May 2021 MedicAide

MedicAide May 2021 of 29

In This Issue

Correct Billing of Laboratory Tests – Modifier 90........................................................................ 2 Payment Error Rate Measurement (PERM) ................................................................................ 3 Update to Criteria for Gravity Feeding Bags .............................................................................. 3 Attention Suppliers: Wheelchairs ............................................................................................ 3 Hysterectomy Form Requirements .......................................................................................... 4 Attention Personal Assistance Agencies and Home Health Agencies: EVV Claim Denials Beginning July 1,2021 ............................................................................................................................... 4 Notice of Upcoming Provider Meetings ..................................................................................... 4 Meeting About Access to Medications for Opioid Use Disorder ...................................................... 5 Project ECHO Idaho - Hepatitis C Provider Trainings ................................................................. 22 Provider Training Opportunities in 2021 .................................................................................. 24 Medical Care Unit Contact and Prior Authorization Information.................................................... 25 DHW Resource and Contact Information ................................................................................. 26 Insurance Verification .......................................................................................................... 26 Gainwell Technologies Provider and Participant Services Contact Information ................................ 27 Gainwell Technologies Provider Services Fax Numbers .............................................................. 27 Provider Relations Consultant (PRC) Information ...................................................................... 28

Information Releases MA21-01 - COVID19 Vaccine and Idaho Medicaid – AMENDED ............................................................. 6 MA21-09 - COVID19 Healthy Connections Referral Requirements Reinstatement ................................... 10 MA21-11 - Swingbed & AND Rates 2021 ......................................................................................... 12 MA21-12 - Changes to HC Primary Careram 2021MA21-12 Changes to HC Primary Care Program 2021 ..... 13 MA21-13 - HC Value Care Program ................................................................................................ 16 MA21-14 - COVID19 CFA Medicaid Provider Stabilization Fund ............................................................ 19

The content of this guidance document is not new law, but is an interpretation of existing law prepared by the Idaho Department of Health and Welfare to provide clarity to the public regarding existing requirements under the law. This document does not bind the public, except as authorized by law or as incorporated into a contract. For additional information or to provide input on this document, contact the Idaho Division of Medicaid by emailing [email protected] or by calling (208)334-5747.

An Informational Newsletter for Idaho Medicaid Providers

From the Idaho Department of Health and Welfare, May 2021

Division of Medicaid

mailto:[email protected]


Correct Billing of Laboratory Tests – Modifier 90 The Medicaid Program Integrity Unit has identified physicians that are inappropriately billing laboratory tests to Medicaid with modifier 90. The Current Procedural Terminology manual states

to use modifier 90 when laboratory procedures are performed by a party other than the treating or reporting physician or other qualified health care professional. Modifier 90 is only to be used when an independent laboratory sends a specimen to a reference laboratory for testing. A reference laboratory is defined as a laboratory that receives a specimen from another laboratory and performs one or more tests on such specimen. IDAPA 16.03.09.655.01 addresses provider reimbursement for laboratory and radiology services

and states:

01. Provider of Service. 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:

a. An independent laboratory that can bill for a reference laboratory;

b. A transplant facility that can bill for histocompatibility testing; and

c. Healthcare professionals acting within the licensure and scope of their

practice to comply with IDAPA 16.02.12, “Procedures and Testing to be Performed

on Newborn Infants.”

Section 4.23.2 of the March 2021 Idaho Medicaid Provider Handbook, Physician and Non-Physician Practitioner, addresses laboratory coverage for physician office laboratories and states:

Physicians can bill Medicaid for clinical diagnostic laboratory services they personally performed or supervised in their office. Those services are reimbursed at the rate

established by Medicaid.

Physician office or group practice office laboratories must hold a current Clinical Laboratory Improvement Amendments (CLIA) certificate on file with Gainwell Technologies before Medicaid will reimburse for testing performed in the physician office laboratories. Payments will be denied to any laboratory submitting claims for services or dates not covered by their CLIA certificate.

Physician-owned laboratories may not bill for tests sent to independent laboratories or pathology laboratories. Physicians are not eligible to bill Modifier 90. Medicaid only pays the actual provider of service.

If a provider did not perform the laboratory test, it is inappropriate to bill Medicaid. The laboratory services should be billed by the provider that performs the test except as noted in the provider handbook. The Department will recover payments and assess civil monetary penalties to providers that bill for laboratory services they did not perform.


Payment Error Rate Measurement (PERM) The PERM program measures improper payments in Medicaid and produces an improper payment rate for each state program. The improper payment rate is based on reviews of fee-for-service

(FFS), managed care, and eligibility compo nents of Medicaid for the Fiscal Year (FY) under review. The improper payment rate is not a “fraud rate”, but simply a measurement of payments made that did not meet statutory, regulatory or administrative requirements. The current PERM cycle is reviewing payments made by Idaho Medicaid from July 1, 2020 through June 30, 2021. Requests from PERM auditors for provider medical records associated with the sampled FFS claims will begin in May/June 2021. Providers will have 75 calendar days from the date of the

request letter to submit the record. During this 75 calendar day period, reminder phone calls and written requests will be made to providers if records are not received. If documentation in the record submitted is incomplete to support the claim, additional documentation will be requested before the review is completed. Providers will then have 14 calendar days from the date of the request letter to submit this additional documentation.

Errors: All claims with no documentation or incomplete documentation from the provider will be determined to be paid in error. Sanctions: If a claim is determined to be in error, Idaho Medicaid will pursue recovery of the payment for the claim. Accurate PERM measurements cannot be produced without provider cooperation in submitting documentation. A correct finding of proper payment cannot be made without the medical record from the provider. All records are equally important, even those for low dollar claims. For more information about PERM, please see our Frequently Asked Questions at: https://www.idmedicaid.com/Lists/FAQs/Current.aspx

Update to Criteria for Gravity Feeding Bags Idaho Medicaid is updating the criteria for coverage of gravity feeding bags (B4036). In addition to the coverage for B4036 in Noridian’s local coverage determination (LCD), Idaho Medicaid will cover B4036 without a prior authorization for participants with cecostomies, when necessary to flush out the colon. The same limitations apply of 1 unit allowed per day. Questions and comments about this article may be submitted to the Medical Care Policy Team at

[email protected].

Attention Suppliers: Wheelchairs The Department of Health and Welfare is updating its policy to allow the purchase of wheelchairs with a prior authorization. This policy change will be implemented retroactively back to October

1, 2020. All wheelchairs without a prior authorization are still capped rentals per the August MedicAide Newsletter article. Questions and comments about this article may be submitted to the Medical Care Policy Team at [email protected].

https://www.idmedicaid.com/Lists/FAQs/Current.aspx




Hysterectomy Form Requirements Providers cannot print the page with the example of hysterectomy consent form requirements from the Physician and Non-Physician Practitioner, Idaho Medicaid Provider Handbook, and use it

as a hysterectomy consent form. This does not legally constitute a consent form. Claims submitted in this way are denied for having an invalid form. Providers may either create their own form or use the Sterilization Consent Form (HW0034 or HW0034S). If a provider elects to create their own form, they must treat it as any other standalone informed consent form. In addition to the language the provider drafts for the form, it must also contain the participant’s signature, Medicaid ID number or date of birth, the date it is

signed, and the language verbatim in the handbook example: “I have been informed orally and in writing that the hysterectomy will render me permanently incapable of reproducing. I was informed of these consequences prior to the surgery being performed.”

Questions and comments about this article may be submitted to the Medical Care Policy Team at [email protected].

Attention Personal Assistance Agencies and Home Health Agencies: EVV Claim Denials Beginning July 1,2021

COUNTDOWN: ONLY 8 WEEKS LEFT BEFORE EVV CLAIM DENIALS BEGIN. All EVV data must be reported and provided through your chosen and designated EVV vendor. Testing checklist should have already been obtained by your chosen and designated EVV vendor now to avoid claim denials beginning on July 1, 2021. For more information on EVV, please visit https://healthandwelfare.idaho.gov/providers/idaho-medicaid-providers/electronic-visit-verification-evv.

Notice of Upcoming Provider Meetings Due to the ongoing COVID-19 public health emergency, all provider meetings will be held via telephone only.

DMEPOS Providers Bi-annual Meeting

Thursday, June 24, 2021

1:30 p.m. (MDT)

Teleconference Call-in

USA Toll: 1-720-650-7664

Access Code: 177 687 3995

Meeting Password: 56496866

Home Health Annual Meeting

Wednesday, June 16, 2021

10:30 a.m. (MDT)


USA Toll: 1-240-454-0879



https://healthandwelfare.idaho.gov/providers/idaho-medicaid-providers/electronic-visit-verification-evv

https://healthandwelfare.idaho.gov/providers/idaho-medicaid-providers/electronic-visit-verification-evv



Therapy Providers Quarterly Meeting

Friday, June 25, 2021

10:30 a.m. (MDT)


USA Toll: 1-720-650-7664



If you would like to be added to the contact list for these meetings, or you have an issue you’d like to appear on the agenda, e-mail your request to [email protected].

Meeting About Access to Medications for Opioid Use Disorder

The Medical Care Advisory Committee (MCAC) will be helping the Idaho Division of Medicaid and Optum Idaho host a conversation about medications for opioid use disorder (MOUD) during their monthly meeting on Wednesday May 26, 2021 from 1:30-3pm. The discussion will focus on buprenorphine/naloxone (Suboxone) and how Medicaid can help facilitate access to this life saving treatment for opioid use disorder (OUD). We are interested in learning how we can better

support primary care providers, outpatient substance use treatment providers, and organizations that exclusively provide MOUD. We need all hands on deck, if we are going to impact the opioid epidemic in Idaho and make sure that patients with OUD in urban, rural, and frontier communities across our state can access MOUD. This will be a facilitated brainstorming session and most likely the beginning of an on-going conversation that may include more detailed discussions regarding incentives or alternative reimbursement models for MOUD.

The MOUD discussion will begin at 2pm, however feel free to join us from the beginning of the MCAC meeting if you would like. Please RSVP for the meeting by emailing [email protected]

Join from the meeting link https://idhw.webex.com/idhw/j.php?MTID=m3b432d029d80f47e88b7dd0791be49ff

Join by meeting number Meeting number (access code): 133 638 4666 Meeting password: psPEyZqJ635 (77739975 from phones and video systems) Tap to join from a mobile device (attendees only) +1-415-655-0003,,1336384666#77739975# US Toll +1-720-650-7664,,1336384666#77739975# United States Toll (Denver) Some mobile devices may ask attendees to enter a numeric meeting password. Join by phone

+1-415-655-0003 US Toll +1-720-650-7664 United States Toll (Denver)

https://dxcportal.sharepoint.com/sites/IDInterComm/molina/TQD/Communications/MedicAide%20Newsletter/2021/May/May%20MedicAide%20Newsletter/[email protected].

https://clicktime.symantec.com/a/1/mTaA8HPJkwoIDx-mdPNCg4ShQMEAAVBdneXAUpvkTH0=?d=MTl3m07rzJ0OIa9LONVdk65wXvYhKqDcsKgCSHoF42R6BsDn9O84KU5rngJZfh8O9vEl3u9DMHvAL6uZPlFFUlH8FU428TZOie3unmcGoLm8RojhND_-hXCGa1jtUA_Twm50WePmy6stGTmkGd-Edke9xUAEMA65kDYqyHJ4X5mTyYvAIgzDpxlDmKUyhitEEOpj-Gp0rEw49SfWvMUmeqMOb74R_iVEmGaKGfA9kSfZaeTAvJbjYRFRRllAq1zAm5V-ZNEidJirbxO0Da2CqDn8YK5OlhzhMqsFn66p8JezPSWJE_O6yOhafJKY2oY48rzvIwxPa2F_SNxMpjPkmayGRa38xlN5-DPlRfmU-nvB8eo8vtHPz9xtO3AN0ZIWC3izfAjBkURPRoTYkddc-odLMAPt9oyxuWpg5YwNB_RB7fVwzCzA9Fhr76zc46eEpBleLpeMsUEzVhFOot428622YbofgQOdaFqQ5PSAZ6RCFSi5qSVayKiUazU%3D&u=https%3A%2F%2Fhealthandwelfare.idaho.gov%2Fabout-dhw%2Fboards-councils-committees%2Fmedical-care-advisory-committee


https://idhw.webex.com/idhw/j.php?MTID=m3b432d029d80f47e88b7dd0791be49ff

tel:%2B1-415-655-0003,,*01*1336384666%2377739975%23*01*

tel:%2B1-720-650-7664,,*01*1336384666%2377739975%23*01*


Figure 1MA21-01 - COVID19 Vaccine and Idaho Medicaid – AMENDED


Figure 2MA21-09 - COVID19 Healthy Connections Referral Requirements Reinstatement


Figure 3MA21-11 - Swingbed & AND Rates 2021


Figure 4MA21-12 - Changes to HC Primary Careram 2021MA21-12 Changes to HC Primary Care Program 2021


Figure 5MA21-13 - HC Value Care Program


Figure 6MA21-14 - COVID19 CFAC Medicaid Provider Stabilization Fund


Project ECHO Idaho - Hepatitis C Provider Trainings


Provider Training Opportunities in 2021 You are invited to attend the following webinars offered by Gainwell Technologies Regional Provider Relations Consultants.

May: Certified Family Home This training will walk Certified Family Homes through the process of signing up for a trading partner account, viewing prior authorizations, creating patient rosters, verifying eligibility, accessing remittance advice reports, and submitting and reviewing claims. 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.

May June July

Certified Family Home

Long Term Care

Respite Care

10-11:00 AM MT

5/18/2021 6/15/2021 7/15/2021

5/19/2021 6/16/2021 7/20/2021

5/20/2021 6/17/2021 7/21/2021

2-3:00 PM MT

5/12/2021 6/9/2021 7/8/2021

5/13/2021 6/10/2021 7/14/2021

5/18/2021 6/15/2021 7/15/2021

5/20/2021 6/17/2021 7/21/2021

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 28 of this newsletter.

http://www.idmedicaid.com/


Medical Care Unit Contact and Prior Authorization Information

Prior Authorizations, Forms, and References

To learn about prior authorization (PA) requirements or quality improvement organization (QIO) review, or to print request forms, go to the Medical Care forms library. Prior authorization request forms containing the “fax to” number can be found at www.idmedicaid.com. Select 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 or for services which do not require a PA. The MCU is currently handling a very high volume of PA requests; turnaround is therefore slower than usual and PAs may take up to 30

days to be reviewed. To Check Prior Authorizations Status Log on to your Trading Partner Account on www.idmedicaid.com. Choose Form Entry, then choose View Authorizations. If you are unable to identify the reason for a denied service, a Gainwell Technologies 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 (TPA) User Guide located under User Guides at www.idmedicaid.com. To speak to a Gainwell Technologies 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 contact numbers below or e-mail [email protected].

For the Durable Medical Equipment, Prosthetics, Orthotics & Supplies (DMEPOS) PA Policy and Medical Criteria, please go to the Resources tab on the Durable Medical Equipment page. Please review the DMEPOS PA Policy and Medical Criteria to obtain important information, policy, and guidance related to requesting PAs for DMEPOS items. This document also includes the medical

criteria used by the department in most circumstances related to DMEPOS requests.

Fax Number Phone Number

Administratively Necessary Days 1 (877) 314-8779 1 (866) 205-7403

Ambulance* 1 (877) 314-8781 1 (800) 362-7648

Breast & Cervical Cancer 1 (877) 314-8779 1 (866) 205-7403

Durable Medical Equipment 1 (877) 314-8782 1 (866) 205-7403

Hospice 1 (877) 314-8779 1 (866) 205-7403

Preventive Health Assistance 1 (877) 845-3956 1 (866) 205-7403

Service Coordination 1 (877) 314-8779 1 (866) 205-7403

Surgery-Procedure-Lab 1 (877) 314-8779 1 (866) 205-7403

Therapy: OT, PT, SLP 1 (877) 314-8779 1 (866) 205-7403

Vision 1 (877) 314-8779 1 (866) 205-7403

https://publicdocuments.dhw.idaho.gov/WebLink/Browse.aspx?id=2512&dbid=0&repo=PUBLIC-DOCUMENTS



https://www.idmedicaid.com/User%20Guides/Trading%20Partner%20Account%20(TPA)%20User%20Guide.pdf



https://healthandwelfare.idaho.gov/Medical/Medicaid/MedicalCare/DurableMedicalEquipment/tabid/271/Default.aspx

http://healthandwelfare.idaho.gov/LinkClick.aspx?link=701&tabid=217




http://healthandwelfare.idaho.gov/Medical/MedicaidCHIP/PreventiveHealthAssistance/tabid/221/Default.aspx

http://healthandwelfare.idaho.gov/LinkClick.aspx?link=2281&tabid=217&portalid=0&mid=1664





*Idaho Medicaid contracts with Medical Transportation Management (MTM) for all non-emergency medical transportation (NEMT) services. Please go to http://www.mtm-inc.net/idaho/ or call 1 (877) 503-1261 for more information.

DHW Resource and Contact Information

DHW Website https://healthandwelfare.idaho.gov/

Idaho CareLine 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

Telligen 1 (866) 538-9510

Fax: 1 (866) 539-0365

http://IDMedicaid.Telligen.com

Healthy Connections Regional Health Resource Coordinators

Region I

Coeur d'Alene

1 (208) 666-6766

1 (800) 299-6766

Region II

Lewiston

1 (208) 799-5088

1 (800) 799-5088

Region III

Caldwell

1 (208) 455-7244

1 (208) 642-7006

1 (800) 494-4133

Region IV

Boise

1 (208) 334-0717

1 (208) 334-0718

1 (800) 354-2574

Region V

Twin Falls

1 (208) 736-4793

1 (800) 897-4929

Region VI

Pocatello

1 (208) 235-2927

1 (800) 284-7857

Region VII

Idaho Falls

1 (208) 528-5786

1 (800) 919-9945

In Spanish

(en Español)

1 (800) 378-3385

Insurance Verification

HMS

PO Box 2894

Boise, ID 83701

1 (800) 873-5875

1 (208) 375-1132

Fax: 1 (208) 375-1134

http://www.mtm-inc.net/idaho/

http://www.healthandwelfare.idaho.gov/



Gainwell Technologies Provider and Participant Services Contact Information

Provider Services

MACS (Medicaid Automated Customer Service)

1 (866) 686-4272 1 (208) 373-1424

Provider Service Representatives Monday through Friday, 7 a.m. to 7 p.m. MT

1 (866) 686-4272 1 (208) 373-1424

E-mail [email protected] [email protected]

Mail P.O. Box 70082 Boise, ID 83707

Participant Services

MACS (Medicaid Automated Customer Service)

1 (866) 686-4752 1 (208) 373-1432

Participant Service Representatives Monday through Friday, 7 a.m. to 7 p.m. MT

1 (866) 686-4752 1 (208) 373-1424

E-mail [email protected]

Mail – Participant Correspondence P.O. Box 70081 Boise, ID 83707

Medicaid Claims

Utilization Management/Case Management P.O. Box 70084 Boise, ID 83707

CMS 1500 Professional P.O. Box 70084 Boise, ID 83707

UB-04 Institutional P.O. Box 70084 Boise, ID 83707

UB-04 Institutional

Crossover/CMS 1500/Third-Party Recovery (TPR)

P.O. Box 70084

Boise, ID 83707

Financial/ADA 2006 Dental P.O. Box 70087 Boise, ID 83707

Gainwell Technologies Provider Services Fax Numbers

Provider Enrollment 1 (877) 517-2041

Provider and Participant Services 1 (877) 661-0974





Provider Relations Consultant (PRC) Information

Region 1 and the state of Washington 1 (208) 373-1309 [email protected]

Region 2 and the state of Montana 1 (208) 373-1326 [email protected]

Region 3 and the state of Oregon 1 (208) 373-1475 [email protected]

Region 4 and all other states 1 (208) 373-1351 [email protected]

Region 5 and the state of Nevada 1 (208) 373-1357 [email protected]

Region 6 and the state of Utah 1 (208) 373-1325 [email protected]

Region 7 and the state of Wyoming 1 (208) 373-1408 [email protected]









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.

Gainwell Technologies PO Box 70082 Boise, Idaho 83707

MedicAide is the monthly informational newsletter for Idaho Medicaid providers.

Editor: Shannon Tolman

If you have any comments or suggestions, please send them to: Shannon Tolman,

[email protected] Medicaid – Communications Team

P.O. Box 83720 Boise, ID 83720-0009 Fax: 1 (208) 364-1811



May 2021 MedicAide

Documents

Transcript of May 2021 MedicAide