Montana medical billing and payer rules

Timely filing in Montana medical billing and payer rules

Montana medical billing and payer rules surprise billing vs the federal NSA

Major payers

How does Montana Medicaid billing work?

Montana Medicaid is run by the Montana Department of Public Health and Human Services (DPHHS) under the name Montana Healthcare Programs. The provider information site at medicaidprovider.mt.gov carries the claims manual, fee schedules, forms and provider notices.

Most claims are fee-for-service: you bill Montana Healthcare Programs directly, and the contractor Conduent handles correspondence, claims processing and provider file updates for DPHHS. Provider Relations is (800) 624-3958, and enrollment questions go to MTEnrollment@conduent.com.

Two member rules matter at the front desk. Under ARM 37.85.406, as the claims manual states it, you may not bill a member for the difference between your charge and the Medicaid payment, for a covered service you accepted the member for even if the claim denied, or for a no-show appointment. If a claim denies because the member was not eligible, you may bill the member directly.

The manual also says members covered under Montana Healthcare Programs or Medicaid Expansion are not assessed a co-payment on claims paid on or after January 1, 2020. Check eligibility in the MATH Web Portal before the visit and again before you bill.

Which claims system does Montana Medicaid use, and what changes in 2027?

Montana Medicaid claims run today through the MATH Web Portal, a clearinghouse or the Provider Services Portal, and a new system is planned for 2027. DPHHS contracted Gainwell Technologies for the Montana Healthcare Claims System (MTHCS), and its Claims Modernization page says the current system has processed claims since 1984.

The claims manual says the MATH portal lets a provider verify eligibility, check claim status, view claims history and upload valid X12N files. To receive electronic remittance advice there, you complete an EDI Provider Enrollment Form and an EDI Trading Partner Agreement. For an 835 file to reach a clearinghouse you also complete an 835 Request form, and the clearinghouse must itself be enrolled.

A provider site notice dated July 27, 2026 says all EDI transactions will move from Conduent to Gainwell EDI, and trading partners must register, obtain a new Trading Partner ID and complete certification before submitting production transactions. Put a named person on the update list now.

What replaced Passport to Health in Montana Medicaid?

Primary Care Montana (PCMT) began on July 1, 2026, and Passport to Health, Patient-Centered Medical Home and Comprehensive Primary Care Plus ended on June 30, 2026. A DPHHS notice dated March 20, 2026 describes PCMT as a new primary care case management (PCCM) model. The provider site also lists Team Care and Plan First programs.

The notice dated August 21, 2026 says claims for dates of service on or before June 30, 2026 still need a Passport referral ID, and after that date the ID is no longer required. That split matters for old accounts: a claim for a May 2026 service that is rebilled in 2027 still needs the number.

What is the Montana Medicaid timely filing limit?

Montana Medicaid requires a clean claim within twelve months of the later of the date of service or the date retroactive eligibility or disability is determined. The claims manual cites ARM 37.85.406 and defines a clean claim as one that can be processed without additional information or action from the provider.

The submission date is the date the Department or its claims processing contractor received the claim, and the manual adds that all problems with claims must be resolved within the 12-month period. The provider FAQ words the same limit as the 365-day timely filing limit, so treat the earlier of the two as your deadline.

Retroactive eligibility has its own rule. When you accept the member's retroactive eligibility, you have 12 months from the date it was determined to bill. When the date of service is more than 12 months before the claim is submitted, attach a copy of the Provider Notice of Eligibility (Form 160-M).

Do I enroll each provider and each location separately with Montana Medicaid?

You enroll each billing organization and each person who bills on their own, but a rendering provider who works for an organization can practice at several locations. The Provider Enrollment page defines the types, and picking the wrong one is the usual reason an application stalls.

A sole proprietor provider may not share a tax ID with an organization NPI or another individual NPI, and anyone enrolled that way must be disenrolled and re-enrolled. Revalidations submitted for a sole proprietor under a shared tax ID will be denied. Organizations enroll as a Group, which uses taxonomy code 193200000X or 193400000X, or as a Facility, which covers all other organization taxonomies.

Ordering, referring and prescribing (ORP) providers must also be enrolled. A DPHHS notice dated April 1, 2026 cites 42 CFR 455.410 and says that if an enrolled provider submits a claim for services ordered, referred or prescribed by a non-enrolled provider, that claim will be denied.

How should a Montana hospital bill UB-04 claims to Montana Medicaid?

A Montana hospital sends facility claims to Montana Medicaid on the UB-04 or the 837I, and Medicare Part A claims go to Noridian. The claims manual says Montana's claims processing system supports 40 lines on a UB-04 and 21 lines on a CMS-1500.

The provider FAQ says hospitals, dedicated emergency departments and provider-based clinics need a rendering or attending NPI and taxonomy, and the claim denies when that information is missing or is the same as the billing provider. For a CMS-designated provider-based entity, the facility portion goes on the UB-04 or 837I under the hospital NPI, with the professional as the attending provider. The professional portion goes on the CMS-1500 or 837P with the professional as the rendering provider.

For physician-administered drugs, Montana requires the NDC on claims with certain procedure codes. On a paper UB-04 the NDC goes in form locator 43 with the N4 qualifier and the 11-digit code in 5-4-2 format without hyphens. Paper claims go to Claims Processing, P.O. Box 8000, Helena, MT 59604.

A denied Medicare crossover must carry the Explanation of Medicare Benefits (the manual writes EOMB) with denial reason codes and be billed to Montana Healthcare Programs on paper. Our hospital and facility billing service handles this split between the Medicare claim and the Medicaid crossover.

Who is the Medicare MAC for Montana?

The Medicare Administrative Contractor (MAC) for Montana Part A and Part B claims is Noridian Healthcare Solutions, LLC, in Jurisdiction F. CMS's MAC list shows Jurisdiction F covering Alaska, Arizona, Idaho, Montana, North Dakota, Oregon, South Dakota, Utah, Washington and Wyoming, and shows Noridian as the DME MAC (DME D) for Montana.

Home health and hospice are different. The same CMS list names CGS Administrators, LLC for the home health and hospice jurisdiction (15) that includes Montana. Our Medicare payer guide covers enrollment, appeals and the steps shared across all MACs.

Under 42 CFR 424.44, a Medicare claim must be filed no later than the close of the period ending 1 calendar year after the date of service. The rule extends that time when CMS or a contractor finds the miss was caused by error or misrepresentation of an employee, a Medicare contractor or an HHS agent, so a missed date is worth a reviewed appeal.

What is the Montana prompt pay law for insurers?

Montana's prompt pay rule is section 33-18-232 of the Montana Code Annotated: an insurer must pay or deny a claim within 30 days after it receives a proof of loss. If it makes a reasonable request for additional information or documents, it has 60 days from receiving the proof of loss, unless it has notified the insured, assignee or claimant why it has not paid in full, or has a reasonable belief of fraud that it has reported to the commissioner.

Section 33-18-231 defines proof of loss as any claim documentation an insurer receives on which payment is requested, and defines insurer to include health service corporations, HMOs, self-insurers and third-party administrators. If an insurer fails to comply and owes the claim, it pays the claim plus 10 percent annual interest from the date the claim was due. A claim is due 30 days after receipt of proof of loss, or 60 days if the insurer made a reasonable request. Interest is payable only if the interest due exceeds $5.

Section 33-18-233 lets the commissioner impose a fine after a hearing when an insurer, as a general course of business practice, fails to pay claims on time or pay interest. An insurer that shows it paid 90 percent of the dollars outstanding within 20 working days and all of it within 30 working days during the prior 6 months is not subject to the fine.

A second statute works against you after payment. Under section 33-22-150, if a health insurance issuer limits the time to submit a claim, it gets the same time after payment to audit and ask for a refund or offset. If it sets no limit, it has 12 months after payment. Where a provider error caused the incorrect payment, the clock starts at the issuer's actual knowledge but never extends beyond 24 months after payment. Log every payment date so a recoupment letter can be checked against these windows.

Does Montana have its own surprise billing law?

Based on CMS's December 27, 2021 letter to Montana, the federal independent dispute resolution process decides the out-of-network rate for insured plans in Montana. CMS wrote that Montana has no applicable All-Payer Model Agreement and identified no state law governing the out-of-network rate.

That letter is from 2021 and no later Montana statute is cited here. Confirm with the Commissioner of Securities and Insurance before a high-dollar dispute. Our page on state surprise billing laws shows how other states compare.

Federal timing still drives the work. Under 45 CFR 149.510, a party may start open negotiation during the 30-business-day period beginning on the day the provider receives the initial payment or notice of denial, and the open negotiation period lasts 30 business days. Federal IDR is then started with a notice during the 4-business-day period beginning on the first business day after open negotiation ends. Our out-of-network billing and IDR service tracks both clocks, and the emergency medicine billing guide shows the claim detail.

Montana does have an emergency coverage rule for managed care plans. Section 33-36-205 says a health carrier offering a managed care plan must provide or pay for emergency services screening and emergency services without prior authorization, and must pay for emergency services from a nonnetwork provider in the service area when using a participating provider would delay care and worsen the condition. Coverage remains subject to coinsurance, copayments and deductibles. That statute governs coverage, not the amount an out-of-network provider may bill, and this page cites no Montana statute that sets a balance billing limit.

How do we handle billing in Montana?

We work the Montana rules above as account-level controls: a twelve-month Medicaid deadline on every account, a proof-of-loss clock on every commercial claim, and a named owner for the 2027 trading partner change. Claims are sent within 24 hours of charge entry, and denials are worked within 48 hours.

Out-of-network disputes run through open negotiation and federal IDR with deadline management on both clocks. If you want a Montana review of your Medicaid, Medicare and commercial A/R, book a call.