MHCP rates for incarcerated individuals

Legislation limits the amount counties pay for medical services provided to incarcerated individuals in a county jail to the maximum allowed Minnesota Health Care Programs (MHCP) payment rate for the services, whether or not they have MHCP eligibility.

Medical provider requirements

If an incarcerated person is covered by other health insurance, the health care provider must bill that insurance before submitting the bill to the appropriate county or the Department of Corrections (DOC) for reimbursement. If the person is enrolled in an MHCP managed care organization (MCO) during the month services are received, bill the MCO. DHS-contracted MCOs are required to cover out-of-network emergency or urgent care. Other health care services must meet the MCO’s guidelines for network and service authorizations.

After all other payment sources have paid, or when the person is not covered by other insurance or enrolled in an MCO, the health care provider must complete a paper claim form to submit to the county or DOC for reimbursement.

Use one of the following standard claim forms, based on the type of services:

• ADA dental claim form for dental services
• CMS-1500 claim form for physician and professional services
• UB-04 claim form for medical services in an institutional setting

Include the following information on the claim form:

• Appropriate codes
  • CDT (Current Dental Terminology: an alpha-numeric code set used to report dental procedures and services)
  • CPT (Current Procedural Terminology: a numeric code set used to report medical procedures and services)
  • HCPCS (Healthcare Common Procedure Coding System: an alpha-numeric code used to identify products, supplies, and services not included in CPT)
  • Revenue codes (Codes that identify accommodations, ancillary services or billing calculations or arrangements)
• Appropriate modifiers (two-digit alpha, numeric, or alphanumeric code used to indicate a service or procedure that is altered without changing the procedure’s definition or code)
• Usual and customary amount charged for each service
  • If applicable, provide an explanation of benefits from all other payment sources
  • Provide invoices for medical equipment or services that may be subject to pricing

For pharmacy claims, use a CMS 1500 claim form and include:

• NDC (National Drug Code)
• Date of service
• Number of units
• Total charge>

County and DOC requirements

Counties and DOC must first use the MHCP fee schedule to determine MHCP total allowed amounts following these steps:

1. Go to the MHCP Fee Schedule
2. Read and then accept the End User License Agreement
3. Select the MHCP Fee Schedule in PDF
4. Determine the type of claim form
5. Enter the procedure or service code in the ”Find” search option on your webpage or scroll to find the service code
6. Look at the factor in the FACT CODE column to determine if the service is allowed, noncovered, or requires pricing or a report. Some service codes may have multiple factor codes; review all factor codes before determining payment. 
7. If the factor code is one of the following, proceed as indicated:
   • D, H, L, P, 4, 8: MHCP does not cover this service
   • 9: Code is discontinued, send the claim back to the provider and have provider resubmit with a current code
   • C, G, K, O, Q, S, T, 3, 7: Include an invoice or other description of service

Determine MHCP rate

If the service code does not have a fact code listed, use the following guidelines to determine the MHCP rate.

MHCP rate guidelines

Claim types and pricing information

• ADA claims: use price in TOTAL ALLOW column
• CMS-1500: use price in TOTAL ALLOW column
  If a code is followed by a modifier, you may need to use one of the following columns to determine the rate:
  • ANESTH BASE VALUE + appropriate anesthesia formula: For anesthesia modifiers, use the Anesthesia Formulas section near the beginning of the fee schedule to find the rate associated with the listed modifier.
    For example, the modifier AA formula is: (Base Units + (Time Units / 15)) X 18.00. If a provider billed code 36471 with modifier AA for 38 units, you would calculate (3 + (38/15)) X 18.00 = (3 + 2.5) X18 = 5.5 X18 = 99.00
  • PROF COMPONENT: For professional components, modifier 26, use the PROF COMPONENT column to price the service.
  • TECH COMPONENT For technical components, modifier TC, use the TECH COMPONENT column to price the service.
  • RENTAL ALLOW For equipment rental, KH, KI, KJ, KR, LL and RR modifier, use the RENTAL ALLOW column to price the service.

• UB-04 claims: use price in APC/ASC ALLOW column
  For claims with type of bill 013X, 014X, 07XX, 083X, or 085X, review the explanations of PSI (Payment Status Indicator) and Facility Component Pricing Hierarchy near the beginning of the fee schedule. The payment rate is the:
  1. APC (Ambulatory Payment Code) rate. If no rate in the APC/ASC column, see 2.
  2. TC rate. If no rate in the TECH COMPONENT column with factor code E, see 3.
  3. System calculates a facility charge allowable. For UB-04 claims with any other type of bill, include an invoice or additional description.

When no MHCP allowed amount is listed on the MHCP fee schedule, DHS will determine the price manually.

Fax claim forms to DHS

Fax: 651-431-7439

• Use secure fax to send a cover sheet that includes your first and last name, phone number and your fax number with the provider’s completed paper claim form and any corresponding invoices.
• Allow 30 business days for processing. DHS will respond by secure fax with a cover sheet that includes your original paper claim form and corresponding documentation that displays the MHCP allowed amount.

Direct questions or disputes about the MHCP fee schedule to DHS PR Training.

Legal references

Minnesota Statutes 241.021, subd. 4 Health Care.
Minnesota Statutes 641.15, subd. 2 Medical Aid