Provider Connection

Clean Claim Revisited

‘Clean Claim’ denials are the most common reasons for nonpayment of a bill and is explained on the EOR as “Claim contains incomplete/missing other procedure and /or invalid information, and no appeal rights are afforded because the claim is unprocessable. Please submit a new claim with the complete/correct information.”

The most common errors on the CMS 1500 which result in this denial include:

Box 10a – Should reflect ‘Y’ if services are related to a work related injury;

Box 14 – Incorrect date of injury, please call MSF if you do not have this date. It is also listed on the EOR.

Box 24J – Missing rendering provider which typically coincides with the provider name listed in Box 31;

Box 32 and/or 32a – If place of service is other than 12 (home), then Box 32 must denote the facility name and physical address where services were provided. Box 32a must include the NPI for this entity;

Box 33a – Missing the NPI for the billing provider.

A word about NPI (National Provider Identifier) numbers – The NPI number is matched with the name and number registered on the NPPES (National Plan & Provider Enumeration System). If the name and NPI on the bill does not match the name and NPI on NPPES, the bill will deny. Please ensure service facilities used in Box 32 are registered on the NPPES website.

Other Denials and/or Reason Codes Defined

Procedure insufficiently identified or quantified:
The documentation does not support the code billed,or
the documentation may be incomplete, or
a DME item dispensed to the injured worker is not documented in the note, or
the E/M level billed is not supported by the submitted documentation.

Timed procedure – submit time:
A code with a time element is billed, but the time spent per service or modality is not documented in the note.

Claim denied – not compensable:
The claim as a whole is deemed not compensable so is not accepted as a Workers’ Compensation
claim.

Unrelated:
The service that is being billed is deemed unrelated to injury of record. If the documentation submitted includes work done for conditions not related to the injury the bill may be denied in whole or by line depending upon the services billed with the corresponding diagnosis. If an injured worker is seeking treatment for unrelated conditions, they should be seen at a separate appointment.

Payment of this bill does not constitute acceptance of conditions/injuries not directly related to the injury of record:
This reason code is not a denial but is used if there are conditions/injuries mentioned in the documentation that are not being treated at the appointment or that are difficult to separate out and advises that payment of the bill does not mean that any unrelated problems are not considered accepted as part of the Workers’ Compensation claim.

Lockhart Lein:
Indicates that the injured worker is represented by an attorney who has argued for and won medical coverage related to a workers’ compensation claim. Lockhart was a 1999 Supreme Court Decision “Lockhart vs New Hampshire Insurance “ which states in part “attorney lien codified at § 37-61-420, MCA, applies to medical benefits recovered due to the efforts of an attorney in a worker’s compensation case…”

110%:
Indicates that a claim has a designated treating provider assigned. This was part of HB334 and refers to Montana Code Annotated (MCA) 39-71-1101 which became effective July 1, 2011. The designated treating provider is responsible for the management and coordination of care of an injured worker including filling out the work status form at each visit and defining the treatment plan within the Utilization and Treatment guidelines of the injured worker. The designated treating provider receives 110% of the Montana Non-Facility Fee Schedule.

90%:
Indicates a provider other than the designated treating provider and receives 90% of the Montana Non-Facility Fee Schedule when there is a treating provider designated on a claim.

back to Provider Connection

Bill Status – 1-866-274-7464

Main Phone Number 406-495-5000 or 800-332-6102

Main Fax  406-495-5020

Medical Team – 406-495-5011

Submit your Claims and/or Correspondence To
Montana State Fund
PO Box 4759
Helena, MT  59604

RMS (Bill Status)
Phone  866-274-7464
Email customer.care@risingms.com

For questions about information in this bulletin, call 800-332-6102 and ask for a member of the Medical Team.
For questions about Advanced Nurse Review contact Kym Vonada at 406-495-5389.


Medical Team

Michele Fairclough
Medical Team Leader
406-495-5362

Justin Kennedy
Nurse Manager
406-495-5417

Shannon Hadley
Provider Relations Specialist
406-495-5245

Kym Vonada
Medical Auditor
406-495-5389

Annalyn Stewart
Medical Payment Auditor
406-495-5367

Sheryl Semans
Pharmacy Liaison
406-495-5010

Susan Bomar
Medical Payment Auditor
406-495-5271

Cindy Gallus
Medical Customer Service Liaison
406-495-5189

Sherri Sprenger
Medical Customer Service Liaison
406-495-5420

Shannon Mergenthaler
Medical Customer Service Liaison
406-495-5185

Maggie Pentecost
Medical Customer Service Liaison
406-495-5322

Jamie Statton
Medical Customer Service Liaison
406-495-5386

Website Information

Montana State Fund montanastatefund.com

Department of LaborDepartment of Labor and Industry (DLI) website.
The website includes the Facility and Non-Facility Fee Schedule information as well as the Administrative Rules of Montana (ARM) and the instruction set for the Non-Facility Fee Schedule. Historical fee schedule information can also be found on this website.

If you have questions regarding the fee schedules call 406-444-6530 and someone will direct you to a DLI representative. For NPI information click here National Plan and Provider Enumeration System (NPPES)