December 2021 MedicAide

1 MedicAide December 2021 Page 1 of 20 In This Issue Documentation Must Support the Service Billed .. 2 RALF Quality Assurance Activities - 2022 Changes .. 3 ECHO Idaho s CE/CME-eligible Podcast .. 4 Provider Training Opportunities in 2021-2022 .. 16 DHW Resource and Contact Information .. 17 Insurance Verification .. 17 Gainwell Technologies Provider and Participant Services Contact Information .. 18 Gainwell Technologies Provider Services Fax Numbers .. 18 Provider Relations Consultant (PRC) Information.

2 19 Information Releases MA21-25 COVID19 Vaccine And Idaho Medicaid AMENDED .. 8 MA21-28 Change In Outpatient Hospital Reimbursement Methodology - APC .. 14 The content of this guidance document is not new law, but is an interpretation of existing law prepared by the Idaho Department of Health and Welfare to provide clarity to the public regarding existing requirements under the law. This document does not bind the public, except as authorized by law or as incorporated into a contract. For additional information or to provide input on this document, contact the Idaho Division of Medicaid by emailing or by calling (208)334-5747.

3 An Informational Newsletter for Idaho Medicaid Providers From the Idaho Department of Health and Welfare, December 2021 Division of Medicaid MedicAide December 2021 Page 2 of 20 Documentation Must Support the Service Billed Medicaid Program Integrity Unit has identified an issue, where some providers are only listing the Current Procedural Terminology (CPT ) code in place of fully documenting the extent of the service provided. Providers are required to generate documentation at the time of service sufficient to support each claim or service billed to Medicaid.

4 The content of the medical record determines the proper CPT code assignment. As a reminder to all providers, claims billed to Medicaid must be in accordance with the coding guidelines as defined by the American medical Association s CPT manual as well as the National Correct Coding Initiative for Medicaid services. These guidelines provide instructions detailing when and how to assign codes, which codes can and cannot be reported together, and other factors critical to compliant coding. IDAPA describes requirements for documentation of services and states: 101.

5 DOCUMENTATION OF SERVICES AND ACCESS TO RECORDS. 01. Documentation of Services. Providers must generate documentation at the time of service sufficient to support each claim or service, and as required by rule, statute, or contract. Documentation must be legible and consistent with professionally recognized standards. Documentation must be retained for a period of five (5) years from the date the item or service was provided. Documentation to support claims for services includes, but is not limited to, medical records, treatment plans, medical necessity justification, assessments, appointment sheets, patient accounts, financial records or other records regardless of its form or media.

6 Specifically, Section of the Idaho Medicaid Provider Handbook, General Information and Requirements for Providers, addresses documentation requirements. It states, in pertinent part: Providers are required to generate records at the time the service is delivered and maintain all records necessary to fully document the extent of services submitted for Medicaid reimbursement. This includes documentation of referrals made or received on behalf of Medicaid participants enrolled in the Healthy Connections (HC) Program.

7 Services that haven t been documented are considered to not have occurred and are not reimbursable. The person delivering the services and any supervising providers must legibly sign, date and time the documentation to attest that the records are a true and accurate account of the services delivered. Any records requiring amendment or corrections must be clearly and permanently identified as such while leaving the original contents of the document legible. Amendments and corrections are intended to provide clarification and cannot be used to add new services for billing or retroactively establish medical necessity.

8 Amendments and corrections separately require the author to be clearly identified with their credentials, a signature and the date of the changes. Documentation created after a Department records request is made will not be accepted. Intentional deception or misrepresentation made with the knowledge that the deception could result in an unauthorized benefit constitutes fraud, and offending individuals will be referred for prosecution. Services billed to Medicaid without documentation supporting the service billed may be subject to recoupment and civil monetary penalties.

9 MedicAide December 2021 Page 3 of 20 RALF Quality Assurance Activities - 2022 Changes In 2022, the Bureau of Long Term Care, Quality Assurance team is expanding their current quality assurance (QA) oversight of Residential Assisted Living (RALF) providers to include a review of Service Plans for Medicaid participants receiving services on the Aged & Disabled Waiver or receiving Personal Care Services. The BLTC QA team currently reviews progress notes associated with billed claims on a quarterly basis for RALF providers.

10 Including a review of associated participant service plans will allow the QA team the opportunity to work collaboratively with RALF providers to ensure that all Service Plans are developed in accordance with the requirements outlined in Idaho Adminstrative Rules (IDAPA) , Medicaid Enhanced Plan Benefits, Section 317. These requirements include: Participant Strengths & Preferences Individually identified goals and outcomes Services and Supports Risk Factors Understandable Language Plan Monitor Appropriate Signatures RALF providers will be notified when their review is scheduled and will be given three (3) weeks to submit the required documentation.