Sym Citycom 300i Specifications Manual For National Hospital Inpatient

Printing the manual material found at this website for long-term use is not advisable.

Inpatient and Outpatient Quality Reporting Specifications Manuals

Department Policy material is updated periodically and it is the responsibility of the users to check and make sure that the policy they are researching or applying has the correct effective date for their circumstances. To print this manual, right click your mouse and choose "print". This publication supersedes all previous Hospital Inpatient Services handbooks.

All Rights reserved. Term "Medicaid" replaced with "Montana Healthcare Programs" throughout the manual.

Manual Organization. Manual Maintenance. Rule References. Getting Questions Answered. General Coverage Principles.

Utilization Reviews 42 CFR Coverage of Specific Services. Claim Forms. Hospital Services Beyond Medical Necessity. Medicare Benefits Exhausted. Services Provided to Passport to Health Members. Services That Require Prior Authorization.

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Discharges and Transfers. Bundled Services.

Unbundled Services ARM Billing for Abortions and Sterilizations. Billing Unlisted Services or Procedures. Billing Electronically with Paper Attachments. Paper Claims. Present on Admission. Ungroupable DRG.

Relative Weights and Reimbursement Data. Computational Formulas and Definitions.

Department of Public Health and Human Services

Payment Factors. Hospital Residents. Payment Examples for Dually Eligible Members.

Hours for Key Contacts are 8 a. Monday through Friday Mountain Time , unless otherwise stated. For additional contacts and websites, see the Contact Us link in the left menu on the Provider Information website.

Box Helena, MT To qualify a member for residency status or to submit claims for hospital residents: Phone Fax Hospital Program Officer Health Resources Division P.

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Thank you for your willingness to serve members of the Montana Healthcare Programs and other medical assistance programs administered by the Department of Public Health and Human Services.

This manual provides information specifically for hospital inpatient services. Other essential information for providers is contained in the separate General Information for Providers manual. Providers are responsible for reviewing both manuals. A table of contents and an index allow you to quickly find answers to most questions.

The margins contain important notes with extra space for writing notes. There is a list of contacts at the beginning of each manual. There is also space on the inside of the front cover to record your NPI for quick reference when calling Provider Relations.

Manuals must be kept current. Changes to manuals are provided through provider notices and replacement pages. Manual replacement pages can be downloaded from the provider type pages on the Provider Information website and are identified by a note at the top of the page indicating Replacement Page and the date. They are designed to be printed on the front and back of each page, so they are always in sets of two beginning with an odd page followed by an even page, even though one of the pages may not have any changes.

When replacing a page in a paper manual, file the old pages and provider notices in the back of the manual for use with claims that originated under the old policy. Providers must be familiar with all current rules and regulations governing the Montana Healthcare Programs.

Sheila Hogan, Director

Provider manuals are to assist providers in billing Montana Healthcare Programs; they do not contain all Montana Healthcare Programs rules and regulations. Rule citations in the text are a reference tool; they are not a summary of the entire rule. In the event that a manual conflicts with a rule, the rule prevails. Links to rules are available on the Provider Information website.

See the Contact Us link in the left menu on the Provider Information website.

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Providers are responsible for knowing and following current Montana Healthcare Programs rules and regulations. In addition to the general Montana Healthcare Programs rules outlined in the General Information for Providers manual, the following rules and regulations are also applicable to the hospital inpatient program:.

Montana Healthcare Programs claims are electronically processed and usually are not reviewed by medical experts prior to payment to determine if the services provided were appropriately billed. Although the computerized system can detect and deny some erroneous claims, there are many erroneous claims it cannot detect.

For this reason, payment of a claim does not mean the service was correctly billed or the payment made to the provider was correct. Periodic retrospective reviews are performed that may lead to the discovery of incorrect billing or incorrect payment. If a claim is paid and the Department later discovers the service was incorrectly billed or paid or the claim was erroneous in some other way, the Department is required by federal regulation to recover any overpayment, regardless of whether the incorrect payment was the result of Department or provider error or other cause.

The provider manuals are designed to answer most questions; however, questions may arise that require a call to a specific group such as a program officer, Provider Relations, or a prior authorization unit.

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A list of key contacts and websites is available online. On the Provider Information website, choose the Contact Us link in the left menu.

Providers should also read the monthly Claim Jumper newsletter for Montana Healthcare Programs updates and changes. Montana Healthcare Programs provider manuals, provider notices, replacement pages, fee schedules, forms, and more are available on the Provider Information website.

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Montana Healthcare Programs covers inpatient hospital services when they are medically necessary. This chapter provides covered services information that applies specifically to inpatient hospital services. Like all healthcare services received by Montana Healthcare Programs members, these services must also meet the general requirements listed in the Provider Requirements chapter of the General Information for Providers manual. Inpatient services must be ordered by a licensed physician or dentist and provided in an institution maintained primarily for treatment and care of patients with disorders other than tuberculosis or mental diseases.

The institution must be currently licensed by the designated state licensing authority in the state where the institution is located, must meet the requirements for participation in Medicare as a hospital, and must have in effect a utilization review plan that meets the requirements of 42 CFR Services for Children ARM It is designed to prevent, identify, and then treat health problems before they become disabling. Under EPSDT, Montana Healthcare Programs eligible children may receive any medically necessary covered service, including all inpatient hospital services described in this manual.

All applicable Passport to Health and prior authorization requirements apply. In addition to being listed on the fee schedule, all services provided must also meet the coverage criteria listed in the Provider Requirements chapter of the General Information for Providers manual and in this chapter.

Use the fee schedule in conjunction with the more detailed coding descriptions listed in the current ICD coding book.

Take care to use the fee schedule and coding books that pertain to the date of service. Fee schedules are available on the Provider Information website.

At the time a claim is submitted, the hospital must have on file a signed and dated acknowledgment from the attending physician that the physician has received the following notice:.

Anyone who misrepresents, falsifies or conceals essential information required for payment of federal funds, may be subject to fine, imprisonment or civil penalty under applicable federal laws. Existing acknowledgments signed by physicians already on staff remain in effect as long as the physician has admitting privileges at the hospital.

The provider may, at its discretion, add to the language of this statement the word Medicare so that two separate forms will not be required by the provider to comply with state and federal requirements.

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The Department or its contractor may at any time review paid claims, provider documentation for medical necessity, appropriate billing, etc. Providers must maintain documentation of medical necessity for services such as initial hospitalization, transfers, and readmissions. For more information on provider requirements for maintaining documentation, see the Record Keeping section in the Provider Requirements chapter of the General Information for Providers manual. Also see the Claims Review section in the Introduction chapter of this manual.

Providers must contact the Department to obtain hospital residence status prior to billing Montana Healthcare Programs. To qualify for residency status, a member must meet the following requirements:.

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The provider must maintain written records of inquiries and responses about the present and future availability of openings in nursing facilities and the Home and Community-Based Waiver Program. A redetermination of nursing facility or waiver availability must be made at least every 6 months. Hospitalized Montana Healthcare Programs members and Montana Healthcare Programs applicants being considered for nursing facility placement from the hospital shall be referred in a timely manner to the preadmission screening team.

Elective Deliveries Effective July 1, , all facilities must have a hard-stop policy in place regarding non-medically necessary inductions prior to 39 weeks and nonmedically necessary Cesarean sections at any gestational age. The policy must contain the following:.

Sym citycom 300i specifications manual for national hospital inpatient

Effective October 1, , Montana Healthcare Programs will reduce reimbursement rates for non-medically necessary inductions prior to 39 weeks, and non-medically necessary Cesarean sections at any gestational ages. All hospital claims with an admit date on or after October 1, , will require coding changes to delivery claims.

Hospital inpatient claims and birthing center claims will require the use of condition codes for all induction and Cesarean section deliveries.