in this issue - idaho medicaid health pas online newsletters/november 2011... · over 35 other...

MedicAide November 2011 of 17

In This Issue

Trading Partner ALERT: ............................................................................................................ 2 Electronic Healthcare Transactions ............................................................................................. 2

Version 5010 Deadline Approaching ........................................................................................ 2 What Comes after 5010? ICD-10! ........................................................................................... 2

Preventive Health Assistance for Wellness ................................................................................... 3 Split Billing for Private Insurance COB Claims .............................................................................. 3 Healthy Connections Enrollment and Access to Care ..................................................................... 4 Attention: Physical, Occupational, and Speech Therapy Providers ................................................... 4 Tips for Primary Care Providers on Tobacco Cessation .................................................................. 5 Medicaid Mental Health Managed Care Web Site .......................................................................... 5 View Share of Cost Online ......................................................................................................... 6 Provider Handbook Updates ...................................................................................................... 6 Medicaid Program Integrity ....................................................................................................... 7

Refunding Identified Overpayments ........................................................................................ 7 Claims Processing Cycle ............................................................................................................ 7 Provider Training Opportunities in November ..............................................................................12 Prior Authorization Contact Information .....................................................................................13 Transportation ........................................................................................................................13 DHW Resource and Contact Information ....................................................................................14 Insurance Verification ..............................................................................................................14 Molina Provider and Participant Services Contact Information .......................................................15 Molina Provider Services Fax Numbers .......................................................................................15 Provider Relations Consultant (PRC) Information .........................................................................16

Information Releases

MA11-25 Hospice Rates ............................................................................................................ 8 MA11-26 Co-Payments ............................................................................................................. 9 MA11-27 Idaho Home Choice ..................................................................................................10

An informational newsletter for Idaho Medicaid Providers

From the Idaho Department of Health and Welfare, November 2011

Division of Medicaid


Trading Partner ALERT: Electronic Healthcare Transactions

Trading Partners must be ready to submit HIPAA X12 electronic transactions using Version

5010 by the federal deadline of January 1, 2012. This requirement is necessary for the

upcoming ICD-10 code changes coming in 2013. Providers using Direct Data Entry will be

automatically compliant by the deadline.

Version 5010 Deadline Approaching

A self-service web portal is available for Trading Partners to test and certify transactions in

the new Version 5010 format. Version 5010 is required for all HIPAA X12 electronic

healthcare transactions beginning January 1, 2012.

Updated Companion Guides for each transaction type are available online at

www.idmedicaid.com. The 5010 Companion Guides provide detailed information about how

Idaho Medicaid expects to receive or send the updated transaction data.

Testing Version 5010 now is necessary in order to fine-tune systems prior to

implementation of Version 5010 on January 1, 2012.

Version 5010 Timeline Complete Testing/Certification November 14, 2011

Begin Certified 5010 Submissions December 12, 2011

Version 5010 Only January 1, 2012

Per federal regulations, transactions received in the Version 4010 format will not

be processed after midnight on December 31, 2011.

What Comes after 5010? ICD-10!

ICD-10 is a new code set which will replace the current ICD-9 in 2013. When ICD-10 is

implemented, it will involve significant changes including the use of seven-digit

alphanumeric codes, and increased detail and specificity.

Idaho Medicaid launched its ICD-10 project in order to meet the federally mandated

requirement to transition to this new code set effective for dates of service beginning

October 1, 2013 forward. Please see information available online at the Centers for Medicare

& Medicaid Services (CMS) website. CMS has developed a variety of resources to help

prepare healthcare providers for the transition from ICD-9 to ICD-10. Please check for

updates as we move forward to the transition deadline.

Failure to successfully transition to Version 5010 by January 1,

2012, may jeopardize future claim processing and payment.

http://www.idmedicaid.com/

http://www.cms.gov/ICD10/05a_ProviderResources.asp

http://www.cms.gov/ICD10/05a_ProviderResources.asp


Preventive Health Assistance for Wellness

The Preventive Health Assistance (PHA) Wellness benefit provides assistance to families

whose children are:

Enrolled in the Medicaid Basic Plan, and

Required to pay a monthly premium to maintain eligibility

These children are automatically enrolled in the Wellness PHA.

How does it work?

The claims processing system is searched to determine if a child is current on receiving

recommended well-child checks and immunizations.

If the child is current, PHA points are earned.

The PHA points are applied as a reduction to the family’s monthly premium.

PHA follows the American Academy of Pediatrics (AAP) recommended schedule for Well-

child checks and the Center for Disease Control and Prevention (CDC) recommendations for

immunizations.

Well-Child Check-up Schedule

Age

Babies 1 Week –

1 Month

2 Months 4 Months 6 Months 9 Months 12 Months

1-3 yr 15 months 18 months 24 months 30 months 36 months

3-19 yr 1 check-up every year

How can Primary Care Providers (PCPs) help?

Be sure to bill Well-Child Checks with the primary diagnosis V20.2 and the appropriate CPT

code (see provider handbook). Please note that if a child comes in for a well-child check

and presents sick you can bill for both as long as both exams were performed.

If you would like to request a supply of PHA brochures or if you would like more information

on PHA Benefits, please call the PHA Unit toll free at 1 (877) 364-1843.

Split Billing for Private Insurance COB Claims

When billing Idaho Medicaid for coordination of benefits (COB) claims submitted through a

private insurance company when some of the services were paid and others denied, you

must split the paid and the denied detail lines on separate claim forms along with the

explanation of benefits (EOB).


Healthy Connections Enrollment and Access to Care

Enrollment in Healthy Connections with a primary care provider (PCP) is month-to-month.

Therefore, new enrollments or a change in PCP is always effective the first of the following

month after a request is received. Requests to enroll with or change a PCP must be received

no later than the 20th of the month.

Situations may occur prompting a participant to request a referral to a new PCP mid-month,

such as a move to a new community. The PCP should make a “transfer of care” referral to

the participant’s new PCP for the remainder of the month. Healthy Connections PCPs are

paid a monthly case management fee and agree by contract to make referrals for medically

necessary services. A newly assigned participant may not have

established care with their PCP before attempting to access

medically necessary specialty care. In this instance, PCPs should

consider issuing a “one time referral until participant has

established care” to ensure reasonable access to medically

necessary care.

If a PCP determines a participant is not enrolled in Healthy Connections when verifying

eligibility, it is recommended that the provider have the participant immediately complete

an enrollment form and the office staff fax it to Healthy Connections at 1 (888) 532-0014.

This will avoid having the participant being assigned to a different PCP.

Attention: Physical, Occupational, and Speech Therapy Providers

House Bill 260 passed by the 2011 Idaho Legislature directs Medicaid to align physical

therapy and speech therapies combined to align with annual Medicare caps and occupational

therapy to align with the annual Medicare cap. Medicare limits therapy services to $1,870

for speech and physical therapy combined, and $1,870 for occupational therapy alone.

Medicaid plans to implement these caps beginning in January 2012. The processes we will

implement are designed to mirror Medicare’s as far as possible in order to comply with the

legislative direction and to keep billing straightforward for therapy providers serving

participants eligible for both Medicare and Medicaid. One difference is that the Medicaid cap

will apply equally to outpatient hospital as well as independent therapy providers. We will

provide detailed information on changes in the December MedicAide newsletter and through

the therapy web page at www.medunit.dhw.idaho.gov in November.

http://www.medunit.dhw.idaho.gov/


Tips for Primary Care Providers on Tobacco Cessation

The Preventive Health Assistance (PHA) benefit provides assistance to participants to help

them quit using tobacco. Medicaid provides assistance to:

Locate cessation programs

Pay for prescription and over the counter cessation products such as: Chantix,

Wellbutrin, inhalers, nasal spray, patches, lozenges or gum.

Idaho Medicaid Recommends Following the Surgeon General’s “5 A” Approach

1. Ask Systematically identify all tobacco users at every visit.

2. Advise Strongly urge all tobacco users to quit.

3. Assess Determine willingness to make a quit attempt.

4. Assist Aid the patient in quitting.

5. Arrange Schedule a follow up and refer your Medicaid patients to the PHA Unit at our

toll free number, 1 (877) 364-1843, or give them a PHA brochure.

If you would like to request a supply of PHA brochures or if you would like more information

on PHA benefits, please call the PHA Unit at 1 (877) 364-1843. Go to

www.surgeongeneral.gov/tobacco to obtain the entire Quick Reference Guide for Clinicians –

Treating Tobacco Use and Dependence.

Please note: Cessation products are not covered under the Medicaid Pharmacy program.

They are only available through the PHA program authorization process.

Medicaid Mental Health Managed Care Web Site

Medicaid recently launched a Web site to help inform stakeholders of the transition to

managed care for mental health services. Below is an excerpt from the website:

The Idaho Medicaid program was directed by the 2011 Legislature to develop a managed

care program for mental health services. Over 35 other states utilize managed care

administration for their mental health programs to improve quality, ensure access for

enrollees, and maximize the cost-effectiveness of taxpayer dollars being spent for Medicaid

mental health services.

Developing a mental health managed care program is a statewide effort of Medicaid staff,

mental health and medical providers, community partners, participants and families. Idaho

Medicaid held a statewide meeting of these stakeholders to gather specific

recommendations and priorities for the main requirements for a Request for Proposal (RFP)

on August 30, 2011. Over 75 people participated in the videoconference meeting at ten

sites throughout the state. This stakeholder input is currently being used to develop the

RFP, which the state hopes to have completed soon, with a contract awarded in 2012.

For additional information, please visit the Medicaid Mental Health Web site @

www.medicaidmhmanagedcare.dhw.idaho.gov. The Web site will be updated as new

information becomes available.

http://www.surgeongeneral.gov/tobacco

http://www.medicaidmhmanagedcare.dhw.idaho.gov/


View Share of Cost Online

Looking for Share of Cost (SOC) information? Now you can view SOC information on your

member eligibility report. Just go to www.idmedicaid.com and sign in to your Trading

Partner Account and click on Eligibility Verification. Enter the member’s first name, last

name, MID or DOB and enter the dates of inquiry. You will receive eligibility and SOC

information. Refer to the TPA-Trading Partner Account Eligibility Verification Guide in the

User Guides for more information.

Provider Handbook Updates

Updates have been made to the Provider Handbook. You may find the link on the left

navigation panel of www.idmedicaid.com. Changes are noted at the beginning of each

document. The updated documents are found in:

Claim Form Instructions

CMS 1500 Instructions

UB04 Instructions

Provider Guidelines

Behavioral Health and Social Services

Chiropractor

Respiratory, Developmental, Rehab, Restorative Services

Speech, Language, and Hearing

Transportation

Reference

Qualis Health Pre-Authorization List (previously titled Select Pre-Authorization List of

Diagnoses and Procedures)


https://www.idmedicaid.com/User%20Guides/Forms/AllItems.aspx



Medicaid Program Integrity

Refunding Identified Overpayments

The Medicaid Program Integrity Unit occasionally receives information from providers that

have conducted self-audits and identified overpayments. Please be advised, pursuant to the

terms of your Idaho Medicaid Provider Agreement, any identified overpayments must be

refunded immediately.

Section 5, Accurate Billing, of the Medicaid Provider Agreement states

providers agree:

To certify by the signature of the Provider or designee, including

electronic signatures on a claim form or transmittal document, that the

items or services claimed were actually provided and medically

necessary, were documented at the time they were provided, and were

provided in accordance with professionally recognized standards of

health care, applicable Department rules, and this Agreement. The

Provider shall solely be responsible for the

accuracy of claims submitted, and shall

immediately repay the Department for any

items or services the Department or the

Provider determines were not properly

provided, documented, or claimed. The

Provider must assure that a duplicate claim

under another program or provider type is not submitted.

Providers who fail to refund identified overpayments to the Department may be subject to

civil monetary penalties and/or termination of their provider agreement.

Claims Processing Cycle

Paper Claims must be received by 5:00 P.M. Monday in order to be included in the next

regular weekly payment processing cycle.

Electronic Claims must be received by 8:00 P.M. Thursday in order to be included in the

next regular weekly payment processing cycle.

Please be advised….any identified

overpayments must be refunded

immediately.


MA11-25 Hospice Rates


MA11-26 Co-Payments


MA11-27 Idaho Home Choice


Provider Training Opportunities in November

The Eligibility training session is open to all Medicaid providers in November. It will be

delivered by Provider Relations Consultants on the following dates and locations:

Location Date Time Location (DHW Office)

Region 1 11/18/2011 1-3 P.M. PDT Coeur d’Alene DHW Office

Conference room #102

1120 Ironwood Drive

Coeur d’Alene, ID

Region 2 11/8/2011 1–3 P.M. PDT Lewiston DHW Office

3rd Floor Conference Room

1118 F Street

Lewiston, ID

Region 3 11/9/2011 1–3 P.M. MDT Caldwell DHW Office

West Sawtooth Conference Room

3402 Franklin Road

Caldwell, ID

Region 4 11/11/2011 1-3 P.M. MDT Boise DHW Office

Suite B Conference Room

1720 Westgate Drive

Boise, ID

Region 5 11/15/2011 1–3 P.M. MDT Twin Falls DHW Office

Conference Room

803 Harrison Street

Twin Falls, ID 83301

Region 6 11/10/2011 1–3 P.M. MDT Pocatello DHW Office

2nd Floor Conference Room, Ste#230

1070 Hiline Road

Pocatello, ID

Region 7 11/15/2011 1-3 P.M. MDT Idaho Falls DHW Office

2nd floor Conference Room

150 Shoup Avenue

Idaho Falls, ID

This session is designed to help providers understand the importance of checking eligibility,

and the different benefit plans available.

Please check the Idaho Medicaid Training Center calendar for upcoming dates by logging

into your Medicaid Training Center user profile and registering for the session in your

region. Additionally, walk-ins are always welcomed!

All onsite classroom sessions are available for registration through the Idaho Medicaid

Training Center. Go to www.idmedicaid.com, and click on Training in the menu on the left

side of the screen. Click on the Idaho Medicaid Training Center information link to

access the registration form.

https://idmolinamedicaidsolutions.elogiclearning.com/admin/secure/login.asp

https://idmolinamedicaidsolutions.elogiclearning.com/admin/secure/login.asp



Prior Authorization Contact Information

Please use these numbers to submit prior authorization requests to Medicaid or to

communicate with Medicaid staff regarding details of prior authorization requests. For

questions regarding claims with an existing prior authorization, please call Provider Services

at 1 (866) 686-4272.

DME Specialist, Medical Care

P.O. Box 83720

Boise, ID 83720-0036

1 (866) 205-7403

Fax: 1 (877) 314-8782

(Attn: DME Specialist)

Pharmacy

P.O. Box 83720

Boise, ID 83720-0036

1 (866) 827-9967

Fax: 1 (800) 327-5541

Medical Care

Attention: Surgery Authorizations

P.O. Box 83720

Boise, ID 83720-0009

1 (208) 287-1148

Fax: 1 (877) 314-8779

Qualis Health

(Inpatient hospital stays greater than three days

and selected diagnoses & procedures, Telephonic

& Retrospective Reviews)

10700 Meridian Avenue N., Ste 100

PO Box 33400

Seattle, WA 98133-0400

http://www.qualishealth.org/healthcare-

professionals/idaho-medicaid

1 (800) 783-9207

1 (206) 364-9700

Fax: 1 (800) 826-3836

Preventive Health Assistance

PHA Unit

P.O. Box 83720

Boise, ID 83720-0009

1 (877) 364-1843

1 (208) 364-1843

Fax: 1 (877) 845-3956

Office of Mental Health and Substance Abuse

(OMHSA)

P.O. Box 83720

Boise, ID 83720-0009

1 (208) 334-0767

1 (866) 681-7062

Fax: 1 (888) 560-1784

Transportation

Effective September 1, 2010, Idaho Medicaid contracted with American Medical Response

(AMR) for all non-emergency medical transportation services. Please go to

www.idahonemt.net or call 1 (877) 503-1267 for more information.

Ambulance Review

1 (800) 362-7648

1 (208) 287-1157

Fax: 1 (877) 314-8781

http://www.qualishealth.org/healthcare-professionals/idaho-medicaid

http://www.qualishealth.org/healthcare-professionals/idaho-medicaid

http://www.idahonemt.net/


DHW Resource and Contact Information

DHW Web site www.healthandwelfare.idaho.gov

Idaho CareLine 2-1-1

1 (800) 926-2588

Medicaid Program Integrity Unit P.O. Box 83720

Boise, ID 83720-0036

[email protected]

Fax: 1 (208) 334-2026

Healthy Connections Regional Health Resource Coordinators

Region I

Coeur d'Alene

1 (208) 666-6766

1 (800) 299-6766

Region II

Lewiston

1 (208) 799-5088

1 (800) 799-5088

Region III

Caldwell

1 (208) 455-7244

1 (208) 642-7006

1 (800) 494-4133

Region IV

Boise

1 (208) 334-0717

1 (208) 334-0718

1 (800) 354-2574

Region V

Twin Falls

1 (208) 736-4793

1 (800) 897-4929

Region VI

Pocatello

1 (208) 235-2927

1 (800) 284-7857

Region VII

Idaho Falls

1 (208) 528-5786

1 (800) 919-9945

In Spanish

(en Español)

1 (800) 378-3385

Insurance Verification

HMS

PO Box 2894

Boise, ID 83701

1 (800) 873-5875

1 (208) 375-1132

Fax:

1 (208) 375-1134

http://www.healthandwelfare.idaho.gov/

mailto:[email protected]


Molina Provider and Participant Services Contact Information

Provider Services

MACS (Medicaid Automated Customer Service)

1 (866) 686-4272 1 (208) 373-1424

Provider Service Representatives Monday through Friday, 7 a.m. to 7 p.m. MT

1 (866) 686-4272 1 (208) 373-1424

E-mail [email protected] [email protected]

Mail P.O. Box 70082 Boise, ID 83707

Participant Services

MACS (Medicaid Automated Customer Service)

1 (866) 686-4752 1 (208) 373-1432

Participant Service Representatives Monday through Friday, 7 a.m. to 7 p.m. MT

1 (866) 686-4752 1 (208) 373-1424

E-mail [email protected]

Mail – Participant Correspondence P.O. Box 70081 Boise, ID 83707

Medicaid Claims

Utilization Management/Case Management P.O. Box 70083 Boise, ID 83707

CMS 1500 Professional P.O. Box 70084 Boise, ID 83707

UB-04 Institutional P.O. Box 70085 Boise, ID 83707

UB-04 Institutional Crossover/CMS 1500/Third-Party Recovery (TPR)

P.O. Box 70086 Boise, ID 83707

Financial/ADA 2006 Dental P.O. Box 70087 Boise, ID 83707

Molina Provider Services Fax Numbers

Provider Enrollment 1 (877) 517-2041

Provider and Participant Services 1 (877) 661-0974





Provider Relations Consultant (PRC) Information

Region 1 and the state of Washington

Dianna Adams

120 Ironwood Drive Suite 102

Coeur d’Alene, ID 83814

1 (208) 559-4793

[email protected]

Idaho Regional Map

Region 2 and the state of Montana

Kristi Irby

1118 F Street

P.O. Box Drawer B

Lewiston, ID 83501

1 (208) 991-7138

[email protected]

Region 3 and the state of Oregon

Rainy Natal

3402 Franklin

Caldwell, ID 83605

1 (208) 860-4682

[email protected]

Region 4 and all other states

Julie Colleran

1720 Westgate Drive, Suite A

Boise, ID 83704

1 (208) 994-2476

[email protected]

Region 5 and the state of Nevada

Brenda Rasmussen

803 Harrison St.

Twin Falls, ID 83301

1 (208) 484-6323

[email protected]

Region 6 and the state of Utah

Kelsey Gudmunson

1070 Hiline Road

Pocatello, ID 83201

1 (208) 870-3997

[email protected]

Region 7 and the state of Wyoming

Kristi Harris

150 Shoup Avenue

Idaho Falls, ID 83402

1 (208) 991-7149

[email protected]



mailto:%[email protected]






Digital Edition

MedicAide is available online by the fifth of each month at

www.idmedicaid.com. There may be occasional exceptions to the

availability date as a result of special circumstances. The electronic

edition reduces costs and allows links to important forms and web

sites. To request a paper copy, please call 1 (866) 686-4272.

MedicAide is the monthly informational newsletter for Idaho Medicaid providers.

Editor: Chris Roberts, Division of Medicaid

If you have any comments or suggestions, please send them to:

Chris Roberts

[email protected]

DHW – Medicaid System Support Team

P.O. Box 83720

Boise, ID 83720-0009

Fax: (208) 332-7974

Molina Medicaid Solutions

PO Box 70082

Boise, Idaho 83707



in this issue - idaho medicaid health pas online newsletters/november 2011... · over 35 other...

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