In This Issue. Information Releases

Transcription

1 An Informational Newsletter for Idaho Medicaid Providers From the Idaho Department of Health and Welfare, October 2017 Division of Medicaid In This Issue School-Based Providers... 2 ACT NOW Mandatory Trading Partner Accounts... 3 MDS 3.0 RAI Manual Revisions-Section O... 3 Attention: Chiropractic Providers... 3 Provider Training Opportunities in Medical Care Unit Contact and Prior Authorization Information... 6 DHW Resource and Contact Information... 7 Insurance Verification... 7 Molina Provider and Participant Services Contact Information... 8 Molina Provider Services Fax Numbers... 8 Provider Relations Consultant (PRC) Information... 9 Information Releases No Information Releases Available MedicAide October 2017 Page 1 of 10

2 School-Based Providers Sleeping Students During recent audits, the Medicaid Program Integrity Unit (MPIU) identified instances of schoolbased providers billing Medicaid for preventative or rehabilitation services while a student is asleep. Services must be provided as defined in administrative code and include a response to the service based on the measurable goals required in the plan of service, which is the individualized educational plan (IEP) in the school setting. When these services are provided, the student must be aware of what is being taught to them and must be able to give a response to the service as documented in the service detail report. School-based services that are identified as preventative or rehabilitation are as follows: Behavioral Intervention Community Based Rehabilitation Services (CBRS) Occupational Therapy Physical Therapy Speech/Audiological Therapy Based on the needs of the individual student there may be a circumstance when a medical assistance service, such as nursing services or personal care services (PCS), can be provided and billed for during times the student is asleep. The school must assure the assessment and plan identifies this activity as a need to support their claims to Medicaid. Overlapping Services In addition, no two preventative or rehabilitation services can be billed to Medicaid when provided at the same time. This is considered overlapping services and only one service can be allowed. Based on the student s need, a medical assistance service can be billed when provided at the same time as a preventative or rehabilitative service. Each service must be provided by separate staff. The school must document the need for both services. Documentation of Services on IEP Schools can bill Medicaid for health-related services that are authorized on the IEP as long as the student is eligible for the service and there is a physician recommendation or order. The school is required to include the type of service on the IEP, e.g., group behavioral intervention, individual CBRS, or individual speech therapy. The IEP must also identify the duration of services provided by listing the minutes or hours of need per day or week. If the student has a need for a Medicaid billable service during a school activity that is outside the school hours, this information must also be included in the IEP. The IEP must guide the student s treatment and identify Medicaid services. MedicAide October 2017 Page 2 of 10

3 ACT NOW Mandatory Trading Partner Accounts The Trading Partner Account (TPA) portal is being upgraded in late 2017 and all providers will be required to have a TPA account. It is critical that all providers sign up for a TPA account now so they are prepared when the upgrade goes live. After the upgrade, billing agencies will no longer have access to the provider enrollment and maintenance materials and resources. Providers must have a TPA account in order to access provider enrollment and provider maintenance forms. Please go to today and sign up for your TPA. Waiting until after the upgrade to register for your TPA could cause delays in your Medicaid transactions. If you have any questions regarding the upgrade, or if you need assistance registering for a TPA account, please contact your regional Provider Relations Consultant (PRC) or the Molina provider services line at 1 (866) MDS 3.0 RAI Manual Revisions-Section O The MDS 3.0 RAI Manual v1.15 October 2017 contains updated instructions effective October 1, The revised RAI Manual can be downloaded from the CMS website at Instruments/NursingHomeQualityInits/MDS30RAIManual.html. Revisions to the instructions for 2 fields, O0600: Physician Examination and O0700: Physician Orders, state CMS does not require completion of this item; however, some States continue to require its completion. It is important to know your State s requirements for completing this item. Idaho does require completion of these two items. These fields are used in the RUG-III calculation of CMI scores used for Medicaid rate setting and are part of the determination as to whether a resident classifies into the Clinically Complex group. If you have any questions, please call the MDS Help Desk at 1 (800) Attention: Chiropractic Providers Beginning October 1, 2017, the process is changing for prior authorization requests for chiropractic services for adults and children. Currently, only six visits are allowed according to IDAPA If medical necessity is clearly demonstrated, an additional 12 visits may be approved through the prior authorization process. PAs are valid for the dates indicated on the authorization. It has been determined that meaningful use above 18 visits per year has not been established as a professionally-recognized standard of healthcare and therefore requests above 18 have been deemed not medically necessary. Other healthcare intervention services may be more appropriate and should be considered. Please direct individuals to their primary care physician for coordination of care and other healthcare alternatives to address their healthcare concern. (Continued on next page) MedicAide October 2017 Page 3 of 10

4 (Chiropractic Cont d) For children receiving chiropractic services, we do consider additional services under Early Periodic Screening Development and Treatment (EPSDT). These services must still be medically necessary and will require a prior authorization. Maintenance therapy is not covered by Idaho Medicaid. Maintenance therapy is defined as a treatment plan that seeks to prevent disease, promote health, and prolong and enhance the quality of life; or therapy that is performed to maintain or prevent deterioration of a chronic condition. When further clinical improvement cannot reasonably be expected from continuous ongoing care, the treatment is then considered maintenance therapy. The following documentation is required to request additional visits for a prior authorization: Completed Chiropractic Request Form Chiropractic evaluation completed within the past year Current plan of care (POC) signed and dated by the chiropractor, physician, or mid-level It must specify: Diagnosis Anticipated short and long-term goals that are outcome-based with measurable objectives Frequency of treatment Expected duration of treatment Discharge plan Reports of current status Communication and coordination with other providers. Documentation may include dates of communication, person contacted, summary of services provided by other providers, and the unique and specific contribution of each provider Copies of the daily entries completed within the last 30 days Number of visits being requested Date range of requested services Current progress notes Please fax all complete and valid PA requests to 1 (877) Failure to provide all required documentation at time of submission will result in denial of the prior authorization request as medical necessity cannot be established. MedicAide October 2017 Page 4 of 10

5 Provider Training Opportunities in 2017 You are invited to attend the following webinars offered by Molina Medicaid Solutions Regional Provider Relations Consultants. October: Respite Care This training will walk Respite Care providers through the process of signing up for a trading partner account, viewing prior authorizations, creating patient rosters, verifying eligibility, accessing remittance advice reports, and submitting and reviewing claims. Training is delivered at the times shown in the table below. Each session is open to any region but space is limited to 25 participants per session, so please choose the session that works best with your schedule. To register for training, or to learn how to register, visit and click on the Training link in the left-hand menu. October Respite Care November Trading Partner Account Upgrade December Trading Partner Account Upgrade 10 a.m a.m. MT 10 a.m a.m. MT 10 a.m a.m. MT 10 a.m a.m. MT 2 p.m. - 3 p.m. MT 2 p.m. - 3 p.m. MT 2 p.m. - 3 p.m. MT 10/11/ /17/ /18/ /19/ /12/ /17/ /19/ /8/ /15/ /16/ /21/ /9/ /16/ /21/ /13/ /19/ /20/ /21/ /14/ /19/ /21/2017 If you would prefer one-on-one training in your office with your Regional Provider Relations Consultant, please feel free to contact them directly. Provider Relations Consultant contact information can be found on page 9 of this newsletter. MedicAide October 2017 Page 5 of 10

6 Medical Care Unit Contact and Prior Authorization Information Prior Authorizations, Forms, and References To learn about prior authorization (PA) requirements, QIO review, or print request forms, go to the medical service area webpage at Prior authorization request forms containing the fax to number can be found at Click on Forms under the References section and you will see the PA request forms under the DHW Forms heading. If you prefer to mail in your form, the mailing address is: Medicaid Medical Care Unit P.O. Box Boise, ID Note: The Medical Care Unit (MCU) does not give authorizations for services over the telephone or for services which do not require a prior authorization. To Check Prior Authorizations Status Log on to your Trading Partner Account on Choose Form Entry, then choose Authorization Status. If you are unable to identify the reason for a denied service, a Molina Medicaid Solutions representative can provide the medical reviewer s reason captured in the participant s non-clinical notes. If you are unable to view the authorization status, please review the Trading Partner Account (TPA) User Guide located under User Guides on To speak to a Molina Medicaid Solutions representative, call 1 (866) , option 3. MCU Medical Review Decisions If you have any questions about medical review decisions, please refer to the following contact numbers or MedicalCareUnit@dhw.idaho.gov. Fax Number Phone Number Administratively Necessary Days 1 (877) (866) Ambulance* 1 (877) (800) Breast & Cervical Cancer 1 (877) (208) Durable Medical Equipment 1 (877) (866) Hospice 1 (877) (866) Preventive Health Assistance 1 (877) (208) Service Coordination 1 (877) (866) Surgery-Procedure-Lab 1 (877) (866) Therapy: OT, PT, SLP 1 (877) (866) Vision 1 (877) (866) * Idaho Medicaid contracts with Veyo Logistics for all non-emergency medical transportation services. Please go to or call 1 (877) for more information. MedicAide October 2017 Page 6 of 10

7 DHW Resource and Contact Information DHW Website Idaho CareLine (800) Medicaid Program Integrity Unit P.O. Box Boise, ID prvfraud@dhw.idaho.gov Fax: 1 (208) Telligen 1 (866) Fax: 1 (866) Healthy Connections Regional Health Resource Coordinators Region I Coeur d'alene Region II Lewiston Region III Caldwell Region IV Boise Region V Twin Falls Region VI Pocatello Region VII Idaho Falls In Spanish (en Español) 1 (208) (800) (208) (800) (208) (208) (800) (208) (208) (800) (208) (800) (208) (800) (208) (800) (800) Insurance Verification HMS PO Box 2894 Boise, ID (800) (208) Fax: 1 (208) MedicAide October 2017 Page 7 of 10

8 Molina Provider and Participant Services Contact Information Provider Services MACS (Medicaid Automated Customer Service) Provider Service Representatives Monday through Friday, 7 a.m. to 7 p.m. MT Mail Participant Services MACS (Medicaid Automated Customer Service) Participant Service Representatives Monday through Friday, 7 a.m. to 7 p.m. MT Mail Participant Correspondence Medicaid Claims Utilization Management/Case Management CMS 1500 Professional UB-04 Institutional UB-04 Institutional Crossover/CMS 1500/Third-Party Recovery (TPR) Financial/ADA 2006 Dental 1 (866) (208) (866) (208) idproviderservices@molinahealthcare.com idproviderenrollment@molinahealthcare.com P.O. Box (866) (208) (866) (208) idparticipantservices@molinahealthcare.com P.O. Box P.O. Box P.O. Box P.O. Box P.O. Box P.O. Box Molina Provider Services Fax Numbers Provider Enrollment 1 (877) Provider and Participant Services 1 (877) MedicAide October 2017 Page 8 of 10

9 Provider Relations Consultant (PRC) Information Region 1 and the state of Washington 1120 Ironwood Drive Suite 102 Coeur d Alene, ID (208) Region.1@MolinaHealthCare.com Region 2 and the state of Montana 1118 F Street P.O. Box Drawer B Lewiston, ID (208) Region.2@MolinaHealthCare.com Region 3 and the state of Oregon 3402 Franklin Caldwell, ID (208) Region.3@MolinaHealthCare.com Region 4 and all other states 1720 Westgate Drive, Suite A Boise, ID (208) Region.4@MolinaHealthCare.com Region 5 and the state of Nevada 601 Poleline Road, Suite 7 Twin Falls, ID (208) Region.5@MolinaHealthCare.com Region 6 and the state of Utah 1070 Hiline Road Pocatello, ID (208) Region.6@MolinaHealthCare.com Region 7 and the state of Wyoming 150 Shoup Avenue Idaho Falls, ID (208) Region.7@MolinaHealthCare.com MedicAide October 2017 Page 9 of 10

10 Molina Medicaid Solutions PO Box Boise, Idaho Digital Edition MedicAide is available online by the fifth of each month at There may be occasional exceptions to the availability date as a result of special circumstances. The electronic edition reduces costs and provides links to important forms and websites. To request a paper copy, please call 1 (866) MedicAide is the monthly informational newsletter for Idaho Medicaid providers. Editors: Shelby Spangler and Shannon Tolman If you have any comments or suggestions, please send them to: Shelby Spangler, Shelby.Spangler@dhw.idaho.gov Shannon Tolman, Shannon.Tolman@dhw.idaho.gov Medicaid Communications Team P.O. Box Boise, ID Fax: 1 (208) MedicAide October 2017 Page 10 of 10