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, 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 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

2 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 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 or the Molina Medicaid website at 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 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. MedicAide October 2015 Page 1 of 10

3 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 RalfRequests@dhw.idaho.gov. 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 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 MedicAide October 2015 Page 2 of 10

4 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 MedicAide October 2015 Page 3 of 10

5 Figure 2: MA15-06 Hospice Rates Figure 1 MedicAide October 2015 Page 4 of 10

6 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 and click on the Training link in the left-hand menu. 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 10/14/ /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 9 of this newsletter. MedicAide October 2015 Page 5 of 10

7 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 October 2015 Page 6 of 10

8 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 October 2015 Page 7 of 10

9 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 (866) (208) (866) (208) idparticipantservices@molinahealthcare.com P.O. Box P.O. Box P.O. Box P.O. Box P.O. Box P.O. Box Molina Provider Services Fax Numbers Provider Enrollment 1 (877) Provider and Participant Services 1 (877) MedicAide October 2015 Page 8 of 10

10 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 October 2015 Page 9 of 10

11 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 October 2015 Page 10 of 10