Durable Medical Equipment Training

Transcription

1 Durable Medical Equipment Training

2 Overview Eligibility Claim Submission Fee Schedule Prior Authorization (PA) required Prior Authorization (PA) pricing Invoice required Medicaid rate Resources Enrollment/Maintenance 2

3 Eligibility

4 Participant Eligibility Why should you check eligibility? To verify a participant has Medicaid coverage on actual date of service To review a participant s eligibility plan and coverage codes Note: 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 Account (TPA) To obtain eligibility information from one of these systems, submit two pieces of identifying information from the following list: Medicaid ID number (ten digits) Social Security Number (SSN) Last Name, First Name Date of Birth 5

6 Navigating the Secure Portal 6

7 Patient Roster 7

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

9 Patient Roster Actions 9

10 Verifying Eligibility Two pieces of identifying information required 10

11 Verifying Eligibility 11

12 Verifying Eligibility 12

13 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 13

14 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. 14

15 Basic Coverage Example 15

16 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 Intermediate Care Facilities for Individuals with Intellectual Disabilities (ICF/IID) 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 16

17 Enhanced Coverage Example 17

18 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 18

19 Pregnant Women Program Example 19

20 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 20

21 QMB Example 21

22 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. 22

23 SLMB Example 23

24 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 24

25 Medicare and Medicaid Eligible Example 25

26 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. Currently there are two MMCP programs; one offered administered by Blue Cross of Idaho, and one administered by Molina Healthcare. Note: Once a participant is on MMCP, they can choose to revert back to Medicare and Medicaid individually. 26

27 MMCP Example 27

28 Claim Submission

29 Claim Submission Methods Claims can be submitted under View & Submit Claims But today, we will show you how to submit claims through View Patient Roster. 29

30 Patient Roster Submit Claim 30

31 Claim Submission 31

32 Claim Submission Coordination of Benefits Note: After clicking Submit in the COB box, you must remember to click Submit on the claim form. 32

33 Fee Schedule

34 Fee Schedule Information found on the fee schedule: PA required PA pricing Invoice required Medicaid rate 34

35 Fee Schedule 35

36 Fee Schedule 36

37 Fee Schedule 37

38 Invoices When billing with invoices, make sure the following are included. Company name of the supplier Company name receiving supplies Item names Quantity received should be the same or more than the quantity being billed Price of item, including shipping Dates received are on or before date of service Note: When an invoice has several items on it, remember to clearly mark the invoice with which item is being indicated on the claim. 38

39 Invoices When you are attaching the invoice for nutritional formulas, make sure you include the following information on the invoice. Number of calories per day ordered by the physician Number of calories per can Number of cans per case Note: One unit of a nutritional formula is defined in the HCPCS manual as 100 calories rather than the number of cans. For billing purposes, providers must convert the number of cans dispensed to the number of 100-calorie units dispensed. 39

40 Did You Know?

41 IDAPA/Medicare Medicaid uses the same HCPCS codes and modifiers that are used by Medicare. Refer to the DME MAC Manual for updated HCPCS codes at IDAPA DHW DME Website are/durablemedicalequipment/tabid/271/default.aspx Other links are available throughout the Suppliers section of the Provider Handbook 41

42 Announcements 42

43 Information Releases 43

44 Provider Handbook 44

45 Provider Handbook 45

46 Fee Schedules 46

47 Fee Schedules 47

48 MedicAide Newsletters 48

49 MedicAide Newsletters 49

50 User Guides 50

51 Training 51

52 Idaho Medicaid Training Center 52

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

54 Enrollment and Maintenance

55 Enrollment/Maintenance Be sure to keep your information up to date. o o o o o Current contact Mailing/W9/physical/ addresses Adding and terming rendering providers Adding and terming service locations Change of ownership 55

56 Enrollment and Maintenance 56

57 Enrollment and Maintenance Forms 57

58 Provider Maintenance 58

59 Provider Maintenance Maintenance is required when any information changes: Physical, mailing, and 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 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.) 60

61 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 61

62 Tips Provider Maintenance The Idaho Molina Medicaid website ( has the following resources: Provider Enrollment - Verifying Enrollment Application Status Provider Handbook User Guides Contact Molina at 1 (866) or idproviderenrollment@molinahealthcare.com for assistance with enrollment or maintenance 62

63 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 63

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