An Informational Newsletter for Idaho Medicaid Providers
From the Idaho Department of Health and Welfare,
October 2015
Division of Medicaid
In This Issue
ICD-10 Compliance .................................................................................................................. 1
Medicaid Program Integrity Unit ................................................................................................. 1
Modifiers and Prior Authorization (PA)......................................................................................... 2
Attention Residential Assisted Living Facility (RALF) Providers ....................................................... 2
Healthy Connections – PCMH ..................................................................................................... 2
Physician Administered Drugs Update ......................................................................................... 3
Provider Training Opportunities in 2015 ...................................................................................... 5
Medical Care Unit Contact and Prior Authorization Information....................................................... 6
DHW Resource and Contact Information ..................................................................................... 7
Insurance Verification ............................................................................................................... 7
Molina Provider and Participant Services Contact Information ........................................................ 8
Molina Provider Services Fax Numbers ........................................................................................ 8
Provider Relations Consultant (PRC) Information.......................................................................... 9
Information Releases
MA15-06 Hospice Rates ............................................................................................................ 4
ICD-10 Compliance
Effective 10/1/2015, ICD-10 Codes Required
Effective 10/1/2015, 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 10/1/2015 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 requirement 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.
For additional information regarding ICD-10 see
https://www.cms.gov/Medicare/Coding/ICD10/index.html or the Molina Medicaid website at
https://www.idmedicaid.com/ICD/10%20Transition.aspx.
Pharmacies submitting drug claims with diagnosis codes through the Magellan POS system will be
required to submit that diagnosis with an ICD-10 code as of 10/1/2015. Claims submitted with
ICD-9 codes on or after 10/1/2015 will deny.
Medicaid Program Integrity Unit
Certified Family Home Location and/or Ownership Changes
The Medicaid Program Integrity Unit has identified Certified Family Home providers who have
continued to bill Medicaid after they moved Medicaid clients from certified family homes into
uncertified homes. Certification is required in order to bill Medicaid for services. The Department
will issue a certificate to a home when all certification requirements are met. The certificate will
be issued in the name of the provider applying for certification and only to the address of the
home listed in the application.
IDAPA 16.03.19.110.04 addresses changes in ownership or location and states:
04. Change of Ownership Certification Requirements. Certificates are not transferable
from one (1) individual to another or from one (1) location to another. The home must be
recertified using the same procedure as a new home that has never been certified when a
change of ownership, lease, or location occurs.
The Department will recover Medicaid payments for services billed when a family home was not
certified and may assess civil monetary penalties from providers who bill contrary to rule.
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Modifiers and Prior Authorization (PA)
Modifiers are used to increase accuracy in compensation, coding consistency, editing, and to
capture payment data. At times, reviewers for Idaho Medicaid may attach a modifier to a
procedure code when a PA is approved.
When providers receive notification of an approved PA, it is essential to check the authorization to
determine if a modifier is attached to any of the approved procedure codes. If there is a modifier
attached to the approved PA, that modifier must be used when billing for the service. The
absence of an approved modifier will result in a claim denial.
Modifiers other than those listed on the approved PA may also be appropriate in billing for the
service, and should be attached to the claim.
Attention Residential Assisted Living Facility (RALF)
Providers
Participants living in a Residential Assisted Living Facility (RALF) with a specific diagnosis of
mental illness (MI), intellectual disability (ID), and/or Alzheimer’s disease and who are assessed
at a level I or II are assigned a Reimbursement Level of IV for payment purposes. If the
participant is assessed as a Reimbursement Level III with MI, ID, or Alzheimer’s disease, a level
III payment is assigned to meet the needs of this specific population. If RALF providers think
that some of their Level IV participants may meet the Level III criteria, please send participant
information to the RALF team at [email protected].
Healthy Connections – PCMH
The Division of Medicaid, Primary Care Unit, is working on an exciting project that will align with
the State Healthcare Innovation Plan (SHIP). In December 2014, the Department received a
four-year SHIP model test grant for $39,683,813 from the Center for Medicare and Medicaid
Innovations to oversee the transformation of the healthcare system in Idaho.
Our Primary Care project will align with the SHIP goals to reduce healthcare costs, improve the
quality of healthcare, and improve the health of Idaho Medicaid participants. This project will
result in changes to the payment structure for the Healthy Connections and Health Home
Programs. These changes are being made to incentivize further expansion of the Patient
Centered Medical Home (PCMH) model of primary care in Idaho. Under this new primary care
structure, providers will receive a per member per month payment to support activities directed
towards practice transformation to the PCMH model. For our Medicaid participants, this will result
in improved access to care, better coordinated care, and improved health outcomes.
Phase 1 of the program will launch in February 2016. For more information, you can contact Meg
Hall, Primary Care Program Manager or regional Healthy Connections Staff. You may also want
to visit the Healthy Connections website at www.healthyconnections.idaho.gov.
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Physician Administered Drugs Update
Effective October 1, 2015, Idaho Medicaid will cover a new CMS established code. The new code
is: Q9979 Injection, Alemtuzumab, 1 mg. This code will require prior authorization (PA).
Also effective October 1, 2015, Idaho Medicaid will require a prior authorization for four other
codes which previously did not require a prior authorization:
• J1931 INJECTION, LARONIDASE, 0.1 MG;
• J3262 INJECTION, TOCILIZUMAB, 1 MG;
• J1290 INJECTION, ECALLANTIDE, 1 MG; and
• INJECTION, C-1 ESTERASE INHIBITOR (HUMAN), BERINERT, 10 UNITS.
The complete list of Physician Administered Drugs Requiring PA for Idaho Medicaid can be found
in the right-hand side of the page under Resources at
http://healthandwelfare.idaho.gov/Default.aspx?TabId=217.
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Figure 2: MA15-06 Hospice Rates
Figure 1
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Provider Training Opportunities in 2015
You are invited to attend the following webinars offered by Molina Medicaid Solutions Regional
Provider Relations Consultants.
October: Electronic Referrals
This course is designed to instruct primary care physicians on how to submit a referral, and
specialists how to retrieve.
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 www.idmedicaid.com
and click on the Training link in the left-hand menu.
October
Referrals
November
Enrollment
10 a.m. 11 a.m. MT
10 a.m. 11 a.m. MT
10 a.m. 11 a.m. MT
10 a.m. 11 a.m. MT
2 p.m. 3 p.m. MT
2 p.m. 3 p.m. MT
2 p.m. 3 p.m. MT
10/14/2015
10/15/2015
10/20/2015
10/21/2015
10/8/2015
10/15/2015
10/20/2015
11/11/2015
11/17/2015
11/18/2015
11/19/2015
11/12/2015
11/17/2015
11/19/2015
12/9/2015
12/15/2015
12/16/2015
12/17/2015
12/10/2015
12/15/2015
12/17/2015
December
Reports
If you would prefer one-on-one training in your office with your Regional Provider Relations
Consultant, please feel free to contact them directly. Provider Relations Consultant contact
information can be found on page 9 of this newsletter.
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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 www.medunit.dhw.idaho.gov. Prior authorization request
forms containing the “fax to” number can be found at www.idmedicaid.com. 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 83720
Boise, ID 83720-0009
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 www.idmedicaid.com. 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
www.idmedicaid.com.
To speak to a Molina Medicaid Solutions representative, call 1 (866) 686-4272, option 3.
MCU Medical Review Decisions
If you have any questions about medical review decisions, please refer to the following contact
numbers.
Administratively Necessary Days
Ambulance*
Breast & Cervical Cancer
Durable Medical Equipment
Hospice
Pharmacy
Preventive Health Assistance
Service Coordination
Surgery-Procedure-Lab
Therapy: OT, PT, SLP
Vision
1
1
1
1
1
1
1
1
1
1
1
Fax Number
(877) 314-8779
(877) 314-8781
(877) 314-8779
(877) 314-8782
(877) 314-8779
(800) 327-5541
(877) 845-3956
(877) 314-8779
(877) 314-8779
(877) 314-8779
(877) 314-8779
Phone Number
1 (208) 364-1830
1 (800) 362-7648
1 (208) 364-1839
1 (866) 205-7403
1 (208) 364-1904
1 (866) 827-9967
1 (208) 364-1843
1 (208) 364-1904
1 (208) 287-1148
1 (208) 364-1904
1 (208) 364-1904
* Idaho Medicaid contracts with American Medical Response (AMR) for all non-emergency
medical transportation services. Please go to www.idahonemt.net or call 1 (877) 503-1261 for
more information.
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DHW Resource and Contact Information
DHW Web site
Idaho CareLine
www.healthandwelfare.idaho.gov
2-1-1
1 (800) 926-2588
Medicaid Program Integrity Unit
P.O. Box 83720
Boise, ID 83720-0036
[email protected]
Fax: 1 (208) 334-2026
Qualis Health
1 (800) 783-9207
Fax: 1 (800) 826-3836
http://www.qualishealth.org/healthcareprofessionals/idaho-medicaid
Healthy Connections Regional Health Resource Coordinators
Region I
1 (208) 666-6766
Coeur d'Alene
1 (800) 299-6766
Region II
1 (208) 799-5088
Lewiston
1 (800) 799-5088
Region III
1 (208) 455-7244
Caldwell
1 (208) 642-7006
1 (800) 494-4133
Region IV
1 (208) 334-0717
Boise
1 (208) 334-0718
1 (800) 354-2574
Region V
1 (208) 736-4793
Twin Falls
1 (800) 897-4929
Region VI
1 (208) 235-2927
Pocatello
1 (800) 284-7857
Region VII
1 (208) 528-5786
Idaho Falls
1 (800) 919-9945
1 (800) 378-3385
In Spanish
(en Español)
Insurance Verification
HMS
PO Box 2894
Boise, ID 83701
MedicAide October 2015
1 (800) 873-5875
1 (208) 375-1132
Fax: 1 (208) 375-1134
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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
E-mail
Mail
Participant Services
MACS
(Medicaid Automated Customer Service)
Participant Service Representatives
Monday through Friday, 7 a.m. to 7 p.m. MT
E-mail
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) 686-4272
1 (208) 373-1424
1 (866) 686-4272
1 (208) 373-1424
[email protected]
[email protected]
P.O. Box 70082
Boise, ID 83707
1 (866) 686-4752
1 (208) 373-1432
1 (866) 686-4752
1 (208) 373-1424
[email protected]
P.O. Box 70081
Boise, ID 83707
P.O. Box 70084
Boise, ID 83707
P.O. Box 70084
Boise, ID 83707
P.O. Box 70084
Boise, ID 83707
P.O. Box 70084
Boise, ID 83707
P.O. Box 70087
Boise, ID 83707
Molina Provider Services Fax Numbers
Provider Enrollment
Provider and Participant Services
MedicAide October 2015
1 (877) 517-2041
1 (877) 661-0974
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Provider Relations Consultant (PRC) Information
Region 1 and the state of
Washington
Robert Hughes
1120 Ironwood Drive Suite 102
Coeur d’Alene, ID 83814
1 (208) 559-4793
[email protected]
Region 2 and the state of Montana
Kristi Irby
1118 F Street
P.O. Box Drawer B
Lewiston, ID 83501
1 (208) 991-7138
[email protected]
Region 3 and the state of Oregon
Rainy Natal
3402 Franklin
Caldwell, ID 83605
1 (208) 860-4682
[email protected]
Region 4 and all other states
Denee Gosnell
1720 Westgate Drive, Suite A
Boise, ID 83704
1 (208) 373-1343
[email protected]
Region 5 and the state of Nevada
Brenda Rasmussen
601 Poleline Road, Suite 7
Twin Falls, ID 83301
1 (208) 484-6323
[email protected]
Region 6 and the state of Utah
Kelsey Gudmunson
1070 Hiline Road
Pocatello, ID 83201
1 (208) 870-3997
[email protected]
Region 7 and the state of Wyoming
Kristi Harris
150 Shoup Avenue
Idaho Falls, ID 83402
1 (208) 991-7149
[email protected]
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Molina Medicaid Solutions
PO Box 70082
Boise, Idaho 83707
Digital Edition
MedicAide is available online by the fifth of each month at www.idmedicaid.com. 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) 686-4272.
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, [email protected]
Shannon Tolman, [email protected]
Medicaid – Communications Team
P.O. Box 83720
Boise, ID 83720-0009
Fax: 1 (208) 364-1811
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