Overview. Eligibility Fee Schedule Resources Enrollment

Transcription

1 Vision

2 Overview Eligibility Fee Schedule Resources Enrollment 2

3 3 Eligibility

4 Participant Eligibility Why Check eligibility? To verify that participant has Medicaid coverage on date of service. To review participant s eligibility plan and coverage. Note: A Medicaid card does not guarantee current Medicaid coverage. 4

5 Verifying Eligibility Three ways to check eligibility: MACS Medicaid Automated Customer Service 1(866) HIPAA compliant vendor software Health PAS-OnLine Trading Partner To obtain eligibility information, submit any two pieces of identifying information from the following list: Medicaid ID number (10 digits add three zeroes to the beginning if the MID is only seven digits) Social Security Number (SSN) Last Name, First Name Date of Birth 5

6 Trading Partner Account 6

7 7 Patient Roster

8 Patient Roster Build Roster Two pieces of identifying information required; MID and DOB recommended 8

9 9 Patient Roster

10 Verifying Eligibility Trading Partner Eligibility 10

11 Verifying Eligibility Trading Partner Eligibility Two pieces of identifying information required; MID and DOB recommended 11

12 Verifying Eligibility Trading Partner Eligibility 12

13 13 Verifying Eligibility

14 Coverage Medicaid offers several coverages that are aligned with health needs and include an emphasis on prevention and wellness. Coverage codes: Basic Coverage Enhanced Coverage (includes Katie Beckett) Pregnant Women Coverage (PW) Medicare Co-insurance & Deductible (QMB) Part B Premium Coverage (SLMB) MMCP Coverage 14

15 Coverage Basic Coverage The Medicaid Basic Coverage type is for healthy, lowincome children, and adults with eligible dependent children. Provides complete health, prevention, and wellness Note: Most Medicaid participants will be enrolled with this coverage type. Visit for list of detailed services covered by each Medicaid plan. 15

16 Coverage Basic Coverage Example 16

17 Coverage Enhanced Coverage The Medicaid Enhanced Coverage type is for participants with disabilities or special health needs. Includes all benefits in Basic Coverage, plus additional benefits: o Nursing Facility o ICF/ID o Private Duty Nursing o Home & Community Based Waiver Services o Service Coordination Many of the services in this plan have medical eligibility and prior authorization requirements 17

18 Coverage Enhanced Coverage Example 18

19 Coverage Pregnant Women Program The Pregnant Women (PW) program is for pregnancy-related services only. This coverage ends on the last day of the month in which the 60 th day after delivery occurs Women have access to prenatal and postpartum care, including: o Normal prenatal services o Nutrition counseling o Risk reduction follow-up o Social service counseling o Chiropractic and physical therapy services o Family planning, including sterilization w/consent o Dental coverage Note: Routine eye exams, eyeglasses and contact lenses are not covered for members on the PW program, unless participant has a vision problem that has been caused by or is exacerbated by the pregnancy. 19

20 Coverage PW Program Example 20

21 Coverage Medicaid and Medicare Not everyone qualifies for regular Medicaid, but they may be eligible for Qualified Medicare Beneficiary (QMB) programs where Medicaid helps pay for Medicare costs including: Monthly Medicare premiums Medicare co-insurance Medicare deductibles 21

22 Coverage QMB Example 22

23 Coverage Specified Low-Income Medicare Beneficiary Coverage What expenses does SLMB cover? Specified Low-Income Medicare Beneficiary (SLMB) Medicare Part B premium only Note: No Medicaid coverage for services. 23

24 Coverage SLMB Example 24

25 Coverage Medicare and Medicaid Eligible What expenses are covered for participants who are fully eligible for both Medicare and Medicaid? Medicare covered services Medicaid covered services 25

26 Coverage Medicare and Medicaid Eligible Example 26

27 Coverage Medicare-Medicaid Coordinated Plan The Medicare-Medicaid Coordinated Plan (MMCP) is for participants who are 21 years old or older, enrolled in Medicare Part A and Part B, eligible for full Medicaid, and reside in an MMCP coverage area. Participants voluntarily enroll in MMCP; after the participant is selected as part of the plan, it is administered by Blue Cross of Idaho. Note: Once a participant is on MMCP, they can choose to revert back to Medicare and Medicaid individually. 27

28 Coverage MMCP Example 28

29 29 Vision Eligibility

30 Vision Eligibility Under 21 Participants under the age of 21 are eligible for the following. Examinations, vision testing, eyeglasses, and contact lenses are covered if Department criteria are met. Additional services are covered if medically necessary to correct or ameliorate defects. 30

31 Vision Eligibility Over 21 Participants 21 years of age and older are eligible for the following: Examinations and vision testing to monitor a chronic medical condition that may damage the eye. Services to treat acute conditions that, if let untreated, may cause permanent or chronic damage to the eye. Eyeglasses and contact lenses are covered: o Following cataract surgery o For contacts to treat Keratoconus o When necessary to prevent further degradation of vision Routine eye exams, eyeglasses, and contact lenses for the purpose of correcting nearsightedness, farsightedness, or astigmatism are not covered. 31

32 Provider Handbook Refer to the Provider Handbook - Eye and Vision Services for additional information to include but not limited to: What is included in an annual exam Refraction procedure Special ophthalmological services Fitting and dispensing Service limitations 32

33 33 Claims Submission

34 34 Claim Submission Methods

35 Patient Roster Submit Claim 35

36 Claim Submission Professional (1500) Claim 36

37 Claim Submission Coordination of Benefits 37

38 Claim Submission Professional (1500) Claim 38

39 39 Prior Authorization

40 Prior Authorization Fitting Fee/Dispensing Fee: Prior authorization is not required for fitting or dispensing of glasses and can be billed when: The participant receives new frames or lenses that are reimbursed by Medicaid Ordered from the Medicaid contractor 40

41 41 Fee Schedule

42 42 Fee Schedule

43 43 Fee Schedule

44 KX Modifier KX modifier Not required when billed with diagnosis from the Vision Chronic or Acute Condition Diagnosis Codes. Required if an exam does not pertain to a diagnosis on the Vision Chronic or Acute Condition Diagnosis Codes list. Supporting medical documentation is required and must be attached to the claim. 44

45 45 Did You Know?

46 Did You Know? Announcements & IRs 46

47 Did You Know? Provider Handbook 47

48 Did You Know? MedicAide Newsletters 48

49 Did You Know? MedicAide Newsletter 49

50 Did You Know? User Guides 50

51 Did You Know? Training 51

52 Did You Know? Training 52

53 Did You Know? Training Opportunities Monthly WebEx Trainings Available to all providers Calendar is located at Regional Workshops Yearly Information will be posted to Individual Training or Questions Contact your local Provider Relations Consultant 53

54 Did You Know? Molina Partnership Contacts Contact Description Phone/ Website Health and Welfare (DHW) Idaho Smiles Dental 1 (800) Magellan Pharmacy Claims Contractor Providers: 1 (800) Participants: 1 (888) Medical Care Unit Optum Idaho PHA (Preventive Health Assistance) Pharmacy Unit with DHW Veyo Disease Management, Durable Medical Equipment, Therapy Services, Ambulance Auths, Hospice, Surgery, Breast and Cervical Cancer, Vision, Dental, Lead Screening Program, Non- Emergency Medical Transportation Idaho Behavioral Health Plan 1 (855) aho/home 1 (877) (Preventive Health Assistance link) medicaidphaprogram@dhw.idaho.gov 1 (866) Fax: 1 (800) Telligen Prior Authorization 1 (866) Non-Emergency Medical Participant & Non-Transport Providers: Transportation 1 (877) Transport Providers: 1 (877)

55 55 Enrollment and Maintenance

56 Enrollment/Maintenance Be sure to keep your information up to date. Current contact Mailing/W9/physical addresses Adding and terming rendering providers Adding and terming service locations Change of ownership 56

57 57 Enrollment/Maintenance

58 Enrollment/Maintenance New Enrollment 58 Note: If enrolling with an NPI, it must be approved prior to beginning the enrollment application.

59 Provider Maintenance Maintenance is required when any information changes: Address Add, term, update service locations Rendering or service provider changes Name changes Change in ownership Note: Contact updates are made through Maintenance Demographic. 59

60 60 Maintenance Forms

61 Maintenance Forms General Category 61

62 Tips Use current forms Complete all sections of the form use N/A when appropriate Utilize the Provider Enrollment Requirements document in the Provider Handbook for type and specialty information, as well as additional requirements New W9 for 1099 changes W9 name and tax ID must match IRS records Update provider credentials (licenses, certifications, insurance, etc.) 62

63 Tips License Updates Updated Credentials: License As long as there are no changes to information, license updates are not required if you are licensed with the following: Idaho State Board of Nursing Idaho State Board of Medicine Idaho State Board of Pharmacy 63

64 Tips License Updates The Molina Medicaid website ( has the following resources: o Provider Enrollment - Verifying Enrollment Application Status o Provider Handbook o User Guides Contact Molina at 1 (866) or idproviderenrollment@molinahealthcare.com for assistance with enrollment or maintenance 64

65 Provider Relations Consultants Region 1 and the state of Washington 1 (208) Region.1@MolinaHealthCare.com Region 2 and the state of Montana 1 (208) Region.2@MolinaHealthCare.com Region 3 and the state of Oregon 1 (208) Region.3@MolinaHealthCare.com Region 4 and all other states 1 (208) Region.4@MolinaHealthCare.com Region 5 and the state of Nevada 1 (208) Region.5@MolinaHealthCare.com Region 6 and the state of Utah 1 (208) Region.6@MolinaHealthCare.com Region 7 and the state of Wyoming 1 (208) Region.7@MolinaHealthCare.com 65

66 Thank you for attending our Vision Training. Please take a few minutes to complete the evaluation. This provides us with valuable information for future trainings. 66