Vision
Overview Eligibility Fee Schedule Resources Enrollment 2
3 Eligibility
Participant Eligibility Why Check eligibility? To verify that participant has Medicaid coverage on date of service. To review participant s eligibility plan and coverage. Note: A Medicaid card does not guarantee current Medicaid coverage. 4
Verifying Eligibility Three ways to check eligibility: MACS Medicaid Automated Customer Service 1(866)686-4272 HIPAA compliant vendor software Health PAS-OnLine Trading Partner To obtain eligibility information, submit any 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
Trading Partner Account https://www.idmedicaid.com 6
7 Patient Roster
Patient Roster Build Roster Two pieces of identifying information required; MID and DOB recommended 8
9 Patient Roster
Verifying Eligibility Trading Partner Eligibility 10
Verifying Eligibility Trading Partner Eligibility Two pieces of identifying information required; MID and DOB recommended 11
Verifying Eligibility Trading Partner Eligibility 12
13 Verifying Eligibility
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
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 www.healthandwelfare.idaho.gov for list of detailed services covered by each Medicaid plan. 15
Coverage Basic Coverage Example 16
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
Coverage Enhanced Coverage Example 18
Coverage 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 Note: Routine eye exams, eyeglasses and contact lenses are not covered for members on the PW program, unless participant has a vision problem that has been caused by or is exacerbated by the pregnancy. 19
Coverage PW Program Example 20
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
Coverage QMB Example 22
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
Coverage SLMB Example 24
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
Coverage Medicare and Medicaid Eligible Example 26
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
Coverage MMCP Example 28
29 Vision Eligibility
Vision Eligibility Under 21 Participants under the age of 21 are eligible for the following. Examinations, vision testing, eyeglasses, and contact lenses are covered if Department criteria are met. Additional services are covered if medically necessary to correct or ameliorate defects. 30
Vision Eligibility Over 21 Participants 21 years of age and older are eligible for the following: Examinations and vision testing to monitor a chronic medical condition that may damage the eye. Services to treat acute conditions that, if let untreated, may cause permanent or chronic damage to the eye. Eyeglasses and contact lenses are covered: o Following cataract surgery o For contacts to treat Keratoconus o When necessary to prevent further degradation of vision Routine eye exams, eyeglasses, and contact lenses for the purpose of correcting nearsightedness, farsightedness, or astigmatism are not covered. 31
Provider Handbook Refer to the Provider Handbook - Eye and Vision Services for additional information to include but not limited to: What is included in an annual exam Refraction procedure Special ophthalmological services Fitting and dispensing Service limitations 32
33 Claims Submission
34 Claim Submission Methods
Patient Roster Submit Claim 35
Claim Submission Professional (1500) Claim 36
Claim Submission Coordination of Benefits 37
Claim Submission Professional (1500) Claim 38
39 Prior Authorization
Prior Authorization Fitting Fee/Dispensing Fee: Prior authorization is not required for fitting or dispensing of glasses and can be billed when: The participant receives new frames or lenses that are reimbursed by Medicaid Ordered from the Medicaid contractor 40
41 Fee Schedule
42 Fee Schedule
43 Fee Schedule
KX Modifier KX modifier Not required when billed with diagnosis from the Vision Chronic or Acute Condition Diagnosis Codes. Required if an exam does not pertain to a diagnosis on the Vision Chronic or Acute Condition Diagnosis Codes list. Supporting medical documentation is required and must be attached to the claim. 44
45 Did You Know?
Did You Know? Announcements & IRs 46
Did You Know? Provider Handbook 47
Did You Know? MedicAide Newsletters 48
Did You Know? MedicAide Newsletter 49
Did You Know? User Guides 50
Did You Know? Training 51
Did You Know? Training 52
Did You Know? Training Opportunities Monthly WebEx Trainings Available to all providers Calendar is located at www.idmedicaid.com Regional Workshops Yearly Information will be posted to www.idmedicaid.com Individual Training or Questions Contact your local Provider Relations Consultant 53
Did You Know? Molina Partnership Contacts Contact Description Phone/E-mail Website Health and www.healthandwelfare.idaho.gov Welfare (DHW) Idaho Smiles Dental 1 (800) 936-0978 www.dentaquest.com Magellan Pharmacy Claims Contractor Providers: 1 (800) 922-3987 https://idaho.fhsc.com Participants: 1 (888) 773-9466 Medical Care Unit Optum Idaho PHA (Preventive Health Assistance) Pharmacy Unit with DHW Veyo Disease Management, Durable www.medunit.dhw.idaho.gov 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) 202-0983 https://m1.optumidaho.com/web/optumid aho/home 1 (877) 364-1843 www.medicaid.idaho.gov (Preventive Health Assistance link) medicaidphaprogram@dhw.idaho.gov 1 (866) 827-9967 www.medicaidpharmacy.idaho.gov Fax: 1 (800) 327-5541 Telligen Prior Authorization 1 (866) 538-9510 http://idmedicaid.telligen.com Non-Emergency Medical Participant & Non-Transport Providers: http://idahotransport.com Transportation 1 (877) 503-1261 Transport Providers: 1 (877) 986-7421 54
55 Enrollment and Maintenance
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 56
57 Enrollment/Maintenance
Enrollment/Maintenance New Enrollment 58 Note: If enrolling with an NPI, it must be approved prior to beginning the enrollment application.
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. 59
60 Maintenance Forms
Maintenance Forms General Category 61
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.) 62
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 63
Tips License Updates The Molina Medicaid website (www.idmedicaid.com) has the following resources: o Provider Enrollment - Verifying Enrollment Application Status o Provider Handbook o User Guides Contact Molina at 1 (866) 686-4272 or e-mail idproviderenrollment@molinahealthcare.com for assistance with enrollment or maintenance 64
Provider Relations Consultants Region 1 and the state of Washington 1 (208) 559-4793 Region.1@MolinaHealthCare.com Region 2 and the state of Montana 1 (208) 991-7138 Region.2@MolinaHealthCare.com Region 3 and the state of Oregon 1 (208) 860-4682 Region.3@MolinaHealthCare.com Region 4 and all other states 1 (208) 373-1343 Region.4@MolinaHealthCare.com Region 5 and the state of Nevada 1 (208) 484-6323 Region.5@MolinaHealthCare.com Region 6 and the state of Utah 1 (208) 870-3997 Region.6@MolinaHealthCare.com Region 7 and the state of Wyoming 1 (208) 991-7149 Region.7@MolinaHealthCare.com 65
Thank you for attending our Vision Training. Please take a few minutes to complete the evaluation. This provides us with valuable information for future trainings. 66