Information Releases

Transcription

1 An Informational Newsletter for Idaho Medicaid Providers From the Idaho Department of Health and Welfare, January 2013 Division of Medicaid In This Issue Contact Lens Providers... 1 Changes to the Long Term Care Notice of Admission and Discharge Form, HW Attention Physicians and Hospitals... 1 Attention Providers of Physician Administered Drugs:... 1 HMS Awarded Recovery Audit Contract by the State of Idaho... 2 Attention Electronic Referral Users... 2 Set yourself up for success with ICD-10!... 3 Medicaid Program Integrity Unit... 3 Medicaid Fraud Unit Media Release... 4 Nursing home, ICF-ID and Waiver Participant... 4 Share of Cost (SOC)... 4 Frequently Asked Questions (FAQ)... 4 Share of Cost (SOC) Frequently Asked Questions (FAQ) (Cont)... 5 Eligibility Verification... 6 Provider Workshops... 6 Idaho Medicaid Health Home Program... 6 Provider Training Opportunities in January...16 Prior Authorization Contact Information...17 Transportation...17 DHW Resource and Contact Information...18 Insurance Verification...18 Molina Provider and Participant Services Contact Information...19 Molina Provider Services Fax Numbers...19 Provider Relations Consultant (PRC) Information...20 Information Releases MA12-20 Idaho Medicaid Health Home Program... 7 MA12-21 Revenue Codes 0510, 0456, 0760, and MA Current Procedural Terminology (CPT) Code Changes...11 Figure 2: Limitations... Error! Bookmark not defined.

2 Contact Lens Providers Idaho Medicaid prior authorizes (PA) contact lenses for children under the age of twenty-one (21) when certain criteria are met. Effective January 1, 2013, all contact lens fitting fees must also be prior authorized. Providers will no longer need to use the KX modifier. When submitting a PA request for contact lenses, providers should also request approval of the appropriate fitting fee using one of the following CPT codes: According to IDAPA , contact lenses are covered for children only when there is documentation that an extreme myopic condition requiring a correction equal to or greater than plus or minus ten (+/-10) diopters, or if there is an extreme medical condition that does not allow correction through the use of conventional lenses such as cataract surgery, keratoconus, or other extreme conditions as defined by the Department. Contact lenses for adults are not covered except in severe cases such as for treatment of keratoconus. If the above criteria are met for contact lenses, then the Department will also approve the request for the contact lens fitting fee. Changes to the Long Term Care Notice of Admission and Discharge Form, HW-0458 The process for communicating when a Medicaid participant enters or leaves a Long Term Care Facility will be changing. This spring, a new function will be available on the Molina Medicaid Web site for communicating when a Medicaid participant enters or leaves a Nursing Facility or ICF-ID Facility. The Molina Medicaid Web site will also provide the capability of uploading documents needed for determining a participant s level of care. The paper form (HW-0458) that is currently sent or ed to the Self-Reliance Long Term Care Unit, will be discontinued as of April Training will be available in various forums to learn about the new website functions. Watch for more information during January-March via the Molina Medicaid Web site, the IHCA web site, and MedicAide Newsletters. Attention Physicians and Hospitals New Procedure Code Requiring Prior Authorization Effective January 1, 2013, CPT code arthrodesis pre-sacral interbody technique, must be pre-authorized by Qualis Health (800) Attention Providers of Physician Administered Drugs: Effective January 1, 2013, Idaho Medicaid will no longer reimburse providers for procedure code S5000 Prescription drug, generic. Providers must use the appropriate HCPCS procedure code for each drug, or use the miscellaneous code, J3490 when no HCPCS code has been assigned. MedicAide January 2013 Page 1 of 21

3 HMS Awarded Recovery Audit Contract by the State of Idaho In 2010, Section 6411 of the Patient Protection and Affordable Care Act (ACA) required states to implement Recovery Audit Contracts (RACs) in order to help ensure the fiscal integrity of their Medicaid programs. After a competitive procurement process, the state of Idaho Department of Health and Welfare (IDHW) announced that Health Management Systems (HMS) has been selected to serve as the State s RAC vendor. HMS has been a trusted partner in Medicaid program integrity initiatives for more than 25 years and is currently the Medicaid RAC vendor in over 30 states. HMS has an office located in Boise, as well as experts located throughout the country. All reviews are performed by teams of registered nurses and certified coders and overseen by board certified physicians. HMS will also be providing a dedicated Provider Relations team to support outreach, education, and other support via toll free phone lines and secure 24/7 online access to the HMS Provider Portal. At this time, IDHW and HMS are in the early implementation phase of the RAC program and have yet to define specific audit targets. In the coming months, HMS and IDHW will be conducting joint outreach and informational webinars to further define the scope of the Idaho RAC program. When specific provider types have been identified for RAC review, HMS and IDHW will contact the applicable provider associations and offer targeted educational opportunities. More information will be forthcoming prior to full scale implementation. IDHW will work with HMS to ensure compliance with Centers for Medicare and Medicaid Service s (CMS) final rule regarding Medicaid RACs. Among the highlighted requirements include: RACs must identify both overpayments and underpayments and recover overpayments States must adequately incentivize the detection of underpayments and must notify providers of such underpayments when identified by the RAC States must coordinate the recovery audit efforts of their Medicaid RACs with other auditing entities RACs must not review claims that are older than 3 years from the date of the claim, unless it receives approval from the State RACs should not audit claims that have already been audited by another entity States must provide appeal rights under State law or administrative procedures to Medicaid providers that seek review of an adverse RAC determination RACs must work with the State to develop an education and outreach program for providers and other stakeholders Attention Electronic Referral Users You must have access to submit or retrieve an electronic referral. Please refer to the TPA Guide Referral Section 2: Account Maintenance for instructions on how to determine if you have the appropriate access. If you need assistance determining the TPA administrator on your account please contact the EDI helpdesk 1(866) MedicAide January 2013 Page 2 of 21

4 Set yourself up for success with ICD-10! The implementation of ICD-10 will impact providers, their processes, systems and documentation. Set yourself and your organization up for success by knowing and understanding what these impacts are and how your organization is going to address them. For example: What is your Electronic Health Record (EHR) vendor doing to transition to ICD-10 and how will it impact you? If you have not selected an EHR system, here are some questions for discussion with your vendor. 1) Will the system be able to accommodate ICD-10-CM and ICD-10-PCS code sets? 2) How has the vendor supported their existing customers in making the transition to ICD-10? 3) What customer support and training for ICD-10 will be offered, and will it be included in the contract? 4) Will the software application be able to accommodate both ICD-9 and ICD-10 codes and code descriptions if so, for how long? If you already have a certified EHR system, here are some questions to ask your vendor about options and pricing. 1) What is your timeline and plan for transition to ICD-10? 2) What is the anticipated impact to our staff? 3) Will the system enable use of both ICD-9 and 10 codes? If so, for how long? 4) Will there be additional costs to accommodate ICD-10 codes? 5) Will my contract need to be modified to include ICD-10 codes? What are the terms? 6) Will my system be ICD-10 ready by 2013 so I can begin ICD-10 testing? 7) What level of customer support and training is offered? Are those costs included in the contract? If not, what are the anticipated additional costs? Medicaid Program Integrity Unit Laboratory tests performed by independent laboratories During recent audits, the Medicaid Program Integrity Unit identified physician offices that inappropriately billed laboratory tests to Medicaid with modifier 90. Modifier 90 is described in the Current Procedural Terminology manual as reference (outside) laboratory. IDAPA addresses billing of laboratory tests as follows: Payment for laboratory tests can only be made to the actual provider of that service. An exception to the preceding is made in the case of an independent laboratory that can bill for a reference laboratory. A physician is not an independent laboratory. Modifier 90 is to be used only when an independent laboratory sends a specimen to a reference laboratory for testing. If a provider does not perform the laboratory test, it is inappropriate to bill Medicaid for the test. The laboratory that performs the test is the provider that bills Medicaid. The Department will recover payments and assess civil monetary penalties to any providers that are not independent laboratories and bill Medicaid for laboratory tests they do not perform. MedicAide January 2013 Page 3 of 21

5 Medicaid Fraud Unit Media Release For Immediate Release Media Contact: Bob Cooper (208) Date: November 13, 2012 John Baird Sentenced for Medicaid Fraud (Boise) - Idaho Falls resident John K. Baird was sentenced today on one count of provider fraud and one count of grand theft, Attorney General Lawrence Wasden said. Seventh District Judge Joel Tingey sentenced Baird to serve five years in prison. The court suspended the prison sentence and placed Baird on probation for five years and ordered him to pay $84,850 in restitution. Baird owned The Living Farm, a business providing mental health and psychosocial rehabilitative (PSR) services. Baird used unqualified staff that did not have the education required to provide the PSR services. Baird was informed in 2008 that The Living Farm was in violation of rules for use of unqualified staff to perform PSR services. Baird, 49, pleaded guilty to the charges on October 1, By pleading guilty, Baird admitted that he submitted false claims to Medicaid for PSR services provided by an unqualified employee of The Living Farm. The Aberdeen School District contracted for PSR services from The Living Farm. The school district billed Medicaid, and received payments from Medicaid for these services provided by The Living Farm's unqualified staff. In 2010, the district's superintendent informed Idaho Medicaid that the district may have been misled into inappropriately billing Medicaid for services provided by The Living Farm's unqualified staff. The school district entered into a repayment agreement for the overpayment amount. The criminal investigation was initiated by a referral from the Idaho Department of Health and Welfare's Bureau of Audits and Investigations. Bonneville County Prosecutor Bruce L. Pickett referred this case to the Idaho Attorney General's Medicaid Fraud Control Unit. Nursing home, ICF-ID and Waiver Participant Share of Cost (SOC) Frequently Asked Questions (FAQ) What is Share of Cost (SOC) and how is it calculated? Some Medicaid participants who reside in Long Term Care facilities or receive Community- Based Waiver services must pay a monthly contribution toward the cost of their care. This contribution is commonly referred to as the Share of Cost. A participant s SOC is calculated by the Department of Health and Welfare s Self Reliance Division based on the Medicaid participant s reported and verified income. SOC amounts are subject to change if a participant s income changes. How is SOC used -in claims processing? Self-Reliance staff enters SOC into the Department s Eligibility System. The eligibility system communicates this information to the Molina Medicaid System. The monthly SOC amount is deducted from claims payment to the provider when the service billed requires a contribution from the participant. SOC is deducted on a monthly basis on claims as they are submitted, until the monthly contribution has been paid in full. MedicAide January 2013 Page 4 of 21

6 Share of Cost (SOC) Frequently Asked Questions (FAQ) (Cont) How is this process different for claims with a date of service BEFORE June 1, 2010? Prior to June 1, 2010, Providers entered the SOC amount on submitted claims based on information they received from the Department. Medicaid claims were paid based on the self-declared calculation from the provider. Providers who need to reprocess claims which were incorrectly paid for services rendered prior to June 1, 2010, should enter the selfdeclared amount of SOC on the re-submitted claim. How do I know what Share of cost amount has been reported by Self Reliance? Providers can check participant SOC amounts in their secure online Trading Partner Account on the Molina Medicaid Web site. Instructions for checking participant eligibility and SOC are in the TPA-Trading Partner Account Eligibility Verification Guide found in the User Guides. What if the Participant s eligibility or Share of Cost is incorrect? If a provider believes a participant s eligibility or SOC has been determined incorrectly or is based on outdated information, the participant or their authorized representative should call Self-Reliance directly at 1 (877) , and ask to speak with a Self-Reliance Specialist. It is important to communicate that you are questioning the information used in calculating eligibility and Share of Cost. Be prepared to provide verification of changes in income, resources or other information you think should be considered for the SOC calculation. If you experience difficulty reporting the information, or if you are told a Self-Reliance Specialist will contact you and you do not receive a return call by the 3rd business day after your request, please Julie Hammon at hammonj@dhw.idaho.gov. What if the Share of Cost amount on a claims payment differs from the Share of Cost amount published on the Molina Medicaid web site? If the SOC amount listed on the Molina Medicaid Web site differs from the amount on the processed claim, please call Molina Provider Services at 1 (866) Nursing Home providers can send an with their questions directly to idnursinghomes@molinahealthcare.com for resolution. Why is Share of Cost sometimes recalculated for past periods? If a participant has incorrectly reported income to Self-Reliance, a recalculation is completed for the correct SOC. When this recalculation occurs, it is communicated to the Molina Medicaid System, which may result in claims adjustment. Beginning in April 2013, SOC recalculations for past periods will only be sent to the Molina Medicaid system if the recalculated SOC is less than initially reported. If the recalculated SOC is greater, Self Reliance will recover the additional money directly from the participant. Providers will no longer be required to recover additional money from participants when the SOC increases for past periods. This change is being implemented for participants in Community-Based Waiver services, Nursing Facilities and ICF-ID facilities. More information on this change be provided during February and March through the IHCA web site, Molina Medicaid website and MedicAide Newsletters. MedicAide January 2013 Page 5 of 21

7 Eligibility Verification Patient eligibility information is available on the Web and is also provided through the Molina automated call system. The Molina call center staff provide eligibility information as a courtesy to providers who are unable to use these automated systems, however, it is the provider s responsibility to verify a participant s eligibility. The call center has specific requirements imposed on them by the State to be available to thousands of Medicaid providers for multiple issues in a timely fashion. This is not possible if one staff member must spend a lengthy amount of time to support eligibility inquiries for a single provider, particularly when other systems exist for the provider to check eligibility on their own. The State requests that providers limit their eligibility inquiries to the call center staff to five participants per call in order to allow other providers timely response to their inquiries. Providers can also create a participant roster in their TPA account which may be helpful to them in checking eligibility for multiple participants. By uploading the roster, they can click the radio button next to the participant name and request eligibility information. The TPA Patient Roster Guide on the provider portal can guide them through the process. Providers should be checking participant eligibility on the day they are to be seen. Provider Workshops Provider workshops will be held in February. Workshops will provide training on how to read the Trading Partner Eligibility Receipt, entering and retrieving Electronic Referrals on the Trading Partner Account, and Hot Medicaid Topics. The half-day workshops will be held in two Idaho locations from 8:00 A.M. to Noon. February 5 th - Idaho Falls, Idaho Department of Health and Welfare February 8 th - Coeur d Alene at Kootenai Medical Center Register at under Training. Idaho Medicaid Health Home Program The Idaho Medicaid Health Home Program will begin on January 1, The Centers for Medicare and Medicaid Services recently approved the state plan amendment for Health Homes. To view general program requirements, request an estimated number of qualified participants within your clinic, or to get updates and additional program information, please visit the Idaho Medicaid Health Home web page at When verifying Medicaid eligibility, the enrollment segment for participants enrolled in this program will appear as Idaho Medicaid Health Home Benefit Plan. All Healthy Connections policies, procedures, and requirements (including referrals) apply to Health Home providers and participants. The Health Home program guidelines and requirements can be found in the Idaho Medicaid Provider Handbook, General Participant & Provider Information chapter, Section 2.6. Healthy Connections Providers participating in the Idaho Medicaid Health Home Program will be paid a higher per-member per-month fee to provide care coordination for participants with qualifying chronic conditions. Healthy Connections patients that do not qualify for health homes will remain in the current program and status. If you have questions or need additional information, you can send an to the project team at medicalhomeproject@dhw.idaho.gov. MedicAide January 2013 Page 6 of 21

8 MA12-20 Idaho Medicaid Health Home Program MedicAide January 2013 Page 7 of 21

9 MedicAide January 2013 Page 8 of 21

10 MA22-21 Revenue Codes 0510, 0456, 0760, and 0761 MedicAide January 2013 Page 9 of 21

11 MedicAide January 2013 Page 10 of 21

12 MA Current Procedural Terminology (CPT) Code Changes MedicAide January 2013 Page 11 of 21

13 MedicAide January 2013 Page 12 of 21

14 MedicAide January 2013 Page 13 of 21

15 MedicAide January 2013 Page 14 of 21

16 MedicAide January 2013 Page 15 of 21

17 Provider Training Opportunities in January You are invited to attend the following webinars offered by Molina Medicaid Solutions Regional Provider Relations Consultants. Electronic Referral Training - This course is designed to instruct Primary Care Physician on how to submit a referral and Specialists to Retrieve. Claims Adjustment Training - This course will assist you in adjusting claims for quick claim resolution on the Trading Partner Account. Training is delivered at the below times. 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. Date Electronic Referral Training Claim Adjustment Training 01/09/2013 2:00 P.M. MT 10:00 A.M. MT 01/14/2013 2:00 P.M. MT 10:00 A.M. MT 01/15/ :00 A.M. MT & 2:00 P.M. MT 10:00 A.M. MT & 2:00 P.M. MT 01/17/ :00 A.M. MT & 2:00 P.M. MT 10:00 A.M. MT & 2:00 P.M. MT 01/18/ :00 A.M. MT 2:00 P.M. MT Register to create your one-time user profile Click on Idaho Medicaid Training Center 1. Create your user name A minimum of eight characters Must contain letters, numbers, and special characters 2. Create your password A minimum of eight characters Must contain at least one upper case letter, one lower case letter, one number, and one special character (@, #, $, %, ^, *, +, -) 3. Obtain the access code You must call 1 (866) to obtain your Access Code If you need assistance registering for this class contact idedisupport@molinahealthcare.com If you would prefer one on one training in your office with your Regional Provider Relations Consultant please feel free to contact directly. Provider Relations Consultant Contact Information Region 1 and State of Washington Dianna Adams Region.1@MolinaHealthCare.com (208) Region 2 and State of Montana Kristi Irby Region.2@MolinaHealthCare.com (208) Region 3 and State of Oregon Rainy Natal Region.3@MolinaHealthcare.com (208) Region 4 and all other states Region 5 and State of Nevada Region 6 and State of Utah Debbie Schiller Region.4@MolinaHealthCare.com (208) Brenda Rasmussen Region.5@MolinaHealthcare.com (208) Kelsey Gudmunson Region.6@MolinaHealthCare.com (208) Region 7 and State of Wyoming Kristi Harris Region.7@MolinaHealthCare.com (208) MedicAide January 2013 Page 16 of 21

18 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) DME Specialist, Medical Care P.O. Box Boise, ID Pharmacy P.O. Box Boise, ID Medical Care Attention: Surgery Authorizations P.O. Box Boise, ID Qualis Health (Inpatient hospital stays greater than three days and selected diagnoses & procedures, Telephonic & Retrospective Reviews) Meridian Avenue N., Ste 100 PO Box Seattle, WA Preventive Health Assistance PHA Unit P.O. Box Boise, ID Office of Mental Health and Substance Abuse (OMHSA) P.O. Box Boise, ID (866) Fax: 1 (877) (Attn: DME Specialist) 1 (866) Fax: 1 (800) (208) Fax: 1 (877) (800) (206) Fax: 1 (800) (877) (208) Fax: 1 (877) (208) (866) Fax: 1 (888) Transportation Idaho Medicaid contracts with American Medical Response (AMR) for all non-emergency medical transportation services. Please go to or call 1 (877) for more information. Ambulance Review 1 (800) (208) Fax: 1 (877) MedicAide January 2013 Page 17 of 21

19 DHW Resource and Contact Information DHW Web site Idaho CareLine (800) Medicaid Program Integrity Unit P.O. Box Boise, ID prvfraud@dhw.idaho.gov Fax: 1 (208) 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 January 2013 Page 18 of 21

20 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 Boise, ID (866) (208) (866) (208) idparticipantservices@molinahealthcare.com P.O. Box Boise, ID P.O. Box Boise, ID P.O. Box Boise, ID P.O. Box Boise, ID P.O. Box Boise, ID P.O. Box Boise, ID Molina Provider Services Fax Numbers Provider Enrollment 1 (877) Provider and Participant Services 1 (877) MedicAide January 2013 Page 19 of 21

21 Provider Relations Consultant (PRC) Information Region 1 and the state of Washington Dianna Adams 120 Ironwood Drive Suite 102 Coeur d Alene, ID (208) Region.1@MolinaHealthCare.com Region 2 and the state of Montana Kristi Irby 1118 F Street P.O. Box Drawer B Lewiston, ID (208) Region.2@MolinaHealthCare.com Region 3 and the state of Oregon Rainy Natal 3402 Franklin Caldwell, ID (208) Region.3@MolinaHealthCare.com Region 4 and all other states Deb Schiller 1720 Westgate Drive, Suite A Boise, ID (208) Region.4@MolinaHealthCare.com Region 5 and the state of Nevada Brenda Rasmussen 803 Harrison St. Twin Falls, ID (208) Region.5@MolinaHealthCare.com Region 6 and the state of Utah Kelsey Gudmunson 1070 Hiline Road Pocatello, ID (208) Region.6@MolinaHealthCare.com Region 7 and the state of Wyoming Kristi Harris 150 Shoup Avenue Idaho Falls, ID (208) Region.7@MolinaHealthCare.com Idaho Regional Map MedicAide January 2013 Page 20 of 21

22 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, spangles@dhw.idaho.gov Shannon Tolman, tolmans@dhw.idaho.gov Medicaid - Communications Team P.O. Box Boise, ID Fax: (208) MedicAide January 2013 Page 21 of 21