division of medicaid in this issue newsletters... · 2020. 5. 9. · medicaid fraud and abuse...
TRANSCRIPT
MedicAide March 2011 Page 1 of 17
In This Issue System Improvements for Claims and Eligibility Status ................................................................. 2
Claim Status ........................................................................................................................ 2 Eligibility Status.................................................................................................................... 2
Using the Copy Claim Feature .................................................................................................... 2 Proof of Timely Filing ................................................................................................................ 2 Medicaid Program Integrity ....................................................................................................... 3
Fraud Reporting Procedures ................................................................................................... 3 AMR Acess2Care ...................................................................................................................... 3 Medicaid Fraud Control Unit ....................................................................................................... 4
Twin Falls, ID resident found guilty of Provider Fraud ................................................................ 4 Tips for PCPs on Tobacco Cessation ............................................................................................ 4 Preventive Health Assistance for Wellness ................................................................................... 5 System Updates and Announcements ......................................................................................... 6
Medicare Excluded Service ..................................................................................................... 6 Mental Health Code H0031 ..................................................................................................... 6 Physical and Occupational Therapy POS ................................................................................... 6 Psychosocial Rehab Visit Limits ............................................................................................... 6 Patient Information Notification .............................................................................................. 6
Need a Claim Reviewed? ........................................................................................................... 6 Provider Training Opportunities in March ..................................................................................... 7 Step One: Registering for Provider Training ................................................................................. 8
New User Registration Instructions ......................................................................................... 8 Step Two: Using the Idaho Medicaid Training Center ...................................................................10
How to Register for Provider Training Sessions ........................................................................10 The 2011 Idaho HealthCare Conference - SAVE THE DATES! ........................................................12 DHW Contact Information ........................................................................................................13 Insurance Verification ..............................................................................................................13 Prior Authorization Contact Information .....................................................................................14 Transportation ........................................................................................................................14 Molina Provider and Participant Services Contact Information .......................................................15 Molina Provider Services Fax Numbers .......................................................................................15 Provider Relations Consultant (PRC) Information .........................................................................16
Information Releases There are no new information releases this month.
An informational newsletter for Idaho Medicaid Providers
From the Idaho Department of Health and Welfare, March 2011
Division of Medicaid
MedicAide March 2011 Page 2 of 17
System Improvements for Claims and Eligibility Status
Claim Status
An exciting new feature has been added to the claim
status functionality. You are no longer required to
enter a date span to return claims upon entry into
the claim status module. Instead, the 40 most recent
claims will be displayed immediately. Along with the
40 most recent claims there is now a link at the
bottom of the claim screen that will allow you to
choose to go to the next page and return the next set of claims and also page back. You still
have all of the search options you had in the past to identify specific claims. This feature
makes it easier and quicker to get to recent submissions. The display also now includes the
primary diagnosis code on the first screen.
Eligibility Status
Along with the update to claim status there has also been an update to eligibility inquiries.
Dates will now only be displayed if the date span of the inquiry extends prior to or after the
dates of eligibility for the participant. If the date span entered on the inquiry falls fully
within the participant’s eligibility segment it will be displayed as fully ACTIVE and effective
or termination dates are not presented. If the FROM date is previous to the beginning date
of eligibility, then it will display with a status of PARTIAL and the effective date will show. If
the TO date is past the eligibility termination date, then it will display with a status of
PARTIAL and the termination date will show. Otherwise, dates are not displayed.
Using the Copy Claim Feature
When using the copy claim feature for online billing, please be aware that prior
authorizations (PAs) fill in automatically. Therefore, if the prior authorization has changed
from the last claim, you must remove the old prior authorization on the new claim, or it will
deny. Please remove any PA from claims when using the copy claim feature to avoid denials
for wrong PA entered on claim.
Proof of Timely Filing
Did you know that a copy of retro-eligibility is accepted as proof of timely filing for providers
and participants? Just attach a copy of the retro-eligibility letter along with the claim when
you submit. The claim will pend and then be manually reviewed for approval as long as the
proper documentation is attached.
MedicAide March 2011 Page 3 of 17
Medicaid Program Integrity
Fraud Reporting Procedures
Medicaid fraud and abuse affects everyone - taxpayers, Medicaid clients, and Medicaid
providers. With the state’s current budget crisis, it is crucial that the limited funds available
be used to pay for services that were actually provided, provided by qualified staff in
accordance with professional standards, medically necessary, and provided in accordance
with Department rules and regulations.
The Medicaid Program Integrity Unit conducts client and provider reviews, provider audits,
and preliminary fraud investigations. A separate unit within the Attorney General’s Office,
the Medicaid Fraud Control Unit, conducts criminal investigations and prosecutes cases of
health care fraud and elderly abuse. If you suspect fraud or abuse, there are four avenues
available to report your concerns:
Call: 1 (208) 334-5754 (message phone)
E-mail a fraud complaint to: [email protected]
Fax a complaint to: 1(208) 334-2026
Mail to: Medicaid Program Integrity Unit
P. O. Box 83720
Boise, ID 83720-0036
Complaints should include your name, phone number, e-mail address if applicable, and a
detailed description of the suspected fraudulent or abusive conduct. Anonymous complaints
are also accepted, however, history has shown complaints which include the complainant’s
name and allow contact with the complainant to obtain additional information tend to
produce better results.
AMR Acess2Care
Please be advised that effective March 14th, 2011, AMR will no longer accept Bulk
Scheduling Forms from Medical Providers or Transportation Providers via fax or email.
This change is being implemented to mitigate scheduling conflicts and errors and to allow
for increased accuracy and efficiency. The change also provides more detailed case
management to meet both IDHW and AMR standards.
Transportation requests submitted prior to March 14th will be entered and scheduled for
90 days or less if requested. Medicaid participants and/or their responsible care givers will
be notified by AMR agents of this change by telephone at the time of form entry. Any
subsequent changes to previously submitted schedules will need to be called into our call
center at 1 (877) 503-1261.
Effective March 14th, Medicaid participants, their parent or guardian, or Medicaid providers
specifically responsible for assisting participants with transportation needs such as service
coordinators, psychosocial rehabilitation providers, certified family home providers and
MedicAide March 2011 Page 4 of 17
discharge planners will be required to contact the AMR call center at 1 (877) 503-1261 for
all transportation requests or changes for trips occurring on or after March 14th, 2011.
Please contact the AMR office if you have any questions.
AMR Acess2Care
660 E. Franklin Road, Ste 120
Meridian, ID 83642
(877) 503-1261
Medicaid Fraud Control Unit
Twin Falls, ID resident found guilty of Provider Fraud
On January 28, 2011, following a three day jury trial, Amy Prestin, 38, of Twin Falls, Idaho
was found guilty of Provider Fraud, a felony. The state presented evidence that
documented Prestin’s submission of progress notes and billing sheets from July 2005 to May
2006 to her employer concerning psychosocial rehabilitation for a client that did not
happen.
Once Prestin’s former employer found out what had happened, the Idaho Department of
Health and Welfare was contacted and Prestin was placed on administrative leave. The case
was initially investigated by the IDHW Medicaid Program Integrity Unit and was then
referred to Attorney General Lawrence Wasden’s Medicaid Fraud Control Unit for further
investigation. The case was prosecuted by the Office of Attorney General at the request of
Twin Falls County Prosecutor Grant Loebs.
As a result of her conviction, Prestin will face mandatory suspension by the State of Idaho
and the United States of America as a provider or employee of a provider from all federally
funded health care programs, such as Medicaid, Medicare, TRICARE (health care for active
and retired military service members and their dependants), Indian Health Service, and
Federal Employees Health Benefits (FEHB), among others.
Tips for PCPs on Tobacco Cessation
The Preventive Health Assistance (PHA) benefit provides assistance to participants to help
them quit using tobacco. We provide assistance:
Locating cessation programs
Paying for prescription and over the counter cessation products such as: Chantix,
Wellbutrin, inhalers, nasal spray, patches, lozenges or gum.
Idaho Medicaid Recommends Following the Surgeon General’s “5 A’s” Approach
1. Ask Systematically identify all tobacco users at every visit.
2. Advise Strongly urge all tobacco users to quit.
3. Assess Determine willingness to make a quit attempt.
4. Assist Aid the patient in quitting.
5. Arrange Schedule, follow up, contact and refer your Medicaid patients to the PHA Unit
at our toll free number, 1 (877) 364-1843 or give them a PHA brochure.
MedicAide March 2011 Page 5 of 17
If you would like to request a supply of PHA brochures or if you would like more information
on PHA benefits, please call the PHA Unit at 1 (877) 364-1843.
Go to www.surgeongeneral.gov/tobacco to obtain the entire Quick Reference Guide for
Clinicians – Treating Tobacco Use and Dependence.
Please note: Cessation products are not covered under the Medicaid Pharmacy program.
They are only available through the PHA program authorization process.
Preventive Health Assistance for Wellness
The Preventive Health Assistance (PHA) Wellness benefit
provides assistance to families whose children are:
1) Enrolled in the Medicaid Basic Plan and
2) Required to pay a monthly premium to maintain eligibility.
These children are automatically enrolled in the Wellness PHA.
How does it work?
The claims processing system is searched to determine if a child is current on receiving
recommended well-child checks and immunizations. If the child is current, PHA points are
earned. The PHA points are applied as a reduction to the family’s monthly premium.
PHA follows the American Academy of Pediatrics (AAP) recommended schedule for Well-
child checks and the Center for Disease Control (CDC) recommendations for Immunizations.
Well-Child Check-up Schedule
Age
Babies 1 Week–1 Month 2 Months 4 Months 6 Months 9 Months 12 Months
1-3 yr 15 months 18 months 24 months 30 months 36 months
3-19 yr 1 check-up every year
How can Primary Care Providers (PCPs) help?
Be sure to bill Well-Child Checks with the primary diagnosis V20.2 and the appropriate CPT
code (see provider handbook). Please note that if a child comes in for a well-child check
and presents sick, you can bill for both as long as both exams were performed.
If you would like to request a supply of PHA brochures or if you would like more information
on PHA Benefits, please call the PHA Unit toll-free at 1 (877) 364-1843.
MedicAide March 2011 Page 6 of 17
System Updates and Announcements
Medicare Excluded Service
CPT code G9007 (coordinated care fee) has been placed with the Medicare Non-Covered
Services in the Medicare Excluded Services group. This will prevent many claims from
pending and requiring manual processing.
Mental Health Code H0031*
HCPCS code H0031 (mental health assessment by non-MD) was one of the procedures
impacted by the recent budget reductions. However, the procedure is still allowed for
provider specialty Mental Health Service Coordination (a/k/a Case Management). Please
note if your specialty is Mental Health Clinic or Psychosocial Rehabilitation, this procedure
will deny.
Physical and Occupational Therapy POS
POS 13 (assisted living facility) has been added to physical therapy benefits. In addition,
POS 31, 32 and 33 have been added for both physical and occupational therapies. Impacted
claims will be identified and reprocessed.
Psychosocial Rehab Visit Limits*
The system has been configured to respond properly to claims that are filed either on a
rolling week or a calendar week for a series of psychosocial rehab benefit terms. The terms,
H2017, H2014 and H0036 were incorrectly denying for exceeding the benefit limit for visits.
The units for these terms have been increased to accommodate billing schedules. A monthly
reconciliation will occur to ensure the benefit limit has not been exceeded.
Patient Information Notification
An error message has been added to the system during invalid participant searches.
Previously, no information was displayed. Now, when providers search for someone who is
not on a patient roster, the message “No member found” will display.
*Please refer to DHW Information Release IR MA 10-20 for more details. Information
Releases can be found at www.idmedicaid.com on the left navigation page.
Need a Claim Reviewed?
Please use the Claim Review Request form found online.
Simply download the form, fill it out and mail it to:
Molina Medicaid Solutions
P.O. Box 70082
Boise, Idaho 83707
Claim Review Requests cannot be faxed.
MedicAide March 2011 Page 7 of 17
Provider Training Opportunities in March
The provider training session, Claims Options for Providers, is available in March 2011 and is
open to all enrolled Medicaid providers. It will be offered on the following dates:
Location Date Time Location (DHW Office)
Region 1 3/11/2011 9 -11 A.M. PST Coeur d’Alene
Conference room #102
1120 Ironwood Dr.
Coeur d’Alene, ID
Region 2 3/10/2011 9 -11 A.M. PST Lewiston DHW Office
Basement conference room, (new location)
1118 F Street Lewiston, ID
Region 3 3/16/2011 9 -11 A.M. MST Caldwell DHW Office
Room #190
3402 Franklin Rd.
Caldwell, ID
Region 4 3/15/2011 9 -11 A.M. MST Boise DHW Office
Suite B conference room
1720 Westgate Dr.
Boise, ID
Region 5 3/3/2011 9 -11 A.M. MST Twin Falls DHW Office
Conference rooms A/C
601 Poleline Rd.
Twin Falls, ID
Region 6 3/24/2011 9 -11 A.M. MST 2nd Floor conference room
1070 Hiline Road
Pocatello, ID
Region 7 3/1/2011 9 -11 A.M. MST Idaho Falls DHW Office
2nd Floor conference room
150 Shoup Ave.
Idaho Falls, ID
The Claims Options for Providers training session has been designed to instruct providers on
how to make an adjustment to a claim within claims status. Training objectives include:
How to identify when a claim can or cannot be edited
How to reverse a claim
How to copy the last claim
How to upload an attachment to a previously submitted claim
Please check the Idaho Medicaid Training Center calendar for upcoming dates by logging
into your Medicaid Training Center user profile and registering for the session in your
region. Need to register? Use the step-by-step instructions on the following pages.
MedicAide March 2011 Page 8 of 17
Step One: Registering for Provider Training
New User Registration Instructions
To enter the Idaho Medicaid Training Center, go to www.idmedicaid.com, and click on
Training in the menu on the left side of the screen. Click on the Idaho Medicaid Training
Center Information link to access the Idaho Medicaid Training User Registration link which
takes you directly to the online registration form.
Once you have accessed the Idaho Medicaid Training Center, you can easily generate your
one time user profile by selecting the New Users Click Here link located at the bottom of
the blue banner. This will take you directly to the online registration form (note that all
required fields are indicated by an asterisk).
The first time you enter the Center as a new user, you will need to register and complete a
user profile. Please complete all the fields on the registration page (see image on the next
page), including your e-mail address. The e-mail address is critical so the system can send
you training registration confirmations, upcoming training events, updated schedule
changes, and other important news regarding training. A table is provided displaying
required fields.
Idaho Medicaid Training Center User Profile Required Fields
(Asterisks Appear in Front of Each Required Field)
*First Name Required
*Last Name Required
*Access Code Required
Phone Number Not required, but should be entered
Email Address Not required, but is critical to receiving updates
*User Name Required
*Password Required
*Confirm Password Required
MedicAide March 2011 Page 9 of 17
SECURITY POLICY: Email address, phone number, and zip code are highly recommended
fields when creating your user profile. Without this information, we will be unable to help
with any request for a user name reset, forcing you to create another user profile.
If you are an Idaho State provider, you need to enter the access code ID-PROVIDER when
you create your user profile. This ensures that the training calendar and list of events,
sessions, and courses seen are for Idaho enrolled providers.
NOTE: if you use any other access code when generating your user profile, you will not
access the provider training calendar or the appropriate group of training sessions.
MedicAide March 2011 Page 10 of 17
Step Two: Using the Idaho Medicaid Training Center
How to Register for Provider Training Sessions
Once a provider has an Idaho Medicaid Training Center onetime user profile generated, they
can access the provider training calendar at any time 24/7 and self-register in upcoming
sessions. To register for any upcoming training session select the Workshops/Seminar
link seen in the banner bar at the top of the home page to see the training calendar.
The training calendar will open in a monthly view allowing you to search specific sessions.
Results will show all upcoming training for the search string entered.
In the calendar view, select any specific date to locate session links. Selecting a link will
open a class overview, objectives, details and a button to “Register” in the session.
MedicAide March 2011 Page 11 of 17
Once the details are seen, the session defaults to “I would like to register only myself”.
By selecting the button, the session is automatically placed on the
workshop/seminar list. In the following example, the session is “full”, and the provider is
placed in a holding queue and alerted if a space becomes available.
MedicAide March 2011 Page 12 of 17
The provider will
receive 6) days and (1) day out from the actual training session. If other questions arise,
please contact Regional Consultant (PRC) through the region’s mailbox or the phone
numbers noted
the newsletter.
The provider will receive automatically
Idaho Falls - May 3, 2011 Pocatello - May 4, 2011
Burley - May 5, 2011 Lewiston – May 10, 2011
Coeur d’Alene – May 11, 2011 Boise – May 17, 2011
Details in the April edition of MedicAide
The 2011 Idaho HealthCare Conference
SAVE THE DATES!
This example demonstrates why an
active work email address is critical for
the onetime user profile. If an email
changes, users can update their profile
to ensure they will receive updates.
MedicAide March 2011 Page 13 of 17
DHW Contact Information
DHW Web site www.healthandwelfare.idaho.gov
Idaho CareLine 2-1-1
1 (800) 926-2588
Medicaid Program Integrity Unit P.O. Box 83720
Boise, ID 83720-0036
Fax:
1 (208) 334-2026
Healthy Connections Regional Health Resource Coordinators
Region I
Coeur d'Alene
1 (208) 666-6766
1 (800) 299-6766
Region II
Lewiston
1 (208) 799-5088
1 (800) 799-5088
Region III
Caldwell
1 (208) 455-7244
1 (208) 642-7006
1 (800) 494-4133
Region IV
Boise
1 (208) 334-0717
1 (208) 334-0718
1 (800) 354-2574
Region V
Twin Falls
1 (208) 736-4793
1 (800) 897-4929
Region VI
Pocatello
1 (208) 235-2927
1 (800) 284-7857
Region VII
Idaho Falls
1 (208) 528-5786
1 (800) 919-9945
In Spanish
(en Español)
1 (800) 378-3385
Insurance Verification
HMS
PO Box 2894
Boise, ID 83701
1 (800) 873-5875
1 (208) 375-1132
Fax:
1 (208) 375-1134
MedicAide March 2011 Page 14 of 17
Prior Authorization Contact Information
Please use these numbers to submit prior authorization requests to Medicaid or to
communicate with Medicaid staff regarding details of prior authorization requests. For
questions regarding claims with an existing prior authorization, please call Provider Services
at 1 (866) 686-4272 to contact Molina if you have questions regarding claims with an
existing prior authorization.
DME Specialist, Medical Care
P.O. Box 83720
Boise, ID 83720-0036
1 (866) 205-7403
Fax:
1 (877) 314-8782
(Attn: DME Specialist)
Pharmacy
PO Box 83720
Boise, ID 83720-0036
1 (866) 827-9967
Fax:
1 (800) 327-5541
Therapy and Surgery PA Requests
PO Box 83720
Boise, ID 83720-0036
1 (208) 287-1148
Fax:
1 (877) 314-8779
Qualis Health
(Telephonic & Retrospective Reviews)
10700 Meridian Ave. N.
Suite 100
Seattle, WA 98133-9075
http://www.qualishealth.org/cm/idaho-medicaid
1 (800) 783-9207
Fax:
1 (800) 826-3836
1 (206) 368-2765
Preventive Health Assistance
PHA Unit
PO Box 83720
Boise, ID 83720-0009
1 (877) 364-1843
1 (208) 364-1843
Fax:
1 (877) 845-3956
Office of Mental Health and Substance Abuse
(OMHSA)
PO Box 83720
Boise, ID 83720-0036
1 (208) 334-0767
1 (866) 681-7062
Fax:
1 (888) 560-1784
Transportation
Beginning September 1, 2010, Idaho Medicaid contracted with American Medical Response
(AMR) for all non-emergency medical transportation services. Please go to
www.idahonemt.net or call 1 (877) 503-1267 for more information.
Ambulance Review
1 (800) 362-7648
1 (208) 287-1157
Fax:
1 (877) 314-8781
MedicAide March 2011 Page 15 of 17
Molina Provider and Participant Services Contact Information
Provider Services
MACS (Medicaid Automated Customer Service)
1 (866) 686-4272 1 (208) 373-1424
Provider Service Representatives Monday through Friday, 7 a.m. to 7 p.m. MT
1 (866) 686-4272 1 (208) 373-1424
E-mail [email protected] [email protected]
Mail P.O. Box 70082 Boise, ID 83707
Participant Services
MACS
(Medicaid Automated Customer Service)
1 (866) 686-4752
1 (208) 373-1432
Participant Service Representatives Monday through Friday, 7 a.m. to 7 p.m. MT
1 (866) 686-4752 1 (208) 373-1424
E-mail [email protected]
Mail – Participant Correspondence P.O. Box 70081 Boise, ID 83707
Medicaid Claims
Utilization Management/Case Management P.O. Box 70083 Boise, ID 83707
CMS 1500 Professional P.O. Box 70084 Boise, ID 83707
UB-04 Institutional P.O. Box 70085 Boise, ID 83707
UB-04 Institutional
Crossover/CMS 1500/Third Party Recovery (TPR)
P.O. Box 70086 Boise, ID 83707
Financial/ADA 2006 Dental P.O. Box 70087 Boise, ID 83707
Molina Provider Services Fax Numbers
Provider Enrollment 1 (877) 517-2041
Provider and Participant Services 1 (877) 661-0974
MedicAide March 2011 Page 16 of 17
Provider Relations Consultant (PRC) Information
Region 1 and the state of Washington
Paul McKinzie
1120 Ironwood Drive Suite 102
Coeur d’Alene, ID 83814
1 (208) 559-4793
Idaho Region Map
Region 2 and the state of Montana
Kristi Irby
1118 F Street
P.O. Box Drawer B
Lewiston, ID 83501
1 (208) 991-7138
Region 3 and the state of Oregon
Rainy Natal
3402 Franklin
Caldwell, ID 83605
1 (208) 860-4682
Region 4 and all other states
Deanna LaCombe
9415 W. Golden Trout Way
Boise, ID 83704
1 (208) 994-2476
Region 5 and the state of Nevada
Brenda Rasmussen
803 Harrison St.
Twin Falls, ID 83301
1 (208) 484-6323
Region 6 and the state of Utah
Kelsey Gudmunson
1070 Hiline Road
Pocatello, ID 83201
1 (208) 870-3997
Region 7 and the state of Wyoming
Kristi Harris
150 Shoup Avenue
Idaho Falls, ID 83402
1 (208) 991-7149
MedicAide March 2011 Page 17 of 17
Digital Edition
As part of our commitment to cost savings, we are using paperless
processes wherever possible. MedicAide is online and will be available
electronically by the fifth of each month. Our new digital edition,
posted at www.idmedicaid.com also allows links to important forms
and web sites, plus it is eco-friendly.
MedicAide is the monthly informational newsletter for Idaho Medicaid providers.
Editor: Chris Roberts, Division of Medicaid
If you have any comments or suggestions, please send them to:
Chris Roberts
DHW – Medicaid System Support Team
PO Box 83720
Boise, ID 83720-0009
Fax: (208) 364-1811
Molina Medicaid Solutions
PO Box 70082
Boise, Idaho 83707