In This Issue Newsletters/October...MedicAide October 2019 Page 4 of 16 J1303 Injection,...
16
MedicAide October 2019 Page 1 of 16 In This Issue Idaho Medicaid Plus Open Enrollment Update .............................................................................. 2 Attention DME Suppliers: Oxygen Concentrators .......................................................................... 2 HCPCS Coverage Update for October 2019 .................................................................................. 3 Medicaid Program Integrity Unit ................................................................................................. 5 Services Must be Billed in Accordance with Medicaid Rules, Regulations and Policies......................... 5 Numerical Fee Schedule – Update .............................................................................................. 6 Medicaid Expansion Provider Listening Session on October 21, 2019 .............................................. 7 Notice of Upcoming Provider Meetings ........................................................................................ 7 Provider Training Opportunities in 2019 .....................................................................................11 Medical Care Unit Contact and Prior Authorization Information......................................................12 DHW Resource and Contact Information ....................................................................................13 Insurance Verification ..............................................................................................................13 DXC Technology Provider and Participant Services Contact Information .........................................14 DXC Technology Provider Services Fax Numbers .........................................................................14 Provider Relations Consultant (PRC) Information.........................................................................15 Information Releases MA19-13 Nursing Facility Rates and Assessment Schedules - Medicare Changes to Prospective Payment System ................................................................................................................................... 8 MA19-14 Medicaid Hospice Rates Update .................................................................................... 9 An Informational Newsletter for Idaho Medicaid Providers From the Idaho Department of Health and Welfare, October 2019 Division of Medicaid
Transcript of In This Issue Newsletters/October...MedicAide October 2019 Page 4 of 16 J1303 Injection,...
MedicAide October 2019 Page 1 of 16
In This Issue Idaho Medicaid Plus Open Enrollment Update .............................................................................. 2 Attention DME Suppliers: Oxygen Concentrators .......................................................................... 2 HCPCS Coverage Update for October 2019 .................................................................................. 3 Medicaid Program Integrity Unit ................................................................................................. 5 Services Must be Billed in Accordance with Medicaid Rules, Regulations and Policies ......................... 5 Numerical Fee Schedule – Update .............................................................................................. 6 Medicaid Expansion Provider Listening Session on October 21, 2019 .............................................. 7 Notice of Upcoming Provider Meetings ........................................................................................ 7 Provider Training Opportunities in 2019 .....................................................................................11 Medical Care Unit Contact and Prior Authorization Information ......................................................12 DHW Resource and Contact Information ....................................................................................13 Insurance Verification ..............................................................................................................13 DXC Technology Provider and Participant Services Contact Information .........................................14 DXC Technology Provider Services Fax Numbers .........................................................................14 Provider Relations Consultant (PRC) Information .........................................................................15
Information Releases MA19-13 Nursing Facility Rates and Assessment Schedules - Medicare Changes to Prospective Payment System ................................................................................................................................... 8 MA19-14 Medicaid Hospice Rates Update .................................................................................... 9
An Informational Newsletter for Idaho Medicaid Providers
From the Idaho Department of Health and Welfare, October 2019
Division of Medicaid
MedicAide October 2019 Page 2 of 16
Idaho Medicaid Plus Open Enrollment Update Open enrollment for active Idaho Medicaid Plus (IMPlus) members is coming up! IMPlus has an open enrollment period annually during which existing members can elect to change Health Plans. Open enrollment will begin October 15th and continue through December 7th, 2019. All open enrollment selections will go into effect on January 1, 2020. Members can expect to receive their open enrollment letter around October 1, 2019. The letter describes three options:
1. Make no changes to the current Health Plan administering their IMPlus program. 2. Request a change to their IMPlus Health Plan. Members can submit their enrollment
change request by completing the IMPlus enrollment form included with the open enrollment letter or by calling (833) 814-8568.
3. Enroll in the Medicare-Medicaid Coordinated Plan (MMCP) available through Molina Healthcare of Idaho and Blue Cross of Idaho. The MMCP is a program that integrates both Medicare and Medicaid into a single plan at no cost to the member. Members can enroll in the MMCP by calling the Health Plan they wish to enroll with.
Blue Cross of Idaho (888) 495-2583 Molina Healthcare of Idaho (866) 403-8293
What you can expect as a provider? Providers may serve dual-eligible participants that move from one duals’ program to another, or from one participating Health Plan to another. It will be important to verify each participants eligibility to ensure claims are submitted to the proper entity.
• IMPlus: If you are a provider that typically bills Medicare (Primary Care Physician, Hospital, Specialists, Pharmacy, etc.) there are no changes to your current claims process.
• IMPlus: If you are a provider that typically bills Medicaid (Aged & Disabled Waiver, Behavioral Health, Skilled Nursing Facility, Personal Care Services, etc.) then you will submit the claims to either Blue Cross of Idaho or Molina Healthcare of Idaho.
• MMCP: Submit claims to the Health Plan. Important: All enrollment changes made during open enrollment will go into effect on January 1, 2020. Providers can utilize the DXC Technology provider portal to verify a dual eligible participant’s program and Health Plan. For additional information, please review the Idaho Dual Eligible Programs Provider Quick Reference Guide and the Idaho Medicaid Plus FAQs at http://mmcp.dhw.idaho.gov or contact [email protected].
Attention DME Suppliers: Oxygen Concentrators Idaho Medicaid pays for medically necessary oxygen concentrators with an all-inclusive monthly rate found on the Idaho Medicaid Numerical Fee Schedule. This rate includes the rental of the delivery system, its contents, maintenance, repair, and any necessary supplies. Separate payments may be made for both stationary and portable systems when medically necessary. In July 2018 the Department updated its policy for oxygen concentrators to move to a capped rental with that month, July 2018, being the first to apply towards the cap. After further consideration the Department will be aligning its policy with Medicare to allow a thirty-six-month rental during the reasonable useful lifetime period of five years. This calculation will be retroactive to July 2018 to allow additional coverage of previously provided equipment. As the
MedicAide October 2019 Page 3 of 16
Department continues to align its oxygen policy with Medicare, suppliers will be solicited for comment on any future changes. Questions about this article may be submitted to the Medical Care Policy Team at [email protected].
HCPCS Coverage Update for October 2019 The following codes are being added for coverage. Please, allow additional time for the system to be updated. Claims will be reprocessed if completed after the effective date. All statute, rule and provider handbook requirements apply.
Covered Codes Codes Description Effective Date PA Always
Required PA Reviewer
C1818 Integrated keratoprosthesis
10/1/2019 NO N/A
J0121 Injection, omadacycline, 1 mg
10/1/2019 YES Pharmacy Unit
J0122 Injection, eravacycline, 1 mg
10/1/2019 YES Pharmacy Unit
J0222 Injection, Patisiran, 0.1 mg
10/1/2019 YES Pharmacy Unit
J0291 Injection, plazomicin, 5 mg
10/1/2019 YES Pharmacy Unit
J0593 Injection, lanadelumab-flyo, 1 mg (code may be used for Medicare when drug administered under direct supervision of a physician, not for use when drug is self-administered)
10/1/2019 YES Pharmacy Unit
J1096 Dexamethasone, lacrimal ophthalmic insert, 0.1 mg
10/1/2019 YES Pharmacy Unit
J1097 phenylephrine 10.16 mg/ml and ketorolac 2.88 mg/ml ophthalmic irrigation solution, 1 ml
10/1/2019 NO N/A
MedicAide October 2019 Page 4 of 16
J1303 Injection, ravulizumab-cwvz, 10 mg
10/1/2019 YES Pharmacy Unit
J1943 Injection, aripiprazole lauroxil, (aristada initio), 1 mg
10/1/2019 YES Pharmacy Unit
J1944 Injection, aripiprazole lauroxil, (aristada), 1 mg
10/1/2019 YES Pharmacy Unit
J2798 Injection, risperidone, (perseris), 0.5 mg
10/1/2019 YES Pharmacy Unit
J3031 Injection, fremanezumab-vfrm, 1 mg (code may be used for Medicare when drug administered under the direct supervision of a physician, not for use when drug is self-administered)
10/1/2019 YES Pharmacy Unit
J3111 Injection, romosozumab-aqqg, 1 mg
10/1/2019 YES Pharmacy Unit
J7314 Injection, fluocinolone acetonide, intravitreal implant (Yutiq), 0.01 mg
10/1/2019 YES Pharmacy Unit
J7331 Hyaluronan or derivative, synojoynt, for intra-articular injection, 1 mg
10/1/2019 NO N/A
J7332 Hyaluronan or derivative, triluron, for intra-articular injection, 1 mg
10/1/2019 NO N/A
J7401 Mometasone furoate sinus implant, 10 micrograms
10/1/2019 YES Pharmacy Unit
MedicAide October 2019 Page 5 of 16
J9118 Injection, calaspargase pegol-mknl, 10 units
10/1/2019 YES Pharmacy Unit
J9119 Injection, cemiplimab-rwlc, 1 mg
10/1/2019 YES Pharmacy Unit
J9204 Injection, mogamulizumab-kpkc, 1 mg
10/1/2019 YES Pharmacy Unit
J9210 Injection, emapalumab-lzsg, 1 mg
10/1/2019 YES Pharmacy Unit
J9269 Injection, tagraxofusp-erzs, 10 micrograms
10/1/2019 YES Pharmacy Unit
J9313 Injection, moxetumomab pasudotox-tdfk, 0.01 mg
10/1/2019 YES Pharmacy Unit
Q5116 Injection, trastuzumab-qyyp, biosimilar, (trazimera), 10 mg
10/1/2019 YES Pharmacy Unit
Q5117 Injection, trastuzumab-anns, biosimilar, (kanjinti), 10 mg
10/1/2019 YES Pharmacy Unit
Q5118 Injection, bevacizumab-bvzr, biosimilar, (Zirabev), 10 mg
10/1/2019 YES Pharmacy Unit
Questions about this article may be submitted to the Medical Care Policy Team at [email protected].
Medicaid Program Integrity Unit Services Must be Billed in Accordance with Medicaid
Rules, Regulations and Policies Idaho Medicaid providers are required to abide by rules and regulations governing medical assistance. Providers are notified of coverage policies, service limitations, and other conditions for payment through IDAPA rules, Medicaid Information Releases, provider handbooks, newsletters and other program notices. Providers often contact DXC Technology, Medicaid’s MMIS claims processing contractor, and inquire about client eligibility, client benefits, and whether or not procedure codes and diagnostic codes are billable. DXC Technology representatives answer general questions regarding eligibility and claims processing and can validate whether or not a procedure or diagnostic code is valid and
MedicAide October 2019 Page 6 of 16
if there are frequency limitation edits in the system or if codes require prior authorization for billing. They can also verify whether or not a Medicaid client is eligible to receive certain services or benefits. However, information provided by DXC Technology is not a replacement for any written policy, rule, or direction given by the Department and does not alleviate providers of their responsibility to know and follow those rules. The fact that codes are valid and billable or the fact that a Medicaid client is eligible to receive certain benefits is not a guarantee the service is reimbursable. Services are subject to medical necessity, prior authorization, frequency limitations, coverage restrictions, program eligibility requirements, and other conditions for payment. DXC Technology representatives do their best to assist providers in their efforts, but they do not approve or authorize services for payment and are not responsible for providers following the Medicaid rules regardless of the information they provide. Obtaining information that a code is valid and billable or that a client is eligible for certain benefits is not an authorization to bill. All services are subject to review and recoupment of payment if services were not paid in accordance with guidelines, policies, and rules. By receiving information from a DXC Technology’s customer service representative or making payment for a billed service, the MMIS system is not “approving” the service. The MMIS system is merely making payment based on the information submitted. Please ensure that all services billed to Idaho Medicaid are billed in accordance with Medicaid rules, regulations and policies.
Numerical Fee Schedule – Update Reimbursement rates may change during the year without update to the numerical fee schedule information published on the Internet. In an attempt to lessen administrative burden, the Department of Health and Welfare is going to update the fee schedule on a quarterly basis. If there are any significant changes identified by the Department, the numerical fee schedule will be updated accordingly. Providers should review the fee schedule for any changes to covered codes or allowable amounts. The numerical fee schedule information can be found on the Idaho Department of Health and Welfare website - https://healthandwelfare.idaho.gov/Providers/Providers-Medicaid/MedicaidFeeSchedule/tabid/268/Default.aspx. Inclusion or exclusion of a procedure code, supply, product or service does not imply Medicaid coverage, reimbursement, or lack thereof. Fee schedules are prepared as tools to assist Medicaid providers and are not intended to grant rights or impose obligations. Every effort is made to ensure the accuracy of the information within the fee schedules as of the date they are posted. Medicaid makes no guarantee that compilation of fee schedule information is error-free and will bear no responsibility or liability for the results or consequences of the use of these schedules. Providers are always encouraged to verify participant eligibility criteria through the DXC portal. Please contact DXC Provider Services at 1(866) 686-4272 for assistance. If your provider’s office has any comments about this operational change, please contact the Idaho Division of Medicaid, Office of Reimbursement within 30 days to at (208) 287-1180 or email [email protected]. This process may be subject to change based on the discretion of the Department. Any code is subject to be reviewed by the Department at any time.
MedicAide October 2019 Page 7 of 16
Medicaid Expansion Provider Listening Session on October 21, 2019
The Idaho Department of Health and Welfare is inviting all interested providers and stakeholders to participate in the third of a series of Medicaid Expansion Provider Listening Sessions focused on Medicaid expansion for providers. It will be held 10/21/2019; 3:00 – 4:00 PM Mountain Standard Time (MST). The listening session is an opportunity for providers and stakeholders to ask questions and to share input for the Department to consider as it implements Medicaid expansion. The Department anticipates high interest and participation in this session. The questions and input will be recorded during the session and will support additional website content that will be posted to the Department’s Medicaid expansion website. To attend in person, come to the main entrance of Idaho Medicaid at 3232 Elder Street, Boise, ID 83705. Please provide time to sign in and find a seat in conference room D-East. Parking is free. To attend via Phone, dial 1-415-655-0003; guest code: 801 742 732; Password: 93238734 To attend via WebEx, dial 1-415-655-0003; guest code 801 742 732; Password 93238734; Meeting Link: https://idhw.webex.com/idhw/j.php?MTID=m5dba93402b8e52e862090d531608ab0e Because there will be other opportunities for sharing input on the waivers required in Senate Bill 1204 (which will be posted here - https://medicaidexpansion.idaho.gov) the Department will not be seeking input on those waivers during the October 21, 2019 listening session. This listening session will be for comments and questions specific to providers and continuity of care. We look forward to your participation on October 21, 2019 from 3:00 to 4:00 MST.
Notice of Upcoming Provider Meetings
Idaho Hospital Association Biannual Meeting
Topics
Monday, November 4, 2019 – 1:00 p.m. (MDT)
Coordination of Benefits Phase III Remittance Remarks
Department of Health & Welfare Once in a Lifetime – ICD-10-PCS Medicaid Central Office Billing Therapy Under 96112 & 96113 3264 Elder Street Prior authorization for CPT® 87634 JAD Conference Room Paperclip Icon for Claim Documentation Boise, ID 83705 Mammography Code Reimbursement Teleconference Call-in Incarcerated Individuals Reimbursement Policy USA Toll-Free: 1-866-499-0396 OPPS Codes for Non-OPPS Payors Access Code: 803 617 458
If you would like to be added to the contact list for these meetings, or you have an issue you’d like to appear on the agenda, e-mail your request to [email protected].
MedicAide October 2019 Page 8 of 16
Figure 1MA19-13 Nursing Facility Rates and Assessment Schedules - Medicare Changes to Prospective Payment System
MedicAide October 2019 Page 9 of 16
Figure 2MA19-14 Medicaid Hospice Rates Update
MedicAide October 2019 Page 10 of 16
MedicAide October 2019 Page 11 of 16
Provider Training Opportunities in 2019 You are invited to attend the following webinars offered by DXC Technology Regional Provider Relations Consultants.
October: 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 www.idmedicaid.com.
October November December
Eligibility COB Claims
Adjustments
10-11:00 AM MT
10/15/19 11/19/2019 12/17/2019
10/16/19 11/20/2019 12/18/2019 10/17/19 11/21/2019 12/19/2019
2-3:00 PM MT
10/9/19 11/13/2019 12/11/2019 10/10/19 11/14/2019 12/12/2019 10/15/19 11/19/2019 10/17/19 11/21/2019
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 15 of this newsletter.
MedicAide October 2019 Page 12 of 16
Medical Care Unit Contact and Prior Authorization Information
Prior Authorizations, Forms, and References To learn about prior authorization (PA) requirements, QIO 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. Select 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 or for services which do not require a prior authorization. To Check Prior Authorizations Status Log on to your Trading Partner Account on www.idmedicaid.com. Choose Form Entry, then choose View Authorizations. If you are unable to identify the reason for a denied service, a DXC Technology 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 (TPA) User Guide located under User Guides on www.idmedicaid.com. To speak to a DXC Technology 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 or e-mail [email protected].
For DMEPOS PA policy, please see the DMEPOS PA Policy and Medical Criteria under the Resources tab on the DME page. Please review the DMEPOS PA Policy and Medical Criteria to obtain important information, policy, and guidance relating to requesting PAs for DMEPOS items. This document also includes the medical criteria used by the department in most circumstances related to DMEPOS requests.
Fax Number Phone Number Administratively Necessary Days 1 (877) 314-8779 1 (866) 205-7403 Ambulance* 1 (877) 314-8781 1 (800) 362-7648 Breast & Cervical Cancer 1 (877) 314-8779 1 (208) 364-1826 Durable Medical Equipment 1 (877) 314-8782 1 (866) 205-7403 Hospice 1 (877) 314-8779 1 (866) 205-7403 Preventive Health Assistance 1 (877) 845-3956 1 (208) 364-1843 Service Coordination 1 (877) 314-8779 1 (866) 205-7403 Surgery-Procedure-Lab 1 (877) 314-8779 1 (866) 205-7403 Therapy: OT, PT, SLP 1 (877) 314-8779 1 (866) 205-7403 Vision 1 (877) 314-8779 1 (866) 205-7403
*Idaho Medicaid contracts with Medical Transportation Management (MTM) for all non-emergency medical transportation (NEMT) services. Please go to http://www.mtm-inc.net/idaho/ or call 1 (877) 503-1261 for more information.
MedicAide October 2019 Page 13 of 16
DHW Resource and Contact Information DHW Website 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
Telligen 1 (866) 538-9510 Fax: 1 (866) 539-0365 http://IDMedicaid.Telligen.com
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 October 2019 Page 14 of 16
DXC Technology 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
DXC Technology Provider Services Fax Numbers Provider Enrollment 1 (877) 517-2041 Provider and Participant Services 1 (877) 661-0974
MedicAide October 2019 Page 15 of 16
Provider Relations Consultant (PRC) Information
Region 1 and the state of Washington 1 (208) 559-4793 [email protected]
Region 2 and the state of Montana 1 (208) 991-7138 [email protected]
Region 3 and the state of Oregon 1 (208) 860-4682 [email protected]
Region 4 and all other states 1 (208) 912-3970 [email protected]
Region 5 and the state of Nevada 1 (208) 484-6323 [email protected]
Region 6 and the state of Utah 1 (208) 870-3997 [email protected]
Region 7 and the state of Wyoming 1 (208) 991-7149 [email protected]
MedicAide October 2019 Page 16 of 16
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.
DXC Technology PO Box 70082 Boise, Idaho 83707
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
