Durable Medical Equipment

Transcription

1 Durable Medical Equipment

2 Overview Eligibility Fee Schedule PA/Invoice Required Resources Enrollment 2

3 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 To obtain eligibility information from one of these systems, submit two pieces of identifying information from the following list: Medicaid ID number (10 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 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 The Pregnant Women (PW) program is for pregnancy-related services only. Pregnant Women Program 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 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 Claim Submission

30 Claim Submission Methods Claims can be submitted under Claim Submission But today, we will show you how to submit claims through the Patient Roster. 30

31 Patient Roster Submit Claim 31

32 Claim Submission Professional (1500) Claim 32

33 Claim Submission Coordination of Benefits Note: After clicking Submit in the COB box, you must remember to click Submit on the claim form. 33

34 34 Fee Schedule

35 Fee Schedule Information found on the fee schedule: PA required PA pricing Invoice required Medicaid rate 35

36 36 Fee Schedule

37 37 Fee Schedule

38 38 Fee Schedule

39 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. 39

40 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. 40

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 42 Did You Know?

43 Did You Know? Announcements & IRs 43

44 Did You Know? Provider Handbook 44

45 Did You Know? MedicAide Newsletters 45

46 Did You Know? MedicAide Newsletter 46

47 Did You Know? User Guides 47

48 Did You Know? Training 48

49 Did You Know? Training 49

50 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 50

51 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)

52 Enrollment and Maintenance 52

53 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 53

54 54 Enrollment/Maintenance

55 Enrollment/Maintenance New Enrollment 55 Note: If enrolling with an NPI, it must be approved prior to beginning the enrollment application.

56 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. 56

57 57 Maintenance Forms

58 Maintenance Forms General Category 58

59 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.) 59

60 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 60

61 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 61

62 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 62

63 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. 63