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, August 2015 Division of Medicaid In This Issue ICD-10 Testing Opportunity Opens... 1 Medicaid Program Integrity... 1 Site of Service Differential Will Be Applied to Podiatrists Claims... 2 Intrauterine Device (IUD)... 2 Bovill Woman Sentenced for Medicaid Fraud... 2 Provider Training Opportunities in Medical Care Unit Contact and Prior Authorization Information...15 DHW Resource and Contact Information...16 Insurance Verification...16 Molina Provider and Participant Services Contact Information...17 Molina Provider Services Fax Numbers...17 Provider Relations Consultant (PRC) Information...18 Information Releases MA15-05 P&T Committee Recommendations for April and May

2 ICD-10 Testing Opportunity Opens Effective 8/3/15, ICD-10 testing will be reopened for all Trading Partners who would like to test their ICD-10 claim files (EDI submitters). The first round of testing will be offered from 8/3/15 to 8/14/15 for Trading Partners to validate their ICD-10 claim files for accurate ICD-10 format changes and accurate data in ICD-10 related fields; EDI X-12, 837 transaction testing (submission to response file). The second round of testing will be offered from 8/17/15 to 9/18/15 for trading partners to complete end-to-end testing and validate accurate claims processing and payment. Trading Partners must successfully complete their EDI validation for ICD-10 in order to participate in endto-end testing (submission to remittance advice). ALL Trading Partners who want to participate in ICD-10 testing MUST BE REGISTERED. To register, us at and include: your user ID, username (full first and last name), trading partner ID, company name, and address. To assist us in tracking registrants, please include your trading partner name in the subject line. For more information related to Medicaid and ICD-10, including additional test details, see our ICD-10 web page at Please note: Testing is specific to electronic claims submitters. Providers who submit claims directly on the Molina Medicaid provider portal or via paper are not within the scope of this testing. Medicaid Program Integrity NCCI Edits The Medicaid Program Integrity Unit wants to remind providers that claims billed to Idaho Medicaid must be in accordance with the coding policies and guidelines as defined in the American Medical Association s Current Procedural Terminology (CPT) Manual and must follow the National Correct Coding Initiative (NCCI) policy and edits Idaho Medicaid put into place on April 1, NCCI edits are a program of coding policies and edits established by the Centers for Medicare and Medicaid (CMS) services, and have been used by the Medicare program since January of 1996 to ensure accurate coding and reporting of services. The NCCI edits are based on coding policies and conventions defined in the American Medical Association s Current Procedural Terminology (CPT) Manual, national Medicare policies, coding guidelines developed by national societies, standard medical and surgical practices, and current coding practices. NCCI edits include HCPCS/CPT code pairs that should not be submitted together as well as units of service that are medically unlikely edits (MUEs). These edits apply to claims that include the same provider, same participant, and the same date of service. MedicAide August 2015 Page 1 of 19

3 Site of Service Differential Will Be Applied to Podiatrists Claims Effective for dates of service on or after September 1, 2015, Idaho Medicaid will begin paying podiatry providers 70% of the rate on file, to account for the site of service differential, for claims billed with place of service 21, 22, 23, 24, 25, 31, 51, 52, 61, or 62. All other podiatry claims will continue to pay according to the Medicaid fee schedule. Please check the website for the current rate on file. Medicaid Fee Schedule If you have any questions, please contact Lourie Neal, Senior Financial Specialist at the Office of Reimbursement: 1 (208) Intrauterine Device (IUD) Effective August 1, 2015, an IUD insertion may be billed when performed immediately after a delivery or C-section, as well as in the office. The physician, not the hospital, must bill for the IUD. Include the following on the claim: IUD J code (J7300 J7303) and its NDC (National Drug Code) Procedure code with the FP modifier (family planning) Diagnosis V25.11 (prior to 10/1/2015) or Z (10/1/2015 and after) For additional information regarding family planning, see the Family Planning section of the Allopathic and Osteopathic Physicians handbook at Bovill Woman Sentenced for Medicaid Fraud (Boise) Bovill resident, Pamela Jean Lockman, has been sentenced on one count of Provider Fraud, Attorney General Lawrence Wasden announced today. Second District Judge John Stegner sentenced Lockman to one to five years in prison. The court suspended the prison sentence and ordered her to serve 30 days in jail. She was placed on probation for three years and ordered to reimburse the Idaho Department of Health and Welfare, $3,920 and reimburse the Attorney General s Office $232 for investigative costs. Lockman, 52, pleaded guilty on May 18, 2015, to one count of provider fraud, a felony. Additional counts were dismissed pursuant to a plea agreement. (Continued on page 3) MedicAide August 2015 Page 2 of 19

4 (Bovill Woman Sentenced Cont d) Lockman was a non-emergency transportation provider from 1997 through Her business was driving Medicaid recipients to and from medical appointments. The Attorney General s Medicaid Fraud Control Unit investigation revealed that, for the year 2010, Lockman submitted claims for driving 17,020 miles on dates where her clients had no corresponding medical services. In addition, for dates where corresponding medical services were found, Lockman overbilled 22,186 miles for the miles it would have actually taken to complete a round-trip between the clients homes and the appointment. The Medicaid Program Integrity Unit previously terminated Lockman from the Medicaid program for billing another $15,308 for undocumented/non-covered services in The case was initially investigated by the Medicaid Integrity Unit and then referred to the Attorney General s Medicaid Fraud Unit. Bill Thompson, Latah County Prosecutor appointed the Attorney General s Office to prosecute the case. The prosecution was handled by Deputy Attorney General Laura Perkovic. MedicAide August 2015 Page 3 of 19

5 Figure 1: MA15-05 P&T Committee Recommendations for April and May 2015 MedicAide August 2015 Page 4 of 19

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15 Provider Training Opportunities in 2015 You are invited to attend the following webinars offered by Molina Medicaid Solutions Regional Provider Relations Consultants. August: Eligibility This course is designed to instruct primary care physicians on how to determine eligibility. 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. 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 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 18 of this newsletter. MedicAide August 2015 Page 14 of 19

16 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 August 2015 Page 15 of 19

17 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 August 2015 Page 16 of 19

18 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 Boise, ID (866) (208) (866) (208) idparticipantservices@molinahealthcare.com P.O. Box Boise, ID P.O. Box Boise, ID P.O. Box Boise, ID P.O. Box Boise, ID P.O. Box Boise, ID P.O. Box Boise, ID Molina Provider Services Fax Numbers Provider Enrollment 1 (877) Provider and Participant Services 1 (877) MedicAide August 2015 Page 17 of 19

19 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 August 2015 Page 18 of 19

20 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 August 2015 Page 19 of 19