Information Releases

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1 An informational newsletter for Idaho Medicaid Providers From the Idaho Department of Health and Welfare, January 2011 Division of Medicaid In This Issue Changes in Intrauterine Device (IUD) Reimbursement... 2 Healthy Connections (HC) Referral Requirement for Urgent Care Clinics Change... 2 Self Reliance Long Term Care Unit... 2 Attention Physician and Hospital Providers... 2 New Arthrodesis Codes and Medicaid Program Integrity... 3 Recommendations or Referrals for School-Based Services... 3 Medicaid-Reimbursed Psychological and Neuropsychological Testing Policy Changes... 3 Tips for PCPs on Tobacco Cessation... 5 Do Your Patients Need to Lose or Gain Weight?... 6 Utilization Management of Mental Health Services... 6 Provider Training Opportunities... 7 Attention Agencies Providing Nursing Services... 7 Private Duty Nursing (PDN), Nursing Services... 7 System Updates... 8 Invalid SG Modifier Corrected... 8 Service codes J0585, J0475, 64614, no longer require PA... 8 CPT Code E2620 Added To Physician Services Benefits... 8 Transportation Waiver Code A Resource Utilization Group (RUG) Codes... 8 Codes Added for Therapies... 8 New Pricing for Procedure Code Anesthesia Codes Added... 8 Place of Service (POS) Code Site of Service Reduction Codes... 9 Notice of Decision Delivery... 9 Hospital Lab Rates... 9 Repayment Agreement... 9 DHW Contact Information...14 Insurance Verification...14 Prior Authorization Contact Information...15 Transportation...15 Molina Provider and Participant Services Contact Information...16 Molina Provider Services Fax Numbers...16 Provider Relations Consultant (PRC) Information...17 Information Releases MA11-01 Restructuring of the Healthy Connections Primary Care Case Management Fee...11 MA11-02 CMS Coverage Changes for Compounding Ingredients...13 MedicAide January 2011 Page 1 of 18

2 Changes in Intrauterine Device (IUD) Reimbursement Reimbursement changes for IUDs were effective November 1, 2010 for the following: Mirena IUD J7302 is paid at $ Paragard IUD J7300 is paid at $ Healthy Connections (HC) Referral Requirement for Urgent Care Clinics Change Beginning January 1, 2011, a referral will no longer be needed for participants accessing an urgent care clinic after their Healthy Connections provider s office is closed (i.e. after hours and on weekends). This change was proposed during provider meetings that were held to discuss ways to reduce costs to the Medicaid program. The change is intended to save money by reducing participants after hour use of the emergency department. Urgent care clinics must verify and document that the participant has presented after hours. A Healthy Connections referral to an urgent care clinic is still required during normal business hours. Urgent care clinics should always report their findings to the Healthy Connections provider, and participants should be advised to follow up with their Healthy Connections provider if necessary. Self Reliance Long Term Care Unit Nursing facility staff can either fax or correspondence to the Long Term Care Unit. The address for the Self Reliance Long Term Care Unit is MyBenefits@dhw.idaho.gov. The fax number for the Long Term Care Unit is 1 (208) Attention Physician and Hospital Providers New Arthrodesis Codes and The following new CPT codes require review effective for services performed on or after January 1, 2011: Arthrodesis, anterior interbody, including disc space preparation, diskectomy, osteophytectomy and decompression of spinal cord and/or nerve roots; cervical below C cervical below C2, each additional interspace (add on code) These two codes have been added to Qualis Health s Select Pre-authorization List of Diagnoses and Procedure Codes, which is available online at: Click on Idaho Medicaid Provider Manual and then refer to Appendix A. MedicAide January 2011 Page 2 of 18

3 Medicaid Program Integrity Recommendations or Referrals for School-Based Services Recent audits of school-based services have revealed instances where the participant s (student s) record did not contain the recommendation or referral by a physician or other practitioner of the healing arts such as a nurse practitioner, clinical nurse specialist, or physician's assistant for the school-based services billed to Medicaid. A recommendation or referral by a physician or other practitioner of the healing arts is required for all Medicaid services for which the school district or charter school is receiving reimbursement (IDAPA ). It is preferred that the order is from the student s primary care provider if the student is on the Healthy Connections Program; however, it is not required. The recommendation or referral should be located in the student s file or the physician or other practitioner of the healing arts can sign the Individualized Education Program, Individualized Family Service Plan, or Services Plan for evaluations and therapies billed to Medicaid. Documentation to support the services billed to Medicaid must be maintained by the provider and retained for a period of six years. This documentation must be available for immediate review upon written request by the Department and its agents or the US Department of Health and Human Services and its agents (IDAPA ). This includes the required referrals and recommendations. Medicaid-Reimbursed Psychological and Neuropsychological Testing Policy Changes Medicaid changed its policies governing psychological testing effective January 1, 2011 as part of the response to House Bill 701 from the 2010 legislature. The psychological and neuropsychological testing benefits are now a stand-alone benefit with its own four (4) hour service limit for services provided by the psychologist and technicians and two (2) hours for testing administered by a computer. More hours are available through a prior-authorization (PA) process. This change is not an attempt at cost-savings but is a necessary change in order for psychological and neuropsychological testing services to remain as they were prior to January 1, For a cost savings, Medicaid reduced the assessment/evaluation benefit from twelve (12) to four (4) hours annually effective January 1, As you know, testing services used to be a part of this twelve (12) hour limitation. By carving out testing services from the assessment/evaluation benefits Medicaid is able to preserve the testing benefits at the full capacity that they were previously utilized. Adding the PA process was a necessary operation to support psychologists in their determinations of how much testing is appropriate for their participants. MedicAide January 2011 Page 3 of 18

4 Medicaid has dedicated resources to administer the psychological and neuropsychological benefits in order to promote an efficient and effective PA process. It is Medicaid s intent to process requests as soon as they are received. Psychologists may submit their requests prior to delivering the service, after having delivered some of the service or within sixty (60) calendar days following the provision of the service. Medicaid has learned that commonly many psychologists conduct a psychiatric diagnostic interview (code or 90802) as a part of the process to help determine the questions that need to be answered through testing and to establish the composition of the battery to be administered. With the reduction in the assessment/evaluation benefits psychologists may discover that the participant has exhausted his benefits for such an assessment. If the participant is under age twenty-one (21) a request for more benefits of this nature may be requested through the EPSDT program. To access information about this process, please see the DHW website or go to: 123&mid=4137. If the participant is age twenty-one (21) or older no additional assessment/evaluation benefits are available once the participant uses the amounts allowed by rule. Medicaid staff is available to help you access any existing psychiatric diagnostic evaluations that may exist for such participants. To facilitate the quickest possible turnaround time for requesting an authorization for psychological and neuropsychological testing, Medicaid is providing a form that providers may choose to use to make their requests. This form can be accessed at: If a psychologist chooses to communicate the request otherwise there is an added risk of miscommunication and possible delay in authorization but Medicaid staff will make every attempt to process such requests as quickly as any other. The psychologist (or other staff) must provide the following information when requesting psychological or neuropsychological testing hours above the service limits already allowed by rule: 1. Participant s Name 2. Participant s Medicaid number 3. Provider s Name 4. Provider s Agency name & contact information 5. Provider s Medicaid number 6. Provider credentials 7. Provider license number 8. Service Date(s) 9. Number of requested hours per CPT code 10. Number of hours previously utilized in each CPT code (in current calendar year) 11. Reason testing or additional testing is necessary 12. Therapists must submit documented evidence of education or training qualifying him/her to perform psychological testing. (Psychologists and service extenders, please disregard this item.) MedicAide January 2011 Page 4 of 18

5 A prior-authorization will be issued for only the hours requested above the service limits. For example: a request is received for six (6) hours of code 96101, with zero hours previously utilized in this calendar year. A PA for two (2) hours will be either approved or denied. Whereas if the request was for six (6) hours and indicated four (4) hours of code had already been used, then a PA for six (6) hours would be generated. Providers will only be able to access the PA number electronically through Molina. Medicaid appreciates the participation of all psychologists in the Medicaid program. Staff at the Office of Mental Health and Substance Abuse (OMHSA), the unit charged with administering these benefits, intends to continue to communicate with psychological and neuropsychological testing stakeholders to ensure the applicable policies achieve what they are intended for and do not create unnecessary barriers. OMHSA staff is available to answer your questions at (208) or Tips for PCPs on Tobacco Cessation The Preventive Health Assistance (PHA) benefit provides assistance to participants to help them quit using tobacco. We provide assistance: Locating cessation programs Paying 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 s 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 follow up contact and refer your Medicaid patients to the PHA Unit at our toll free number, 1(877) 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) Go to 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. MedicAide January 2011 Page 5 of 18

6 Do Your Patients Need to Lose or Gain Weight? The Preventive Health Assistance (PHA) benefit may be able to help pay for a weight management program. PHA provides assistance to Medicaid patients who meet the Centers for Disease Control definition of being obese or underweight. To qualify for this benefit, Medicaid patients must: be over the age of 5 have a Body Mass Index (BMI) in the obese or underweight range, and want to improve health through weight management. If you have a patient you think may qualify, please refer them to the PHA Unit at 1(877) , 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) (toll-free). Utilization Management of Mental Health Services The purpose and work of the Office of Mental Health and Substance Abuse (OMHSA) has evolved to now include additional utilization management processes intended to ensure participants obtain the services that best match their healthcare needs and to ensure providers have access to necessary information and support in order to provide such services. OMHSA care managers are now working directly with provider agencies and participants as they navigate the mental health benefits, policies and procedures. A care manager, who is specifically assigned to your agency, is available for you if you have questions about how to best serve one of your participant(s) or if you need information about your participants such as the identity of the previous provider or copies of medical records when you are not able to obtain them through the usual channel of asking providers directly. The care managers are also working with participants and their natural supports (with appropriate permissions) to help participants understand their benefits and assist them in making the choices available to them. Care managers are also conducting random Quality Assurance reviews as a follow up to the work described above. When you receive a communication from OMHSA or another provider in which records are requested please support these efforts at building a better and more effective mental health program by supplying those records as soon as possible. To access a care manager please call (208) or MedicAide January 2011 Page 6 of 18

7 Provider Training Opportunities The Language of RAs is a new training session available in January 2011 open to all Medicaid providers. It will be offered on the following dates: Location Date Time Location (DHW Office) Region 1 1/14/ A.M. PT Conference Room #102, 1120 Ironwood Dr. Coeur D Alene, ID Region 2 1/13/ A.M. PT 3 rd Floor Conference Room, 1118 F Street Lewiston, ID Region 3 1/19/ A.M. MST Room #190, 3402 Franklin Rd. Caldwell, ID Region 4 1/18/ A.M. MST Suite B Conference Room, 1720 Westgate Dr. Boise, ID Region 5 1/6/ A.M. MST Conference Room A/C, 601 Poleline Rd. Twin Falls, ID Region 6 1/7/ A.M. MST Ste# 230, 1070 Hiline Rd., Pocatello, ID Region 7 1/4/ A.M. MST 2 nd Floor Conference Room, 150 Shoup Ave. Idaho Falls, ID This training session is designed to assist in locating, retrieving, and reading Remittance Advices (RAs). The current RA form fields will be identified along with tips assisting providers with working and understanding their RAs. 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, all walk-ins are always welcomed!! All onsite classroom sessions are available for registration through the Idaho Medicaid Training Center. Go to and click on Training in the menu on the left side of the screen. Click on Idaho Medicaid Training Center and log in for the time, date, and locations in your region. Although it is not required, registering for the session will alert users of any changes that may occur in case a session is cancelled or rescheduled. Attention Agencies Providing Nursing Services Private Duty Nursing (PDN), Nursing Services The decision to use an RN or LPN is dependent on the medical needs of the participant, type of services required, and must be consistent with the scope of nursing practice. This decision will ultimately be made by the Medicaid nurse reviewer but s/he will take the opinion or input of the agency nurse into consideration before making the final decision. Functions of a Licensed Practical Nurse (LPN) can be found within the legal definition of licensed practical nurse, Section (3), Idaho Code, (Nursing Practice Act) as well as in the Rules of the Idaho State Board of Nursing, IDAPA Determining Scope of Practice and IDAPA Licensed Practical Nurse (LPN). MedicAide January 2011 Page 7 of 18

8 Invalid SG Modifier Corrected System Updates The SG modifier (ambulatory surgical center) was causing claims to deny for CPT codes and (paravertebral injection). The SG modifier has been corrected to ensure claims process correctly. The modifier does not impact billing; therefore, any claims denied for this reason will be reprocessed. Service codes J0585, J0475, 64614, no longer require PA Requirements for Prior Authorizations have been removed from service codes J0585 (Botulinum toxin) and J0475 (Baclofen injection); and (chemical denervation of muscles) and (definitive procedures for cranial fossae). Claims for these services will be reprocessed. CPT Code E2620 Added To Physician Services Benefits CPT code E2620 (positioning wheelchair back cushion) has been added to Physician Services benefits. Claims with this code will be reprocessed. Transportation Waiver Code A0080 Waiver code A0080 (non-emergency transportation with vehicle provided by volunteer) has been added back for agencies and individual providers. This waiver code is not included in the outsourced transportation contract. Resource Utilization Group (RUG) Codes Resource Utilization Group (RUG) codes are not accepted and claims will deny. Please refer to the provider handbook for specific billing questions. Codes Added for Therapies CPT codes (orthotics management and training; prosthetic training; checkout for orthotic/prosthetic use) has been added for physical, and occupational therapies within Healthy Connections, Open Access and Lock-In. New Pricing for Procedure Code Procedure code (RSV-immune globulin for intramuscular use) has a new pricing segment. The new pricing is effective beginning 12/01/2010 and requires a Prior Authorization. Anesthesia Codes Added Two new CPT codes have been added to Anesthesia-Other Services contract terms. The codes are CPT (injection, anesthetic agent; trigeminal nerve) and (greater occipital nerve). MedicAide January 2011 Page 8 of 18

9 Place of Service (POS) Code 51 All physician and mid-level contracts now have a Place of Service (POS) code 51 (inpatient psychiatric facility) for the physician/mid-level term. This corrects a problem which caused claims to deny for hospital services (subsequent hospital care, per day) and (inpatient hospital discharge services). Impacted claims will be adjusted. Site of Service Reduction Codes The Site of Service Reduction Codes has been posted under the Provider Handbook, References Section. You can click on the link at the left for Provider Handbook, or use this link Notice of Decision Delivery Many providers have requested electronic rather than paper Notices of Decision (NODs). A solution for providing electronic NODs to providers is being implemented in stages. First, pay-to providers who have a Trading Partner Agreement will no longer be sent paper versions of prior authorizations (PA) and referral notices if their selected preference is electronic. Other providers will begin receiving their selected preference by the end of this year. Hospital Lab Rates Hospital outpatient lab services and ER lab services have had their contracted rates adjusted. Variable rates have been set to 100% of the UCR fee schedule. This adjustment affects over 300 hospital and ER labs. The change will be made retroactive to June 1, Repayment Agreement Did you receive a non-claim interim payment during the transition from HP/EDS to Molina? There are several options for repayment of those funds now. If you are interested in repaying your non-claim interim funds now, print the repayment agreement form on the next page and follow the instructions. MedicAide January 2011 Page 9 of 18

10 MedicAide January 2011 Page 10 of 18

11 MA11-01 Restructuring of the Healthy Connections Primary Care Case Management Fee MedicAide January 2011 Page 11 of 18

12 MedicAide January 2011 Page 12 of 18

13 MA11-02 CMS Coverage Changes for Compounding Ingredients MedicAide January 2011 Page 13 of 18

14 DHW 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 2011 Page 14 of 18

15 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) to contact Molina if you have questions regarding claims with an existing prior authorization. DME Specialist, Medical Care P.O. Box Boise, ID Pharmacy PO Box Boise, ID Therapy and Surgery PA Requests PO Box Boise, ID Qualis Health (Telephonic & Retrospective Reviews) Meridian Ave. N. Suite 100 Seattle, WA Preventative Health Assistance PHA Unit PO Box Boise, ID (866) Fax: 1 (877) (Attn: DME Specialist) 1 (866) Fax: 1 (800) (208) Fax: 1 (877) (800) Fax: 1 (800) (206) (877) (208) Fax: 1 (877) Transportation Beginning September 1, 2010, Idaho Medicaid contracted 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 2011 Page 15 of 18

16 Molina Provider and Participant Services Contact Information Provider Services MACS (Medicaid Automated Call Service) Provider Service Representatives Monday through Friday, 7 a.m. to 7 p.m. MT Mail Participant Services MACS (Medicaid Automated Call 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 2011 Page 16 of 18

17 Provider Relations Consultant (PRC) Information Region 1 and the state of Washington Paul McKinzie 1120 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 Deanna LaCombe 9415 W. Golden Trout Way 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 MedicAide January 2011 Page 17 of 18

18 Molina Medicaid Solutions PO Box Boise, Idaho Digital Edition As part of our commitment to cost savings, we are using paperless processes wherever possible. MedicAide is online and will be available electronically by the fifth of each month. Our new digital edition, posted at also allows links to important forms and web sites, plus it is eco-friendly. 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 DHW Medicaid System Support Team PO Box Boise, ID Fax: (208) MedicAide January 2011 Page 18 of 18