352421.0118
HELP Plan Update
Effective January 1, 2018, the administration of the Montana HELP Plan was transitioned from Blue Cross and
Blue Shield of Montana (BCBSMT) to Conduent (previously known as Xerox). Customer Service inquiries, eligibility
inquiries, claims submissions and claims processing for dates of service in 2016 and 2017 will continue
to be handled by BCBSMT, with those claims being processed through December 31, 2018.
Any claims for services rendered in 2018 that are submitted to BCBSMT will be rejected and a notification letter
will be sent to the provider indicating the participant is not eligible.
The BCBSMT HELP Plan Provider Manual provides direction and contact information for the HELP Plan-TPA
administered by BCBSMT related to dates of service in 2016 and 2017.
Beginning January 1, 2018 HELP Plan participants will be presented with a Montana Access to Health
identification card. Eligibility can be verified using the MATH Web Portal, http://medicaidprovider.mt.gov/
before providing services.
Participants have the standard Medicaid benefit package. Prior authorization requirements differ from those
of the BCBSMT HELP Plan-TPA.
For HELP Plan services provided in 2018, refer to the Montana Medicaid provider page
http://medicaidprovider.mt.gov.
For Information regarding Montana Medicaid prior authorizations (PAs) refer to
http://medicaidprovider.mt.gov/priorauthorization.
Contact Type BCBSMT HELP-TPA Montana Medicaid/Conduent

Dates of Service 2016 & 2017 Dates of Service 2018
Provider Services Phone Number 1-877-296-8206 1-800-624-3958
Claims Submittal Address HELP Plan Claims Claims Processing

P.O. Box 3387 P.O. Box 8000
Scranton, PA 18505 Helena, MT 59604
Contents
Chapter 1: Contact Information................................................................................... 1
Chapter 2: General Information................................................................................... 5
Chapter 3: Professional Claims................................................................................ 11
Chapter 4: Facility Claims.......................................................................................... 17
Chapter 5: Benefit Management.............................................................................. 23
Chapter 6: Pharmacy.................................................................................................. 35
Chapter 7: Coordination of Benefits........................................................................ 37
Chapter 8: Appeals...................................................................................................... 39
Chapter 9: Administrative Policies.......................................................................... 49
Chapter 10: Enrollment Screening and Credentialing.......................................... 61
Chapter 11: Compensation Policies......................................................................... 75
Chapter 12: Care Coordination and Wellness Programs.................................... 57

Chapter 1: CONTACT
INFORMATION
Chapter 1: Contact Information January 2018
BCBSMT Overview Introduction

Blue Cross and Blue Shield of Montana (BCBSMT) is a Division The Blue Cross and Blue Shield of Montana HELP Plan provider
of Health Care Service Corporation, a Mutual Legal Reserve manual is updated quarterly and contains information to assist
Company, an Independent Licensee of the Blue Cross and your office with day-to-day business operations involving
Blue Shield Association. BCBSMT and its Participants. Your office will be notified of
changes in the Blue ReviewSM quarterly newsletter and/
HELP Plan Overview or by direct mail. If you have questions regarding this manual
or updates, contact your Provider Network Representatives
During the 2015 Legislative session, the Montana Legislature
at 1-800-447-7828, Extension 6100, or by e-mail at
Enacted Senate Bill 405, the Montana Health and Economic
hcs-x6100@bcbsmt.com.
Livelihood Partnership (HELP) Act, which expands health care
services for state residents between the ages of 19 and 64,
whose household income is 138% or less of the federal poverty BCBSMT Support Areas
level (FPL). This Medicaid expansion program is referred to BCBSMT provides support to its physicians, professional
as the “HELP Plan.” The HELP Plan creates affordable health providers and institutional/facility providers through:
plan coverage and access to providers for this segment of the • Provider Customer Service
State’s population. THE HELP Plan is sponsored by the Montana
• Provider Network Representatives
Department of Public Health and Human Services (DPHHS).
• Medical Directors
Blue Cross and Blue Shield of Montana was selected as the
• Utilization Management Department
third-party administrator (TPA) of the HELP Plan for HELP Plan
participants whose household income is 51%-138% of the FPL. Providers and their staff are encouraged to contact these
sources when they have questions and/or need assistance:
HELP Plan Benefits • Floyd Khumalo, 406-437-5248,
The HELP Plan is effective January 1, 2016. There are no thamsanqa_F_khumalo@bcbsmt.com
retroactive benefits prior to this date. • Susan Lasich, 406-437-6223, Susan_Lasich@bcbsmt.com
Benefits are only available for medically necessary services • Laura Knaff, 406-437-6961, Laura_Knaff@bcbsmt.com
provided by a HELP Plan in-network provider, with the exception • Christy McCauley, 406-437-6068,
of urgent, emergent or preauthorized services. Christy_McCauley@bcbsmt.com
Eligibility is dependent upon the participant’s income. • Leah Martin, 406-437-6162, Leah_Martin@bcbsmt.com
Premiums and copayments are dependent upon the

participant’s income. Network Management Department
(Provider Relations)
BCBSMT, as the TPA of the HELP Plan, contracts with health
care providers for the HELP Plan provider network and processes Network Management, commonly known as provider relations,
claims for specific services, while Conduent/DPHHS processes is the department responsible for issues beyond the scope of the
claims for specific services. The directions of which services BCBSMT Customer Service Department, such as:
are processed by each entity are defined in Chapter 2 - General • Provider network development, HELP Plan enrollment
Information Professional Claims. screening, credentialing and provider data maintenance
• Provider compensation analysis, methodologies,
and implementation
• Provider database maintenance
2
E-mail Network Management at HCS-X6100@bcbsmt.com or Conduent HELP Plan Contacts

call 1-800-447-7828, Extension 6100, for new provider contracts Conduent processes claims on behalf of DPHHS. Contact
and provider contract questions, NPI questions, credentialing Conduent using the following methods:
and re-credentialing status, provider workshops, and complex
• Provider Services 1-800-624-3958
claims issues beyond the scope of Customer Service. If the
Provider Network Representatives are unavailable at the time • Visit the Montana Healthcare Programs Provider Information
of your call, your message will be returned within 24 hours. website at http://medicaidprovider.mt.gov/
Or refer to the provider section of the BCBSMT web portal at • Claims questions or other questions contact
www.bcbsmt.com/provider. A provider can submit an update Provider Relations at:
to your clinic location or other information from this page or –– 1-800-624-3958 ( In/out of state)
request new provider contracts. –– 406-442-1837 (Helena) or;
Continue to contact Provider Customer Service at the number
MTPRHELPdesk@conduent.com
on the back of the Participant’s ID card, for routine benefits,
eligibility, and claims questions. You may also register at
www.bcbsmt.com to view benefits, claims, and eligibility
information online.
3
HELP Plan Contacts

Health-e-Web (HEW) 1-877-565-5454 http://www.hewedi.com/
Behavioral Health 1-877-296-8206
BCBSMT Claims Address (Submission of Paper Claims) HELP Plan Claims
PO Box 3387
Scranton, PA 18505
DPHHS (Submission of Paper Claims) Claims Processing
PO Box 8000
Helena MT 59604
Health Care Management 1-877-296-8206
Conduent Dental Services 1-800-624-3958
BCBSMT Electronic Claim Questions or Problems 1-800-447-7828, Extension 6100
Fraud Hotline BCBSMT Special Investigations Department 1-800-543-0867, TTY/TOD 711
(to report suspected fraud and abuse)
Language Interpreter Line 1-800-225-5254
Relay (TTY Deaf, hearing, and/or speech impaired) 1-800-833-8503 Voice, 406-444-1335 Voice TTY
Bilingual (English-Spanish) Customer Service 1-877-233-7055 TTY/TDD 711
Transportation Services 1-800-292-7114
BCBSMT Network Service Representatives 1-800-447-7828, Extension 6100
BCBSMT Provider Resources https://www.bcbsmt.com/provider/
network-participation/the-help-plan
Utilization Management (UM) 1-877-296-8206
Utilization Management Member Appeals 1-877-233-7055
Pharmacy @ DPHHS 1-800-624-3958
Provider Customer Service (Claims, benefits, etc) 1-877-296-8206
DPHHS/Conduent 1-800-624-3958
MTPRHelpdesk@conduent.com
http://medicaidprovider.mt.gov/
BCBSMT Appeals BCBSMT Appeals
PO Box 27838
Albuquerque, NM 87125-9705
1-877-232-5520 Or Fax to 1-866-643-7069
Eligibility Questions Montana Public Assistance Help Line (OPA) at
1-888-706-1535
Corrected Claims Claims
PO Box 3387
Scranton, PA 18505 Or Fax to 1-855-206-9202
HELP Plan Payer ID’s -
ERA’s HELP Plan Payer ID Code - 66004
HELP Plan Eligibility & Benefits Requests (270) and Claim
Status Inquiries (276) Payer ID Code BCBMT.
4
Chapter 2: GENERAL
INFORMATION
Chapter 2: General Information January 2018
PARTICIPANT IDENTIFICATION (ID) CARDS

Participant ID Numbers
The HELP Plan Alpha Prefix is YDM.
Participant Verification
Verification of HELP Plan participant eligibility is available from
several sources:
• Membership Identification (ID) card
• Register or log into the BCBSMT Secure Provider Portal
at www.bcbsmt.com for eligibility, benefits and
claims information.
• Provider service line for the HELP Plan: 1-877-296-8206
Although each participant should present a membership card
upon request for service, this card cannot fully ensure current
eligibility, so providers are encouraged to obtain verification
via the BCBSMT Secured Services provider portal. Moreover,
given how often a participant’s coverage can change, it is highly
recommended a copy of the participant’s ID card be taken each
time a participant visits.
HELP Plan Identification Card Differentiating a HELP Plan Participant from a

An example of the identification card provided to each HELP Plan Medicaid Participant:
participant is shown below. Remember that not all membership If a participant presents with a Standard Medicaid card as
ID cards are alike, so read the front and back carefully for any shown below, all services are processed by Conduent.
special information about the participant’s plan.
• The HELP Plan ID card contains both BCBSMT’s and
DPHHS’s logos.
• The HELP Plan is specified
• The Alpha Prefix is YDM
• HELP Plan participants have a 7-digit Medicaid CHIMES
identification number, in comparison to the usual 9-digit
BCBSMT member ID. When using the BCBSMT Secure
Provider Portal, two (2) leading zeros will auto populate.
• The HELP Plan ID Card does not contain a group number. A
group ID number is not required to submit HELP Plan claims.
• For ease of searching in the BCBSMT Secure Provider Portal,
use the Group ID MCAID1.
• Hard copy claims are submitted to BCBSMT HELP Plan Claims,
PO BOX 3387, Scranton, PA 18505.
• Bill the HELP Plan participant’s name exactly as it is listed on
the ID card to prevent claim rejections.
6
HELP Plan Participant Registration Benefits:

Inasmuch as DPHHS intends to reallocate additional and HELP Plan Participant Benefits are provided via the HELP Plan
supplemental payments over Medicaid and HELP Plan inpatient Participant Guide, which is displayed on the Provider Section of
days, which were previously solely dependent on Medicaid the BCBSMT public website, under the Network Participation
inpatient days, it is recommended that the facility establish a Tab, and the HELP Plan Tab or via the BCBSMT Secure
separate payor category for the HELP Plan, so it might easily Provider Portal.
identify its participants and their charges, allowances, and • At the inception of the program, the Maximum Out-of-Pocket
utilization as well as to accurately support additional and amounts will not display.
supplemental payments. Having these patients classified under • Please refer to the copayment table in the Participant Guide
the HELP Plan may also assist the provider to track copayment for copayment information
collection and bad debt/write-offs. • Providers may not collect a copayment until the claim has
finalized and the Provider Claims Summary (PCS) or Electronic
BCBSMT Secure Provider Portal Remittance Advice (ERA) or 835 reflects the participant’s
Eligibility, benefits, and finalized claims may be viewed for HELP responsibility amount.
Plan participants on the BCBSMT Secure Provider Portal.
Claims:
Eligibility:
HELP Plan Participant Claims Status may be verified through the
• Eligibility may be searched by first name, last name and date
BCBSMT Secure Provider Portal.
of birth, or by the HELP Plan participant’s ID number.
• At the inception of the program, finalized claims
• HELP Plan participants have a 7-digit Medicaid CHIMES only will display.
identification number, in comparison to the usual 9-digit
BCBSMT member ID. When using the BCBSMT Secure • The HELP Plan ID Card does not contain a group number. A
Provider Portal, two (2) leading zeros will auto populate. group ID number is not required to submit HELP Plan claims.
• Searches within the provider portal may be performed with or • For ease of searching for claims in the BCBSMT Secure
without the leading zeros. Provider Portal, use the Group ID MCAID1
• The HELP Plan ID Card does not contain a group number. A • HELP Participant eligibility, benefits and claims status may also
group ID number is not required to submit HELP Plan claims. be verified by calling 1-877-296-8206.
–– For ease of searching in the BCBSMT Secure Provider Portal, BlueCard® Program (out-of-state claims)
use the Group ID MCAID1.
In regard to the HELP Plan, the BlueCard program only
applies to urgent/emergent services or services that have
been preauthorized. Otherwise, there is no access to the
BlueCard Network.
7
To determine where to send claims, please refer to the following table:

Claims Processed Claims Processed
Service/ Benefit
by BCBSMT by DPHHS
Ambulatory Patient Services
Primary Care X
Specialists X
Other Practitioner (APRN, Physician Assistant) X
Hospice X
Adult Dental Preventive Services X
Urgent Care X
Home Health Care - Limit 180 Annual Visits X
FQHC/RHC Services X
Family Planning Services and Supplies X
Adult Dental Treatment Services (Includes TMJ Services) X
Routine Eye Exams/Fittings – Limit 1 Exam Every 2 Years for Adults X
Hearing Aid X
Dialysis X
Allergy Treatment X
Telehealth Services (Type of Service Delivery) X
Indian Health Service (IHS) and Tribal Health Services X
Outpatient Surgery Facility X
Audiology X
Outpatient Hospital X
Adult Eye Glasses - Limit One Pair Every 12 Months X
Accident Related Dental Surgery and Services X
Other Individualized Education Services (Related to X
a Medical Condition Other Than Diabetes)
Non-Emergency Transportation Services (Includes: Personal X
Per Diem for Mileage; Including Taxis if Trip is >16 Miles, In-
Town Bus Rates; Meals; Lodging; Non-Emergency Wheelchair;
and Adult Companion for Children Under Age 21)
8

Service/ Benefit
by BCBSMT by DPHHS
Emergency Services
ER Department Services X
Air & Ground Ambulance X
Hospitalization
Observation/Anesthesia X
Inpatient Services (Includes: Transplant, Physicians, and Surgical) X
Cosmetic Surgery X
Transplant and Donor Services (Excludes: Donor X
Searches and Experimental Treatments)
Blood Transfusions X
Reconstructive Breast Surgery X
Maternal and Newborn Care (pre and post)
Prenatal and Postnatal Care X
Delivery and All Inpatient Services for Maternity X
Long Acting Reversible Contraceptives Inserted at Time of Delivery (LARC) X
Mental Health and Substance Use Disorder Including Behavioral Health
Mental/Behavioral Health Outpatient Services (Not provided in an IMD) X
Mental/Behavioral Health Inpatient Services (Not provided in an IMD) X
Substance Use Outpatient Services (Not provided in an IMD) X
Substance Use Inpatient Services (Not provided in an IMD) X
Pharmacy Distributed/ Prescription Drugs (Identical coverage as existing Medicaid)
Home Infusion X
Tobacco Cessation X
OTCs X
Vaccines X
Contraceptives X
Physician Administered Medications X
9

Service/ Benefit
by BCBSMT by DPHHS
Rehabilitative and Habilitative Services and Devices
Outpatient Rehabilitative - No Limits (Including: Services X
Provided for Physical Therapy; Speech Therapy;
Occupational Therapy and Cardiac Therapy)
Habilitative Services X
Prostheses (Included: to replace a body part X
missing due to accident, illness, or injury)
DME (Includes: blood glucose testing and supplies; spacers for X
metered dose inhalers; enteral solutions; syringes and needles)
Skilled Nursing Services – 60 day annual limit (No custodial care) X
Cochlear Implants (All ages) X
Transitional Services (Includes: swing beds and short term rehabilitation) X
Laboratory Services - Imaging, X-Ray, and Lab
Diagnostic Test (X-Ray and Lab) X
Imaging (CT/PET Scans and MRI) X
Preventive and Wellness Services and Chronic Disease Management
Preventive Care, Screening, Immunizations X
Breast Pumps - Limit One Per Birth X
Preventive Health Services X
Diabetes Prevention Program X
Diabetes Self-Management Education X
Pediatric Services Including Oral and Vision Services (EPSDT: under age 21) X
10
Chapter 3: PROFESSIONAL
CLAIMS
Chapter 3: Professional Claims January 2018
National Provider Identifier (NPI) Number Guidelines for Printing Claim Forms
The provider’s NPI number is the key to prompt payment of Professional providers filing paper claims with BCBSMT must
claims. Always include this number when submitting claims for use the CMS-1500 claim form. For assistance with completing
HELP Plan participants; otherwise, the claims will be returned the CMS-1500 claim form, refer to the CMS-1500 User Guide
to the provider. in the Education and Reference Center of BCBSMT’s provider
website. Contact your print vendor to request a supply of
Providers must submit claims for services under the provider
paper claim forms. The form also may be ordered online at
number assigned to them. Submitting claims for payment under
http://bookstore.gpo.gov, or by calling 202-512-1800.
another provider’s number is considered fraud as defined under
Montana Code Annotated 33-1-1202(1). A provider may not Please follow these guidelines when printing claim forms:
let another provider use his/her NPI number to submit claims • Ensure the printed information on claim forms is in dark black
except as described in the Locum Tenens Policy or Provider- in- print or type so the optical reader can recognize it accurately.
Training Policy. Copies of these policies are available under Never use red ink for any claim-related information. The
Administrative policies. optical reader cannot read red ink
For questions about the NPI number, contact your Network • Use high-quality, original CMS-1500 and UB 04 claim forms.
Management Provider Service Representative. • Ensure the forms are aligned properly when printing so the
claim information corresponds to the appropriate field.
Time Limitation for Filing Claims
BCBSMT requires that claims be submitted no later than one Where to Submit Paper Claims
year following the date of service. BCBSMT encourages electronic submittal of claims.
In the event you submit paper claims, they should be
All claims must provide enough information about the services
submitted to BCBSMT at:
for the plan to determine whether or not they are a covered
medical expense. Submission of such information is required HELP Plan Claims Correspondence
before payment will be made. In certain instances, BCBSMT P.O. Box 3387
may require that additional documents or information including, Scranton, PA 18505
but not limited to, accident reports, medical records, and/or Or via Fax to 1-855-206-9202
information about other insurance coverage, claims, payments,
Paper claims should be submitted to Conduent/DPHHS at:
and settlements, be submitted within the time frame requested
for the additional documentation before payment will be made. Claims Processing Unit
P.O. Box 8000
For questions, contact BCBSMT HELP Plan Provider Customer
Helena, MT 59604
Service at 1-877-296-8206.
Paper claims should be submitted on a CMS-1500 or UB 04
Claims Xten form using current:
• Diagnosis codes ICD-10
BCBSMT uses McKesson ClaimsXten™ code auditing software in
processing commercial business claims. • AMA CPT procedure codes
• HCPCS codes for professional services, and
This software allows efficient, consistent claim review to
evaluate the accuracy and adherence of reported services to • ASA procedure codes for anesthesia services.
accepted national reporting standards (i.e., unbundling, mutually
exclusive, and incidental).
ClaimsXten is a trademark of McKesson Information Solutions, Inc., an independent third

party vendor that is solely responsible for its products and services.
12
Electronic Claims CMS-1500 Form Required Fields

HIPAA requires covered entities submitting electronic claims The CMS-1500 claim form is available at most office supply
to use a HIPAA-compliant vendor. Health-e-Web (HeW) is the stores and accommodates NPI reporting. The form is also
preferred data network that health care providers, financial published at www.bcbsmt.com (click “Providers” and then
institutions, employer groups, and payers use to ensure “Forms”). See ‘Guidelines for Printing Claim Forms’ above
efficient claims submission and information sharing. Questions for more details.
concerning electronic claims submission for the HELP Plan should
The following table explains the CMS-1500 form fields. The
be directed to:
numbers in the left column correspond to the form in Appendix
Health-e-Web A. Fields not required by BCBSMT are labeled Not required.
P.O. Box 1540
No. Field Name Explanation
Helena MT 59624
1 Plan Type Check the appropriate box.
http://www.hewedi.com 1a Insured’s ID Number Enter the participant’s
877-565-5457 Toll Free BCBSMT ID number
406-449-0190 Fax as it appears on the
identification card. Be sure
HELP Payor ID-66004
to include the alpha prefix.
Eligibility & Benefits Requests (270) and Claim Status Inquiries 2 Patient’s Name Enter the participant’s
(276) can be submitted electronically using Payer ID BCBMT. given name. (LN, FN, MI)
Subscriber ID must include the 3-character alpha prefix (YDM) 3 Patient’s Birth Date, Sex Indicate the participant’s
followed by the numeric member ID/Medicaid ID. month, day, and year of
If using a clearinghouse other than HeW, we recommend you birth in numbers (e.g., 3-16-
contact them for their Electronic Payor ID for the HELP Plan. 48). Select patient gender.
4 Insured’s Name Enter the participant’s
Corrected Claims name as it appears
on the BCBSMT
Electronic identification card.
Electronically submit claim with bill type ending in 5 or 7 to 5 Patient’s Address & Enter the patient’s address
indicate a corrected claim. Phone Number and phone number.
6 Patient Relationship Check appropriate
Paper to Insured box for relationship
Clearly indicate on the claim Corrected Claim, Corrected of the patient to the
Diagnosis, or some other indicator identifying the claim as participant, if known.
corrected, and what is being corrected (e.g., procedure code, 7 Insured’s Address Enter the insured’s
date of birth, etc.). address.
8 Patient Status Check the appropriate box.
Send all HELP Plan corrected claims to BCBSMT at: 9 Other Insured’s Name Not required.
HELP Plan Claims Correspondence 10 Is Patient’s Condition Check the appropriate
P.O. Box 3387 Related to box if the participant’s
Scranton, PA 18505 condition is related to
employment or an auto
Send all HELP Plan corrected claims to accident, or check “other.”
Conduent/DPHHS at: 11a Insured’s DOB Insured’s date of birth.
Claims Processing Unit 11b Insured’s Plan Name Insured’s plan name.
P.O. Box 8000
Helena, MT 59604 13
No. Field Name Explanation No. Field Name Explanation

11c Other Health Plan Enter information Y or 19 Reserved for Local Use See provider-in-training
N if there is another at the beginning of this
health plan. section. Enter unlisted
12 Patient’s or Authorized Not required. procedure codes.
Person’s Signature 20 Outside Lab Charges Enter Y or N if claim
13 Insured’s or Authorized Not required. includes lab services
Person’s Signature provided outside of a
14 Date of Current Illness/ Enter the date provider’s office.
Injury/Pregnancy (month, day, year) the 21 Diagnosis or Nature Specify ICD codes. Codes
participant became of Illness or Injury will be required on a
injured (e.g., 2-10-01). per-procedure basis in
15 If the Patient Has Had Enter the date Item 24D. Enter primary
the Same or Similar (e.g., 2-10-01). diagnosis code first.
Illness. Give First Date 22 Medicaid Not required.
16 Dates Patient Unable Not required. Resubmission Code
to Work in Current 23 Prior Authorization Leave blank, or if
Occupation Number applicable, enter the
17 Name of Referring Enter the name of the pre-service authorization
Physician or Other Source referring physician. 17a number in its entirety
and 17b also must be given by BCBSMT.
completed when listing 24a Date(s) of Service Enter the month, day, and
a referring physician. year for each service.
For anesthesiology and If you are providing the
assistant surgeon claims, same level of medical
use this space for the care for consecutive
chief surgeon’s name. days, include the “from/
For laboratory and x-ray to” dates and show the
claims, enter the name of per-day charge in 24f.
the physician who ordered 24b Place of Service Enter the appropriate
the diagnostic services. (POS) Code place of service code.
17a Other ID Enter taxonomy code. Refer to the Place of
Service Compensation
17b NPI Enter the referring
Policy published at www.
provider’s NPI.
bcbsmt.com for a list of
18 Hospitalization If the patient was
place of service codes.
Dates Related to hospitalized when the
24c EMG Enter Y for emergency
Current Services services were rendered,
or N for all others.
enter the dates of
hospitalization.
14

24d Procedures, Services, Describe the services 26 Patient’s Account No. Not required (However,
or Supplies rendered or procedures BCBSMT suggests
performed using CPT-4, entering this number as a
HCPCS, NDC, or ASA method to help balance the
procedure codes and Provider Claims Register/
appropriate modifiers. Remit to claims submitted).
Explain any unusual 27 Accept Assignment Enter Y if provider pay
services or circumstances and N if participant pay.
related to the procedure 28 Total Charge Enter the total of all
in the space provided. charges from 24f.
Attach reports to the 29 Amount Paid Not required.
claim form, if necessary.
30 Balance Due Not required.
Refer to the Modifier Use
31 Signature of Physician Sign and date to certify
When Coding Claims policy
or Supplier Including services were rendered.
published at bcbsmt.com\
Degrees or Credentials The signature Box 31
Providers (click Provider
certifies the information
Policies). One code per line.
is true and does not
24e Diagnosis Pointer Enter the diagnostic (ICD)
affect claims processing,
code(s) per procedure or
nor does it necessarily
service represented in
represent the treating
Box 21 with the numbers
or billing provider.
1-4. One code per line.
32 Service Facility Location Enter complete address.
24f Charges Enter the amount billed
32a Service Facility NPI Enter the provider’s NPI.
for the procedures or
services described in 24d. 32b Service Facility PIN Enter the provider’s NPI.
24g Days or Units Enter the number of 33 Billing Provider Enter required information.
times the procedure Info & Ph #
was performed. Indicate 33a NPI Enter the billing provider’s
anesthesia time in NPI. An individual provider
number of minutes. rendering and billing for
24h EPSDT Family Plan Not required. services should enter
their NPI in Box 33a.
24I ID Qualifier Not required.
33b Other ID Enter the provider’s NPI.
24J Rendering Provider ID # Rendering providers in
a group practice should
enter their individual NPI
number in Box 24j as the
rendering provider and
then list the group’s billing
NPI number in Box 33a.
25 Federal Tax ID Number Enter the provider’s
federal tax ID number.
15
42 CFR 455 SUBPART E COMPLIANCE ORDERING,

REFERRING, OR PRESCRIBING PROVIDER OR OTHER
PROFESSIONAL REQUIREMENT
42 CFR 455 Subpart E Compliance requires that all claims
submitted by CHIP and/or Healthy Montana Kids (HMK), HELP
Plan (HELP), and Medicaid providers for payment for items
and services to contain the NPI of the physician or other
professional who referred, ordered, attended or admitted such
items or services.
Although the Blue Cross Blue Shield Montana (BCBSMT)
Provider Manual already lists this requirement, this is a reminder
for all HMK, HELP Plan and Medicaid providers to ensure that
these providers’ NPIs are included on all claim forms in order to
prevent any denial of claims.
Please refer to the following documents for detailed claim
filing instructions:
• CMS-1500 Form Required Fields section in Chapter 3
Professional Claims in the BCBSMT Provider Manual;
• Instructions for completing CMS-1500 Form
in the Provider Forms and Document section of the
BCBSMT website;
• UB-04 Form Required Fields section in Chapter 10 Hospital
Claims in the BCBSMT Provider Manual; and
• UB-04 User Guide in the Provider Forms and Document
section of the BCBSMT Provider website.
16
Chapter 4: FACILITY CLAIMS
Chapter 4: Facility Claims January 2018
FILING CLAIMS
Introduction No. Field Name Explanation
7 Reserved for NUBC Not required
This chapter applies to hospitals that submit claims to BCBSMT
assignment
on behalf of their patients. Hospitals should submit claims
according to UB-92 Editor and Medicare guidelines, and they 8a Patient name Enter the participant’s
will be compensated according to their established BCBSMT given name
hospital contract(s). 8b Patient identifier Enter the unique patient
ID, if necessary
UB-04 Form Required Fields 9a Patient address Enter the patient’s
street address
Facility providers filing paper claims with BCBSMT must use the
9b Patient address Enter the patient’s city
UB-04 claim form. For assistance with completing the UB-04
9c Patient address Enter the patient’s state
claim form, refer to the UB-04 User Guide in the Education
and Reference Center of the BCBSMT Provider website. For 9d Patient address Enter the patient’s zip code
additional information on the UB-04 claim form, visit the National 9e Patient address Enter the patient’s two-
Uniform Billing Committee (NUBC) website at nubc.org. letter country code
10 Birth date Enter the participant’s
The form is also published at www.bcbsmt.com. If you
month, day, and year
use this form, print it in color, so our optical character reader
of birth numerically
can scan your claims into the system. Be sure to use dark
(e.g., 3-16-48)
type or print.
11 Sex M for male and F for female
The following table explains the UB-04 form fields. The numbers 12 Admission – date Enter the admission date
in the left column correspond to the form in Appendix A. Fields for inpatient services
not required by BCBSMT are labeled “Not required.”
13 HR Enter the hour of admission
No. Field Name Explanation for inpatient services
1 Billing provider name, Enter the full name, 14 Type Enter the priority type
address, and phone address, and phone for inpatient services
2 Pay to name and address Enter the full name and 15 SRC Enter the referral
address if different code, if necessary
from number 1 16 DHR Enter the discharge hour
3a Pat. cntl. # Enter the patient 17 Stat Enter the patient’s status
control number 18 Condition codes Enter the condition code
3b Med. rec. # Enter the medical record for inpatient services
number, if necessary 19 Condition codes Enter the condition code
4 Type of bill Enter the 3- or 4-digit for inpatient services
type of bill 20 Condition codes Enter the condition code
5 Federal tax ID number Enter the billing entity for inpatient services
tax ID number 21 Condition codes Enter the condition code
6 Statement covers Enter the date span for inpatient services
period – from through of services 22 Condition codes Enter the condition code
for inpatient services
18

23 Condition codes Enter the condition code 35 Occurrence span – Enter the occurrence
for inpatient services code/from/through code and date span
24 Condition codes Enter the condition code for other party liability
for inpatient services purposes, if necessary
25 Condition codes Enter the condition code 36 Occurrence span – Enter the occurrence
for inpatient services code/from/through code and date span
26 Condition codes Enter the condition code for other party liability
27 Condition codes Enter the condition code 37 Reserved for NUBC Not required
for inpatient services 38 Responsible party Enter the name and address
28 Condition codes Enter the condition code name and address for other party liability
29 Acc. state Enter what state the 39 Value codes – Enter the code and
accident occurred for code/amount amount, if necessary
other party liability 40 Value codes – Enter the code and amount
purposes, if necessary code/amount
30 Reserved for NUBC Not required 41 Value codes – Enter the code and amount
31 Occurrence – code/date Enter the occurrence code/amount
code and date for 42 Revenue code Enter the appropriate
other party liability revenue code(s)
purposes, if necessary 43 Description Enter the revenue
32 Occurrence – code/date Enter the occurrence codes description
code and date for 44 HCPCS/rate/HIPPS code Enter the codes for
other party liability inpatient services
purposes, if necessary 45 Service date Enter the service date
33 Occurrence – code/date Enter the occurrence 46 Service units Enter the service unit(s)
code and date for 47 Total charges Enter the total charges
other party liability 48 Non-covered charges Enter the non-covered items
purposes, if necessary
34 Occurrence – code/date Enter the occurrence
50 Payer name Enter the payer name
code and date for
51 Health plan ID Enter the participant’s
other party liability
health plan ID number
purposes, if necessary
19

52 Relationship information Enter the relationship 73 Reserved for NUBC Not required
information 74 Principal procedure Enter primary procedure
53 Assignment benefits Enter assignment code/date code (required for inpatient
of benefits and home IV services)
54 Prior payments Enter prior payments 74a Other procedure Enter other procedure codes
55 Est. amount due Enter the estimated code/date and date, if necessary
amount due 74b Other procedure Enter other procedure
56 NPI Enter the facility NPI code/date codes and date
57 Other/prv. ID Enter any other provider NPI 74c Other procedure Enter other procedure
58 Insured’s name Enter patient name code/date codes and date
59 Patient relation Enter patient relation 74d Other procedure Enter other procedure
60 Insured’s unique ID Enter the patient health code/date codes and date
plan ID number 74e Other procedure Enter other procedure
61 Group name Enter the group name code/date codes and date
62 Insurance group number Enter the group 75 Reserved for NUBC Not required
insurance number 76 Attending – NPI/ Enter the physician
63 Treatment Enter the prior authorization qual./last/first responsible for home health
authorization codes number assigned by treatment plan when claim
BCBSMT or APS Healthcare has services other than
non-scheduled transport
64 Document control number Not required
77 Operating – NPI/ Enter operating
65 Employer name Not required
qual./last/first physician NPI
66 Diagnosis Enter the diagnosis code(s)
78 Other – NPI/qual./ Enter other physician/
last/first provider NPI
69 Admit diagnosis Enter the admitting
79 Other – NPI/qual./ Enter other physician/
diagnosis for
last/first provider NPI
inpatient services
80 Remarks Not required
70 Patient reason diagnosis Enter the reason diagnosis
81 CC – A/B/C/D Not required
71 PPS. code Enter the PPS code
for DRG claims
72 ECI Enter accident
diagnosis code(s)
20
HOSPITAL BILLING PROCEDURES

Billing Requirements Exceptions to CMS Billing
Hospital will submit charges on a CMS-1450 (UB-04) claim form, Below is a list of revenue codes for which BCBSMT will require a
or its successor, and must follow generally accepted guidelines CPT/HCPCS code:
with the following clarifications and exceptions:
275 Pacemaker
• Hospital will provide information needed for description of
unlisted procedures 53X Osteopathic Services
• Hospital will not submit $0 charges on lines 63X Drugs requiring specific identification
• Hospital will submit their claims with the appropriate provider 77X Preventative care services
identification number based on the services being rendered
88X # Session Miscellaneous Dialysis
• Hospital understands and agrees that prior to payment a
clean claim must be submitted to BCBSMT for services 942 Other Therapeutic Services - Education / Training
provided to participant
946 Complex medical equipment - routine
• Hospital will be compensated for medically necessary
observation and treatment room charges up to the semi- 947 Complex medical equipment - ancillary
private room rate (private room rate if there is no semi- 96X Professional fees
private room rate)
• Hospital cannot balance bill participant for services that 97X Professional fees
are deemed “provider responsibility” on the provider claims 98X Professional fees
summary, to the extent this clause is consistent with CMS
regulations when applied to coordinating of benefits with a
Medicare recipient and Montana law
Provider Based Billing
• The facility must use the UB-04 billing guideline requirements Provider-based clinics must use G0463 for the facility fee portion
due to outpatient prospective payment system (OPPS). If of the outpatient clinic visits. This applies to PPS hospitals/
hospital builds inclusive services into its APC charges, it facilities for the hospital or facility portion of clinic visit codes
cannot bill for these items separately (e.g., if supply charges 99201-99205 and 99211-99215. If claims are submitted with
are built into a surgical charge, these items may not be 99201-99205 and 99211-99215, the claim lines will be denied.
billed separately).
Critical Access Hospitals are exempt from the requirement to
• Hospital will bill the appropriate units per the CPT / HCPCS bill the G0463.
coding requirements (For example: J2250 1 unit is equivalent
to 1mg. If billing for 10 mg, then “10” will be in the unit’s
column (FL46) so the compensation will calculate accurately.)
21
42 CFR 455 SUBPART E COMPLIANCE ORDERING,

REFERRING, OR PRESCRIBING PROVIDER OR OTHER
PROFESSIONAL REQUIREMENT
42 CFR 455 Subpart E Compliance requires that all claims
submitted by CHIP and/or Healthy Montana Kids (HMK), HELP
Plan (HELP), and Medicaid providers for payment for items
and services to contain the NPI of the physician or other
professional who referred, ordered, attended or admitted such
items or services.
Although the Blue Cross Blue Shield Montana (BCBSMT)
Provider Manual already lists this requirement, this is a reminder
for all HMK, HELP Plan and Medicaid providers to ensure that
these providers’ NPIs are included on all claim forms in order to
prevent any denial of claims.
Please refer to the following documents for detailed claim
filing instructions:
• CMS-1500 Form Required Fields section in Chapter 3
Professional Claims in the BCBSMT Provider Manual;
• Instructions for completing CMS-1500 Form
in the Provider Forms and Document section of the
BCBSMT website;
• UB-04 Form Required Fields section in Chapter 10 Hospital
Claims in the BCBSMT Provider Manual; and
• UB-04 User Guide in the Provider Forms and Document
section of the BCBSMT Provider website.
22
Chapter 6: PHARMACY
Chapter 6: Pharmacy January 2018
HELP Plan Pharmacy Benefits Durable Medical Equipment (DME) Provider

HELP Plan pharmacy benefits are processed by Please note that the HELP Plan requires claims for DME to be
Conduent/DPHHS. submitted to BCBSMT, while claims for prescription medication
are processed by DPHHS. Please find a table outlining billing
For specific information regarding the pharmacy benefits,
guidelines for the various BCBSMT lines of business:
refer to the HELP Plan Evidence of Coverage at
https://www.bcbsmt.com/static/mt/provider/pdf/ Network Claims Address Claims Address for
evidence-of-coverage.pdf. for DME PHARMACY
For information regarding pharmacy benefits, call HELP Plan (TPA) HELP Plan Claims Claims Processing
1-800-624-3958. P.O. Box 3387 P.O. Box 8000
Scranton, PA 18505 Helena, MT 59604
Healthy Blue Cross & Blue Blue Cross & Blue
Montana Kids Shield of MT Shield of MT
(HMK) P.O. Box 7982 P.O. Box 7982
Helena, MT 59604 Helena, MT 59604
Medicare Blue Cross & Blue Blue Cross & Blue
Advantage Shield of MT Shield of MT
P.O. Box 6227 P.O. Box 6227
Helena, MT 59604 Helena, MT 59604
BCBSMT Blue Cross & Blue Contact Prime
Commercial Shield of MT Therapeutics
Lines of P.O. Box 7982
Business Helena, MT 59604
If you bill BCBSMT electronically for durable medical equipment,

please note that the BIN, PCN, and Group information on the
HELP Plan ID card are for pharmacy only. Please work with your
clearinghouse or third party processor to ensure that you submit
under the appropriate payor identification number for DME
services for the HELP Plan.
Prime Therapeutics LLC is a separate pharmacy benefit management company contracted by
BCBSMT to provide pharmacy benefit management and related other services. BCBSMT, as
well as several independent Blue Cross and Blue Shield Plans, has an ownership interest in
Prime Therapeutics.
36
Chapter 5: BENEFIT
MANAGEMENT
Chapter 5: Benefit Management January 2018
PREAUTHORIZATION Include a note that you are requesting a retro authorization.

Preauthorization is required in order to receive some Benefits. 60 days after the date of discharge/service file an appeal by
A list of covered Benefits that require Preauthorization are faxing 1-866-643-7069 or mail to:
noted under each covered Benefit. The appropriate Claim
BCBSMT Appeals
Administrator is identified for claim processing purposes under
P.O. Box 27838
each covered Benefit.
Albuquerque, NM 87125-9705
If Preauthorization is not requested by the Participant or
Participating Provider, the claim will be denied on the basis of no BCBSMT Administered Claims
Preauthorization. The Participant may appeal the denial of the BCBSMT has designated certain covered services which require
claim as outlined in the Article entitled “Complaints, Appeals, Preauthorization in order for the Participant to receive the
and Confidential Information.” If it is determined that the maximum Benefits possible.
services were not Medically Necessary; were
If the Participant uses a Participating Provider for covered
Experimental, Investigational, or Unproven; were not performed services, the Participating Provider is responsible for satisfying
in the appropriate treatment setting; the Participant may be the requirement for Preauthorization.
responsible for the full cost of the services, if an Advanced
If the Participant uses a Non-Participating Provider for covered
Benefit Notice (ABN) has been signed.
services, the Participant is responsible for satisfying the
Preauthorization is required even if the HELP Plan is the requirement for Preauthorization.
secondary carrier.
To request Preauthorization, the Participant or his/her Physician
Retroactive Authorization Requests must call the Preauthorization number shown on the Participant’s
Identification Card before receiving treatment. BCBSMT will
For retro-authorizations requests:
assist in coordination of the Participant’s care so that his/
1-15 days after the date of discharge/service please fax the retro her treatment is received in the most appropriate setting for
request to 406-437-5850. his/her condition.
16-60 days after the date of discharge/service please fax the Preauthorization does not guarantee that the care and services a
retro request, including clinical documentation and the claim to Participant receives are eligible for Benefits.
1-855-206-9202 or mail to:
HELP Plan
P.O. 3387
Scranton, PA 18505
SECTION I: PREAUTHORIZATION PROCESS FOR OBSERVATION

AND RECOVERY CARE BEDS/ROOMS
BCBSMT administers claims for Observation/Recovery Beds/ and in accordance with BCBSMT Medical Policy guidelines.
Rooms and Preauthorization is required. Observation Beds/Room and Recovery HELP Plan Evidence of
Coverage Effective January 1, 2016 26
Participating Providers may contact BCBSMT at
1-877-296-8206. Providers may fax the Preauthorization Care Beds/Rooms services are subject to the
to (406) 437-5850. Participants may contact BCBSMT at following limitations:
1-877-233-7055. 1. The HELP Plan will pay Observation Beds/Room and
Recovery Care Beds/Rooms benefits when provided for
Payment will be made for Observation Beds/Rooms and
less than 24 hours.
Recovery Care Beds/Rooms when necessary,
2. Benefits for Observation Beds/Rooms and
Recovery Care Beds
24
SECTION II: PREAUTHORIZATION PROCESS FOR

INPATIENT SERVICES
Preauthorization must be requested before the Participant’s If BCBSMT determines that the Participant’s treatment does
scheduled Inpatient admission. BCBSMT will consult with the not require Inpatient level of care, the Participant and the
Participant’s Physician, Hospital, or other facility to determine Participant’s Provider will be notified of that decision. If the
whether Inpatient level of care is required for the Participant’s Participant proceeds with an Inpatient stay without approval, the
Illness or Injury. BCBSMT may decide that the treatment Participant may be responsible to pay the full cost of the services
the Participant needs could be provided just as effectively received, if an ABN has been signed.
in a different setting (such as the Outpatient department
of the Hospital, an Ambulatory Surgical Facility, or the
Physician’s office).
SECTION III: PREAUTHORIZATION PROCESS FOR MENTAL

ILLNESS, SEVERE MENTAL ILLNESS AND CHEMICAL
DEPENDENCY SERVICES
All Inpatient and partial hospitalization services related to
treatment of Mental Illness, Severe Mental Illness, and Chemical
Dependency must be preauthorized. Preauthorization is also
required for the following Outpatient Services:
• Psychological Testing;
• Neuropsychological Testing;
• Electroconvulsive Therapy; and
• Intensive Outpatient Treatment.
Preauthorization is not required for therapy visits to

a Physician or other professional Provider licensed
to perform covered services. However, all services
are subject to the provisions in the section entitled
Concurrent Review.
25
SECTION IV: PREAUTHORIZATION PROCESS FOR OTHER

OUTPATIENT SERVICES
In addition to the Preauthorization requirements outlined • Cardiac rehabilitation;
above, BCBSMT also requires Preauthorization for certain • MRIs, PET scans, GI radiology, and CT scans; and
Outpatient services. The following services and items require
• All services provided by a non-covered or non-participating
Preauthorization: provider, with the exception of Emergency Services.
• Home Health Care and Hospice services, including Private
Duty Nursing and Personal Care Services for EPSDT; For additional information on Preauthorization, the Participant
• Outpatient Therapies (PT, OT, ST); or the Provider may call the Participant Services number on the
Participant’s identification card.
• Potentially experimental, investigational or
cosmetic procedures; It is NOT necessary to preauthorize standard x-ray and lab
• Transplant evaluations for the following transplant surgeries: services or Routine office visits.
heart, lung, heart/lung, liver, pancreas, kidney, bone marrow, If BCBSMT does not approve the Outpatient Service, the
corneal, and small bowel; Participant and the Participant’s Provider will be notified of that
• Other services: Dental anesthesia, Dental trauma, decision. If the Participant proceeds with the services without
Termination of pregnancy, Uvulopalatopharyngoplasty (UPPP), approval, the Participant may be responsible to pay the full cost
Cochlear implants; of the services received, if an ABN has been signed.
• Laminectomy;
The Benefits section details the services that are subject to
• Genetic testing and/or counseling; Preauthorization.
• DME, medical supplies, orthotics and prosthetics over
$2,500 and including the following: diabetic shoes, power
wheelchairs, diapers, under pads and incontinent supplies,
specialty beds, and cochlear implant devices.
SECTION V: PREAUTHORIZATION REQUEST

INVOLVING EMERGENCY CARE
If the Participant is admitted to the Hospital for Emergency Care
and there is no time to obtain Preauthorization, the Participant’s
Provider must notify BCBSMT within two business days
following the Participant’s emergency admission.
SECTION VI: PREAUTHORIZATION REQUIRED FOR CERTAIN

PRESCRIPTION DRUG PRODUCTS AND OTHER MEDICATIONS
Prescription Drug Products, which are self-administered, process 3. Prescription Drugs – Covered under the Prescription
under the Prescription Drug Program Benefit. There are other Drug Program Benefit administered by DPHHS.
medications that are administered by a Covered Provider, which Certain prescription drugs, which are self-administered,
process under the medical Benefits. require Preauthorization. Please refer to the Prescription
Drug Program section for complete information about
26
the Prescription Drug Products that are subject to 4. Other Medications – Covered Under Medical Benefits
Preauthorization and quantity limits, the process for Medications that are administered by a Covered Provider
requesting Preauthorization and related information. Please will process under the medical Benefits. Certain medications
refer to the Pharmacy provider manual located at the administered by a Covered Provider require
following website: http://medicaidprovider.mt.gov/ or by
calling 1-800-624-3958. Preauthorization. The medications that require Preauthorization
are subject to change by BCBSMT.
To determine which medications are subject to Preauthorization,
please refer to the Prescription Drug Program section for
complete information.
SECTION VII: GENERAL PROVISIONS APPLICABLE TO ALL

REQUIRED PREAUTHORIZATIONS
1. No Guarantee of Payment or received. When a service is denied as non-covered,
Preauthorization does not guarantee payment of Benefits. Even Participating Providers may not balance bill the Participant
if the Benefit has been Preauthorized, coverage or payment for the services, unless the Participant or the Participant’s
can be affected for a variety of reasons. For example, the authorized representative has signed an ABN. For non-
Participant may have become ineligible as of the date of service covered services, providers may bill Participants only
or the Participant’s Benefits may have changed as of the when providers and Participants have agreed in writing
date the service. prior to the services being provided.
DPHHS Administered Claims
2. Request for Additional Information
A request for Preauthorization must be submitted for
The Preauthorization process may require additional
consideration in the following manner:
documentation from the Participant’s health care provider
or pharmacist. In addition to the written request for • A written request for Preauthorization must be submitted to
DPHHS in writing by the Participating Provider.
Preauthorization, the health care provider or pharmacist may
be required to include pertinent documentation explaining the • The written request should explain the proposed services
proposed services, the functional aspects of the treatment, the being sought, the functional aspects of the service, and why
projected outcome, treatment plan and any other supporting it is being done.
documentation, study models, prescription, itemized repair and • Any additional documentation such as study molds, x-rays, or
replacement cost statements, photographs, x-rays, etc., as may photographs necessary for a determination should be mailed
be requested by BCBSMT to make a determination of coverage to the address listed on the Participant’s ID card. HELP Plan
pursuant to the terms and conditions. Participant’s names, addresses, and Participant numbers
must be included.
3. Failure to Obtain Preauthorization
DPHHS will review the request and all necessary supporting
Any treatment the Participant receives that is not a documentation to determine whether the services are Medically
covered service; or is not determined to be Medically Necessary. The decision will be made in accordance with the
Necessary; or was Experimental, Investigational, terms of this EOC. In no event shall a coverage determination be
Unproven; or is not performed in the appropriate setting made more than 14 days following receipt of all documents.
will be excluded from the Participant’s Benefits. This
applies even if Preauthorization approval was requested
27
A request for Preauthorization does not guarantee that Benefits Pharmacy Claims
are payable. Attending an appointment prior to receiving
Many drug products require Preauthorization before the
Preauthorization approval may result in the HELP Plan Participant
pharmacist provides them to the Participant. For the
paying costs of a service determined to not be Medically
Pharmacy drug Preauthorization process, please refer to
Necessary; not covered; Experimental, Investigational, Unproven;
the Pharmacy provider manual located at the following
or performed in an inappropriate setting.
website: http://medicaidprovider.mt.gov/ or by
calling 1-800-624-3958.
SECTION VIII: CONCURRENT REVIEW

Whenever it is determined by BCBSMT that Inpatient care or HELP Plan Prior Authorization Requirements
an ongoing course of treatment may no longer meet Medical
With the exception of services provided in an emergency, the
Necessity criteria or is considered Experimental, Investigational,
following services require a prior Authorization:
or Unproven, the Participant, Participant’s Provider or the
Participant’s authorized representative may submit a request to Service
BCBSMT for continued services. Out of network provider requests (all levels of care except
emergency services)
Inpatient facilities:
• Acute Care Facility/Hospital
• Post-acute facility
Experimental or investigational procedures
Potentially cosmetic procedures, including but not limited to:
• Varicose vein treatment
• Breast reduction
• Surgery to treat malocclusion
• Blepharoplasty
• Lipectomy
• Abdominoplasty
• Panniculectomy
• Rhinoplasty
Laminectomy (except codes 63030, 63056, 63057, 64999
and 72275)
28
Service Service
Transplant evaluation and surgeries for: Contact lens services for the following covered services only
• Heart (for dates of service on and after 1/1/17. Dates of service prior
• Lung to 1/1/17 were processed by DPHHS):
• Contact lens exam
• Heart/lung
• Contact lens fittings
• Liver
• Contact lenses for the diagnosis of keratoconus, aphakia,
• Pancreas
anisometropia of 2 diopters or more or if the sight cannot be
• Kidney corrected to 20/40 with eyeglasses only.
• Bone marrow Other services:
• Corneal • Dental anesthesia
• Small bowel • Dental trauma
Genetic testing and/or counseling • Termination of pregnancy
Radiology: • Uvulopalatopharyngoplasty (UPPP)
• MRIs, PET scans, GI Radiology, CT scans for the following • Cochlear implants
codes: 78459, 78491, 78492, 78608, 78609, 78811, 78812,
Behavioral Health Services
78813, 78814, 78815, 78816, 77058, 77059, 75571, 75572,
75573, 75574, 91110 and 91111 Out of network provider requests (all levels of care except
emergency services)
DME, Medical Supplies, Orthotics and Prosthetics over $2,500.
Inpatient acute care
Including diabetic shoes, diapers and underpads, power Residential Treatment Center
wheelchairs, specialty beds, cochlear implant devices and the
Mental Health Services (Partial hospitalization and intensive
following: A9276, A9277, A9278, E0181, E0184, E0185, E0271,
outpatient) – H0035 and S9480
E0637, E0641, E0642, E0651, E0652, E0660, E0667, E0668,
E0700, E0705, E0935, E0936, G0151, G0248, G0249, L1904, Substance Abuse Services (Partial hospitalization and
L5629, L5631, L5637, L5645, L5647, L5649, L5650, L5652, intensive outpatient) – S0201 and H0015
L5661, L5665, L5666, L5668, L5670, L5671, L5700, L5701, Psychological testing – 96101, 96102, 96103
L5781, L5785, L5910, L5920, L5940, L5950, L5962, L5968, Neuropsychological Testing – 96118, 96119, 96120
L8400, L8410, L8420, L8430, L8440, L8460, L8470, L8480, Electroconvulsive Therapy (ECT) – 90870
V2623, V2627, A6199, A6242, L2785.
Outpatient therapies
• Physical therapy
• Speech therapy
• Occupational therapy
Cardiac Rehabilitation
Home Health Care and Hospice (including private duty nursing
and personal care services for EPSDT)
Specialty Drugs - J1459, J1556, J1557, J1559, J1561, J1562,
J1566, J1568, J1569, J1572, 90283, 90284, J2357, J1745,
J0490, Q2043, J3262, J2323, J9035, C9257, J9310, J0585,
J0587, J9228, C9027, C9453, J0881, J0882
29
Blue Cross and Blue Shield of Montana HELP Plan
Blue Cross and Blue Shield of Montana HELP Plan

Please write clearly, then print and fax to 406-437-5850
Preauthorization Request
_____URGENT
Please write clearly,(ifthen printprovide
checked and faxanticipated
to 406-437-5850
date of service) Anticipated Date of Service: ____________
Preauthorization Request
Please attach supporting documentation to facilitate your request (e.g., the history & physical, letter of medical
_____URGENT (if checked provide
necessity, original photographs, anticipated
etc.) This date
form must beofplaced
service) Anticipated
on top Date of Service:
of the information ____________
you are submitting.
Participant/Patient Data:
Please attach supporting documentation to facilitate your request (e.g., the history & physical, letter of medical
Identification Number: Date of Service:
necessity, original photographs, etc.) This form must be placed on top of the information you are submitting.
(Include the three –digit alpha prefix)
Participant/Patient Data:
Patient’s Name: Date of Birth:
Identification Number: Date of Service:
(Include the three –digit alpha prefix)
Procedure Codes:
Patient’s Name: Date of Birth:
Diagnosis
ProcedureCodes
Codes:(if a medical service only) CPT/HCPCS code(s) include unit of
(List primary first): measure/frequency for supplies & services :
Diagnosis Codes (if a medical service only) CPT/HCPCS code(s) include unit of
(List primary first): measure/frequency for supplies & services :
Services Rendered: Please check one of the below:
______Provider Office ______Outpatient Facility ______Inpatient Facility
Services Rendered: Please check one of the below:
Office or Facility Name: _____________________________________
______Provider Office ______Outpatient Facility ______Inpatient Facility
Address: _________________________________________________
Phone:or__________________________________________________
Office Facility Name: _____________________________________
NPI Number:
Address: _____________________________________________
_________________________________________________
Phone: __________________________________________________
Please attach or include any additional supporting
NPI Number: clinical information in the space below:
_____________________________________________
Please attach or include any additional supporting clinical information in the space below:
Provider Data:
NPI Number: Today’s Date:
Provider Data:
Physician/Professional
NPI Number: Provider Name: Today’s Date:
Address:
Physician/Professional Provider Name:
Name of Requester:
Address: Requester’s Phone:
Name of Requester: Requester’s Phone:
Confidentiality Note: The information contained in this facsimile message is privileged and confidential and is intended only
for the exclusive information and use of the addressee. If you are not the intended recipient, any copying, use or distribution
is unauthorized. If you are responsible for delivering this message to the addressee, it may not be copied, used, or distributed
Confidentiality
except as directed Note: Theaddressee.
by the informationI you contained in this facsimile
have received message
this message is privileged
in error, and confidential
please notify us immediatelyand by
is intended
telephone only
so
for the exclusive information and use of the addressee.
that we can arrange for its return to us at no cost to you. If you are not the intended recipient, any copying, use or distribution
is unauthorized. If you are responsible for delivering this message to the addressee, it may not be copied, used, or distributed
except asofdirected
A Division byService
Health Care the addressee.
Corporation, aI you have
Mutual Legalreceived this message
Reserve Company, in error,Licensee
an Independent pleaseofnotify usCross
the Blue immediately by telephone
and Blue Shield Association so
that we can arrange for its return to us at no cost to you.
30
A Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield Association
ADVANCE BENEFIT NOTIFICATION

Overview a. Non-covered services;
An ABN must be signed by the HELP Plan participant prior to the b. Experimental services;
service being rendered and billed. The signed ABN signifies the c. Unproven services;
participant understands and agrees that they will be responsible d. Services performed in an inappropriate setting;
for the full payment of that particular service. If the participant
e. Services that are not medically necessary; or
is 19 or 20, any non-covered service requests must be reviewed
through the EPSDT program. f. Services that require prior authorization and are not
prior authorized.
Services that fall in this category have been categorized as
experimental, investigational, or unproven by BCBSMT based on BCBSMT will comply with the Early and Periodic Screening,
the predominate evidence-based opinion of independent experts; Diagnostic, and Treatment (EPSDT) services for participants
or the service is not deemed experimental or investigational under the age of 21. EPSDT is federally mandated to meet
in itself pursuant to the above criteria, but would otherwise the physical, emotional, medical, and developmental needs of
not be medically necessary as provided in conjunction with children as early as possible. EPSDT provides preventive, well-
the provision of a treatment, procedure, device, or drug that is child checks, immunizations, and access to medically necessary
experimental, investigational, or unproven, or it is not a benefit. health care services that are not available to adults. Requests for
medically necessary non-covered services will be reviewed and
Providers may only charge HELP Plan participants for the approved or denied by BCBSMT according to the EPSDT State
following services if an ABN is signed prior to service delivery: Plan Amendment.
COPAYMENTS
HELP PLAN COPAYMENTS • Inpatient hospital - $75 per discharge;
1. Except as otherwise provided by state or federal laws or • Nonemergency services provided in
regulations, each participant in the HELP Plan must pay to an emergency room - $8;
the provider of service copayments as described below not to • Pharmacy-preferred brand drugs - $4;
exceed the cost of service.
• Pharmacy-non-preferred brand drugs,
2. All HELP Plan participants receive a credit in the amount of including specialty drugs - $8;
their premium obligation toward the first copayments accrued
up to two percent of household income. • Professional services - $4;
3. Premiums and copayments combined may not exceed • Outpatient facility services - $4;
an aggregate limit of five percent of the annual family • Durable medical equipment - $4; and
household income. • Lab and radiology - $4.
4. Participants with incomes at or below 100 percent of the FPL 5. Participants with incomes above 100 percent of the FPL are
are responsible for the following copayments: responsible for the following copayments:
31
• Inpatient hospital - 10 percent of Uncollected Copayment Report

provider reimbursed amount;
Participating Providers must compile, analyze, and provide
• Nonemergency services provided in an annual Uncollected Copayment Report for all services
an emergency room - $8; covered by the HELP Plan. The reports must include the
• Pharmacy-preferred brand drugs - $4; following information:
• Pharmacy-non-preferred brand drugs, • The total amount of copayments the providers were unable to
including specialty drugs - $8; collect from participants;
• Professional services - 10 percent of • The efforts providers made to collect the copayments; and
provider reimbursed amount;
BCBSMT will collect this uncollected payment report from
• Outpatient facility services - 10 percent
Participating Providers on an annual basis.
of provider reimbursed amount;
• Durable medical equipment - 10 percent of
provider reimbursed amount; and
• Lab and radiology - 10 percent of
provider reimbursed amount.
6. Copayments are subject to a quarterly aggregate cap
of one-quarter of three percent of the annual household
income. Copayments may not be charged in a quarter after a
household has met the quarterly aggregate cap.
7. Copayments may not be charged for:
• Preventive health care services;
• Immunizations provided according to a schedule
established by the department that reflects guidelines
issued by the Centers for Disease Control and Prevention;
• Medically necessary health screenings
ordered by a health care provider;
• Generic pharmaceutical drugs;
• Eyeglasses purchased by the Medicaid program
under a volume purchasing agreement; and
• Other services exempt by applicable federal authority.
8. Copayments may not be charged for services rendered in
circumstances of third party liability (TPL) claims where the
HELP Plan is the secondary payor under ARM 37.85.407. If a
service is not subject to TPL, but is covered by the HELP Plan,
copayments are applied.
9. Copayments may not be charged to the participant until
the claim has processed through the claims adjudication
process and the provider has been notified of payment
and amount owing.
32
Example of the Uncollected Copayment report:
Please respond to the following questions in regard to the reporting period from January 1, 2017-June 30, 2017.
1. Have you or any providers in your practice provided services to any HELPTPA Plan participants during the specified
time frame?
Yes_____ Go to question 2.
No _____ Complete the information immediately below and return the form.
Practice Name _________________
Provider NPI Provider Last Name Provider First Name Title
2. Did you provide services between January 1, 2017 and June 30, 2017 to any HELP TPA Plan participants who
were responsible for paying copayments?
Yes_____ If yes, go to Question 3.
No _____ If no, stop and return the form.
3. Complete the information on the attached form. If you run out of room, make additional copies of the form as
necessary to complete your reporting.
Provider Provider Participant Participant Participant Billed Date of Copay
Via Telephone
NPI Name HELP Plan ID Last Name First Name Services Service Amount Not
Via E-Mail
Via Mail
Collected
Other
If attempts made to collect the copayments were Other, provide a brief description: ____________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
33
Services Reimbursed Directly by Medicaid Physician Administered Drugs

1. Covered services for participants in the HELP Plan enrolled BCBSMT requires providers to bill claims for physician-
with the BCBSMT, except as otherwise provided in (2), administered drugs and include valid and accurate NDCs and
are reimbursed directly by the BCBSMT according to the HCPCS codes in compliance with 42 CFR 447.520 and the
schedule found at https://medicaidprovider.mt.gov.
Social Security Act, sections 1927(b)(2)(A) and 1903(m)(2)(A).
2. The following services received by participants enrolled with This is standard billing practice and should be followed for the
the BCBSMT are reimbursed directly through the Department HELP Plan.
of Public Health and Human Services:
• FQHC; • Diabetes
• RHC; prevention programs;
• Dental; • Transportation;
• Eyeglasses; • Prescription drugs;
• Indian Health Services • Home infusion;
and tribal health services; • Hearing aids; and
• Audiology.
3. The services specified in (2) are reimbursed at the established
Medicaid reimbursement rates for those services.
34
Chapter 7: COORDINATION
OF BENEFITS
Chapter 7: Coordination of Benefits January 2018
THIRD PARTY LIABILITY (TPL)

When a Participant Has TPL (ARM 37.85.407) If the third party has only potential liability, the provider may bill
the HELP Plan first. Do not indicate the potential third party on
A HELP Plan participant may have insurance coverage in addition
the claim. Instead, notify BCBSMT or DPHHS first, depending on
to the HELP Plan, but may not have dual coverage with standard
the appropriate entity for claims processing.
Medicaid or Medicare.
When a HELP Plan Participant has additional medical coverage, Requesting an Exemption
it is often referred to as third-party liability or TPL. In most cases,
Providers may request to bill the HELP Plan first under certain
providers must bill other insurance carriers before billing the
circumstances. In each of these cases, the claim and required
HELP Plan. When services are covered by the HELP Plan and
information should be sent directly to the following addresses:
another source, any payment the participant receives from the
other source must be turned over to the Montana Department of For claims processes by BCBSMT:
Health and Human Services (DPHHS). Providers are required to
HELP Plan Claims Correspondence
notify HELP Plan participants of such.
P.O. Box 3387
Preauthorization requirements apply even if the HELP is Scranton, PA 18505
the secondary carrier.
For claims processed by DPHHS/Conduent:
Exceptions to Billing Third-Party Claims Processing Unit

P.O. Box 8000
Liability Carrier First
Helena, MT 59604
In a few cases, providers may bill the HELP Plan first:
• When a HELP Plan participant is also covered by the Crime
Victim Compensation Program, providers must bill the HELP
Program first. These are not considered a third-party liability.
• When a participant has HELP Plan eligibility and MHSP
eligibility for the same month, the HELP Plan must
be billed first.
• ICD prenatal and ICD preventive pediatric diagnosis conditions
may be billed to the HELP Plan first. In these cases, the HELP
Plan will pay and then recover payment directly from the
third-party payor.
The following services may also be billed to the HELP Plan first.
Refer to Chapter 2, General Information, to determine where to
submit claims, BCBSMT or DPHHS.
• Nursing facility • Home and
• Audiology community-based services
• Dental and denturist • Optometry
• Drugs • Oxygen in a nursing facility
• Eyeglasses • Personal assistance/
Community First Choice
• Hearing aids and batteries
• Transportation (other
than ambulance)
38
Chapter 8: APPEALS
Chapter 8: Appeals January 2018
HELP PLAN PARTICIPANT BENEFIT APPEALS

Appeals for claims administered by BCBSMT Appeals for claims administered by DPHHS
First Level Appeal Appeal Process
If providers do not agree with a denial or partial denial of a claim, If providers do not agree with a denial or partial denial of
providers have 90 days from receipt of the denial to appeal the a claim, providers have 90 days from receipt of the denial to
decision on the claim. Participants must write to BCBSMT and appeal the decision on the claim or mail it to the address below:
ask for a review of the claim denial. BCBSMT will acknowledge
Office of Fair Hearings
providers requests for appeals within 10 business days of
Montana DPHHS
receipt of requests.
Po Box 202953
To file a written appeal, providers must state their issue and ask Helena, MT 59620-2953
for a review of the denied claim and send it to:
FAX: 406-444-1861
Blue Cross and Blue Shield of Montana
Attention: Appeals and Grievances Department The Office of Fair Hearings will contact providers to conduct
P.O. Box 27838 impartial Fair Hearing. The Hearing Officer will research statues,
Albuquerque, NM 87125-9705 rules, regulations, policies, and court cases to reach conclusions
of law. After weighing evidence and evaluating testimony, the
Confidential Fax: 866-643-7069
Office of Fair Hearing issues written decisions that are binding
Providers will receive a written response to their appeal unless appealed to the state Board of Public Assistance, the
within 45 days of receipt. If providers do not agree with the DPHHS Director, or a district court.
First Level determination, providers may choose to make a
Second Level Appeal with the Department of Public Health and Administrative Disputes
Human Services.
Definition
Second Level Appeal Disputes regarding administrative matters may arise when
If providers do not agree with the First Level determination by a contracted provider wishes to protest BCBSMT’s decision
BCBSMT, providers may fax a Second Level appeal request that the provider has breached the provider’s participation
to (406)-444-3980 within 90 days of receiving the First Level agreement, or violated a BCBSMT policy.
determination or mail it to the address below:
Office of Fair Hearings Examples
Montana Department of Public Health and Human Services • Non-compliance with administrative terms in the participation
P.O. Box 202953 agreement or provider manual
Helena, MT 59620-2953 • Billing the participant improperly
The Office of Fair Hearings will contact providers to conduct • Failure to submit requested medical records
an impartial administrative hearing and/or a Fair Hearing. The • Failure to submit timely claims
Hearing Officer will research statutes, rules, regulations, policies, • Failure to respond to complaints
and court cases to reach conclusions of law. After weighing
• Failure to meet access and availability standards
evidence and evaluating testimony, they issue written decisions
that are binding unless appealed to the state Board of Public • Any change in specialty services provided or location of
Assistance, the Department Director, or a district court. hospital that may materially affect the hospital’s ability to
perform its obligations under the provider’s BCBSMT contract.
40
Resolution Process
The following process occurs to resolve an administrative dispute:
Step Action
1 Health Care Delivery verifies the contractual breach or administrative violation.
2 BCBSMT notifies the provider of the contractual breach or administrative violation and of the right to request
reconsideration, via certified mail, no later than 30 days after receipt of the notice from BCBSMT.
If the provider Then
Does not request a reconsideration within The provider’s rights are relinquished and no action occurs. The
30 days original decision stands.
Requests reconsideration outside the 30 The provider’s rights are relinquished and no action
day time frame occurs. The original decision stands.
Requests a reconsideration within the 30
The first level review occurs as defined below.
day time frame
3 First level reviews:
The written appeal is reviewed by a BCBSMT Chief Medical Officer (CMO), who was not involved in the initial
decision on the subject of the dispute. The reviewer may overturn or uphold the original decision.
If the original Then the decision is communicated to the provider, via certified mail, within 10 days of the
decision is decision, and
Overturned Health Care Delivery is notified to reinstate the provider, and no further action occurs.
Upheld The letter informs the provider of the right to request a second level appeal within thirty (30)
days of receipt of the notice from BCBSMT.
Does not request a The provider’s rights are relinquished and no action
reconsideration within 30-days occurs. The original decision stands.
Requests reconsideration The provider’s rights are relinquished and no
outside the 30-day time frame action occurs. The original decision stands.
Requests a reconsideration The second level review occurs as defined
within the 30-day time frame below.
4 Second level reviews:

The written appeal is reviewed by a BCBSMT CMO or the President, who was not involved in the initial decision on
the subject of the dispute, or in the first level review. The reviewer may overturn or uphold the original decision.
Upheld No further action occurs.
41
Competency and Conduct Termination/ Examples

Summary Suspension for Consumer Safety Such terminations may occur as a result of the following, but
not limited to:
Definition
• Fraudulent activity
The BCBSMT Chief Medical Officer (CMO) may make a
• Allegations of professional misconduct
determination to immediately suspend a provider’s participation
when the provider’s conduct is deemed to pose a significant risk • Licensing board actions
to the health, safety or welfare of BCBSMT Participants. • Charge or conviction of a crime
BCBSMT will investigate such instances on an expedited basis, • Hospital disciplinary action.
and makes the dispute resolution process to any participating
provider subject to the suspension of participation status.
42
Resolution Process
The following process occurs to resolve a dispute following a summary suspension:
Step Action
1 BCBSMT notifies the provider of the summary suspension and of the right to request reconsideration in writing no
later than 30 days after receipt of the notice from BCBSMT.
day time frame
The written appeal is reviewed by the BCBSMT Credentialing Committee at a regularly scheduled meeting. The
Committee may overturn or uphold the original decision.
Upheld The letter informs the provider of the right to request a second level appeal within thirty (30)
days of receipt of the notice from BCBSMT.
Requests reconsideration The provider’s rights are relinquished and no action
outside the 30-day time frame occurs. The original decision stands.
Requests a reconsideration
The second level review occurs as defined below.
within the 30-day time frame
Professional Competence, Conduct and Examples

Quality of Care Issues Such terminations may occur as a result of:
• Belief that a quality of care issue exists
Definition
• Disciplinary history
Disputes may arise when an existing participating provider’s
participation is terminated based upon professional • Trend or pattern of quality of care issues
competence or conduct. • Convictions
• Complaints and grievances regarding a provider
• Deficiencies identified through a facility survey process.
43
Resolution Process
The following process occurs to resolve a dispute following a termination due to competency or conduct:
Step Action
1 The BCBSMT Credentialing Committee makes the initial determination to terminate a provider based on
professional competency, conduct, or quality of care issues.
2 BCBSMT notifies the provider of the termination due to competency or conduct and of the right to request
reconsideration, in writing, no later than 30 days after receipt of the notice from BCBSMT.
day time frame
The written appeal is reviewed by the BCBSMT Physician Advisory Committee (PAC). The PAC is the first–level
panel consisting of at least three qualified individuals, of which at least one must be a participating provider, who
is not otherwise an employee or involved in the day to day operations of the network or plan and who is a clinical
peer of the provider that filed the dispute. The PAC may request additional participation of a participating provider
who is a clinical peer of the provider that filed the dispute. The PAC may overturn or uphold the original decision.
Upheld The letter informs the provider of the right to request a second level review and the methods
to request such consideration within 30 days of receipt of the notice from BCBSMT.
Requests reconsideration The provider’s rights are relinquished and no
outside the 30-day time frame action occurs. The original decision stands.
Requests a reconsideration The second level review occurs as defined
within the 30-day time frame below.
Fair Hearing Process – Level 2 Dispute • Summary suspensions;

Resolution Process • Terminations as a result of competency and conduct, after the
first level dispute resolution process has been exhausted and
Definition the provider still disputes the decision;
This process is the level two dispute resolution process for • Complaints and grievances regarding a provider; and
participating provider terminations as a result of “for cause” • Deficiencies identified through a facility survey process.
contract terminations such as:
44
Resolution Process
The following process occurs after the first level dispute resolution process has been exhausted and the provider still disputes
the decision.
Step Action
1 When the request for a level two review is received, BCBSMT provides the provider-appellant (hereinafter “appellant”)
a notice of hearing stating:
• The name of the arbitrator or hearing officer and names of panel Participants, including the participating providers.
• The time, date, and place of the hearing, which date shall not be less than 30 calendar days after the date of the
notice of hearing. All hearings will be held in Helena, Montana, and
• A list of witnesses (if any) expected to testify at the hearing on behalf of BCBSMT.
Within 10 working days of mailing the notice of hearing, BCBSMT shall provide the appellant with copies of all
materials and documentation considered during the initial determination.
2 At the discretion of BCBSMT, the hearing will be held before:
• An arbitrator mutually acceptable to the appellant and BCBSMT and a participating provider, who was not involved in
the original decision, or
• A hearing officer who is appointed by BCBSMT and who is not in direct economic competition with the appellant
and a participating provider who was not involved in the original decision and who, otherwise is not an employee
or involved in the day to day operations of the network or plan and who is a clinical peer of the provider that
filed the dispute.
• A hearing panel of individuals who are appointed by BCBSMT, including at least one participating provider, who are
not in direct economic competition with the appellant. The panel will include a hearing officer, who will preside over
the hearing.
3 The appellant may present the appeal in writing or in person. During the hearing, the appellant has the right to:
• Representation by an attorney or other person of the appellant’s choice,
• Have a record made of the proceedings (copies may be obtained by the appellant upon payment of any reasonable
charges associated with the preparation of the record),
• Call, examine, and cross-examine witnesses,
• Present evidence determined to be relevant by the arbitrator or hearing officer, regardless of its admissibility in a
court of law, and
• Submit a written statement at the close of the hearing.
4 At least 15 working days prior to the hearing:
• The appellant shall provide BCBSMT with a list of witnesses (if any) expected to testify at the hearing on behalf of
the appellant, and
• The parties shall exchange any exhibits or documentation to be presented at the hearing.
Minutes of discussion at Credentialing Committee meetings are confidential.
45
5 The hearing shall be confidential and informal. The arbitrator or hearing officer shall control the hearing and make all
decisions regarding evidentiary and procedural questions, including the methodology and procedure that will be followed
for the presentation of the evidence. The arbitrator or hearing officer may preclude the presentation of duplicative,
irrelevant, or unnecessary evidence and may limit the number of witnesses.
The statutory rules of evidence that govern state and federal court proceedings do not apply.
The decision of the arbitrator or hearing officer on the admissibility of the evidence and procedural matters is final.
The right to a hearing is forfeited if the appellant fails, without good cause, to appear at the hearing.
6 After the hearing, and upon consideration of all the relevant material, the arbitrator, hearing officer, or hearing panel
shall make its recommendation to BCBSMT as to whether to uphold, reverse, or modify with provisional stipulations the
Credentialing Committee’s decision.
Within 10 working days of the completion of the hearing, the appellant will receive:
• The written recommendation of the arbitrator, hearing officer, or hearing panel, including a statement of the basis for
the recommendation, and
The written decision of BCBSMT, including:
• A statement of the basis for the decision.
• A notice that this is a final decision and all avenues of appeal have been exhausted.
• Notice of the effective date of eligibility, suspension, termination, limitation of practice or provisional approval of
credentialing for the provider network.
The recommendation shall be based solely on the evidence provided at the hearing:
• In the case of a hearing panel, the recommendation shall be by a majority vote of the members of the hearing
panel. The deliberations of the hearing panel are confidential and no panel member may be called to testify in any
proceeding concerning the deliberations, discussion, recommendation, or internal proceedings of the hearing panel.
7 The final decision is communicated to the provider via certified mail.
Contractual Inquiries Inquiry/Complaint

An inquiry/complaint is an initial verbal or written communication
Contractual Inquires/Appeals
requesting additional information, confirmation or clarification
If a BCBSMT participating provider has an inquiry or complaint, regarding benefits, pricing, claim adjudication, and/or claims
which does not fall under one of the other two categories above processing guidelines. Responses range from a quick and informal
and relates to the provider’s contract, an initial attempt should exchange of information to a written response. An inquiry/
be made to resolve it by communication with the Health Care complaint is not considered an appeal.
Delivery Department. If a resolution cannot be reached, a written
appeal process is available.
46
Contractual Appeal Appeals should be mailed to:

Contractual appeals can be requested for reconsideration Customer Service Department
regarding benefits, pricing, claims adjudication, and/or claims Blue Cross and Blue Shield of Montana
processing guidelines. All contractual appeals must be submitted P.O. Box 4309
in writing using the Provider Review Form located on BCBSMT’s Helena, MT 59604
website at www.bcbsmt.com under forms. Contractual appeals
Or you may fax your appeal to: 406-441-4604
inquiries must be received by BCBSMT within one hundred
eighty (180) days of the initial claims adjudication date to Providers will be notified of a decision for contractual appeals in
be considered. a timely manner. If the appeal results in additional payment, the
provider will be notified on his/her detail of remittance. All other
The written request should include the following information:
appeal responses will be mailed directly to the provider.
• Name of the participant
• Participant ID number
• Nature of the complaint
• Facts upon which the complaint is based
• Resolution provider is seeking
• Include a claim form, copy of the detail of remittance or any
documentation (including medical records) that you want to
include for consideration.
47
THIS PAGE
INTENTIONALLY
LEFT BLANK.
Chapter 9:
ADMINISTRATIVE POLICIES
Chapter 9: Administrative Policies January 2018
HIPAA INFORMATION
Privacy Authorization
Pursuant to regulations under the Health Insurance Portability BCBSMT may require written authorization from its participants
and Accountability Act (HIPAA) of 1996, BCBSMT will only to disclose information to covered entities under HIPAA for
disclose the minimum necessary Protected Health Information health information other than payment, treatment, or its own
(PHI) for treatment, payment, and BCBSMT health care health care operations. Any requests for information other than
operations on those participants with whom the health care payment, treatment, or health care operations will be directed to
provider has or had a relationship. the BCBSMT Privacy Office at 1-800-447-7828.
Any requests for information that pertain to the health care Privacy Office
provider’s health care operations other than those listed above Blue Cross and Blue Shield of Montana
will be directed to the BCBSMT Privacy Office at P.O. Box 4309
Helena, MT 59604
1-800-447-7828.
Verification Notification of Changes

Immediately notify Network Management in writing when any
BCBSMT must verify the identity of a caller requesting
change is made to the following:
information concerning participant PHI. When calling BCBSMT,
be prepared to give your National Provider Identifier (NPI), • Name • Accepting/Not
• Credentials Accepting new patients
tax identification number (TIN), and your first name. A
department and/or position title would also be helpful for • Address • On-call list
BCBSMT Participant Services Representatives to accurately • Phone number • Patient age restrictions
document the inquiry. • Licensure
• Specialty
• Tax ID or Social • Leave of
Minimum Necessary absence or sabbatical
Security number
When sending printed documentation to BCBSMT for any
reason, send only the minimum necessary information to A “Provider Change of Status” form may be submitted
complete the task, e.g., black out other patient information electronically by logging into the Secure Provider Portal and
on your “Provider Claims Summary” that is not related selecting the “Update Office Info” tab, or a hard copy form may
to your inquiry. be downloaded. Click on “Provider”, then “Forms & Documents”,
“Provider Change of Status” form.
E-mail the change form to MTHCSSPEC@bcbsmt.com or mail
or fax all changes to:
ATTN: Network Management
P.O. Box 4309
Helena, MT 59604
FAX: 406-437-7879
50
Emergency services Definitions

In accordance with 42 C.F.R. 447.54, HELP Plan participants are EMERGENCY MEDICAL CONDITION
not subject to cost sharing for emergency services, unless the Emergency medical condition means a medical condition
visit is determined to be non-emergent, and the hospital takes manifesting itself by acute symptoms of sufficient severity
the following steps: (including severe pain) that a prudent layperson, who possesses
1. Conducts an EMTALA-compliant medical screening an average knowledge of health and medicine, could reasonably
examination that concludes the participant’s condition expect the absence of immediate medical attention to result
is non-emergent;
in the following:
2. Provides the individual with the name and location of an • Placing the health of the individuals (or, for a pregnant
alternative non-emergency services provider; participant, the health of the participant or her unborn child) in
3. Informs the individual of the amount of his or her cost sharing serious jeopardy.
obligation for non-emergency services provided in the • Serious impairment to bodily functions.
Emergency Department;
• Serious dysfunction of any bodily organ or part.
4. Determines that the alternative provider can provide services
at a lower cost sharing amount; and EMERGENCY SERVICES
5. Provides a referral to schedule treatment by the Emergency services means covered inpatient and outpatient
alternative provider. services that are as follows:
The above requirements must be documented in the medical • Furnished by a provider that is qualified to furnish these
records and validated by BCBSMT, in order for the cost share services under this title.
for non-emergency services provided in the Emergency Room • Needed to evaluate or stabilize an emergency medical
to be waived. condition.
51
E-Mail Security 2. Confirm your email address and click “Submit”:

BCBSMT uses e-mail software called “Cisco IronPort CRES” for
secure messaging.
This message then gets encrypted using BCBSMT’s Cisco
appliance onsite, with the keys needed to decrypt the message
stored in Cisco’s cloud. When a recipient receives a message
from HCSC that is encrypted he/she follows the instructions
attached to open the message.
Opening a secure message using “Cisco Registered Envelope
Service” (CRES) for the first time, as follows;
1. Click on the securedoc.html attachment at the bottom of your
secure email to open it:
3. You will be taken to the registration window. Click Register:
4. You will get this message:
52
5. Check your email for the activation email. It will be 8. Your email will open successfully:
similar to this:
The ZIX system uses three dictionaries that scan all messages
and attachments to determine what will be encrypted.
Messages must have a match with at least two lists before
being encrypted. These dictionaries are:
1. HIPAA: The largest list that contains diagnosis and
procedure codes and thousands of keywords, such as claims
and prescription.
2. Relationships: Family relationship keywords, such as
mother and father.
6. Select “Click here to activate this account” and follow the
prompt for creating a password and some security questions. 3. Identifiers: Unique combinations, such as member ID and
Social Security number.
You will receive a message from ZIX informing you an encrypted

e-mail has been sent to you from BCBSMT. If you currently use
the ZIX system, you will receive encrypted e-mails directly;
otherwise, you must click on the link to the ZIX message
center and create a password before you can view the e-mail.
If you have not used ZIX for 90 days, you will need to create
a new password.
You may also download a free 30-day trial of ZixMail at
www.zixcorp.com to receive BCBSMT correspondence
directly without going to the ZIX message center. You will be
able to send encrypted e-mails to any recipient without altering
7. Upon completion of #6 you’ll get the following window. Click your current e-mail address or e-mail system.
Continue and enter the updated password:
If you have any questions, call Customer Service at
1-800-447-7828.
53
APPOINTMENT AVAILABILITY • A maximum wait time for routine-care appointment with a

STANDARDS AND MEASURES primary care provider to be 45 days;
BCBSMT monitors provider availability through participant • A maximum wait time for urgent care with a primary provider
to be two days;
complaints tracking and responses to an annual participant
satisfaction survey. • A maximum wait time for routine-care appointment with a
specialist to be 60 days; and
Montana HELP Plan Participating Providers agree to adhere to
• A maximum wait time for urgent care with a specialist
the following timely access to care standards:
to be four days.
LOCUM TENENS PROVIDER POLICY

Scope Purpose
This policy applies to all lines of Blue Cross and Blue Shield of This policy documents BCBSMT administrative guidelines
Montana (BCBSMT) business except Medicare. for a locum tenens provider’s use of the BCBSMT provider
identification number(s) (i.e., ID number(s)) assigned to a
provider, who is on leave of absence (“provider on leave”) from
his/her practice.
Note: Copies of this specific policy can be located under
“Administrative policies”.
PROVIDER IN TRAINING POLICY

Scope Purpose
This policy applies to all lines of BCBSMT business with the BCBSMT recognizes the value of services being provided
exception of Medicare. to its participants by providers in training for their health
care profession. This policy establishes billing guidelines for
providers in training.
Note: Copies of this specific policy can be located under
Administrative policies.
PROVIDER NETWORK PARTICIPATION POLICY

Scope • Healthy Montana Kids (HMK) Provider Network
• Blue Cross Medicare Advantage (PPO) and Blue Cross
SM
This policy applies to the following networks:

Medicare Advantage (HMO) provider networks
SM
• BCBSMT traditional participating provider network

• HELP Plan PPO provider network.
• BCBSMT managed care provider network
• Blue Focus POS provider network
SM
• Montana HealthLink (PPO) – includes HealthLink PPO network

• Blue Options POS provider network
SM
with the traditional provider network wrapped around it for

the BlueCard program
54
Rural Health Clinic (RHC)/Federally Qualified The 30-day waiting period may be waived for either
Health Center (FQHC) Claims of the following:
• Premature Delivery. The Informed Consent of
Submit claims for clinic services provided at an RHC or FQHC to
Sterilization must be completed and signed by the
DPHHS/Conduent on a UB-04 claim form with Type of Bill 711 for Participant at least 30 days prior to the estimated delivery
RHC and 771 for FQHC, and revenue code 521 for medical clinic date and at least 72 hours prior to the sterilization.
services and 900 for mental health clinic services.
• Emergency Abdominal Surgery. The Informed
Submit claims electronically with the standard payor id billed Consent to Sterilization form must be completed and
for the Montana HELP Plan and the participant’s HELP Plan signed by the Participant at least 72 hours prior to the
identification number on the ID Card with the YDM alpha prefix, sterilization procedure.
or submit hard copy claims to: 2. Participant must be at least 21 years of age when
Claims Processing Unit signing the form.
P. O. Box 8000 3. Participant must not have been declared mentally
Helena, MT 59604 incompetent by a federal, state, or local court, unless the
member has been declared competent to specifically consent
Bill inpatient, outpatient and emergency room services provided to sterilization.
at an RHC/FQHC to BCBSMT on a CMS-1500 claim form, with
4. Participant must not be confined under civil or criminal
place of service 21, 22, or 23, including the rendering provider, status in a correctional or rehabilitative facility, including a
with the standard payor id billed for the Montana HELP Plan, and psychiatric hospital or other correctional facility for treatment
the participant’s HELP Plan identification number on the ID Card of the mentally ill.
with the YDM alpha prefix, or submit hard copy claims to:
Before performing a sterilization, the following
HELP Medicaid Claims Correspondence
requirements must be met:
P.O. Box 3387
• The Participant must have the opportunity to have questions
Scranton, PA 18505
regarding the sterilization procedure answered to his/her
OR satisfaction.
Fax: 855-206-9202 • The Participant must be informed of his/her right to withdraw
or withhold consent any time before the sterilization procedure
being considered is irreversible.
Abortions, Hysterectomies, and Sterilizations
• The Participant must be made aware of the discomforts
Abortions and risks which may accompany the sterilization procedure
being considered.
A completed HELP Plan Physician Certification for Abortion
Services (MA-37) form must be attached to every abortion claim • The Participant must be informed of the benefits and
or payment will be denied. Complete only one section of this advantages of the sterilization procedure.
form. This is the only form accepted for abortions. • The Participant must know that he/she must have at least 30
days to reconsider his/her decision to be sterilized.
Sterilization/Hysterectomy (ARM 37.86.104) • An interpreter must be present and sign for Participants who
Elective sterilizations are sterilizations done for the purpose of are blind or deaf, or do not understand the language to assure
becoming sterile. The HELP Plan covers elective sterilization for the person has been informed.
men and women when all of the following requirements are met: Informed consent for sterilization may not be obtained under the
1. Participant must complete and sign the Informed Consent to following circumstances:
Sterilization (MA-38) form at least 30 days, but not provider
• If the Participant is in labor or childbirth.
network more than 180 days, prior to the sterilization
procedure. This form is the only form accepted for elective • If the Participant is seeking or obtaining an abortion.
sterilizations. If this form is not properly completed, payment • If the Participant is under the influence of alcohol or other
will be denied. substance which affects his/her awareness.
55
For elective sterilizations, a completed Informed Consent of • For Participants who have become retroactively eligible for
Sterilization (MA-38) form must be attached to the claim for the HELP Plan, the physician must certify in writing that
each provider involved or payment will be denied. This form the surgery was performed for medical reasons and must
must be legible, complete, and accurate. It is the provider’s document one of the following:
responsibility to obtain a copy of the form from the primary or –– The individual was informed prior to the hysterectomy
attending physician. that the operation would render the member permanently
incapable of reproducing.
For medically necessary sterilization, including hysterectomies,
oophorectomies, salpingectomies, and orchiectomies, one –– The reason for the hysterectomy was a life-
of the following must be attached to the claim, or payment threatening emergency.
will be denied: –– The Participant was already sterile at the time of the
• A completed HELP Plan Hysterectomy Acknowledgment hysterectomy and the reason for prior sterility.
form (MA-39) for each provider submitting a claim. It is the When submitting claims for retroactively eligible Participants,
billing provider’s responsibility to obtain a copy of the form
for which the date of service is more than 12 months earlier
from the primary or attending physician. Complete only one
than the date the claim is submitted, contact the member’s local
section of this form. When no prior sterility (Section B) or
life-threatening emergency (Section C) exists, the Participant Office of Public Assistance and request a Notice of Retroactive
(or representative, if any) and physician must sign and Eligibility (160-M). Attach the form to the claim.
date Section A of this form prior to the procedure. (See 42
CFR 441.250 for the federal policy on hysterectomies and
sterilizations.) Also, for Section A, signatures dated after the
surgery date require manual review of medical records by the
HELP Plan. The HELP Plan must verify that the Participant (and
representative, if any) was informed orally and in writing, prior
to the surgery, that the procedure would render the Participant
permanently incapable of reproducing. The Participant does
not need to sign this form when Sections B or C are used.
PROVIDER REQUIREMENTS
Written Participating Provider Agreement The participating provider and BCBSMT are independent parties
contracting with each other solely for the purpose of effecting
All providers, including professional providers and institutional/
the provisions of the written agreement. The participating
facility providers, must enter into a written agreement with
provider provides services to BCBSMT participants in the
BCBSMT to participate in the BCBSMT provider networks.
capacity of an independent contractor.
This written agreement obligates the provider to participate in
The participating provider is bound by the administrative policies,
the PPO and Traditional provider networks, which the Federal
medical policies, provider manual rules, and regulations adopted
Employee Program (FEP) and BlueCard Program access. An
or amended by BCBSMT.
additional amendment must be signed to participate in the
BCBSMT HELP Plan and managed care provider networks. When initially entering into an agreement, the participating
provider must sign the BCBSMT “Participating Provider
Standalone contracts exist for additional networks, including
Agreement”, the HELP Plan and any other amendments, and list
Healthy Montana Kids (HMK) and Medicare Advantage.
all current individual providers on Attachment A of the contract.
The participating provider may add individual providers to its
group by completing the “Addition of Individual Provider” form
(Attachment B).
56
Prior to participation, when a new provider joins the BCBSMT Obligations and Responsibility
provider networks, the provider must successfully complete the According to the written agreement, both the participating
credentialing process, if the provider is not already credentialed provider and BCBSMT agree to certain obligations and
with BCBSMT. In addition, for participation in the HELP Plan responsibilities, as defined below:
provider network, the provider must complete the screening
process required by 42 CFR 455 Subparts B and E. An individual Each party agrees to notify the other party within five business
provider will not be considered as participating until the date the days of receipt of notice of the following:
provider is approved by the BCBSMT Credentialing Committee. • Notice to the participating provider of any disciplinary
BCBSMT will not retroactively credential a provider or the proceeding reported to or initiated by the applicable board
provider’s effective/start date. of examiners of any state in which the participating provider
is licensed or any action that may be brought against the
If the participating provider is comprised of a group of licensed participating provider by any professional society or facility
health care providers, the participating provider represents and acting through its professional staff, directors, or trustees;
warrants that it is duly authorized to enter into the BCBSMT • Notice to BCBSMT from the Montana Commissioner of
“Participating Provider Agreement” on behalf of such individual Securities and Insurance that may affect BCBSMT’s ability to
providers and has the authority to bind its individual providers. perform its obligations under the agreement;
• Any action taken against either party by any governmental
Requirements agency that may affect the other party’s ability to perform the
obligations under the agreement;
Conditions for Participation
• Any action against or lapse of the participating provider’s
Conditions for participation as a participating provider include license, controlled substance permit, medical staff
the following: membership or clinical privileges;
• The participating provider agrees to cooperate and to
• Any felony arrest information or indictment or any criminal
require each individual provider to cooperate with BCBSMT
charge naming the participating provider;
in compliance with all applicable Credentialing Criteria
established by the BCBSMT Credentialing Committee; • Any cancellation or material modification of the participating
provider’s professional liability insurance or BCBSMT’s
• The provider is a fully licensed health care provider in the
industry standard insurance coverage;
state of Montana;
• Any judgment or finding against the participating provider
• The provider is practicing within the scope of such license;
that might materially impair his/her ability to perform under
• The provider warrants that all information submitted for this agreement.
credentialing and re-credentialing is accurate and truthful;
Upon reasonable request by either party, the other party
• The provider is not currently being sanctioned by any
governmental agency for violation of any federal medical agrees to provide copies of any documents filed or prepared
program rules or regulations including but not limited to in connection with any item identified above, unless such
Medicare and Medicaid; documents are deemed protected information.
• The provider maintains malpractice liability insurance. The participating provider agrees to the following:
• As applicable, the participating provider will comply with all
plan notification and prior authorization requirements.
The participating provider will promptly notify BCBSMT if he/she

becomes aware that a Participant:
• Was hospitalized on the date the participant’s initial
enrollment under a HELP Plan became effective;
57
• Has obtained other insurance coverage; Disclosures

• Has committed acts of physical or verbal abuse that pose a The participating provider agrees that BCBSMT may list
threat to providers or other participants; or such information as the name, specialty, business address,
• Has allowed a non-Participant to use the BCBSMT-issued business telephone number and board status in BCBSMT’s
identification card to obtain services. provider directory.
The participating provider must notify BCBSMT in writing at
least thirty (30) days prior to any change in business address, Transparency
payment address, business telephone number, office hours, tax The participating provider authorizes BCBSMT to publicly release
identification number, state license number, DEA registration general cost, utilization, and other information consistent with
number, and/or change in employment status. BCBSMT’s consumer transparency programs.
The participating provider will cooperate with BCBSMT in
matters relating to coordination of benefits with other carriers Prohibitions Regarding Discrimination
or responsible parties, to make inquiry regarding and provide The participating provider will not refuse to accept a BCBSMT
BCBSMT relevant information relating to any other coverage participant as a patient on the basis of race, color, religion,
held by a participant, and to abide by the BCBSMT coordination sex, age, veteran status, national origin, health status, medical
of benefits, subrogation, and duplicate coverage policies condition of the patient, and/or participation in a health plan
determinations procedures and rules, as well as with the as a private purchaser or as a participant in a publicly financed
applicable state and federal regulations. program; provided, however, the participating provider should not
render services because of lack of training, skill, or experience or
Cooperation because of licensure restrictions if failure to render the service
would endanger the health, life, or safety of the patient because
The participating provider will cooperate with BCBSMT in
of the patient’s health status or medical condition.
programs of utilization management, quality assurance, quality
improvement, audits, peer review, and all internal and external BCBSMT does not prohibit or discourage the participating
grievance procedures. Each party agrees to use its best efforts provider from discussing with or communicating in good faith
to assure that activities conducted pursuant to any quality to a current, prospective, or former BCBSMT participant, or the
assurance program or utilization management plan will be participant’s designee, information or opinions regarding:
conducted in such a manner as to be subject to and obtain the • The participant’s health care, including, but not limited to, the
benefits of applicable laws conferring immunity on peer-review Participant’s medical condition or treatment options, including
committees and their participants, and rendering peer-review alternative medications, regardless of BCBSMT coverage
documents and information confidential and non-discoverable. limitations; or
• The provisions, terms, requirements or services of BCBSMT as
Access to Premises they relate to the medical needs of the BCBSMT participant
The participating provider provides BCBSMT, or its authorized
representatives, the right to enter at reasonable times the
participating provider’s premises or other places where services
under this agreement are performed to inspect, monitor, or
otherwise evaluate the services performed. The participating
provider will provide reasonable facilities and assistance for the
safety and convenience of the persons performing those duties.
58
MONTANA HEALTHCARE PROGRAMS NOTICE The NDC on the claim must be the NDC that was
NATIONAL DRUG CODE (NDC) BILLING REQUIREMENTS dispensed to the member.
The Federal Deficit Reduction Act of 2005 mandates that all NDC Formatting
State Medicaid Programs require the submission of National When billing the HELP Plan, the required NDC is 11 digits.
Drug Codes (NDCs) on claims submitted with certain procedure The NDC should be structured in the 5-4-2 format. Some
codes for physician-administered drugs. This mandate affects manufacturers omit leading zeros in one of the three positions.
all providers who submit claims for procedure-coded drugs both This results in a 10-digit number, which is invalid. To ensure
electronically and manually. proper payment, the provider must add the appropriate leading
The HELP Plan requires all claims submitted for physician zero to the affected segment of the format.
administered drugs to include the NDCs, the corresponding The table below indicates where the leading zero should be
CPT/HCPCS codes, and the units administered for each code. placed in three separate examples.
The HELP Plan reimburses only in the case where a drug
is manufactured by companies that have a signed rebate NDC Example Conversion: 10-Digit to 11-Digit Format
agreement with the Centers for Medicare and Medicaid Leading Zero Location 10-Digit Examples Add Zero
Services (CMS). 5-digit segment XXXX-XXXX-XX 0XXXX-XXXX-XX
A list of drug manufacturers who have a rebate agreement is on 4-digit segment XXXXX-XXX-XX XXXXX-0XXX-XX
the Provider Information website at: 2-digit segment XXXXX-XXXX-X XXXXX-XXXX-0X
http://medicaidprovider.mt.gov/Portals/68/docs/current/ Access to Medical Records
labelersrebatecurrent.pdf.
Subject to any applicable disclosure and confidentiality laws,
When a procedure code requires an NDC, the HELP Plan covers upon BCBSMT’s request, the participating provider will
only those NDCs that are rebateable. provide BCBSMT, or its authorized third-party reviewer, with
all records necessary to comply with BCBSMT’s auditing
Physician Administered Drugs programs, including but not limited to, utilization management,
Physician administered drugs are processed by BCBSMT. case management, disease management, fraud and abuse,
claim reviews and audits, billing practices, and quality
BCBSMT requires the use of National Drug Codes (NDCs) and
assurance programs.
related information when drugs are billed on professional/
ancillary electronic (ANSI 837P) and paper (CMS-1500) claims.
As of May 1, 2015, the NDC pricing effective date, professional/ Confidentiality
ancillary claims for drugs must include NDC data in order to be Both BCBSMT and the participating provider agree that Private
processed by BCBSMT. Health Information (PHI) to which it has access or receives
pursuant to the agreement will be kept confidential and will not
Refer to the BCBSMT Provider Secure Provider Portal for NDC
be disclosed to any person except as authorized by state law,
Billing Guidelines.
by federal law and/or by a participant through an appropriate
An NDC is considered rebateable only if all of the consent or authorization.
following conditions are met:
Each party is responsible for any breach of its confidentiality
• The drug is a HELP Plan covered drug.
obligations, including any obligations each may have under
• The dispensed NDC is valid. state or federal law, both during the term of the agreement and
• The drug dispensed is not terminated. after termination.
• The drug is a product of an eligible manufacturer.
• The DESI indicator is not 5 or 6.
59
Chapter 10:
ENROLLMENT SCREENING
AND CREDENTIALING
Chapter 10: Enrollment Screening and Credentialing January 2018
CONTRACTING AND CREDENTIALING

Overview persons convicted of crimes, site visits, criminal background
checks, federal database checks, enrollment screening based on
Definitions provider risk category (including unannounced pre and post site
visits where applicable).
Prior to participation in the HELP Plan provider network,
a provider must sign a HELP Plan contract amendment, A provider should submit the completed credentialing application
successfully be credentialed by BCBSMT and complete the and provider enrollment application (as necessary) to BCBSMT
provider enrollment screening compliant with 42 CFR 455 at least 45 days prior to his/her starting date of practice to allow
Subparts B & E. time for processing of the applications.
Each of these, contracting, credentialing and enrollment A provider’s participation effective date is the
screenings are separate processes. credentialing approval date.
Contracting is two parties entering into an agreement voluntarily BCBSMT does not back date effective dates of participation.
to create legal obligations between them.
Credentialing is the process by which BCBSMT reviews and Provider Enrollment Screening (HELP/HMK)
validates the professional qualifications of health care providers, According to the CMS Federal Regulations, BCBSMT should
both institutional and professional providers, who apply for not duplicate provider enrollment screening efforts already
participation with our health insurance organization, ensuring performed by Medicare, Montana Medicaid, or another state’s
that they meet the required professional standards. Medicaid or CHIP Program. Verification of participation in
one of these programs meets the intent of the enrollment/
Provider enrollment screening is required by the Centers for
screening process for participation in the HELP Plan and HMK
Medicare and Medicaid (CMS), and is the process by which
provider networks.
Blue Cross and Blue Shield of Montana (BCBSMT) reviews
and validates the identity of providers, both institutional and If the provider is not participating and, therefore, has not been
professional providers, and ensures standards required by screened by one of these agencies, the provider must complete
federal law are met. and submit a complete provider enrollment screening application.
Apply in Advance of the Start of Practice Credentialing Applications

The BCBSMT provider contracts require successful completion For professional providers, BCBSMT uses the Council for
of credentialing and enrollment screening prior to participation in Affordable Quality Healthcare (CAQH) on-line credentialing
the BCBSMT HELP Plan provider network. application/data repository.
Credentialing and re-credentialing criteria are the rules and Providers already registered with CAQH must ensure their
regulations that govern BCBSMT’s credentialing and re- information is current and authorize BCBSMT to view
credentialing process for the HELP Plan. The applicable HELP their credentials.
Plan screening criteria and credentialing and re-credentialing
Providers not previously registered may self-register and
criteria are be consistent with the applicable Montana and
complete their information on-line any time and authorize
federal statutes, rules and regulations, including, without limit,
BCBSMT to view their credentials.
the Centers for Medicare and Medicaid Services (CMS) Medicaid
requirements for provider screening and enrollment requirements For institutional/facility providers, BCBSMT uses a paper
as outlined under 42 Code of Federal Regulations 455 Subparts credentialing application.
B and E, including but not limited to disclosure of information
regarding ownership and control, business transactions and
62
Prior to Applying for Participation Credentialing Process

Before a provider can apply to join the BCBSMT provider Step Action
networks, the provider must have a current, active, unrestricted 1 To begin the application process a provider must first
Montana license. The provider may not have been sanctioned by request a BCBSMT provider record.
or excluded from participating in government programs. • Practices new to BCBSMT may access an
on-line form on the BCBSMT website at
Credentialing Committee www.bcbsmt.com/provider/
The BCBSMT Credentialing Committee consists of practicing network-participation/contract-request to
complete and submit electronically.
physicians and non-physician health care providers representing
multiple specialties from across Montana, and representatives • Individual professional providers joining an existing
from BCBSMT. Each applicant’s credentials are reviewed by contracted practice must complete and submit the
the Credentialing Committee for approval of participation in the "Add Sheet"/ Exhibit B of the Professional Provider
Agreement. And may skip Step 2.
BCBSMT provider networks.
2 After BCBSMT creates the required provider record,
a contract is forwarded to the provider. The provider
Provider Rights
must complete the necessary information, sign, date,
Providers have the right to obtain information regarding and return the contract.
their credentialing status upon request by e-mailing 3 BCBSMT then rosters the professional provider with
MTHCSSPEC@bcbsmt.com or calling 1-800-447-7828, CAQH. The system automatically searches for a
Extension 6100. completed CAQH application daily until one is found.
Prior to review, the provider has the right to correct incomplete, BCBSMT begins to process the institutional provider/
inaccurate, or conflicting credentialing information. facility credentialing application.
4 The Credentialing Team reviews the application for
Providers Requiring Credentialing completeness and may need to clarify application
All professional and institutional providers must be credentialed details with the provider. Three (3) attempts to obtain
prior to participation in all of the BCBSMT provider networks, missing information or clarify details are made. After 3
with the exception of the Healthy Montana Kids (HMK) network. attempts, application is administratively denied.
Only physicians must be credentialed for HMK. 5 BCBSMT verifies the information supplied in
the application with the primary sources of
Licensing Requirements the information.
• BCBSMT is dependent upon timely response
The provider must have a valid and current license to practice
from those sources.
in the state of Montana. Licensure is verified through the
appropriate Montana State Licensing Board. • The Credentialing Team reviews the information
for any discrepancies and may need to clarify
application details with the provider.
6 The application is presented to the BCBSMT Medical
Director or the BCBSMT Credentialing Committee
for consideration of participation in the BCBSMT
provider networks.
Note: The Credentialing Committee meets twice
monthly.
63
Step Action Step Action

7 BCBSMT sends the provider notice of the 8 Once a provider is approved for network participation,
credentialing outcome within ten (10) business days of BCBSMT executes the provider contract. A copy of
the decision. the contract is sent to the provider with notification
of the effective date of the provider networks. The
provider database is updated with the effective date
of the networks.
• The contract effective date is the credentialing
approval date. Contracts are not backdated.
PROFESSIONAL PROVIDER- MINIMUM CREDENTIALING

CRITERIA- EDUCATION & TRAINING
Overview Recognized Board Certification programs include those approved
by the following:
To be eligible to apply for network participation, the professional
providers outlined in this Education & Training section, must Abbreviation Recognized Board
meet the following minimum requirements. The highest level of ABMS American Board of Medical Specialties
education is verified through the: AOA American Osteopathic Association
• Professional school and training programs ABMFS American Board of Oral &
• Appropriate certification board Maxillofacial Surgeons
Physicians (MD, DO & Oral and Podiatrists

Maxillofacial Surgeons)
Eligibility for BCBSMT HELP Plan and HMK
Eligibility for BCBSMT HELP Plan and HMK Provider Networks Provider Networks
To be eligible to apply for participation in the traditional provider To be eligible to apply for network participation in the traditional
networks, physicians must meet the following requirements: networks, at a minimum, a podiatrist must have:
• Completed a medical degree or foreign equivalent, and; • Completed a podiatric medical degree or foreign equivalent,
• One year post graduate training in general medicine after June 30, 1982; and
• A physician who only completed one year of postgraduate • Completed one year postgraduate training or has
training is approved as a General Practitioner. equivalent experience or training approved by the
Credentialing Committee.
• A physician must have completed a residency in a specialty in
order to be considered a specialist.
Physician Assistants
To be eligible to apply for participation, physician
assistants must have:
• Graduated from a physician assistant program approved by
the American Medical Association Committee on Allied Health
Education and Accreditation, or its successor and
• Maintained certification issued by the National Commission on
Certification of Physician Assistants
64
Advanced Practice Registered Nurses (NPs, Licensed professional counselor

CNMs, CRNAs and CNSs) • Completed a planned graduate program of 60 semester hours,
primarily counseling in nature, 6 semester hours of which were
To be eligible to apply for participation, advanced practice earned in an advanced counseling practicum that resulted in
registered nurses must have: a graduate degree from an institution accredited to offer a
• Graduated from the advanced practice nursing education graduate program in counseling.
required to take the first national certification examination
available from a board-approved national certifying body Licensed clinic social workers
appropriate to the specific field of advanced practice • Completed a doctorate or master’s degree in social work from
registered nursing and a program accredited by the Council on Social Work Education
• A current certificate issued by a board-approved national or approved by the board.
certifying body appropriate to the specific field of advanced
practice registered nursing Optometrists
To be eligible to apply for participation, optometrists must have:
Mental Health Providers • Graduated from a school approved by the board, including
To be eligible to apply for participation, mental health providers schools of optometry accredited the International Association
must meet the following requirements: of Boards of Examiners in Optometry
Psychologists
• Completed a doctoral degree in clinical psychology from
Physical and Occupational Therapists
an accredited college or university having an appropriate To be eligible to apply for participation, physical and occupational
graduate program approved by the American Psychological therapists must have:
Association; or • Graduated from a physical or occupational therapy program
• Completed a doctoral degree in psychology from an approved by one of the following organizations:
accredited college or university not approved by the American –– Committee on Accreditation in Physical Therapy Education
Psychological Association and successfully completed a formal
–– Accreditation Council for Occupational Therapy Education
graduate retraining program in clinical psychology approved by
the American Psychological Association; or
• Completed a doctoral degree in psychology from an accredited Speech-Language Pathologists and Audiologists
college or university and has completed a course of studies To be eligible to apply for participation, speech-language
that meets minimum standards specified in rules by the board. pathologists and audiologists must have:
• Completed an academic, supervised clinical practicum and
Licensed addiction counselor post-classroom sponsored employment requirements of the
• Completed a master’s degree in alcohol and drug studies, American Speech-Language and Hearing Association
psychology, sociology, social work, or counseling, or a
comparable master’s degree from an accredited college
or university. Certified Surgical Assistants
• An LAC who has not completed as master’s degree is To be eligible to apply for participation, certified surgical
required to complete a master’s degree in alcohol and drug assistants must have:
studies, psychology, sociology, social work, or counseling, • Graduated from a National Surgical Assistant Association-
or a comparable master’s degree within 5 years of approval approved program of surgical assisting
to the network.
65
Registered Dietitians • Baccalaureate and masters or a doctoral degree in the field

of dietetics, food and nutrition, or public health nutrition
To be eligible to apply for participation, registered
conferred by an accredited college or university.
dietitians must have:
• Completed appropriate academic requirements for the field of • Completed a program of supervised clinical experience of
dietetics and related disciplines, including; not less than 6 months in length that is designed to train
entry-level dietitians through instruction and assignments in a
clinical setting.
PROFESSIONAL PROVIDER-OTHER MINIMUM

CREDENTIALING REQUIREMENTS
Malpractice Coverage Drug Enforcement Administration
The provider must have current malpractice liability insurance Certification (DEA)
coverage ($1,000,000 per occurrence and $3,000,000 in Physicians, advanced practice nurses and physician assistants
aggregate is encouraged). Coverage is verified through a: must maintain current DEA certification or provide a plan with
• Copy of Malpractice Certificate of Insurance (COI) how they will provide prescriptions to their patients requiring
such. The DEA certification is verified through:
For provider group malpractice policies, the individual
• A copy of a current DEA certificate
professional provider’s name must be listed on the COI, or the
malpractice carrier must provide a list of the names of providers • Registration in the NTIS database
covered by the policy.
Physician Assistants Only
Medicare/ Medicaid Sanctions Physician Assistants must have a supervising physician.
The provider is currently eligible to participate in Medicare and/
or Medicaid programs. A provider cannot have been sanctioned. Individual Criteria and Other Considerations
Lack of sanctions is verified through the:
Other individual review criteria may include, but is not limited to:
• Office of Inspector General Exclusions List
• State board disciplinary action/license restrictions
• Excluded Parties List System (EPLS)
• Hospital disciplinary action
• National Practitioner Data Bank
• Drug Enforcement Agency certification disciplinary
action/restrictions
Hospital Admitting Privileges • Criminal history
Physicians must maintain hospital admitting privileges at an • Alcohol or drug abuse/provider impairment
acute care hospital, or have a formal written admit plan in
• Malpractice suits/claims history
place with another physician or physician group in the same
community of practice to admit on his/her behalf. Privileges are • Claims fraud or abuse
verified with: • Completeness of application
• The appropriate hospital’s medical staff services office • Member complaints
• Formal admit plan • Quality of care issues
66
INSTITUTIONAL PROVIDER CREDENTIALING CRITERIA

Institutional/Facility Provider Credentialing If a quality issue is identified at any time, information regarding
the issue is presented to the Credentialing Committee for review
BCBSMT requires all institutional/facility providers to submit
and action as needed.
a credentialing application. All locations for credentialed
institutions/facilities are credentialed separately. Initial
credentialing is conducted prior to the institution/entity
contract being executed or being listed in the provider directory.
Information collected and the standards for institutional
providers are as follows:
Application Source of Standard
Requirement Information
Current valid State Copy of state Valid, current
of Montana License license(s) license
Current professional Copy of malpractice Current
liability coverage certificate of professional
insurance liability insurance
coverage
Medicare Verification In good standing
Certification of Medicare with Medicare
Certification with
State
Survey results, Copy of appropriate Based on the
as applicable Accrediting committee’s
Body, JCAHO, judgment, the
CHAP, AAHC or survey results
other recognized do not indicate
accrediting body, deficiencies
survey results that would pose
State survey unacceptable risk
results to the patients.
Sleep medicine Verification of Accreditation by
centers accreditation with the American
the American Academy of Sleep
Academy of Sleep Medicine (AASM)
Medicine (AASM) is required within
12 months of
approval to
the network.
67
RE-CREDENTIALING
Time Frame & Application Physicians are required to complete 75 Category I
continuing education credits every three (3) years between
Re-credentialing is performed every three (3) years for both
re‑credentialing cycles.
professional and institutional providers.
The following websites offer free or low-cost continuing medical
Professional providers have the ability to maintain current
education credits:
information in CAQH. If at the time of re-credentialing the
information is not current, the provider is notified to update www.medscape.com www.medconnect.com
information in CAQH. BCBSMT requires an updated provider
www.cmeweb.com www.medsitecme.com
application and re-verification of all of the information, except
the provider’s initial education and training.
BCBSMT Contacts
Facilities providers are sent paper applications and are required
For questions regarding the provider enrollment process,
to update the information.
contact BCBSMT at
The BCBSMT Medical Director or Credentialing Committee
1-800-447-7828, Extension 6100, or via e-mail to
reconsiders each provider’s application for continued
HCSSPEC@bcbsmt.com
participation at re-credentialing.
If information is received that raises quality concerns prior CAQH Resources
to re-credentialing, the provider’s participation may be
Explore the CAQH websit at www.caqh.org for more
reconsidered at that time.
information about the CAQH ProView database and the
Failure to comply with re-credentialing within the three-year time application process.
frame results in the provider’s name being removed from the
CAQH Help Desk: 888-599-1771
directory and/or termination of the provider contract.
Help Desk Email Address: providerhelp@solutions.caqh.org
Re-credentialing Continuing
Education Requirements
State licensing board continuing education requirements are
followed for all professional providers with the exception of
physicians (MDs, DOs, DPMs and oral & maxillofacial surgeons).
HELP PLAN AND HMK PROVIDER ENROLLMENT SCREENING

Policy Purpose
This policy defines the provider enrollment and screening This process ensures every provider participating in HELP
process for providers prior to their participation in the HELP Plan Plan or HMK meet applicable Federal regulations or state
and HMK networks. requirements for the provider type prior to making an enrollment
determination.
Regulatory Requirements & References

This policy is compliant with 42 CFR Part 455 subparts B & E
68
Provider Minimum Eligibility Definitions

To participate in the HELP Plan provider network, a provider: Newly enrolling and revalidating providers are placed in one of
• Must be a participating provider with BCBSMT three screening categories based upon assessment of fraud,
• Must sign a HELP Plan Amendment to the BCBSMT PPO waste and abuse risk of the provider. BCBSMT follows the
Agreement Entity Agreement with BCBSMT categories as defined by CMS for Medicare. The providers are
categorized as follows:
• Must have a valid National Provider Identifier (NPI)
• Must have a valid unrestricted Montana license Limited -Professional Limited- Facilities
• Complete the BCBSMT credentialing process Providers
• Medical Doctors (MDs) • Ambulatory Surgery
To participate in the HMK provider network providers: • Doctors of Osteopathy (DOs) Centers (ASC)
• In a few cases, there can be a stand alone contract with
• Doctors of Dental Surgery/ • Chemical
the HELP Plan. Dependency Centers
Oral Surgeons (DDS/DMDs)
• Must sign an HMK Agreement with BCBSMT • Dialysis
• Doctors of Podiatric
• Must have a valid National Provider Identifier (NPI) Medicine (DPMs) Treatment Centers (ESRD)
• Must have a valid unrestricted Montana license • Doctors of • Hospitals
• Physicians (MDs, DOs and DPMs) must complete the BCBSMT Chiropractic (DCs)* (Acute Care & CAH)
credentialing process • Optometrists (ODs) • Inpatient Mental
Health Facilities
• Nurse Practitioners (NPs)
Sanctions under Federal Health • Laboratories
• Certified Nurse
Programs and State Law Midwives (CNMs) • Oxygen Suppliers
To participate in the HELP Plan and/or HMK provider network • Certified Registered Nurse • Radiology Centers
providers (professional providers and suppliers) or any person Anesthetists (CRNAs) • Psychiatric Residential
with an ownership or controlling interest or who is an agent or • Clinical Nurse Treatment Centers
managing employee of the provider may not: Specialists (CNSs) • Skilled Nursing Facilities
• Have had an imposition of a payment suspension within the • Physician Assistants (PAs) (SNF)
previous 10 years
• Occupational
• Be terminated or otherwise precluded from billing Medicaid; Therapists (OT)
• Be excluded by the Office of Inspector General (OIG) • Speech-Language
• Have had billing privileges revoked by a Medicare contractor Pathologists and Speech
within the previous 10 years and be attempting to establish Therapists (SLPs and STs)
additional Medicare billing privileges by enrolling as a new • Licensed Addiction
provider or supplier or establishing billing privileges for a new Counselors (LACs)
practice location;
• Licensed Clinical
• Be excluded from any federal health care program Professional
• Have been subject to any final adverse action (as defined in 42 Counselors (LCPCs)
CFR 424.502) within the past 10 years; or • Licensed Clinical Social
• Be a provider type or supplier that is prevented from enrolling Workers (LCSWs)
based on a moratorium imposed by DPHHS. • Psychologists (PhDs/
EdDs/PsyDs)
* HMK Only
69
Moderate High Limited Risk- Professional Providers the following

• Community • Newly Enrolling elements are verified:
Mental Health Centers DME (Durable Element Source
• Hospice Agencies Medical Equipment) Current Unrestricted Montana.gov Licensee Lookup
• Physical Therapists (PTs) • Newly Enrolling Home Montana License
Health Agencies Current NPI NPI Registry (NPPES)
• Independent Labs
Lack of OIG Sanctions OIG/LEIE Federal Exclusion
• Radiology Centers website: http://oig.hhs.
• Revalidating DME (Durable gov/exclusions/index.asp
Medical Equipment) Lack of Exclusions from System for Award
Federal Programs Management/ Excluded
Existing Medicare/Medicaid Providers Parties List System
According to the CMS Federal Regulations, BCBSMT should EPLS Web Site
not duplicate provider screening efforts already performed by Validate the Provider’s Identity SSN Master Death File
Medicare, Montana Medicaid, or another state’s Medicaid Other State’s Licenses Appropriate State’s
or CHIP Program. Verification of participation in one of these Licensing Board
programs meets the intent of the enrollment/screening process
Limited Risk- Facility/Institutional Providers the following
for participation in the HELP Plan provider network.
elements are verified:
Element Source
Provider Application Process
Current Unrestricted Montana.gov Facility
As part of the contracting process, a provider is queried as Montana License License Lists
to current participation in Medicare, Montana Medicaid, or
Current NPI NPI Registry (NPPES)
another state’s Medicaid or CHIP Program. If the provider is
Lack of OIG Sanctions OIG/LEIE Federal Exclusion
not participating and, therefore, has not been screened by one
website: http://oig.hhs.gov/
of these agencies, the provider must complete and submit a
exclusions/index.asp
complete provider enrollment application.
Lack of Exclusions from System for Award
Performing the Screening Process Federal Programs Management/ Excluded
If the provider indicated current participation in the Medicare, Parties List System
Montana Medicaid, or another state’s Medicaid or CHIP EPLS Web Site
Program, the following sources are used to verify such: Moderate Risk Providers Must meet the above Limited
Risk provider requirements,
Montana Medicaid Medicare Other State’s
plus an unannounced
Medicaid/
site visit is required.
CHIP Program
High Risk Providers Must meet the above Limited
MT Medicaid Contractor PECOS Appropriate
Risk provider requirements,
- Conduent file state’s program
plus an unannounced site
visit and fingerprint based
criminal history background
70
Application Fees
In accordance with Federal regulations, this process ensures an application fee is collected from specific provider types applying for
participation in HELP Plan or HMK networks, prior to executing the contract.
The following provider types are required to pay an application fee at initial enrollment, at revalidation every 5 years, and when adding
new locations as indicated below:
Initial Change Change of Add New

Provider Type Revalidation
Enrollment of Owner Info Location
Ambulatory Surgery Center (ASC) Yes Yes No No Yes
Community Mental Health Center Yes Yes No No Yes
Critical Access Hospital Yes Yes No No Yes
Durable Medical Equipment Supplier, Prosthetics, Yes Yes No No Yes
Orthotics, & Suppliers
End Stage Renal Disease Facility (ESRD) Yes Yes No No Yes
Histocompatibility Laboratory Yes Yes No No Yes
Home Health Agency Yes Yes No No Yes
Hospice Yes Yes No No Yes
Hospital Yes Yes No No Yes
Independent Diagnostic Treatment Facilities Yes Yes No No Yes
(IDTFs) including:
• Radiology Center
• Sleep Centers
Independent Clinic Laboratory Yes Yes No No Yes
Pharmacy Yes Yes No No Yes
Skilled Nursing Facility Yes Yes No No Yes
The fee is determined by CMS on an annual basis. The 2017 fee is $560.
For providers reporting a change of ownership, the ownership change does not require an application fee if the change does not
require the provider to enroll as a new provider.
According to the CMS Federal Regulations, provider who have paid the application fee to Medicare contractor, Montana Medicaid or
another State’s Medicaid or CHIP program are exempt from being charged a fee for participation in the MT HELP Plan or HMK provider
networks. BCBSMT verifies such enrollment.
Checks should be written to “Blue Cross and Blue Shield of Montana” and submitted with the HELP/HMK Enrollment Application.
In the event a provider fails to submit the application fee, BCBSMT will send a written request to the provider, and will pend the
screening enrollment process until it is received.
The application fee should be submitted to the below address:
ATTN: Network Management Department
PO Box 4309
Helena, MT 59604
If the application fee is not received within 30 days of the request, the provider’s application will be denied.
71
Fingerprint Based Criminal History • Failure to submit sets of fingerprints determined by BCBSMT
Background Checks within 30 days of request
A provider, or any person with 5 percent or greater ownership in the • Failure to comply with site visit
provider, is required to undergo a fingerprint based criminal history • Provider is found to have falsified information on
background check prior to enrollment. the application
• BCBSMT is unable to verify the identity of the applicant.
The provider or person shall go to their local law enforcement office to
obtain the fingerprints. The provider is responsible for any fees associated
with obtaining the fingerprints. Ongoing Monitoring
The fingerprint card should be sent to the following address: On at least a monthly basis, BCBSMT performs searches of
federal databases to monitor for ongoing compliance with the
ATTN: MT Medicaid Team
provider enrollment requirements. In the event a provider is
determined to no longer meet the requirements, BCBSMT will
PO Box 4309
take immediate action to terminate the provider’s contract.
Helena, MT 59604
BCBSMT sends the fingerprint card with the request for the Revalidation Process
criminal history background check to the Montana Department
of Justice for processing and reviews the results when returned. All providers must be revalidated every five years.
Denial or Termination of Enrollment Participating Provider Effective Date Requests

• No provider is considered to be a participating provider until
A provider, or any person with 5 percent or greater ownership they have completed the provider enrollment screening
in the provider, who fails to comply with the provider enrollment process and the BCBSMT credentialing process, including
screening requirements may be denied or terminated accordingly. having been approved by BCBSMT (see the “Credentialing
This includes, but is not limited to: Standards” section for full requirements).
• Failure to submit timely and accurate information –– Effective dates are not made retroactive
• Provider is found to have been convicted of a crime • Claims received prior to credentialing/re-credentialing or
with Medicare, Medicaid or the Title XXI program in the enrollment screenings are treated as out-of-network until the
last 10 years. provider has met all network requirements.
72
–– Note — Benefits are not available for HELP Plan Participants

for services provided by an out-of-network provider, with the
exception of urgent/emergent or preauthorized services.
• Providers are strongly encouraged to submit all necessary
documentation for participation at least 60 days prior to the
intended effective date.
• Once approved, all providers are expected to comply with re-
credentialing and revalidation standards.
• If a provider does not comply with re-credentialing or
revalidation requirements before the current cycle ends,
BCBSMT reserves the right to treat all such claims as
out-of- network.
• If a provider is terminated for not meeting re-credentialing
requirements, the provider will have thirty (30) days from
the termination date to rectify and apply for reinstatement.
Providers who remain terminated beyond thirty (30) days
will have to reapply to the network under the normal
course of business.
73
Chapter 11:
COMPENSATION POLICIES
Chapter 11: Compensation Policies January 2018
Overview
Provider compensation policies for HELP Plan covered benefits
are located on the Department of Public Health and Human
Services website at http://medicaidprovider.mt.gov. Refer
to “Resources by Provider Type” and “RBRVS Fee Schedules”
for specific provider manuals and fee schedules or call Provider
Customer Service at 1-877-296-8206.
Under all circumstances, health care providers must retain
100 percent of the reimbursement amounts claimed by the
state as demonstration expenditures. Moreover, no prearranged
agreements (contractual or otherwise) may exist between the
health care providers and the state and/or local government to
return and/or redirect any portion of the Medicaid payments.
This confirmation of Medicaid payment retention is made with
the understanding that payments that are the normal operating
expenses of conducting business (such as payments related to
taxes (including health care provider-related taxes), fees, and
business relationships with governments that are unrelated
to Medicaid and in which there is no connection to Medicaid
payments) are not considered returning and/or redirecting a
Medicaid payment.
76
Chapter 12:
CARE COORDINATION AND
WELLNESS PROGRAMS
Chapter 12: Care Coordination and Wellness Programs January 2018
Care Coordination and Wellness Program DPHHS Community Based Wellness Programs:
Care Coordination Montana Living Life Well Program:

Chronic-disease self-management education workshops that
The BCBSMT HELP Plan provides Care Coordination services
help adults with one or more chronic conditions learn how to
to your patients, and we encourage providers to reach out to
take an active role in managing their health. The Montana
our team to request these services when needed. Our trained
Living Life Well Program is a six week workshop with a 2.5 hour
care coordinators help participants manage chronic conditions
meeting each week that teaches skills needed to take an active
and non-health-related issues. BCBSMT HELP Plan Care
role in managing health.
Coordinators, many of whom are registered nurses or social
workers, are available to help participants navigate the health Diabetes Self-Management Education:
care system; including setting and keeping appointments,
reviewing eligibility and benefits and connecting participants Diabetes education teaches about the daily needs of people
with social supports to improve health outcomes. To support with diabetes. This class is taught by certified professionals. A
a growing HELP Plan population, BCBSMT uses a combination referral from their PCP is needed. The setting and number of
of care coordination, community outreach and supplemental sessions varies by location and the needs of the patient.
benefits to provide support and education to participants.
Asthma Self-Management Education:
We encourage our providers to contact our Care Coordination Asthma education teaches about the daily needs of people
Department at 877-296-8206, Monday – Friday from with asthma. This class is taught by certified professionals,
8AM to 8PM MST. needs a referral from PCP, initially the education is one hour but
opportunities for follow up sessions are available.
Wellness Program
Arthritis Foundation Exercise Program:
The BCBSMT HELP Plan is committed to stand beside
Group recreational exercise program that helps adults at all
participants by offering various Wellness Programs to assist
levels of fitness, with or without arthritis, become more active
them in achieving and maintaining a healthy life. The Health
and energized. One hour classes that meet two to three times
Assessment allows participants to work with an assigned Care
per week, offered until participant has met their identified
Coordinator on available programs to meet Personal Wellness
goals and may continue for as long as the participant would
Goals. Available programs include Smoking Cessation, Diabetes
like thereafter.
Management, Asthma Management, Disease Prevention and
more. The Program promotes healthy lifestyles, educates on Walk with Ease Program
chronic health conditions, directs the participant in locating
accurate health information, and provides information on how Walk with Ease helps people get started and continue a walking
to access plan benefits. If a participant is enrolled in a Wellness routine. Participants must be able to stand unassisted for five
Program, the provider will be notified and provided the Care minutes but may use a cane or walker while walking. One hour
Coordinators contact information. classes meet three times a week for six weeks.
78
Diabetes Prevention Program: Asthma Management Program:

The Diabetes Prevention Program is for adults at high risk of This program focuses on the cause of asthma and assists the
diabetes and cardiovascular disease. Eligibility must be verified participants in management of their symptoms on a daily basis.
by their PCP. Participants receive group-based education on diet Treatment, medication and activity education are included in this
and exercise to adopt a healthy life style. It is a twelve-month program. This program can last up to six sessions depending
program with a total of twenty-two sessions. on the participant need. It requires a referral or order from the
participant’s PCP and the care coordinator will work with the
Montana Tobacco Quit Line: PCP to get the referral.
The Montana Tobacco Quit Line is a free service to any Montana
resident, that offers counseling over the phone and free nicotine Diabetes Prevention and Management:
replacement therapy that can triple chances of quitting for This program provides individual participants who are at high
good. The quit line has a special program to help pregnant and risk due to family disposition, pre diabetes lab work or recent
postpartum women with more coaching and additional benefits diagnosis an opportunity to learn ways to prevent or manage
and a dedicated line for American Indian callers that has native diabetes. It focuses on diet, exercise, managing a blood glucose
coaches. The program is considered complete after 5 calls but log, new medications, sick days, and general management of
sometimes the participant continues to struggle with smoking this chronic disease or in total prevention. Sessions can last up
cessation and will continue as long as they desire. Generally, to eight weeks. It requires a PCP order or referral and the care
the quit line calls are scheduled two weeks apart, however, coordinator will work with the PCP to get the referral.
the coaches will work around the participant’s schedule. They
will not turn anyone away who is seeking coaching and the Hypertension:
participant can receive as many calls from their coach as needed. Undiagnosed hypertension is one of the greatest risks for heart
For locations of programs available in Montana communities attack and stroke. Early diagnosis and treatment are essential
refer to the website: to prevent further heart damage and control symptoms and ill
effects. Participants are educated by their care coordinator on
http://dphhs.mt.gov/publichealth/chronicdisease/ diagnosis, treatment, and the need for ongoing care through their
CommunityBasedPrograms. PCP. This program focuses on treatment, exercise and weight
loss for management of this condition. Sessions can last up to
BCBSMT Wellness Programs: six weeks. A referral from participant’s PCP is recommended.
BCBSMT Wellness Programs are individualized programs
Tobacco/Smoking Cessation:
structured to meet the needs of participants who may not
be able to attend a community program, or prefer one to Programs to assist with smoking cessation include the Montana
one interaction. Care Coordinators are licensed medical Tobacco Quit Line and other resources. This program may be
professionals who provide this education and interaction over successful for those participants who have tried the Quit Line
the phone. Once the participant agrees to the individualized without success, have tried other options such as medications
training, they work with their care coordinator to set wellness or other alternatives. Care coordinators work with individuals
goals. They are required to have participated in four or more to review prior attempts at cessation and consider other options
individualized sessions. The participant can request more if he/ that may be more successful. Care coordinators work with
she wishes, or the wellness goals have not been met. Currently the participant and their PCP to manage these options and
BCBSMT offers five primary programs, but other programs may alternatives. Assistance and discussions/questions can last up to
be opened based on the needs and requests of the participant. six weeks depending on participant needs.
Requirements for the programs are based on an individuals
assessed risk or if the participant requests to be enrolled in any
wellness program.
79
Weight Loss and Healthy Lifestyle: 1. BCBSMT referred:

Programs offer care coordinator assistance in working with a. All participants, as part of their enrollment into the HELP
participants on a plan in which the participant plans his/her Plan, complete a Health Assessment; this assessment
course of action regarding diet, exercise, positive changes in stratifies the participant into risk levels as described earlier.
lifestyle, and goal setting. Participants can identify triggers and If the participant stratifies into moderate or high risk they
work within the actions they can manage, given their personal are assigned a case manager or a care coordinator who
works with the individual developing a plan of care and
situation. The goal is to encourage healthy changes and new
referral to the wellness programs is made.
habits that will lead to weight loss and a healthier life. Six to
eight weeks is recommended for completion of this program. b. If a participant does not complete a health assessment
or cannot be reached, they are placed into an Integrated
Participation: Predicative Modeling (IPM) category and they are stratified
into a risk category. Case managers or care coordinators will
Participants who have consented to participate in the HELP Plan attempt three times to connect with the participant for a
Healthy Behavior Plan and are involved actively in their care plan program referral.
with their care coordinator will be considered “participating in a
1. DPHHS referred:
wellness program.”
Participation is defined as: The participant working with his/her Montana Chronic Disease Prevention and Health Promotion
care coordinator in developing a care plan, meeting the goals Bureau will refer participants to wellness programs.
identified in the care plan, and attending at least 75% of the
Data Reporting:
wellness program sessions as described under each wellness
program. Participants can choose to attend more sessions The following metrics will be reported for the HELP Plan
if they desire. Healthy Behavior Plan:
• Participation rates;
Participant Enrollment: • Number of engaged participants;
Participants can be enrolled in a wellness program in a • Number of telephonic outreach attempts;
variety of ways:
• Number of participant mailings;
1. Self-refer:
• Referrals to the wellness program by referral type:
a. Call the wellness program directly and complete participant
information sheet. –– Self
b. Call participant services at BCBSMT and request –– Provider
information or enrollment in a wellness program. They will –– Health Assessment (HA)
be assigned a care coordinator who will reach out to them –– IPM, and
and discuss their options.
–– DPHHS
c. Call DPHHS, Montana Chronic Disease Prevention and
• Number of BCBSMT referrals to DPHHS health
Health Promotion Bureau and request enrollment.
education programs;
d. Talk with their primary care provider (PCP).
• Service utilization metrics for participants of multiple wellness
1. Provider initiated: initiatives as described in the RFP; and
a. PCP recommends a specific wellness program based on • Number of participants who have successfully completed a
the health needs of the participant and sends a referral to wellness program.
DPHHS or BCBSMT.
80
Early Periodic Screening, Diagnosis, and

Treatment (EPSDT)
HELP Plan participants 19-20 years of age remain eligible for
the Early Periodic Screening, Diagnosis and Treatment (EPSDT)
benefits.
81
For questions about this guide, contact:

3645 Alice St.
Helena, MT 59601
1-877-233-7055

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HELP PLAN

Contact Type BCBSMT HELP-TPA Montana Medicaid/Conduent

Provider Services Phone Number 1-877-296-8206 1-800-624-3958

Claims Submittal Address HELP Plan Claims Claims Processing

Chapter 2: General Information................................................................................... 5

Chapter 3: Professional Claims................................................................................ 11

Chapter 4: Facility Claims.......................................................................................... 17

Chapter 5: Benefit Management.............................................................................. 23

Chapter 7: Coordination of Benefits........................................................................ 37

Chapter 9: Administrative Policies.......................................................................... 49

Chapter 10: Enrollment Screening and Credentialing.......................................... 61

Chapter 11: Compensation Policies......................................................................... 75

Chapter 12: Care Coordination and Wellness Programs.................................... 57

BCBSMT Overview Introduction

Premiums and copayments are dependent upon the

E-mail Network Management at HCS-X6100@bcbsmt.com or Conduent HELP Plan Contacts

HELP Plan Contacts

PARTICIPANT IDENTIFICATION (ID) CARDS

HELP Plan Identification Card Differentiating a HELP Plan Participant from a

HELP Plan Participant Registration Benefits:

To determine where to send claims, please refer to the following table:

Claims Processed Claims Processed

Claims Processed Claims Processed

ClaimsXten is a trademark of McKesson Information Solutions, Inc., an independent third

Electronic Claims CMS-1500 Form Required Fields

No. Field Name Explanation No. Field Name Explanation

No. Field Name Explanation No. Field Name Explanation

42 CFR 455 SUBPART E COMPLIANCE ORDERING,

No. Field Name Explanation No. Field Name Explanation

No. Field Name Explanation No. Field Name Explanation

HOSPITAL BILLING PROCEDURES

42 CFR 455 SUBPART E COMPLIANCE ORDERING,

HELP Plan Pharmacy Benefits Durable Medical Equipment (DME) Provider

If you bill BCBSMT electronically for durable medical equipment,

PREAUTHORIZATION Include a note that you are requesting a retro authorization.

SECTION I: PREAUTHORIZATION PROCESS FOR OBSERVATION

SECTION II: PREAUTHORIZATION PROCESS FOR

SECTION III: PREAUTHORIZATION PROCESS FOR MENTAL

Preauthorization is not required for therapy visits to

SECTION IV: PREAUTHORIZATION PROCESS FOR OTHER

SECTION V: PREAUTHORIZATION REQUEST

SECTION VI: PREAUTHORIZATION REQUIRED FOR CERTAIN

SECTION VII: GENERAL PROVISIONS APPLICABLE TO ALL

SECTION VIII: CONCURRENT REVIEW

Blue Cross and Blue Shield of Montana HELP Plan

Name of Requester: Requester’s Phone:

ADVANCE BENEFIT NOTIFICATION

• Inpatient hospital - 10 percent of Uncollected Copayment Report

Example of the Uncollected Copayment report:

Practice Name _________________

Provider NPI Provider Last Name Provider First Name Title

Provider Provider Participant Participant Participant Billed Date of Copay

Services Reimbursed Directly by Medicaid Physician Administered Drugs

THIRD PARTY LIABILITY (TPL)

Exceptions to Billing Third-Party Claims Processing Unit

HELP PLAN PARTICIPANT BENEFIT APPEALS

4 Second level reviews:

Competency and Conduct Termination/ Examples

Professional Competence, Conduct and Examples

Fair Hearing Process – Level 2 Dispute • Summary suspensions;

Contractual Inquiries Inquiry/Complaint

Contractual Appeal Appeals should be mailed to:

Verification Notification of Changes

Emergency services Definitions