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, December 2014 Division of Medicaid In This Issue New Claim Denial Edits... 1 Modifier Duo Sentenced for Medicaid Fraud... 3 Medicaid Program Integrity... 4 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 No Information Releases Available

2 New Claim Denial Edits Reporting Rendering Provider, Service Location and Bill Type Information on Your Claim Beginning January 9, 2015, claims that cannot be correctly reported to our federal partners will be denied. Federal reporting errors are most often caused by missing or incorrectly reported: Rendering providers, Service locations, and Bill types When do I need to report a rendering provider on my claim? If your Pay-to provider is a multispecialty or single-specialty group you must declare the NPI of the individual who provided the service in box 24J of the CMS 1500 or in Loop 2310B segment NM109 of the 837P. Please be aware the rendering provider must be an individual that is enrolled with Idaho Medicaid as a part of your group. There are no exceptions to this rule and this will always be required on the claim. When do I need to report a service location on my claim? If your NPI is used to bill more than one line of business for example, you are a hospital who bills inpatient, outpatient, lab, radiology and physician services under the same NPI you must declare the line of business for which you are billing using the appropriate service location indicator in box 32a of the CMS 1500 or in the REF segment of loop 2310C of the 837p for professional claims. For institutional claims use box 2 of the UB04 or the REF segment of loop 2310E. There are no exceptions to this rule and this will always be required on the claim. When do I need to report a rendering provider AND a service location on my claim? If your NPI is used to bill more than one line of business and one of those lines of business is a group of providers, both the service location and the rendering must be on the claim to appropriately report the claim. If the service location is not affiliated to the Pay-to provider, the information will be ignored and your claims may pay incorrectly or deny. What does the Service Location Identifier look like? The Service location identifier is your Pay-to NPI, a dash (-), and three numeric digits; for example, If the service location entered on your claim does not reflect your NPI and three digit suffix the claim might pay incorrectly or deny. (Continued on page 2) MedicAide December 2014 Page 1 of 10

3 (New Claim Denial Edits Cont d) What edits are associated with incorrectly reported Rendering Provider, Service Location, and Bill Type Information? Edit Edit Description CARC # CARC Description RARC # RARC Description 6007 CLAIM SPECIALTY REQUIRED 16 Claim/service lacks information or has submission/billing error(s) which is needed for adjudication. MA130 Your claim contains incomplete and/or invalid information, and no appeal rights are afforded because the claim is unprocessable. Please submit a new claim with the complete/correct information CLAIM TYPE REQUIRED 16 Claim/service lacks information or has submission/billing error(s) which is needed for adjudication. N255 Missing/incomplete/invalid billing provider taxonomy. Examples of when Edit 6007 and 6019 will fire on your claim Edit Is there a Service Location on the claim? Is there a Rendering Provider on the claim? Edit 6007 may have fired because: 6007 No No The claim required a service location, a rendering provider or both N/A Yes The rendering provider is not an individual No Yes The service location was mistakenly entered in the rendering provider field Yes No The rendering provider is in the Service Location field. Edit UB-04 CMS1500 Edit 6007 may have fired because: 6007 Yes N/A A professional claim was billed using UB04 claim form. Edit Bill Type Edit 6019 may have fired because: 6019 No The required bill type is missing or incorrect Possible Solution Resubmit the claim with the appropriate service location, rendering provider or both. Resubmit with the NPI of the individual who rendered the service on the claim. Resubmit with the appropriate service location identifier in the correct field. Resubmit the claim with the rendering provider s NPI in the correct field. Possible Solution Resubmit the claim on the appropriate claim form. Possible Solution Resubmit the claims with the appropriate bill type. MedicAide December 2014 Page 2 of 10

4 Modifier 59 Effective January 1, 2015, CMS is establishing four new HCPCS Modifiers to define subsets of Modifier 59, Distinct Procedural Services, to be used by all State Medicaid Programs. Modifier 59 is the most widely used HCPCS modifier. Modifier 59 is for use in a wide variety of circumstances, and is often incorrectly applied to bypass National Correct Coding Initiative (NCCI) edits. Providers are responsible for accurately, completely, and legibly documenting the services performed. The introduction of subset modifiers is designed to reduce improper use of modifier 59 and help to improve claims processing for providers. The four new modifiers are: XE Separate Encounter: A service that is distinct because it occurred during a separate encounter. This modifier should only be used to describe separate encounters on the same date of service. XS Separate Structure: A service that is distinct because it was performed on a separate organ/structure. XP Separate Practitioner: A service that is distinct because it was performed by a different practitioner. XU Unusual Non-Overlapping Service: The use of a service that is distinct because it does not overlap usual components of the main service. Idaho Medicaid will continue to recognize modifier 59, however, the -59 modifier should not be used when a more descriptive modifier is available. Idaho, through the NCCI edits, may selectively require a more specific modifier X{E, P, S, or U} modifier for billing certain codes at high risk for incorrect billing. For example, a particular NCCI PTP code pair may be identified as payable only with the -XE separate encounter modifier, but not the -59 or other -X{E, P, S, or U} modifiers. The -X{E, P, S, or U} modifiers are more selective versions of the -59 modifier, so it would be incorrect to include both modifiers on the same line. For additional information and instruction, providers should access the Medicaid NCCI page at: Systems/National-Correct-Coding-Initiative.html. The Modifier 59 Article can be found near the bottom of the page. Duo Sentenced for Medicaid Fraud (Boise) Cline M. Waddell and his office manager, Linda J. Hefner, of Assisting Hands Home Care-Boise, LLC, a Nampa business, have been sentenced for defrauding Medicaid, Attorney General Lawrence Wasden said. Waddell, 66, pleaded guilty and was sentenced today. Waddell was aware of Hefner putting her name down for hours she did not work but did not do anything about it and allowed the fraudulent claims to be submitted to the Idaho Medicaid Program. Third District Judge George Southworth accepted a stipulated plea agreement and ordered Waddell to perform 40 hours of community service and pay $300 in fines and court costs. Terms of the plea agreements require both Waddell and Hefner to reimburse Medicaid a total of $12,282, which Waddell paid prior to sentencing. (Continued on page 4) MedicAide December 2014 Page 3 of 10

5 (Duo Sentenced for Medicaid Fraud Cont d) Last month, Third Judicial District Judge Juneal Kerrick sentenced Hefner, 68, on a felony of aiding and abetting Cline Waddell in provider fraud. Pursuant to a stipulated plea agreement, the court placed her on probation for two years, ordered her to perform seven days of sheriff inmate labor detail and perform 100 hours of community service. By pleading guilty, Hefner admitted she put her name as a care provider in the company's computer for providing personal care services to clients when she knew she had not performed the services. Assisting Hands Home Care-Boise then billed Medicaid for those services knowing they had not been performed. Citizens interested in reporting Medicaid fraud, theft, or abuse should contact the Medicaid Fraud Control Unit of the Attorney General's Office by calling 1 (208) or report the fraud online at Medicaid Program Integrity Duplicate Payments Recent audits of services billed to Idaho Medicaid identified outstanding duplicate Medicaid payments for services rendered between 2009 and the current date. Many duplicate payments were the result of claims submitted and processed multiple times in the early months of the implementation of the Molina claims system in In some cases, duplicate payments occurred when Molina reprocessed claims; however, a significant number were due to the submission of multiple claims by providers for the same services. Sometimes the duplicate payments were made because providers submitted corrected claims instead of adjusting the incorrect claims. In the Idaho Medicaid Provider Agreement, providers agree: 5. Accurate Billing. To certify by the signature of the Provider or designee, including electronic signatures on a claim form or transmittal document, that the items or services claimed were actually provided and medically necessary, were documented at the time they were provided, and were provided in accordance with professionally recognized standards of health care, applicable Department rules, and this Agreement. The Provider shall be solely responsible for the accuracy of claims submitted, and shall immediately repay the Department for any items or services the Department or the Provider determines were not properly provided, documented, or claimed. The Provider must assure that a duplicate claim under another program or provider type is not submitted. Providers are required to immediately repay identified overpayments. Provider practices that do not reconcile patient accounts, or practices that post duplicate payments which leave credits on the accounts are inconsistent with sound business and medical practices and result in unnecessary costs to the Medicaid program. When duplicate payments are identified, providers are encouraged to contact the Medicaid Program Integrity Unit at 1 (208) if they need to make repayment arrangements. Providers who self-identify duplicate payments may not be subject to civil monetary penalties. MedicAide December 2014 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. January: 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. January Referrals February Eligibility March Claims Adjustments April Reports May Certified Family Homes June Residential Assisted Living Facilities July Long Term Care August Eligibility September Claims Adjustments 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 1/14/2015 1/15/2015 1/20/2015 1/21/2015 1/8/2015 1/15/2015 1/20/2015 2/11/2015 2/17/2015 2/18/2015 2/19/2015 2/12/2015 2/17/2015 2/19/2015 3/11/2015 3/17/2015 3/18/2015 3/19/2015 3/12/2015 3/17/2015 3/19/2015 4/8/2015 4/15/2015 4/16/2015 4/21/2015 4/9/2015 4/16/2015 4/21/2015 5/13/2015 5/19/2015 5/20/2015 5/21/2015 5/14/2015 5/19/2015 5/21/2015 6/10/2015 6/16/2015 6/17/2015 6/18/2015 6/11/2015 6/16/2015 6/18/2015 7/8/2015 7/15/2015 7/16/2015 7/21/2015 7/9/2015 7/16/2015 7/21/2015 8/12/2015 8/18/2015 8/19/2015 8/20/2015 8/13/2015 8/18/2015 8/20/2015 9/9/2015 9/15/2015 9/16/2015 9/17/2015 9/10/2015 9/15/2015 9/17/ /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 December 2014 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 December 2014 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 December 2014 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 December 2014 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 December 2014 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 December 2014 Page 10 of 10