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In This Issue
CMS Announces Compliance Deadline for ICD-10 ......................................................................... 1 Medicaid Program Integrity ....................................................................................................... 1 Kuna Resident Sentenced for Medicaid Fraud ............................................................................... 2 Idaho Falls Woman Sentenced for Medicaid Fraud ........................................................................ 2 Site of Service Differential Will Be Applied to ............................................................................... 3 Mid-Level Providers’ Claims ....................................................................................................... 3 Save the Date – Fall Workshops ................................................................................................. 3 It’s PERM Time Again ................................................................................................................ 4 Provider Training Opportunities in 2014 ...................................................................................... 7 Medical Care Unit Contact and Prior Authorization Information ....................................................... 8 DHW Resource and Contact Information ..................................................................................... 9 Insurance Verification ............................................................................................................... 9 Molina Provider and Participant Services Contact Information .......................................................10 Molina Provider Services Fax Numbers .......................................................................................10 Provider Relations Consultant (PRC) Information .........................................................................11
Information Releases
MA14-09 Swing Bed and AND Rates ........................................................................................... 6
An Informational Newsletter for Idaho Medicaid Providers
From the Idaho Department of Health and Welfare, September 2014
Division of Medicaid
MedicAide September 2014 Page 1 of 12
CMS Announces Compliance Deadline for ICD-10 The U.S. Department of Health and Human Services (HHS) issued a rule finalizing October 1, 2015 as the new compliance date for health care providers, health plans, and health care clearinghouses to transition to ICD-10, the tenth revision of the International Classification of Diseases. This deadline allows providers, insurance companies, and others in the health care industry time to ramp up their operations to ensure their systems and business processes are ready to go on October 1, 2015. For more information on the rule, view the press release at http://www.cms.gov/Newsroom/MediaReleaseDatabase/Press-releases/2014-Press-releases-items/2014-07-31.html.
Medicaid Program Integrity
Respite Services
The following information applies to respite services under the Children’s Home and Community Based Settings (HCBS) State Plan Option. Respite services provide supervision to a child on an intermittent or short-term basis because of the need for relief of the primary unpaid caregiver, and cannot be provided at the same time other Medicaid services are being provided. Respite may be provided by a certified Developmental Disability Agency (DDA), or by an independent respite provider. An independent respite provider is an individual who has entered into a provider agreement with the Department. Independent respite providers may provide respite in the child’s home, the private home of the respite provider, or the community. Group or center based respite cannot be provided by an independent respite provider. Group respite services provided by a DDA must adhere to the following:
• When group respite is center-based, there must be a minimum of one qualified staff to every six participants.
• When group respite is community-based, there must be a minimum of one qualified staff providing direct services to every three participants.
IDAPA 16.03.10.664.01 outlines documentation requirements for both independent respite providers and DDAs providing respite services. Documentation must include:
• Date and time of visit • Intervention and support service provided • Statement of participant’s response to the service • Length of visit, to include time in and time out • Specific place of service
The Department will recover overpayments and may assess civil monetary penalties from providers for respite service provided contrary to rule, terms of the provider agreement and/or the provider handbook.
MedicAide September 2014 Page 2 of 12
Kuna Resident Sentenced for Medicaid Fraud On July 21st, Kuna resident Johnna Martinez was sentenced for defrauding the Idaho Medicaid program. Judge Deborah A. Bail placed Martinez on probation for five years and ordered 90 days of house arrest and $12,390 in restitution to the Idaho Department of Health and Welfare. Martinez had a contract with Health and Welfare to care for her daughter in Martinez’s home. However, Martinez submitted claims to Medicaid over a year and a half period for payment for days when her daughter was not in the home and could not have received care. Martinez also submitted claims for when she was in Mexico and could not have cared for her daughter who stayed behind in Idaho. On May 23, 2014, a jury found Martinez guilty of provider fraud, computer crime and grand theft after one hour of deliberation and three and a half days of testimony. The case was investigated by the Attorney General Lawrence Wasden’s Medicaid Fraud Control Unit and the U.S. Dept. of Health and Human Services, Office of Inspector General. Ada County Prosecutor Greg Bower appointed Deputy Attorney General Kendal McDevitt to prosecute the case as a Special Ada County Prosecutor.
Idaho Falls Woman Sentenced for Medicaid Fraud (Boise) – Robin Villarreal-Ratcliff, of Idaho Falls, has been sentenced for using a computer to submit fraudulent claims for Medicaid services, Attorney General Wasden announced today. Seventh Judicial District Judge Jon Shindurling gave Villarreal-Ratcliff a withheld judgment and placed her on probation for four years. The judge also ordered 53-year-old Villarreal-Ratcliff to pay $2,889 in combined restitution to the Idaho Department of Health & Welfare and the Attorney General's Office for investigative costs. She must also pay the additional court fines and costs. On June 2, 2014, Villarreal-Ratcliff was found guilty after entering an "Alford plea," thereby admitting that the State has sufficient evidence that a jury would likely find her guilty. The plea covers one felony count of a Computer Crime. Villarreal-Ratcliff operated a family alternative care home that provided personal care services (PCS) in Idaho Falls. During the time period of February 2011 to March 2012, Villarreal-Ratcliff billed Medicaid for providing personal care services to two Medicaid recipients who were children when those services were not actually provided by her, because she was vacationing in Costa Rica; Seattle, Washington; Pensacola, Florida; and Lihue, Hawaii. The Attorney General's Office was appointed as special prosecutor at the request of Bonneville County Prosecuting Attorney Bruce Pickett. The case was prosecuted by Deputy Attorney General Laura Perkovic.
MedicAide September 2014 Page 3 of 12
Site of Service Differential Will Be Applied to Mid-Level Providers’ Claims
Effective for dates of service on or after September 1, 2014, Idaho Medicaid will begin paying mid-level providers 60% 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, 62, or 72. All other mid-level claims will continue to pay at the rate of 85% of the rate on file as instructed in the Provider Handbook. Please check the website for the current rate on file. Provider Handbook https://www.idmedicaid.com/Provider%20Guide/Provider%20Handbook.aspx Medicaid Fee Schedule http://healthandwelfare.idaho.gov/Providers/MedicaidProviders/MedicaidFeeSchedule If you have any questions, please contact Lourie Neal, Senior Financial Specialist at the Office of Reimbursement: 1 (208) 287-1162.
Save the Date – Fall Workshops Fall workshops will be held in Coeur d’Alene on October 10 and in Caldwell on October 16. The workshops will guide Long Term Care providers, Residential Assisted Living Facilities, and Certified Family Homes through Trading Partner Account functionality for the following topics.
• Long Term Care (LTC) Providers o LTC case submissions, including admissions and discharges o ICF/ID Preadmission o Uploading, faxing, and mailing supporting documentation o LTC case statuses o Checking eligibility
• Residential Assisted Living Facilities (RALFs) and Certified Family Homes (CFHs)
o Trading Partner Account registration o Prior authorizations o Patient rosters o Checking eligibility o Claim submission o Remittance advice
Additional details and the registration link will be available soon through the Idaho Medicaid Training Center at www.idmedicaid.com. To register for a training account, visit www.idmedicaid.com, click on the Training link, and click on Idaho Medicaid Training Center Registration.
MedicAide September 2014 Page 4 of 12
It’s PERM Time Again The Improper Payments Information Act of 2002 directs federal agency heads, in accordance with the Office of Management and Budget (OMB) guidance, to annually review its programs that are susceptible to significant erroneous payments and report the improper payment estimates to Congress. The OMB identified the Medicaid and the State Children’s Health Insurance Program (SCHIP) as programs at risk for significant erroneous payments. The Centers for Medicare and Medicaid Services (CMS) measures the accuracy of Medicaid and SCHIP payments made by States for services rendered to participants through the Payment Error Rate Measurement (PERM) program. Under the PERM program, CMS uses two national contractors to measure improper payments in Medicaid and SCHIP; a Review Contractor (RC) and a Statistical Contractor (SC). Provider interactions in this process will be primarily with the RC, A+ Government Solutions, who will collect medical records from providers either in hardcopy or electronic format. The RC will collect medical records which are needed to support medical reviews for PERM on the fee-for-service Medicaid and SCHIP claims to determine if the claims were correctly paid. If a claim is selected in a sample for a service that a provider rendered to either a Medicaid or SCHIP recipient, the RC will contact that provider for a copy of the required medical records to support the medical review of the claim. These contacts will begin in early 2015 for claims processed between 10/1/2014 and 9/30/2015. In order to obtain medical records for a claim sampled for review, the RC will contact providers to verify the correct name and address information and to determine how they want to receive the request (i.e., facsimile or U.S. mail) for medical records. Remember to keep your provider address, phone number, and contact information current in the Medicaid system. Any needed changes should be requested immediately so the medical records requests are received and responded to timely. Refer to Section 2.2.3.1., General Provider and Participant Information, of the provider handbook for information on how to request provider file updates. Once the provider receives the request for medical records, the information must be submitted electronically or in hard copy within 75 calendar days. Please note that it is the responsibility of the provider to ensure that any and all supporting medical records, from any and all provider(s) who rendered a service for which the claim payment under review was requested, is submitted in a timely manner. During this 75 day timeframe, the RC and State officials will follow up to ensure that providers submit the documentation before the timeframe has expired. For reviews that require extra information, the RC will contact providers for additional documentation. Providers will then have 14 calendar days to respond to the request for additional documentation. Understandably, providers are concerned with maintaining the privacy of patient information. However, providers are required by Section 1902(a)(27) of the Social Security Act to retain records necessary to disclose the extent of services provided to individuals receiving assistance and furnish CMS, their contractor or State officials with information regarding any payments claimed by the provider for rendering services. The furnishing of information includes medical records. As for SCHIP, section 2107(b)(1) of the Act requires an SCHIP State plan to provide assurances to the Secretary that the State will collect and provide to the Secretary any information required to enable the Secretary to monitor program administration and compliance and to evaluate and compare the effectiveness of States’ SCHIP plans. (Continued on page 5)
MedicAide September 2014 Page 5 of 12
It’s PERM Time Again (Cont’d) In addition, the collection and review of protected health information contained in individual-level medical records for payment review purposes is permissible by the Health Insurance Portability and Accountability Act of 1996 (HIPAA) and implementing regulations at 45 Code of Federal Regulations, parts 160 and 164. It is important that providers cooperate with submitting all requested documentations in a timely manner. No response or insufficient documentation will count against the State as an error and recovery of the overpayment from the provider. Past studies have shown that the largest cause of error in medical reviews is no documentation or insufficient documentation. As such, it is important that information be sent in a timely and complete manner. Detailed information regarding the PERM program requirements is available on-line at http://healthandwelfare.idaho.gov/Default.aspx?tabid=214. If you have any questions about this matter, please contact your State PERM Contact, Billie Schell-Ruby, at 1 (208) 332-7977 or [email protected]. Thank you for your support of the PERM program.
MedicAide September 2014 Page 6 of 12
Figure 0-1: MA14-09 Swing Bed and AND Rates
MedicAide September 2014 Page 7 of 12
Provider Training Opportunities in 2014 You are invited to attend the following webinars offered by Molina Medicaid Solutions Regional Provider Relations Consultants.
September: 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 www.idmedicaid.com and click on the Training link in the left-hand menu.
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 11 of this newsletter.
10 a.m. - 11 a.m. MT
10 a.m. - 11 a.m. MT
10 a.m. - 11 a.m. MT
10 a.m. - 11 a.m. MT
2 p.m. - 3 p.m. MT
2 p.m. - 3 p.m. MT
2 p.m. - 3 p.m. MT
SeptemberReferrals
9/17/2014 9/18/2014 9/10/2014 9/16/2014 9/18/2014 9/16/2014 9/11/2014
OctoberEligibility
10/15/2014 10/16/2014 10/8/2014 10/21/2014 10/16/2014 10/21/2014 10/9/2014
NovemberEligibility
11/19/2014 11/20/2014 11/12/2014 11/18/2014 11/20/2014 11/18/2014 11/13/2014
DecemberClaims Adjustments
12/17/2014 12/18/2014 12/10/2014 12/16/2014 12/18/2014 12/16/2014 12/11/2014
MedicAide September 2014 Page 8 of 12
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 www.medunit.dhw.idaho.gov. Prior authorization request forms containing the “fax to” number can be found at www.idmedicaid.com. 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 83720 Boise, ID 83720-0009
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 www.idmedicaid.com. 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 www.idmedicaid.com. To speak to a Molina Medicaid Solutions representative, call 1 (866) 686-4272, 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) 314-8779 1 (208) 364-1830 Ambulance* 1 (877) 314-8781 1 (800) 362-7648 Breast & Cervical Cancer 1 (877) 314-8779 1 (208) 364-1839 Durable Medical Equipment 1 (877) 314-8782 1 (866) 205-7403 Hospice 1 (877) 314-8779 1 (208) 364-1904 Pharmacy 1 (800) 327-5541 1 (866) 827-9967 Preventive Health Assistance 1 (877) 845-3956 1 (208) 364-1843 Service Coordination 1 (877) 314-8779 1 (208) 364-1904 Surgery-Procedure-Lab 1 (877) 314-8779 1 (208) 287-1148 Therapy: OT, PT, SLP 1 (877) 314-8779 1 (208) 364-1904 Vision 1 (877) 314-8779 1 (208) 364-1904
* Idaho Medicaid contracts with American Medical Response (AMR) for all non-emergency medical transportation services. Please go to www.idahonemt.net or call 1 (877) 503-1261 for more information.
MedicAide September 2014 Page 9 of 12
DHW Resource and 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 [email protected] Fax: 1 (208) 334-2026
Qualis Health 1 (800) 783-9207 Fax: 1 (800) 826-3836 http://www.qualishealth.org/healthcare-professionals/idaho-medicaid
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 September 2014 Page 10 of 12
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 70084 Boise, ID 83707
CMS 1500 Professional P.O. Box 70084 Boise, ID 83707
UB-04 Institutional P.O. Box 70084 Boise, ID 83707
UB-04 Institutional Crossover/CMS 1500/Third-Party Recovery (TPR)
P.O. Box 70084 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 September 2014 Page 11 of 12
Provider Relations Consultant (PRC) Information
Region 1 and the state of Washington Robert Hughes 1120 Ironwood Drive Suite 102 Coeur d’Alene, ID 83814 1 (208) 559-4793 [email protected]
Region 2 and the state of Montana Kristi Irby 1118 F Street P.O. Box Drawer B Lewiston, ID 83501 1 (208) 991-7138 [email protected]
Region 3 and the state of Oregon Rainy Natal 3402 Franklin Caldwell, ID 83605 1 (208) 860-4682 [email protected]
Region 4 and all other states 1720 Westgate Drive, Suite A Boise, ID 83704 1 (208) 373-1343 [email protected]
Region 5 and the state of Nevada Brenda Rasmussen 601 Poleline Road, Suite 7 Twin Falls, ID 83301 1 (208) 484-6323 [email protected]
Region 6 and the state of Utah Kelsey Gudmunson 1070 Hiline Road Pocatello, ID 83201 1 (208) 870-3997 [email protected]
Region 7 and the state of Wyoming Kristi Harris 150 Shoup Avenue Idaho Falls, ID 83402 1 (208) 991-7149 [email protected]
MedicAide September 2014 Page 12 of 12
Digital Edition MedicAide is available online by the fifth of each month at www.idmedicaid.com. 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) 686-4272.
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, [email protected] Shannon Tolman, [email protected]
Medicaid - Communications Team P.O. Box 83720
Boise, ID 83720-0009 Fax: 1 (208) 364-1811
Molina Medicaid Solutions PO Box 70082 Boise, Idaho 83707
