Home care billing in Montana

Fee-for-service. CMS's 2024 state tables list four primary care case management programs for Montana, Passport, CPC+, Patient Centered Medical Home and the Tribal Health Improvement Program, and case management is the only benefit they cover; none of the four covers home health, personal care or HCBS waiver services.² Passport has run under 1915(b) authority since January 1, 1993 and the other three under 1932(a), and the tables note that Medicare dual eligible individuals are excluded from the PCCM programs. With no health plan in the middle, every home care claim goes to the state's fiscal agent, as the claims section below sets out.

Open vendor model. DPHHS provides Netsmart's Mobile Caregiver+ as the state EVV solution at no cost to providers, and an agency may run an alternate EVV solution only if it meets DPHHS compliance requirements, is certified for use with Montana Medicaid and integrates with Mobile Caregiver+ to transmit the required visit data. Full EVV compliance is required for dates of service on and after July 1, 2024.³ Mobile Caregiver+ also acts as the aggregator. DPHHS states that every claim requiring EVV must have a compliant EVV record and must be submitted through Mobile Caregiver+, and that claims sent without compliant EVV data are denied for the applicable dates of service. The CFCS/PCS training, cited below, adds that EVV applies to live-in caregivers, and CMS lists Montana compliant with the home health EVV requirement as of January 1, 2024.

Services under EVV⁴

• Community First Choice Services and state plan Personal Care Services (provider type 12), agency-based and self-directed, including medical escort
• Big Sky Waiver services (provider type 28), including agency-based and self-directed personal assistance, specially trained attendant, respite, private duty nursing, special child care and in-home therapies
• Developmental disabilities 0208 waiver services (provider type 82), including respite, personal care, companion care, therapies and private duty nursing
• Severe and Disabling Mental Illness waiver services (provider type 88), including behavioral intervention assistant, respite, personal assistance attendant and private duty nursing
• Home health skilled nursing, aide and therapy visits (provider type 53)
• Private duty nursing (provider type 14) and pediatric complex care assistant services (provider type 49)

Two tracks. For Community First Choice and personal assistance, Mountain Pacific Quality Health holds the Senior and Long Term Care Division contract for prior authorization, functional assessments, utilization review and level of care reviews: its registered nurses complete the member's Overview and Service Profile at an initial on-site visit and at annual reviews, screen every personal assistance referral for CFC level of care, and review requests to change service levels by phone.⁶ Home health follows Home Health Policy 410, cited below: every home health service must be prior authorized through the Department's utilization review contractor before it is delivered, the Department will not back date an authorization, and the agency sends a Request for Initial Prior Authorization and Amendment (SLTC 124) with a signed Home Health Certification and Plan of Care (SLTC 126); the contractor enters the authorization number in the MMIS. The policy also gives the agency five business days from the initial visit to request authorization, limits home health to 180 visits within 365 days of the first visit unless the Department extends it, and lets a physician certification cover no more than 60 days. Big Sky Waiver services follow the plan of care written by the member's Case Management Team.

To Montana Healthcare Programs through Conduent, the current claims contractor, electronically by WINASAP 5010, a clearinghouse, the secure provider website or MoveIt DMZ. Under ARM 37.85.406 a clean claim is due within twelve months of the later of the date of service or the date retroactive eligibility or disability is determined, or within six months of a Medicare explanation of benefits or a third party payer's adjustment notice when those apply.⁹ EVV services take a different route: the DPHHS EVV page, cited above, requires those claims to be submitted through Mobile Caregiver+ with a compliant visit record. DPHHS has also contracted with Gainwell Technologies for a new claims processing and payment system planned for 2027, so submission instructions for every route are due to change.

CGS Administrators, LLC is the A/B MAC for Jurisdiction 15, and its home health and hospice workload includes Montana along with Colorado, Delaware, the District of Columbia, Iowa, Kansas, Maryland, Missouri, Nebraska, North Dakota, Pennsylvania, South Dakota, Utah, Virginia, West Virginia and Wyoming; its Part A and Part B claims are for Kentucky and Ohio only.¹¹ For Montana Medicaid, home health is provider type 53 on the DPHHS EVV list, billed by revenue code for skilled nursing, aide and therapy visits, and it needs the Policy 410 prior authorization described above. CMS lists Montana compliant with the Cures Act home health EVV requirement as of January 1, 2024.