Personal Care Services (PCS)
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1 Personal Care Services (PCS)
2 Overview Eligibility Prior Authorization Fee Schedule (Personal Care) 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 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 Verifying Eligibility 6
7 7 Patient Roster
8 Patient Roster Two pieces of identifying information required; MID and DOB recommended 8
9 9 Patient Roster
10 10 Verifying Eligibility
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 Note: PCS is only covered for Enhanced Plan participants. 14
15 Coverage Enhanced Plan 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 Note: Members receiving PCS services must have Enhanced Coverage. 15
16 Coverage Enhanced Plan Example 16
17 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 or Medicaid. 17
18 Coverage MMCP Example 18
19 19 Claim Submission
20 20 Claim Submission Methods
21 21 Patient Roster
22 Claim Submission 22 *Dates of service must be within the Sunday through Saturday calendar week on a single detail line on the claim. The calendar week begins at 12:00 a.m. on Sunday and ends at 11:59 p.m. on Saturday.
23 Authorizations Prior to rendering PCS services, verify that Regional Medicaid Services has issued a PA for the services you are providing Adult PCS is limited to a maximum of 16 hours per week. All PCS must be provided in accordance with a written plan of care. 23
24 24 Authorization Status
25 Authorization Status Search 25
26 Authorization Status Details 26
27 27 Fee Schedule
28 Fee Schedule Information found on the fee schedule: PCS codes Medicaid rate 28
29 29 Fee Schedule
30 30 Fee Schedule
31 Fee Schedule Personal Care Home and Community Based Services Note: These listed $ rates are for illustrative purposes only. Refer to the fee schedule online for the current rates. 31
32 32 Did You Know?
33 Did You Know? Announcements & IRs 33
34 Did You Know? Provider Handbook 34
35 Did You Know? MedicAide Newsletters 35
36 Did You Know? MedicAide Newsletter 36
37 Did You Know? User Guides 37
38 Did You Know? Training 38
39 Did You Know? Training 39
40 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 40
41 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)
42 42 Enrollment and Maintenance
43 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 43
44 44 Enrollment/Maintenance
45 Enrollment/Maintenance New Enrollment 45 Note: If enrolling with an NPI, it must be approved prior to beginning the enrollment application.
46 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. 46
47 47 Maintenance Forms
48 Maintenance Forms General Category 48
49 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.) 49
50 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 50
51 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 51
52 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 52
53 Thank you for attending our Personal Care Services Training. Please take a few minutes to complete the evaluation. This provides us with valuable information for future trainings. 53
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15% 30% $7,350 Individual Unlimited Individual (per calendar year) Out-Of-Pocket Maximum
PLAN FEATURES Deductible (per calendar year) $1,750 Individual $20,000 Individual $3,500 Family $40,000 Family All covered expenses accumulate toward both the preferred and non-preferred Deductible. Unless
ST. CLAIR HOSPITAL APPLICATION FOR FINANCIAL ASSISTANCE / CHARITY CARE DEMOGRAPHICS AND SCREENING
DEMOGRAPHICS AND SCREENING PATIENT DEMOGRAPHIC Patient Name Patient Phone # Patient Address Marital Status: SINGLE MARRIED SEPARATED DIVORCED WIDOWED HOUSEHOLD DEMOGRAPHIC Line Date of Birth Relationship