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Idmedicaid.comIn this issue:
Transition Dates . 1 An informational newsletter for Idaho Medicaid Providers
Welcome from Molina/Unisys . 3 From the Idaho Department of Health and Welfare, Division of Medicaid
Trading Partner Registration Open! . 4 Enrolled in New MMIS? . 5 Submitting Claims During Holdback . 6 Idaho Transition Dates to Remember
HC Providers—Lead Screening Survey . 6 On June 7, 2010, the new MMIS, operated by Unisys (now Molina Medicaid
Reduce Reimbursement Services), will begin processing of all claims except Pharmacy Point of Service Time and Errors with (POS). During May and June there are several key dates you need to be Electronic Billing . 6 aware of. We have outlined these dates below: Electronic Payments . 7 Print & Sign W-9 . 7 May 1st – All new provider applications processed by Molina/Unisys. New
Existing PCP Referrals in provider applications are available on the provider portal at . the New MMIS . 7 Idaho Health Care May 6th and 7th – Provider Training in Nampa for Treasure Valley
Provider Workshops . 9 Sending Paper Claims . 10 May 10th and 11th – Provider Training in Idaho Falls in conjunction
Which Claim Forms? . 10 with the Idaho Health Care Conference (IHCC). Medicaid Administrator May 12th – Provider Training in Pocatello in conjunction with the
Changes: Interpretive Idaho Health Care Conference (IHCC). Services Billing . 11 State Your Case . 11 May 13th and 14th – Provider Training in Burley in conjunction with
Preventive Health the Idaho Health Care Conference (IHCC). Assistance for Wellness 12 PCS Providers . 12 May 17th and 18th – Provider Training in Lewiston in conjunction
Medicaid Program Integrity with the Idaho Health Care Conference (IHCC). - Transportation . 13 Updated Notification of May 19th and 20th – Provider Training in Coeur d'Alene in
Birth Form . 13-14 conjunction with the Idaho Health Care Conference (IHCC). New Provider Portal . 15 DHW Office Closure . 20 Additional class and registration information is available online today
Digital Edition . 20 under the Training Dates link.
May 21st – Molina/Unisys will begin processing paper claims. Paper claims
can be mailed to either HP/EDS or Molina/Unisys through June 3rd. After
June 3rd paper claims must be sent to Molina/Unisys. Paper claim
mailing instructions are on page 10 of this newsletter.
May 22nd – 30th – The new provider portal will not be available for record
updates, maintenance, new applications, trading partner registration or inquiry
in preparation for go live June 7th.
Distributed by the
Division of Medicaid
Health and Welfare
(Continued on page 2) MedicAide May 2010
(Continued from page 1) Information
May 27th – Provider Training in Boise in conjunction with the
DHW Web site
Idaho Health Care Conference (IHCC). Additional class and registration information is available online today at under the Training Dates link.
June 3rd at Midnight – Last time HP/EDS will accept electronic claims for
Toll free: (800) 926-2588 processing and electronic claim status requests. Any claims received after midnight will be rejected and must be resubmitted to Molina/Unisys on or Medicaid Program
Boise, ID 83720-0036 June 4th –
Fax:(208) 334-2026 HP/EDS will process electronic claims received before midnight on All claims, which have been accepted into the system as of midnight Healthy Connections
June 3rd, except nursing home and hospital claims subject to the Regional Health
budget holdbacks, will be paid or denied on June 4th and reported on Resources
the remittance advice (RA) dated June 7th. Nursing home and hospital claims denied June 4th will be reported on the June 7th RA. Region I
Denied claims that can be resubmitted should be sent to Molina/ Coeur d'Alene
Unisys for processing on or after June 7th. As of 5 PM, Molina/Unisys assumes the Eligibility Benefit Inquiry and
Response electronic transaction (270/271). Region II - Lewiston
Nursing home and hospital claims will continue to be subject to the budget holdbacks for claim payment. Providers subject to the budget holdback claims will get a report to verify the status of held claims. Payment for claims processed in June by HP/EDS will be reported on Region III - Caldwell
the HP/EDS RA dated July 5th. June 7th –
Region IV - Boise
Molina/Unisys is responsible for all provider and member services. This includes medical and dental claims and all other electronic All paper claims submitted on or after May 21st will be reported on Region V - Twin Falls
the Molina/Unisys RA. HP/EDS RAs for the week of June 4th will be available to providers. Nursing home and hospital claims impacted by the budget holdbacks Region VI - Pocatello
will not be reported on this RA. A report of held payments for nursing homes and hospitals will be sent to providers in addition to this RA. Region VII
July 1st – July 6th – Claim payments held due to the budget holdbacks will
be released to pay along with paper RAs. Nursing home and hospital providers should expect to receive four separate RAs the week of July 6th. In Spanish (en
July 3rd – HP/EDS posts electronic RA (835 transaction) from budget
July 9th – Last day to retrieve RAs (835 transaction) from HP/EDS.
Welcome from Molina/Unisys
For the past two and a half years, we've worked in partnership with the Boise, ID 83720-0036 Idaho Department of Health and Welfare, Division of Medicaid (DHW), First Health and Thomson Reuters to implement the new Medicaid Management Fax: (800) 352-6044 Information System (MMIS). We are anticipating implementation of this new (Attn: DME Specialist) system on June 7, 2010.
In order to assure success we are heavily reliant on you, our providers, to make sure you are enrolled and approved as a provider in the new MMIS. Boise, ID 83720-0036 (866) 827-9967 Providers who wish to submit claims and receive payment after June 7th ,
must complete the Provider Record Update (PRU) process. If you have not completed your record update and received approval, or are not sure of your status, log on to the secure portal at or call Idaho Qualis Health
Medicaid Provider Enrollment at (866) 686-4272. Our specialists are standing by ready to help you with this critical task. Retrospective Reviews) 10700 Meridian Ave. N. We are confident that the new MMIS will be an innovative solution that Seattle, WA 98133-9075 meets the growing needs of providers and participants alike. While we know there will be challenges during the implementation of the new MMIS, we are working hard to make this transition as smooth as possible for everyone. After June 7th, Molina/Unisys will take over administration of the MMIS
claims processing system. This covers all claims processing except pharmacy point of service (POS) claims. POS claims will continue to be supported by First Health who went live in February, and state analytics, the decision support system provided by Thomson Routers. Molina/Unisys and First Developmental
Health will also be responsible for provider training, billing instructions and Disability and Mental
operational support. (800) 296-0509, #1172 Molina/Molina/Unisys will continue to have Provider Regional Consultants (PRCs) located throughout the state to assist you with non-point of sale claims. I'm pleased to announce you will be familiar with several of our new Other Non-emergent PRCs who came to us with extensive Idaho Medicaid experience from their
(800) 296-0509, #1173 We look forward to beginning a long and successful partnership with the Idaho provider community. Ambulance Review
We also want to make you aware of a recent change that will effect the business name you see and hear from our operational staff going forward. On May 1, 2010, Molina Healthcare acquired the Molina/Unisys Health Information Management division, which is responsible for supporting the Idaho Medicaid program. Although there will be a transition period for our Insurance
business name, there will be no change or disruption in the support you receive. You will continue to use the same contact information and interact with the same local staff as you would have prior to the sale. Our new business name is Molina Medicaid Solutions. We apologize for any confusion this may cause and appreciate your patience as we make this business name transition over the next few weeks. (800) 873-5875 (208) 375-1132 Del Bell, Molina/Unisys Account Manager MedicAide May 2010
From Provider to Partner, Trading Partner
Registration Open Now!
If you have completed your Provider Record Update and received an approval letter, you are ready to enroll as a trading partner in the new MMIS! Correspondence
PO Box 70082
Boise, ID 83707 Trading partner registration is available on the new provider portal at . The registration process is quick and simple, and you Medicaid Claims
will receive an immediate answer to your request. Utilization
Providers who plan to do any of the following electronically must become a
trading partner. Submit claims Check member eligibility CMS 1500
PO Box 70084
Check claim status Prior authorizations Healthy Connections referrals Access online reports such as your remittance advice (RA) and Healthy PO Box 70085 Boise, ID 83707 Connections rosters Your new trading partner agreement will replace any established Electronic Crossover/CMS 1500
Claims Submission Certification and Authorization you have currently in effect Crossover/Third Party
with the implementation of the new claim processing system. Choosing the Correct Trading Partner Entity Type
The following descriptions will help you choose the correct trading partner Financial/ADA 2008
PO Box 70087
entity type before you begin your enrollment. Provider
Providers are entities that have contracted with Idaho Medicaid to perform Fax Numbers
healthcare and other Medicaid related services. You do not have to be a Provider Enrollment
physician to be considered a provider of Medicaid services. (208) 395-2198
Clearinghouses are organizations that typically combine EDI transactions from Provider Services
multiple providers, billing agencies, and other health plans for routing and submission to the appropriate processing entity. Clearinghouses then receive, split, and route the EDI responses to the appropriate originating entity. Clearinghouses typically do not perform medical coding services; however, Assistance Line
they often perform EDI translation services. Molina/Unisys –
Billing agencies prepare and submit claims to Idaho Medicaid on behalf of Record Update
Idaho Medicaid providers. To register, a billing agency must have at least one Phone
Idaho Medicaid provider for whom they perform billing services. If the billing agency bundles claims from multiple providers and submits claims to Idaho Friday, 7 am to 7 pm MT Medicaid through a clearinghouse, the billing agency is not required to register Toll Free (866) 686-4272 as a trading partner. In Boise (208) 373-1424 Software Vendor
Software vendors are application developers that market their product to Medicaid providers. Software vendors will not be required or allowed to register as a trading partner with Idaho Medicaid, but will be able to test their billing software through a registered Idaho Medicaid provider. This helps maintain HIPAA standards and Trading Partner Agreement requirements. Boise, ID 83707 (Continued on page 5) 4 MedicAide
(Continued from page 4) Information
Internal user is reserved for State and Molina/Unisys staff use only. If you feel MAVIS
that you may need access as an internal user, please send an email to for confirmation. Business Associate
Business associates are third party vendors that already have a HIPAA Business Associate agreement on file with the Idaho Department of Health and Boise, ID 83707 Welfare. This entity type is primarily reserved for Prior Authorization approving Medicaid Claims
Boise, ID 83707 What's Next
A testing and certification process must be completed before you are certified
PCS & ResHab Claims
to submit electronic transactions. This is a separate process and more details about the testing process will be available soon. Boise, ID 83707 Are you currently using PES to submit your claims and complete eligibility Fax Numbers
verifications? In the new claim processing system you will complete these same functions on the provider portal through our Direct Data Entry (DDE) Provider Services
process. Providers who choose the DDE option are not required to complete a testing process, but still need to register as a trading partner to gain access to the secure portion of the provider portal. Participant Assistance
Molina/Unisys is available to provide assistance during the registration and certification process. You can contact Molina/Unisys help desk at or Molina/Unisys Provider Enrollment at (866) Are You Enrolled in the New MMIS?
Completing your Provider Record Update (PRU) is the foundation for successful claims
processing. To ensure Molina/Unisys receives your record update application, click the
Submit button when all information is complete. The Submit button is in the bottom right
corner of the Documentation screen in the online port.
We understand that provider enrollment takes time. But it's vitally important that your
enrollment is accurate. Occasionally, there is missing or outdated documentation in a
provider's record. When that happens, we will call you to request this critical information.
Please take the time to send in the missing information as soon as possible to ensure
your record is complete.
Hopefully, you completed and submitted your record update on or before May 7, 2010. If
you haven't, we will continue to accept provider record updates through June 30th.
Please be aware your claims cannot be processed or paid until your application has been
processed and approved by Molina/Unisys and you have signed up as a Trading Partner.
Not sure what PRU is? Frequently Asked Questions (FAQs) and other valuable
information is available onli under the Provider tab.
MedicAide May 2010
Confused About Submitting Claims During the
Payment Holdback Period?
Many providers have asked if they should stop submitting claims once the Region 1
claim payment holdback period begins. It is important for you to continue
submitting your claims during the holdback period.
1120 Ironwood Dr. Coeur d'Alene, ID 83814 The new MMIS, administered by Molina/Unisys, will be up and fully functional to support the Medicaid program. Use this time to submit all transactions required to support your claims processing so you can work through any Fax: (208) 666-6856 transitional issues that may arise.
Attention Healthy Connections Providers – Lead
PO Drawer B Lewiston, ID 83501 Screening Survey
Fax: (208) 799-5167 Medicaid and the Department of Nursing at Boise State University would like
your opinions on lead screening. The Department of Nursing has awarded a grant to Dr Ingrid Brudenell, Karen Godard, RN, CRNP, MSN and Dr. Omair Shamim, Health and Nutrition Services Manager for Friends of Children Caldwell, ID 83605 and Families, Early Head Start and Head Start to assess health care providers' perception of barriers, facilitators, and best practices for lead screening of Fax: (208) 454-7625 children enrolled in Medicaid. Please look for a short survey that will be Region 4
included with your Healthy Connections enrollment mailing in May. Please return the completed survey to the researchers. We greatly appreciate your 1720 Westgate Drive, # A feedback and ideas. If you have questions, please contact Dr. Ingrid Brudenell, at 208-426-1670 or e-mail . Fax: (208) 334-0953
Reduce Reimbursement Time and Errors with
601 Poleline, Suite 3 Twin Falls, ID 83303 Idaho Medicaid encourages all providers to bill electronically either by Fax: (208) 736-2116 uploading the HIPAA 837 using online file exchange, or by entering claims Region 6
directly into the online provider portal using the Direct Data Entry (DDE) option at . Either way, the process is more accurate and 1070 Hiline Road payments are much faster and more secure than submitting paper claims Pocatello, ID 83201 through the postal system. Here are just a few of the advantages: (208) 239-6268 Fax: Electronic Forms Submissions
Claim data is immediately validated for HIPAA compliancy allowing submitter to correct and resubmit the claim information 150 Shoup Avenue Claim Reversal/Replacement transactions and coordination of benefit Idaho Falls, ID 83402 (COB) amounts no longer require paper attachments Fax: (208) 528-5756 Direct Data Entry
Providers, members, and service codes are immediately validated The system will complete a trial adjudication of the claim to validate relational claim data Providers may immediately correct, save, and re-submit claims Claim attachments (such as authorization forms) may be uploaded
Don't Delay – Enroll Today!
If you have never submitted claims electronically, please contact the Technical Services Help Desk today at (866) 686-4272 to get started. You may also enroll at . Select the Provider tab and then the
Register link in the Trading Partner Sign In box. It's that easy!
Get Your Payments Electronically
Help us help you! In order to complete your Electronic Funds Transfer (EFT) Agreement, you must include a copy of a voided check, along with the dated and signed Authorization form.
If you do not have a copy of a voided check or you are registering a savings account for EFT, you will
need to have your bank issue a statement verifying the Transit ABA number and account number. And remember, whether you fax, mail or e-mail, please put your case number on each page. Questions? Call us at (866)-686-4272. Print and Sign That W-9
Most provider record update and new application forms allow electronic signatures – but the W-9 must be printed, signed and returned via mail, fax, or scan-to-e-mail. During your record update or new application you can scan-to-upload the W-9 form.
Need a W-9 Form?
See the navigation box on the left?
Click Forms and follow the link to Supplemental Agreements.
Click Supplemental Agreements and you will find a list of forms, including a W-9.
Existing Primary Care Provider (PCP)
Referrals in the New MMIS
With the transition to the new MMIS, the Division of Medicaid recognizes there will be challenges in transitioning from the old system to the new system. One particular area of concern the Division has recognized is in the area of Healthy Connections referrals. Three specific areas of concern are: There are no existing referrals in the current system to convert for future claims processing The new MMIS will require PCP's to enter referrals within the new system, rather than including the Healthy Connections referral number on the claim The new MMIS will not be available prior to full implementation to enter referrals ahead of claims Given these concerns, the Division has approved a transition approach for referrals to allow providers to get claims paid while also beginning to enter and exchange referrals for future claims. The new MMIS initially will not edit claims for referrals that were authorized prior to implementation of the system. Until
further notice, DO NOT include an HC referral number on claims submitted to Molina/Unisys on or after
June 7, 2010, regardless of the date services were rendered. The Division will continue to:
Require that providers give and receive referrals Require PCP's begin entering new referrals into the new MMIS at go live Require all providers maintain proof of a referral and provide that proof in case of an audit Any service provided without documented proof of a referral could be subject to recoupment. As the numbers of pre-implementation referrals expire, referral payment edits will be phased in. Specific instructions by referral type will be provided well in advance of edits being activated. We appreciate your support with the implementation of the new system and hope this provides you with the necessary transition period to get your referral information entered in the new system. Should you have any questions, please contact your Healthy Connections Representative. MedicAide May 2010
Idaho Health Care Conference 2010
There are two separate provider workshops occurring in May. The Idaho Department of Health and Welfare (DHW) along with the following sponsors is hosting the 2010 Idaho Health Care Conference (IHCC) in several cities throughout the state. Registration starts at 8 a.m. - Classes begin at 8:30 a.m.
Please contact via e-mail: Idaho Falls
Tuesday, May 11, 2010
Wednesday, May 12, 2010
8 a.m. to 4 p.m. 8 a.m. to 4 p.m. Red Lion on the Falls 475 River Parkway - Idaho Falls, ID 1399 Bench Road - Pocatello, ID Please pre-register by: May 3, 2010
Please pre-register by: May 4, 2010
Thursday, May 13, 2010
Tuesday, May 18, 2010
8 a.m. to 4 p.m. 8 a.m. to 4 p.m. Best Western Inn & Convention Center 800 N. Overland Avenue - Burley, ID 621 21st Street – Lewiston, ID Please pre-register by: May 5, 2010
Please pre-register by: May 11, 2010
Wednesday, May 19, 2010
Thursday May 27, 2010
8 a.m. to 4 p.m. 8 a.m. to 4 p.m. Best Western Conference Center Holiday Inn Airport 506 W. Appleway – Coeur d'Alene, ID 3300 Vista Avenue – Boise, ID Please pre-register by: May 12, 2010
Please pre-register by: May 20, 2010
Conference sponsors include the Idaho Department of Health and Welfare - Division of Medicaid, Molina/ Unisys, Blue Cross of Idaho, CIGNA, First Choice Health, Humana Inc., the Idaho State Insurance Fund, Regence BlueShield of Idaho, and TriWest Healthcare Alliance. 8 MedicAide
Detailed Provider Training Workshops
Additionally, Molina/Unisys is hosting detailed provider training sessions on separate days. There are
four classes presented each day. Each class will explore a specific topic area and will give providers
answers to specific claim and billing questions. Treasure Valley
Thursday, May 6, 2010
Friday, May 7, 2010
Monday, May 10, 2010
Red Lion on the Falls 5750 East Franklin Rd. 5750 East Franklin Rd. 475 River Parkway Idaho Falls, Idaho Lewiston
Friday, May 14, 2010
Monday, May 17, 2010
Thursday, May 20, 2010
Best Western Conference Center 800 N. Overland Ave. Coeur d'Alene, Idaho
Navigating the New Portal
8:00 a.m. – 10:00 a.m. each day
Get an in-depth view of the Idaho Medicaid Online Provider Portal. Understand the layout and functionality of eligibility transactions, claims submissions, retrieval and submissions of referrals and prior authorizations and more.
UB/Institutional Claims and Billing
10:30 a.m. – 12:30 p.m. each day
Providers that currently bill using UB-04 claim forms (both paper and electronic) will want to attend this workshop for detailed training on how to submit claims in the new system as well as billing changes.
Professional/CMS1500 Claims and Billing
1:00 p.m. – 3:00 p.m. each day
Providers that bill using CMS1500 (HCFA) forms (both paper and electronic) will want to attend this workshop for detailed training on how to submit claims in the new system as well as billing changes.
3:30 p.m. - 5:00 p.m. each day
Dental providers that bill using ADA forms (both paper and electronic) will want to attend this workshop for detailed training on how to submit claims in the new system as well as billing changes. To register, please go to the Provider portal at and click on the Idaho Medicaid Training Center link in the lower left side of the screen. Space is limited. For providers unable to attend the offered workshops, training materials will be available on the provider portal at . Providers that have completed the Trading Partner agreement and set up an account for Direct Data Entry (DDE), and log into the secure Learning Management System (LMS) will have access to Computer Based Training (CBT) self-paced training that will be posted over the next several months. All providers will have access to the Provider Handbook that contains information they need about how to update the way they submit their claims. User guides and companion guides are available to all providers on the Web site. We encourage you to attend the statewide trainings that will be taking place during May for information on system and billing changes that may impact you and your business. For further information on training dates and topics please visit our Web site at and select the training links on the left hand side of the screen. MedicAide May 2010
Where to Send Paper Claims
To ensure accurate processing and faster payment, please mail your claims and supporting documents to Molina/Unisys at the specific P.O. Box that corresponds to the type of claim. Mail claim forms as follows: UB-04 Crossover/ PO Box 70084
PO Box 70085
CMS 1500 Crossover/ PO Box 70087
Third Party Recovery PO Box 70086
Boise, ID 83707
Examples of non-claim correspondence and where to mail are below. Member Correspondence AHI, HIPP, Healthy Connections, PHA PO Box 70081
Provider Correspondence PO Box 70082
Boise, ID 83707
Utilization Management/ Medical justification, Op reports, Sterilization consent forms, Oxygen levels, Invoice PO Box 70083
Paper Claim Forms: Which Ones and Where?
Molina/Unisys only accepts the following paper claim forms CMS-1500 Dental ADA 2006 Forms can be found at most office supply stores. Message from the Medicaid Administrator
Providers/Stakeholders! We want your feedback on ways the Department of Health and Welfare can reduce costs in order to sustain a viable Medicaid program. Watch the Web site for a survey tool (fast and easy way to provide your input) and calendars with meeting details as they become finalized. 10 MedicAide
Changes: Interpretive Services Billing
For all interpretive services billed on or after June 7, 2010, (through Molina/Unisys), providers must bill in 15 minute increments using the appropriate code/modifier listed in the chart below. PROCEDURE CODE
Oral language Interpretation One unit = 15 min CG – Policy Criteria applied Sign Language Interpretation One unit = 15 min Medicaid covers interpretation services to assist participants who are deaf or have limited English proficiency (LEP) to understand their Medicaid-covered services. Payment will be made to the provider when it is necessary for the provider to hire an interpreter in order to communicate with a participant about their Medicaid-covered services while they are providing a Medicaid-covered service. Payment for interpretation services are subject to the following limitations:
Payment for interpretation services will not be made to providers who cost audit settle with DHW.
Those services are considered as a part of the provider's cost of doing business. This includes providers such as hospitals, home health agencies, rural health clinics (RHC), federally qualified health centers (FQHC), and long-term care facilities. Payment will only be made for interpretive services to assist the participant to understand Medicaid
covered services. If the interpretive services are necessary for any other reason, they may not be billed to Medicaid. Payment will not be made for interpretive services when the provider of the service is able to
communicate in the participant's language or sign language. As with all services billed in 15 minute increments, see General Billing Information of the provider handbook for requirements and limitations in billing 15-minute increments. State Your Case (Number)
When faxing or mailing important provider enrollment documents for your record update or new application, please include a cover sheet and write or type the assigned case number on each page. All necessary documents and forms are online at: . Fax documents to Molina/Unisys at (877) 517-2041. Send documents to Molina/Unisys at Provider Record Update If you have questions about this, please call Provider Enrollment at (866) 686-4272. MedicAide May 2010
Preventive Health Assistance for Wellness
The Preventive Health Assistance (PHA) wellness benefit provides assistance to families whose children are: Enrolled in the Medicaid Basic Plan Required to pay a monthly premium to maintain eligibility
These children are automatically enrolled in the Wellness PHA.
How does it work?
1. The claims processing system is searched to determine if a child is current on receiving recommended well-child checks and immunizations. 2. If the child is current, PHA points are earned. 3. 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
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 at 877-364-1843 (toll-free). ATTENTION PERSONAL CARE SERVICE PROVIDERS
PCS Caregiver Training Requirements for Adults or Children with
Developmental Disabilities (DD)
The Medicaid Enhanced Plan Benefits rule 16.03.10.305.02 Personal Care Services – Provider Qualifications requires caregivers to have completed one of the Department approved developmental disabilities training courses or have experience providing direct services to adults or children with developmental disabilities. Providers who are qualified as a qualified mental retardation professional are exempt from the Department approved developmental disabilities training course. If a provider needs to request temporary approval to provide services or has questions, please contact your regional quality assurance specialist: Regions 1 and 2 - Kim Hickey at (208) 799-4435 Regions 3 & 4 - please contact Kim Hickey at (208) 799-4435 or Michelle Finck at (208) 782-2618 Regions 5, 6, and 7 - Michelle Finck at (208) 782-2618 12 MedicAide
Medicaid Program Integrity
Criminal History Checks and Documentation
Recent audits of commercial transportation providers have revealed three problem areas: the lack of required criminal history background checks; insufficient documentation; and billings for non-covered services. Medicaid Basic Plan Benefits, IDAPA 16.03.09.874.01.e requires Commercial Transportation Providers to: Verify that all staff having contact with participants have complied with IDAPA 16.05.06, "Criminal History and Background Checks." This requirement was implemented to protect both Medicaid clients and the transportation companies themselves from potential lawsuits. Audits have shown some providers had not completed background checks on any staff used to transport Medicaid clients. Additionally, it was found some providers had used individuals with criminal records including designated crimes which would have precluded them from passing the background check. The Department takes the issue of client safety seriously. Civil monetary penalties have been imposed on providers when investigations revealed providers had not completed background checks on staff, and/or utilized convicted felons to transport Medicaid clients. The Department may also recover payment for all services provided by individuals who cannot pass criminal history background checks. Section 5.2 of the Supplemental Transportation Provider Agreement requires commercial transportation providers performing fixed route and demand response door to door services to maintain records sufficient to support the amount and scope of services performed and billed. The specific components are outlined in both the provider agreement, and the Idaho Medicaid Provider Handbook, Transportation Guidelines. Audits have shown some providers are not completing trip logs and are using authorization requests as the sole documentation to support their billings. Prior authorization documents do not confirm that the service was provided; only that approval was requested. Additionally, it has been found that some providers are documenting a round trip as a single entry. This results in the pick-up and drop off locations showing the same address and causes inaccurate reporting. The date, time, and
geographical point of pick-up and drop-off for each trip is required. Providers who fail to document
required information are subject to civil monetary penalties and/or recoupment of services. Lastly, the audits showed some providers are billing for transportation to non-covered services. Medicaid Basic Plan Benefits, IDAPA 16.03.09.872.01.a limits reimbursement for transportation as follows: "The travel is essential to get to or from a medically necessary service or a waiver service covered by Medicaid." As part of the audit process, transportation billings are compared to medical visits. If no corresponding medical visit is found, the medical service provider listed may be contacted to confirm the visit. Payment for transportation billed for which no corresponding medical service can be confirmed will be recouped. Updated Notification of Birth Form
An updated Notification of Birth form is included in this newsletter for your use. Please replace your 2007 form with the current one, which includes a new e-mail address and fax number to expedite processing. Note that the CIN # (Client Identification Number) is also known as the MID (Medicaid/
Member ID) Number. An electronic copy is available under Forms
. Questions may be directed to Arlee Coppinger, Medical Care Unit, (208) 287- (See page 14 for form) MedicAide May 2010
Notification of Birth:
Anticipated Stays Greater Than 72 hours
Notification Date Please fill out as completely as possible Section 1—To be completed by the hospital for a mother that is receiving Idaho Medicaid at the time of birth, and
the baby is anticipated to stay in the NICU unit for over 72 hours.
Bab 's Info
City of Residence
Section 2—To be completed by the Department
or Fax # 208-528-5980
Date Baby's MID# Provided to the SRS Worker (if known) Response section Step 1—To be completed by the Hospital for anticipated stays greater than 72 hours
1. Electronically fill out Section 1 as completely as possible. (Leave baby's CIN# blank)
2. E-mail the form to the IFPC at or Fax it to 208-528-5980.
3. Use the words 'Notification of Birth' in the e-mail subject line to provide for easy identification and quick turn
4. For babies hospitalized for 72 hours or less, continue to follow your current procedure.
Step 2—To be completed by the Department
1. The IFPC researches and processes the request.
2. Section 2 is completed with the babies CIN# inserted in Section 1.
3. The IFPC e-mails, or faxes, the completed form back to the Hospital.
Last updated 2/11/2010 RLC
Have You Visited the New Provider Portal?
This is your 24/7 one-stop shop for provider enrollment, claims and correspondence. Now is a great time to become familiar with all of the information available to you. Just type in your browser address field and press enter. Here's a preview of the Health PAS Web site: Now is a great time to explore and sign up for training! IR 2010-05 - Information Request Related to Personal Care
Service Wage Determination
This Information Release (IR) was published and mailed to impacted providers in March 2010. You can find a copy of
this IR at: click on the Providers tab, then the Medicaid Providers tab, then the
Information Releases link.
March 31, 2010
REVISED MEDICAID INFORMATION RELEASE MA10-03
Prescribing Providers, Pharmacists, and Hospitals Leslie M. Clement, Administrator Division of Medicaid
Preferred Agents for Drug Classes Reviewed at Pharmacy and Therapeutics Committee Meetings on January 15, 2010, and February 19, 2010. MedicAide May 2010
IR MA10-03 (Continued from page 15)
Drug/Drug Classes: Implementation Date: Effective for dates of service on or after April 1, 2010 Idaho Medicaid is noting preferred agents and prior authorization (PA) criteria for the following drug classes as part of the Enhanced PA Program. The information is included in the attached Preferred Drug List. The Enhanced PA Program and drug-class specific PA criteria are based on nationally recognized peer-reviewed information and evidence-based clinical criteria. Medicaid designates preferred agents within a drug class based primarily on objective evaluations of their relative safety, effectiveness, and clinical outcomes in comparison with other therapeutically interchangeable alternative drugs and, secondarily, on cost. Questions regarding the Enhanced PA Program can be referred to the Idaho Medicaid Pharmacy Unit at (208) 364-1829. A current listing of preferred agents, non-preferred agents, and prior authorization criteria for all drug classes is available THERAPEUTIC
Analgesics, Narcotics methadone generic, Kadian®, Embeda®, Duragesic®, Duragesic Matrix®,
fentanyl transdermal generic
Ultram ER®, Ryzolt®, Tramadol ER®,
and morphine ER generic. Avinza®, Opana ER®, Oxycontin® and oxycodone extended release generic Analgesics, Narcotics Reprexain®, acetaminophen/
Nucynta®, Onsolis®, levorphanol generic,
codeine generic, tramadol propoxyphene/acetaminophen generic,
generic, hydrocodone/ pentazocine/acetaminophen generic, acetaminophen generic, aspirin/ oxycodone/aspirin generic, propoxyphene codeine generic, codeine generic, generic, meperidine oral generic, Darvon morphine IR generic, oxycodone N®, Panlor DC/SS®, Opana®, fentanyl IR generic, oxycodone/ buccal generic, Fentora®, hydrocodone/ acetaminophen generic, ibuprofen generic, oxycodone/ibuprofen pentazocine/naloxone generic, generic, butalbital compound/codeine hydromorphone generic, and generic, and dihydrocodeine/ tramadol/acetaminophen acetaminophen/caffeine generic ramipril generic, benazepril and Teveten®, Tevetan HCT®, Atacand®,
benazepril/HCTZ generic, Atacand HCT® , moexepril and moexepril/ captopril and captopril/HCTZ HCTZ generic, Tekturna® , Tekturna HCT® , generic, enalapril and enalapril/ and trandolapril generic HCTZ generic, fosinopril and fosinopril/HCTZ generic, lisinopril and lisinopril/HCTZ generic, quinapril and quinapril/HCTZ generic, Diovan®, Diovan HCT®, Benicar, Benicar HCT®, Micardis®, Micardis HCT®, Cozaar®, Hyzaar®, Avapro® and Avalide® Exforge® and Azor® benazepril/amlodipine generic, Tarka®,
Modulator—Calcium Twynsta®, and Valturna® Combination Drugs The separate component drugs must be used in place of benazepril/amlodipine combinations. Fragmin®, Lovenox®, and There are no agents in this class designated as non-preferred (Continued on page 17) 16 MedicAide
IR MA10-03 (Continued from page 16)
Tegretol XR® , Trileptal®
Banzel®, Vimpat®, Lamictal®1 and
suspension, levetiracetam Lamictal ODT®1, Keppra®1 solution,
generic, divalproex generic, Keppra®1 XR, Depakote®, Trileptal® oral,
methobarbital generic, Stavzor®, Phenytek®, Felbatol® , lamotrigine
phenobarbital generic, generic1 oxcarbazine suspension
clonazepam generic, generic, Topamax sprinkle®1,Topomax
carbamazepine generic, tablets®1
Carbatrol®, Equetro®, phenytoin generic, 1 These anticonvulsants are recommended as mephobarbital generic, preferred for epilepsy and other seizure primidone generic, valproic orders only. Non-seizure indications will still acid generic, Depakote® require that therapeutic prior authorization sprinkle, Depakote ER®, criteria are met. Celontin® , Peganone®, Gabitril®, ethosuximide generic, oxcarbezapine tablets, zonisamide generic1, Lyrica®1, gabapentin generic1 , Keppra
tablets, divalproex ER,
divalproex sprinkle, Lamictal
XR®, and Diastat®
Allegra®, loratadine generic,
Claritin® chew, Semprex D®, Clarinex/ Minimally Sedating loratadine syrup, cetirizine Clarinex D®, Clarinex® syrup, Xyzal, ®, generic, cetirizine syrup OTC Xyzal® syrup, Allegra®syrup , Allegra ODT, and cetirizine syrup RX
and fexofenadine generic Antimigraine Agents, Maxalt/Maxalt MLT®, Relpax® , sumatriptan generic, Treximet®, Amerge®, Imitrex (oral) ®, Imitrex Axert®, Frova®, Zomig/ZomigZMT®, and (nasal) ®, and Imitrex® SQ Levatol®, Innopran XL®, Bystolic®, betaxolol generic, and Coreg CR ® atenolol generic, metoprolol generic, propranolol generic, sotalol generic, nadolol generic, acebutolol generic, labetalol generic, pindolol generic, timolol generic, bisoprolol generic, and carvedilol generic Bladder Relaxant Toviaz®, Enablex®,
Oxytrol® transdermal, Detrol LA®,
oxybutynin generic, and Detrol®, Sanctura®, Sanctura XR®, and oxybutynin ER generic doxazosin generic, terazosin Rapaflo®, Avodart® and finasteride
generic, Proscar®, Uroxatral®, Cardura XL®, and Flomax® Dynacirc CR®, verapamil nisoldipine generic, Cardizem LA®, verapamil generic, diltiazem generic, ER PM, nicardipine generic, Cardene SR®, nifedipine IR/ER generic, Covera-HS®, isradipine generic and Sular® felodipine ER generic and amlodipine generic (Continued on page 18) MedicAide May 2010
IR MA10-03 (Continued from page 17)
Dynacirc CR®, verapamil nisoldipine generic, Cardizem LA®, verapamil ER generic, diltiazem generic, PM, nicardipine generic, Cardene SR®, Covera- nifedipine IR/ER generic, HS®, isradipine generic and Sular® felodipine ER generic and amlodipine generic Epogen®, Aranesp® and
There were no agents in this class recommended as non-preferred Proteins Growth Hormone Genotropin®, Nutropin®,
Saizen®, Tev-Tropin®, Serostim®, Humatrope®,
Nutropin AQ® and Norditropin® Omnitrope® and Zorbtive® Current therapeutic criteria for growth hormone will continue to be required for all agents. Patients currently receiving non-preferred agents will be "grandfathered". These agents will be non-preferred and require prior- authorization for new patients. Hepatitis C Agents Pegasys®, Peg-Intron®, Peg- Intron® Redipen, and ribavirin Starlix® and Prandin® Prandimet® and nateglinide
Avandia®, Actos®, There were no agents designated as non- Avandamet®, Avandaryl®, Actoplus Met®, and Duetact® Impetigo Agents, mupirocin ointment generic Altabax® and Bactroban® cream Lipotropics, Other Trilipix®, Niacor®, Niaspan®,
Fibricor®, Zetia®, Triglide®, Welchol® ,
Antara®, gemfibrozil generic,
Lipofen®, Fenoglide®, fenofibrate generic,
colestipol generic, fenofibric acid, and Lovaza® cholestyramine generic Multiple Sclerosis Betaseron®, Avonex®, Rebif® Extavia®
Otic Antibiotics Coly-Mycin S®,
Cetraxal®, and Cipro®HC
ofloxacin generic otic and
Phosphate Binders PhosLo®, and Renagel® Eliphos®, Fosrenol®, Renvela®, and calcium
omeprazole generic and
Prilosec® OTC and suspension, Kapidex®,
OTC, Aciphex®, Prevacid®
Prevacid® capsule and OTC, Nexium®
solutab, and Nexium® capsule suspension, pantoprazole generic, lasoprazole
generic, and Zegerid® (Continued on page 19) 18 MedicAide
IR MA10-03 (Continued from page 18)
Sedative Hypnotics zaleplon generic, triazolam
Edluar®, temazepam 22.5mg,
generic, chloral hydrate generic, temazepam 7.5mg, Restoril® 7.5mg,
temazepam generic, and Lunesta®, flurazepam generic, zolpidem generic Rozerem®, Ambien CR®, Doral®, and estazolam generic Skeletal Muscle Relaxants baclofen generic, chlorzoxazone Amrix®, orphenadrine generic, generic, cyclobenzaprine orphenadrine compound generic, generic, dantrolene generic, carisoprodol generic, carisoprodol methocarbamol generic, and compound, Soma®, Skelaxin®, tizanidine generic Zanaflex®, and Fexmid® All current therapeutic prior authorization criteria for carisoprodol remain in effect. Ulcerative Colitis Agents Apriso®, sulfasalazine generic,
Sfrowasa®, mesalamine rectal
Asacol®, Pentasa®, and Canasa® generic, balsalazide generic,
Dipentum® and Lialda ® Pulmonary Arterial Tracleer®, Revatio® and
Hypertension (PAH) Agents, Oral Cough and Cold Agents All generic products both All branded products prescription and non- prescription Cough and Cold preparations restricted to participants 7 years and older. Quantity limits of 4 oz. per prescription and no more than two prescriptions per six months per participant. Fibromyalgia Agents Savella® , Lyrica® and
Prescriptions will require a
Immunosuppressives azathioprine generic,
Azasan®, cyclosporine generic, and
modified generic, Gengraf®,
generic, Neoral®, Prograf®,
*Use of non-preferred agents must meet prior authorization requirements. *Use of any covered product may be subject to prior authorization for quantities or uses outside the Food and Drug Administration (FDA) guidelines or indications.
Idaho Medicaid Provider Handbook
This Information Release does not replace information in your Idaho Medicaid Handbook.
MedicAide May 2010
PO Box 70082
Boise, Idaho 83707
Department of Health and Welfare Office
MedicAide is the
Health and Welfare offices will be closed every other Friday to help manage newsletter for Idaho
the State's budget reductions. Medicaid providers.
All Department of Health and Welfare offices will be closed all day on May 14th, May 28th and June 11th. During these closures, the DHW Director's office will remain open. The Chris Roberts,
closures will not affect essential services such as crisis Division of Medicaid
response for mental health, or response to child protection calls for abuse or neglect. Also, the state's two state mental If you have any
health hospitals and Idaho State School and Hospital will comments or
maintain 24/7 operations. suggestions, please
Our offices will resume normal business hours on the following Monday send them to:
DHW - MMIS Project
As part of our commitment to cost savings, we are using paperless processes wherever possible. Beginning with this issue, the "MedicAide" is going online PO Box 83720
and will be available electronically by the fifth of each month. Our new digital Boise, ID 83720-0036
edition, posted also allows links to important forms and web sites, plus it's eco-friendly. Fax: (208) 364-1811
Impressum: Institut für Neue Kulturtechnologien/t0, Neustiftgasse 17, 1070 Wien, Verlagspostamt 1070 Wien, Sponsoring Post GZ02Z033689 S. t0 World Summit on the Information Society World-Information City TUNIS 16-18 November 2005 BANGALORE 14-20 November 2005 TABLE OF CONTENTS P 02 The Black and White (and Grey) of By Lawrence Liang Options to traditional patents - The