In This Issue. Information Releases

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1 An Informational Newsletter for Idaho Medicaid Providers From the Idaho Department of Health and Welfare, September 2015 Division of Medicaid In This Issue Blood Lead Reporting Levels... 1 Hospital Outpatient Observation Change... 1 Effective 10/1/2015, ICD-10 Codes Required... 2 ICD-10 Testing Opportunity Continues... 2 Long Term Care Providers and ICD Idaho Medicaid Vision Program... 4 Attention Providers Billing for J Medicaid Program Integrity Unit... 5 Preventive Health Assistance for Wellness... 6 Importance of Well Child Checks for Children... 6 Children s Developmental Disabilities Program/School-Based Services... 7 Provider Training Opportunities in Medical Care Unit Contact and Prior Authorization Information... 9 DHW Resource and Contact Information...10 Insurance Verification...10 Molina Provider and Participant Services Contact Information...11 Molina Provider Services Fax Numbers...11 Provider Relations Consultant (PRC) Information...12 Information Releases No Information Releases Available

2 Blood Lead Reporting Levels In an information bulletin dated March 30, 2012, the Centers for Medicare & Medicaid Services (CMS) revised its policy with respect to screening Medicaid eligible children for lead poisoning to align with the recommendations of the Centers for Disease Control and Prevention (CDC). Experts now use a reference level of 5 micrograms per deciliter (5 ug/dl) to identify children that have been exposed to lead. This is now the reportable level that has to be reported to the local Idaho Public Health District. However, there is no safe level of lead and providers should follow up appropriately. Providers are required to adhere to IDAPA Lead Poisoning which states: 01. Reporting Requirements. Each case of lead poisoning must be reported to the Department or Health District within three (3) working days of the identification of the case when determined by symptoms or a blood level of: (4/11/15) a. Ten (10) micrograms or more per deciliter (10 ug/dl) of blood in adults eighteen (18) years and older; or (4/11/15) b. Five (5) micrograms or more per deciliter (5 ug/dl) of blood in children under eighteen (18) years of age. (4/11/15) 02. Investigation. Each reported case of lead poisoning or excess lead exposure may be investigated to confirm blood lead levels, determine the source, and whether actions need to be taken to prevent additional cases. (4/11/15) Also, Idaho Administrative Code requires all Idaho Medicaid children be screened for blood lead levels at 12 and 24 months of age. If a child has not been previously tested, they should be tested between 2 and 21 years. Providers needing additional guidance on child wellness services should reference the Idaho Medicaid General Provider and Participant Information handbook, section 2.7 Here are some links to more information about the new reference levels and educational materials. Hospital Outpatient Observation Change Effective September 1, 2015, Idaho Medicaid will allow up to 48 hours to be billed for outpatient observation services. For dates of service prior to 9/1/2015, 24 hours observation is covered. This change in policy is to allow physicians time to complete tests in order to determine if the patient should be discharged or admitted to inpatient care. Claims for observation must be billed separately from an inpatient stay if the patient is admitted. MedicAide September 2015 Page 1 of 13

3 Effective 10/1/2015, ICD-10 Codes Required Effective 10/1/15, ICD-10 diagnosis codes are required on ALL CLAIMS submitted to Idaho Medicaid /Molina Medicaid Solutions. All providers submitting claims to Idaho Medicaid/ Molina Medicaid Solutions for dates of service of 10/1/15 or later must use an accurate ICD-10 diagnosis code. For dates of service of 9/30/15 or earlier, an ICD-9 diagnosis code will be required. This includes all claims submitted via Electronic Data Interchange (EDI), the Molina portal, or paper claim form. Claims submitted with an inaccurate diagnosis code set for the date of service will be denied. ICD-10 Testing Opportunity Continues Additional ICD-10 testing continues for all trading partners who would like to test their ICD-10 claim files (EDI submitters). The first round of testing was successfully completed on 8/14/15 for trading partners to validate their ICD-10 claim files for accurate ICD-10 format changes and data in ICD-10 related fields (EDI X-12, 837 transaction testing [submission to response file]). Available end-to-end test cycles (2) began on 8/17 and will continue through mid-september for trading partners to complete end-to-end testing and validate accurate claims processing and payment (submission to remittance advice; 835). ALL trading partners who want to participate in ICD-10 testing MUST BE REGISTERED. To register, us at and include: your user ID, username (full first and last name), trading partner ID, company name, and address. To assist us in tracking registrants, please include your trading partner name in the subject line. For more information related to Medicaid and ICD-10, including additional test details, see our ICD-10 web page at Please note: Testing is specific to electronic claims submitters. Providers who submit claims directly on the Molina Medicaid provider portal or via paper are not within the scope of this testing. Long Term Care Providers and ICD-10 Including: Adult Residential Living Facility- RALF, Behavior Consultation/Crisis Management, Certified Family Homes, Children s Service Coordination, Chore Services Skilled, Nursing Agency-PDN, Nursing Services, Personal Assistance Agencies, Residential Habilitation-Agency, Supported Employment Services, Adult Day Care (Health), Nursing and Custodial Care, Assistive Technology Supplier, Home Modification, Emergency Response System Companies (Continued on page 3) MedicAide September 2015 Page 2 of 13

4 (Long Term Care Cont d) Idaho Medicaid is ICD-10 compliant. This means the ICD-9 diagnosis code(s) that you currently submit on your claim(s) will change October 1, All services billed require a valid diagnosis code for the participant s condition and date of service in order to be considered for payment. What you need to do: 1. Ensure the method you use to submit claims will allow for the new ICD-10 code and format. a. If you are submitting claims electronically through your Trading Partner Account with Molina Medicaid Solutions, the system has been updated to allow the new code set to be received. b. If you submit paper claims, verify you are using the updated (2/2012) CMS 1500 form. c. If you submit claims electronically through a different software or tool, you will need to ensure with your vendor that these have been updated to allow for the ICD-10 code and format. 2. Know and submit the correct diagnosis code on your claims based on the dates of service. The diagnosis code that you bill with depends on individual participant s services and health conditions. a. For example: If you currently bill with the ICD-9 diagnosis code V60.4 No other household member able to render care, effective 10/1/2015 you will need to start using the ICD-10 compliant diagnosis code of Z74.2 Need assistance at home and no other household member able to render care. i. For dates of service of 9/30/2015 or earlier, continue to use the ICD-9 code on claims ii. For dates of service of 10/1/2015 or later, use the new ICD-10 code on claims b. If you use an ICD-9 diagnosis code other than V60.4, you will need to identify the correct ICD-10 to use. You can find diagnosis code information in the Provider Handbook at > Provider Handbook > Claim Form Instructions > CMS 1500 Instructions. You may also find additional diagnosis code information in the ICD-10 Coding book or online at c. If you use a billing agency to submit claims on your behalf, please communicate these changes to them. Idaho Medicaid has also provided several online resources to help you in this transition. Additional information can be found on the Molina Medicaid website at under the following links: Idaho Medicaid ICD-10 Provider Handbook > Claim Form Instructions > CMS 1500 Instructions Training > Training Documents > Claims and Billing MedicAide September 2015 Page 3 of 13

5 Idaho Medicaid Vision Program This notice contains clarification and reminders about Idaho Medicaid coverage for tints and photochromic lenses. Tint Lenses V2745: tint, any color, solid, gradient, excluding photochromic Idaho Administrative Code for Vision Services, IDAPA b states Payment for tinted lenses will only be made when there is a case of albinism, or other extreme medical conditions as defined by the Department. This code is covered for diagnoses such as albinism, or other medical conditions or ophthalmologic diseases which cause photophobia. Other conditions might be aniridea, aphakia, migraine headaches, retinitis pigmentosa, severe blepharospasm, corneal injury, or congenital abnormalities. Providers need to obtain prior authorization, and list the medical diagnosis with the correct ICD code on the request form. Photophobia alone does not suffice for approval of tinted lenses. A medical diagnosis must also be provided. Idaho Medicaid s contracted optical service laboratory can add tint based upon a percentage (i.e %). Tint can be ordered for solid lens, or as a gradient. Very rarely, a request for special therapeutic rose colored tint F41 (V2799) may be submitted. The request must be accompanied by a letter of medical necessity and an order. The available options for a participant meeting criteria for tinted lenses are listed below: 1. Medicaid will cover one pair of gradient tint lenses (and frame) which could be worn inside and outside. Fax a PA Request for V2745 and other applicable HCPCS codes to the Medical Care Unit (MCU); or 2. Medicaid will cover two pair glasses for a child who needs a pair of regular (non-tint) lenses and a pair with solid tint lenses (prescription sunglasses). Fax a PA request for V2745 and other applicable codes to the MCU. These requests will be considered under the Early and Periodic Screening, Diagnosis and Treatment (EPSDT) definition of medical necessity. It is the responsibility of the participant and his/her guardian to manage the care of two pair of glasses. Non-Covered Item, Photochromic Lenses V2744: Clarification of non-coverage of photochromic lenses: IDAPA a lists photo grey and tint as non-covered. HCPCS V2744 or tints, photochromic, are also known under the brand name of Transition Lenses. PA requests for this item will be denied as non-covered. A vision provider may resubmit for tint lens authorization if there is a medical diagnosis as discussed above. Section 06 also states, A Medicaid Provider may receive payment from a Medicaid participant for vision services that are either not covered by the state plan, or include special features or characteristics that are desired by the participant but are not medically necessary. If a parent or participate desires photochromic lenses, they may pay the difference between what Medicaid will pay for non-tint lenses and the cost of photochromic lenses. In that case, when the order is placed with the optical service laboratory, a message will pop-up which states An ordered item will be billed to the provider s account. MedicAide September 2015 Page 4 of 13

6 Attention Providers Billing for J7302 Attention Providers Billing for J Levonorgestrel-releasing intrauterine contraceptive system, 52 mg Effective September 1, 2015, Medicaid will begin paying for the FDA approved IUD, Liletta. This product will share the same J-code (J7302) as Mirena. Idaho Medicaid has established the reimbursement rate for each according to the Average Actual Acquisition Cost (AAAC) based on provider submitted invoices. To ensure accurate reimbursement and for efficient claims processing, providers will need to append the UC modifier when billing for Mirena. Liletta is to be billed using J7302 without the modifier. Providers must still submit the NDC for the product actually used. Product Procedure Modifier Code Liletta J7302 FP Mirena J7302 UC & FP Medicaid Program Integrity Unit Billing Face-to-Face Time (Office and Other Outpatient Visits) The Medicaid Program Integrity Unit has found instances where providers are billing Medicaid for face-to-face time codes without physician documentation or when physicians are not present during an assessment or evaluation. The American Medical Association s Current Procedural Terminology (CPT ) manual outlines face-to face time as follows: For coding purposes, face-to-face time for these services is defined as only that time that the physician spends face-to-face with the patient and/or family. This includes the time in which the physician performs such tasks as obtaining a history, performing an examination, and counseling the patient. Non face-to-face time for office services also called pre- and post-encounter time- is not included in the time component of an Evaluation and Management code. However, the pre- and post-non-face-to-face work associated with an encounter was included in calculating the total work of typical services in physician surveys. Thus, the face-to-face time associated with the services described by any E/M code is a valid proxy for the total work done before, during and after the visit. There are several face-to-face codes available to use in the CPT manual. When using a face-toface code, it is required to have physician documentation for time spent with the patient. It is not appropriate to bill Medicaid for face-to-face time provided by nursing staff or other staff members. MedicAide September 2015 Page 5 of 13

7 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. These schedules can be found in Section 2.7 Child Wellness Exams of the General Provider and Participant Information handbook. How can Primary Care Providers (PCPs) help? Be sure to bill well-child checks with the correct diagnosis and CPT codes. See the article below entitled Importance of Well Child Checks for Children for additional information. If you would like more information on the PHA wellness benefit, please call the PHA Unit toll free at 1 (877) Importance of Well Child Checks for Children Routine well checks for children (periodic screens) are an important part of preventive health services and are covered by Idaho Medicaid. Idaho Medicaid follows the American Academy of Pediatrics (AAP) periodicity schedule for these exams. Infants and children should receive well checks at the following ages: Well Child Check-up Schedule Age Infancy Newborn 1 month 2 Months 4 Months 6 Months 9 Months 1 week 1-2 ½ Years 12 Months 15 Months 18 Months 24 Months 30 Months 3 19 Years 1 check-up every year For a detailed description of well checks, see the periodicity schedule located in Section 2.7 Child Wellness Exams of the General Provider and Participant Information handbook. Off schedule exams may be provided to children if they meet the criteria for an Interperiodic Screen in Section Wellness Exams for Children Up to the Age of 21, of the Allopathic and Osteopathic Physicians handbook. Physical exams for any other purposes, such as sports or camp physicals, are not considered medically necessary and not covered by Idaho Medicaid. (Continued on page 7) MedicAide September 2015 Page 6 of 13

8 (Well Child Checks Cont d) The AAP added a 30 month exam to the periodicity schedule in All PCPs should encourage patients to get the required screenings and must provide them when requested and within the AAP schedule. If a child is a new patient and the primary care physician (PCP) has no medical record to indicate the child is up to date on exams, then the PCP should conduct a new patient well check and then conduct subsequent exams according to the periodicity schedule. Children enrolled in the Children s Health Insurance Program (CHIP) are subject to a monthly premium of either $10 or $15 for their healthcare coverage. If they are up to date on their well exams and immunizations, they receive a $10 per month reduction in their premiums through the Preventive Health Assistance (PHA) program. We recommend PCPs and families work together to ensure all children receive the AAP recommended wellness visits allowing eligible families to qualify for the PHA premium reduction. Children s Developmental Disabilities Program/ School-Based Services Habilitative Intervention (HI) Certificate of Completion and Continuing Training Requirements The Division of Family and Community Services (FACS) is responsible for processing the renewal applications for individuals who hold a Habilitative Intervention (HI) Certificate of Completion as outlined in IDAPA FACS has identified renewal applications that are not consistently meeting the required number of continuing training hours. FACS will incorporate the following steps to address these renewals that are out of compliance with IDAPA. When an individual submits the renewal application for their Certificate of Completion, if it is determined that the individual did not meet the HI continuing training requirement during year one (1), and a gap in training hours occurred, a letter will be sent to the HI Certificate of Completion holder and a letter will be sent to the Medicaid provider identifying that the staff s qualifications are out of compliance with IDAPA. It is the responsibility of Medicaid providers (Developmental Disability Agencies, School Districts, and Charter Schools) to ensure that HI providers are qualified to provide services. The Medicaid provider is responsible for ensuring the accuracy of claims submitted and shall immediately repay the Department for any services the Department or provider determines were not properly provided or documented. If you have questions with regards to the Habilitative Intervention Certificate of Completion continuing training requirements, please contact Bobbi Hamilton at 1 (208) MedicAide September 2015 Page 7 of 13

9 Provider Training Opportunities in 2015 You are invited to attend the following webinars offered by Molina Medicaid Solutions Regional Provider Relations Consultants. September: Claims Adjustments This course will assist you in adjusting claims on the Trading Partner Account for quick resolution. 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. September Claims Adjustments October Referrals November Enrollment December Reports 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 9/9/2015 9/15/2015 9/16/2015 9/17/2015 9/10/2015 9/15/2015 9/17/ /14/ /15/ /20/ /21/ /8/ /15/ /20/ /11/ /17/ /18/ /19/ /12/ /17/ /19/ /9/ /15/ /16/ /17/ /10/ /15/ /17/2015 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 12 of this newsletter. MedicAide September 2015 Page 8 of 13

10 Medical Care Unit Contact and Prior Authorization Information Prior Authorizations, Forms, and References To learn about prior authorization (PA) requirements, Qualis 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. 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 Authorization Status 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. Fax Number Phone Number Administratively Necessary Days 1 (877) (208) Ambulance* 1 (877) (800) Breast & Cervical Cancer 1 (877) (208) Durable Medical Equipment 1 (877) (866) Hospice 1 (877) (208) Pharmacy 1 (800) (866) Preventive Health Assistance 1 (877) (208) Service Coordination 1 (877) (208) Surgery-Procedure-Lab 1 (877) (208) Therapy: OT, PT, SLP 1 (877) (208) Vision 1 (877) (208) * 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. MedicAide September 2015 Page 9 of 13

11 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) Qualis Health 1 (800) Fax: 1 (800) 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 September 2015 Page 10 of 13

12 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 September 2015 Page 11 of 13

13 Provider Relations Consultant (PRC) Information Region 1 and the state of Washington Robert Hughes 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 Denee Gosnell 1720 Westgate Drive, Suite A Boise, ID (208) Region.4@MolinaHealthCare.com Region 5 and the state of Nevada Brenda Rasmussen 601 Poleline Road, Suite 7 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 September 2015 Page 12 of 13

14 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: 1 (208) MedicAide September 2015 Page 13 of 13