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, March 2015 Division of Medicaid In This Issue Changes for 2015 Laboratory Codes ICD-10 Industry News Update... 1 Medicaid Program Integrity Unit... 2 Save the Date! 2015 Idaho Health Care Conference... 2 Provider Enrollment Changes... 3 Provider Training Opportunities in Medical Care Unit Contact and Prior Authorization Information...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 MA Annual WAHR Survey... 8

2 Changes for 2015 Laboratory Codes This notice is to advise Idaho Medicaid Providers of the current decision regarding coverage of the 2015 new CPT laboratory codes after date of service 2/28/2015. Effective 3/1/2015, Idaho Medicaid will not cover the new 2015 laboratory codes through (63 codes) until Medicare pricing is available. For claims billed for dates of service prior to 3/1/2105, and using CPT codes , an invoice is required to be attached. This is to enable pricing for the new CPT codes which do not currently have a price on file. CMS has created a series of G-codes with pricing that may be used in place of the CPT codes effective 1/1/2015. For dates of service 3/1/2015 and after, Idaho will require providers to use the appropriate HCPCS code within the G-code series. An invoice is needed only if no price is listed on the Numerical Fee Schedule. Please refer to our website for the current Numerical Fee Schedule, at: 268/Default.aspx. ICD-10 Industry News Update Examining ICD-10 Implementation Highlights from the U.S. Subcommittee on Health Hearing By Pamela J. Haney, MS, RHIA, CCS, CIC, COC On February 11, 2015, the U.S. House Energy & Commerce Committee, Subcommittee on Health, chaired by Rep. Joe Pitts (R-PA), convened to hear testimony on the feasibility of implementing ICD-10 on October 1, Most, though not all, of the panelists provided compelling arguments in support of ICD-10 implementation for While there was wide-spread agreement that we need to move ahead with ICD-10, opinions varied on how that should happen. The impact of uncertainty in the implementation date and concerns about expending additional resources with another potential delay were repeated by several speakers. For more highlights of this important Congressional Hearing see: implementation-highlights- testimony/?utm_source=le+haney+blog%3a+examining+icd- 10+Implementation+Eblast&utm_campaign=LE+Haney+Blog%3A+Examining+ICD- 10+Implementation+Eblast&utm_medium= Reminder: Idaho Medicaid is compliant for ICD-10. We completed successful validation of ICD-10 updates to our Molina claims processing system (MMIS) for ICD-10 compliance with an effective date of 10/1/2015. ICD-9 coded claims are required for dates of service through 9/30/2015. Starting 10/1/2015, all claims with a date of service of 10/1/2015 and later are required to be billed with ICD-10 codes. MedicAide March 2015 Page 1 of 17

3 Medicaid Program Integrity Unit Midlevel Practitioner Billing and Medicaid State-licensed physician assistants, certified nurse midwives, and nurse practitioners are eligible to participate in the Idaho Medicaid Program. They must obtain an Idaho Medicaid provider number from Idaho Medicaid. Medicaid reimburses mid-level practitioner services on a fee-for service basis. Most midlevel practitioner reimbursement is 85% (percent) of the physician fee schedule as posted on the DHW website. IDAPA addresses reimbursement of mid-level practitioner services, and states that billing for services must be as provided by the CRNA, NP, NM, or PA, and not represented as a physician service. IDAPA addresses misrepresentation of services and states any representation that a service provided by a nurse practitioner, nurse midwife, physical therapist, physician assistant, psychologist, social worker, or other non-physician professional as a physician service is prohibited. Audits conducted by the Medicaid Program Integrity Unit have identified providers billing nonphysician services as being provided by physicians. Misrepresentation of services by billing nonphysician services as physician services under the physician provider number is subject to recoupment and civil monetary penalties. Save the Date! 2015 Idaho Health Care Conference The dates have been announced for the 2015 Idaho Health Care Conference. This year s theme is Off to the Races! Look for more details soon on Clarkston May 5, 2015 Quality Inn 700 Port Drive Idaho Falls May 12, 2015 Shilo Inn 780 Lindsay Blvd. Twin Falls May 14, 2015 Canyon Crest Event Center 330 Canyon Crest Drive Coeur d Alene May 6, 2015 Best Western CDA 506 W. Appleway Avenue Pocatello May 13, 2015 Red Lion 1555 Pocatello Creek Road Boise May 21, 2015 Boise Hotel & Conference Center 3300 S. Vista Avenue MedicAide March 2015 Page 2 of 17

4 Provider Enrollment Changes In aligning with the Affordable Care Act (ACA), there have been modifications to the requirements of certain provider specialties. These changes will be effective 4/1/15. In the cases where additional documentation is now required, these changes will apply only to new enrollments. Currently-enrolled providers will need to meet these requirements at the time of their revalidation. Provider Specialty Documentation Previous New License Not Staff Only Agency Transportation General Liability Insurance Service Providers Affiliated Not Not Service Affiliation Roster Not Audiologist DEA Optional Not Audiologist - Assistive Technology Supplier Audiologist - Assistive Technology Practitioner DEA Optional Not DEA Optional Not Audiologist - Hearing Aid Fitter DEA Optional Not Behavior Consultation/Crisis Management Additional Terms Not Chore Services Additional s 1. A&D providers cannot enroll as Chore Services. 2. DD providers - Chore Services are not included and must be enrolled as a separate provider. Clinic/Center - Birthing License Not Clinic/Center - Federally Qualified Health Center (FQHC) Group Affiliation Roster Not MedicAide March 2015 Page 3 of 17

5 Provider Specialty Documentation Previous New Clinic/Center - Indian Health Services Group Affiliation Roster Not License Not Staff Only Clinic/Center - Physical Therapy Facility Professional Liability Insurance Service Providers Affiliated None Not Not Service Affiliation Roster Not Clinic/Center - Rural Health Clinics Group Affiliation Roster Not License Staff Only Not Criminal History Check None Commercial Transportation Crossover Only Provider DD Child Independent Therapeutic Consultation DD Child Independent Crisis Intervention - Professional Additional s Rendering provider in a Group 1. Commercial Auto Liability Insurance Policy coverage for cars and drivers must be a minimum of $500,000 personal injury per person. 2. Providers shall complete a background check with DHW s Criminal History Unit (CHU) prior to providing direct participant services to any Medicaid participant. Background checks should be included with the initial application. Not License Not License Not Developmental Disability Agency - Support Only Child Services License Not Certificate Not MedicAide March 2015 Page 4 of 17

6 Provider Specialty Documentation Previous New Service Providers Affiliated None Service Affiliation Roster Not Durable Medical Equipment & Medical Supplies Medicare Certificate Optional Durable Medical Equipment & Medical Supplies - Dialysis Equipment & Supplies Medicare Certificate Optional Durable Medical Equipment & Medical Supplies - Oxygen Equipment & Supplies Medicare Certificate Optional Durable Medical Equipment & Medical Supplies - Parenteral & Enteral Nutrition Medicare Certificate Optional Certificate Optional Not Hearing Aid Vendor DEA Optional Not License Not Individual Transportation Provider General Liability Insurance Not Laboratory-Clinical Medical Laboratory License Not Licensed Midwife Service Affiliation Roster None Not Non-Pharmacy Dispensing Site aka: DME & Suppliers - Supplies only License Not Medicare Certificate Optional Certificate Not PCS Family Alternate Care Home General Liability Insurance Not Pharmacy DME Medicare Certificate Optional MedicAide March 2015 Page 5 of 17

7 Provider Specialty Documentation Previous New PHA-Weight Management-Dietician Medicare Certificate Optional Not PHA-Weight Management-Personal Trainer Service Affiliation Roster None Not Radiologic Technologist Certificate Optional Radiologic Technologist - Quality Management Radiologic Technologist - Bone Densitometry Radiologic Technologist - Cardiac - Interventional Technology Radiologic Technologist - Cardiovascular Interventional Technology Radiologic Technologist - Computed Tomography Radiologic Technologist - Radiation Therapy Radiologic Technologist - Sonography Radiologic Technologist - Vascular - Interventional Technology Radiologic Technologist - Vascular Sonography Radiology Technologist - Magnetic Resonance Imaging Radiology Technologist - Nuclear Medicine Technology Radiology Technologist - Radiography Certificate Optional Certificate Optional Certificate Optional Certificate Optional Certificate Optional Certificate Optional Certificate Optional Certificate Optional Certificate Optional Certificate Optional Certificate Optional Certificate Optional Residential Assisted Living Facility (RALF) Workers Comp Insurance Not Social Worker License Not Certificate Not MedicAide March 2015 Page 6 of 17

8 Provider Specialty Documentation Previous New Spec/Tech, Cardiovascular Certificate Optional Spec/Tech, Cardiovascular - Invasive Specialist Spec/Tech, Cardiovascular - Sonography Spec/Tech, Cardiovascular - Vascular Specialist Certificate Optional Certificate Optional Certificate Optional Specialist/Technologist - EEG Certificate Optional Supported Employment Services Additional Terms Not Technician, Other - EEG Certificate Optional MedicAide March 2015 Page 7 of 17

9 Figure 0-1: MA Annual WAHR Survey MedicAide March 2015 Page 8 of 17

10 MedicAide March 2015 Page 9 of 17

11 MedicAide March 2015 Page 10 of 17

12 MedicAide March 2015 Page 11 of 17

13 Provider Training Opportunities in 2015 You are invited to attend the following webinars offered by Molina Medicaid Solutions Regional Provider Relations Consultants. March: 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. March Claims Adjustments April Reports May Certified Family Homes June Residential Assisted Living Facilities July Long Term Care August Eligibility 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 3/11/2015 3/17/2015 3/18/2015 3/19/2015 3/12/2015 3/17/2015 3/19/2015 4/8/2015 4/15/2015 4/16/2015 4/21/2015 4/9/2015 4/16/2015 4/21/2015 5/13/2015 5/19/2015 5/20/2015 5/21/2015 5/14/2015 5/19/2015 5/21/2015 6/10/2015 6/16/2015 6/17/2015 6/18/2015 6/11/2015 6/16/2015 6/18/2015 7/8/2015 7/15/2015 7/16/2015 7/21/2015 7/9/2015 7/16/2015 7/21/2015 8/12/2015 8/18/2015 8/19/2015 8/20/2015 8/13/2015 8/18/2015 8/20/2015 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 16 of this newsletter. MedicAide March 2015 Page 12 of 17

14 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 March 2015 Page 13 of 17

15 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 March 2015 Page 14 of 17

16 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 March 2015 Page 15 of 17

17 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 March 2015 Page 16 of 17

18 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 March 2015 Page 17 of 17