General Information and Requirements for Providers

1 Idaho Medicaid Provider Handbook General Information and Requirements for Providers Table of Contents General Information and Requirements for Providers .. 1. Responsibilities .. 3. Employees and Contractors .. 4. References: Employees and Contractors .. 4. Documentation .. 5. Electronic Signatures .. 5. References: 6. Ordering, Referring and Prescribing Providers .. 8. References: Ordering, Referring and Prescribing Providers .. 8. Prohibition on Gifts to Participants .. 10. References: Prohibition on Gifts to Participants .. 10. Services for Immediate Family or Household Member.

2 12. Immediate Family Definition .. 12. Household Member Definition .. 12. References: Services for Immediate Family or Household Member .. 12. Payment Error Rate Measurement (PERM) Audits .. 14. References: Payment Error Rate Measurement (PERM) .. 14. Prevention of Waste, Fraud and Abuse .. 16. References: Prevention of Waste, Fraud and Abuse .. 16. Self-Reporting Overpayments .. 18. References: Self-Reporting Overpayments .. 18. Financial Responsibility .. 19. Co-payments .. 20. References: Co-payments .. 20. Share of Cost (SOC) .. 22.

3 Discrepancy Contact 22. Paid Claim 22. References: Participant Financial Responsibility .. 22. and Utilization Review .. 23. Provider Program 24. Retrospective Review .. 25. Reconsideration Request .. 25. Appeal Request .. 25. for 26. Idaho Medicaid Automated Customer Service (MACS) .. 27. Information Releases .. 28. References: Information Releases .. 28. MedicAide Newsletter .. 29. References: MedicAide Newsletter .. 29. Provider Handbooks .. 30. References: Provider Handbooks .. 30. Provider Service Representatives (PSRs) .. 31. June 9, 2021 Page i Idaho Medicaid Provider Handbook General Information and Requirements for Providers Provider Relations Consultants (PRC).

4 32. Enrollment .. 34. Non-billing Ordering, Referring and Prescribing Providers .. 36. References: Non-billing Ordering, Referring and Prescribing Providers .. 36. Crossover Only Providers .. 37. Mental Health Clinics .. 37. Medicaid Provider Identification Numbers .. 38. Individual Provider 38. Multiple Service Locations .. 38. Group Practice .. 38. Provider Licensing .. 40. Ownership and Controlling Interests .. 41. Provider Risk Levels .. 42. Limited Risk Providers .. 42. Moderate Risk 44. High Risk Providers .. 44. References: Provider Risk Levels.

5 44. Provider Enrollment Moratoria .. 45. References: Provider Enrollment Moratoria .. 45. Maintenance of Contact Information .. 46. References: Maintenance of Contact Information .. 46. Provider File Updates .. 47. Provider Recertification .. 48. Provider Termination .. 49. References: Provider Enrollment .. 50. Eligibility and Benefit Plan Coverage .. 51. Medicaid Identification 52. Verifying Participant Eligibility .. 53. Medicaid Automated Customer Service (MACS) .. 53. Trading Partner Account (TPA) .. 54. Vendor Supplied Software.

6 54. Medicaid Participants with Medicare .. 54. References: Verifying Participant Eligibility .. 55. Participant Program Abuse/Lock-In Program .. 56. Primary Care Physician (PCP) .. 56. Designated Pharmacy .. 56. References: Participant Abuse/Lock-in Program .. 57. Medicaid Basic Plan .. 58. Medicaid Enhanced Plan .. 59. Presumptive Eligibility (PE) .. 60. References: Presumptive Eligibility (PE) .. 60. Breast and Cervical Cancer (BCC) Program .. 62. References: Breast and Cervical Cancer (BCC) 62. Early & Periodic Screening, Diagnostic & Treatment (EPSDT).

7 63. EPSDT and Waiver Services .. 63. EPSDT Request Procedure .. 63. June 9, 2021 Page ii Idaho Medicaid Provider Handbook General Information and Requirements for Providers Request Procedure: Services Under State Plan .. 64. Request Procedure: Services Not in State Plan .. 64. Request Procedure: Outpatient Behavioral Health .. 64. Request Procedure: Dental Services .. 64. References: Early & Periodic Screening, Diagnostic & Treatment (EPSDT) .. 65. Incarcerated Persons .. 66. Incarcerated Persons: Third-Party 66. References: Incarcerated Persons.

8 66. Katie Beckett Medicaid Eligibility .. 68. References: Katie Beckett Medicaid Eligibility .. 68. Medicare Savings Program .. 69. Part A Medicare Savings 69. Part B Medicare Savings 69. Dually Eligible Medicare Beneficiaries .. 70. Medicare Part D .. 70. References: Medicare Savings Program .. 71. Managed Care Programs for Dual Eligible 72. Idaho Medicaid Plus (IMPlus) .. 72. Medicare-Medicaid Coordinated Plan (MMCP) .. 72. Billing Procedures for Managed Care Participants .. 72. Otherwise Ineligible Non-citizens (OINC) .. 74. Applying for Eligibility.

9 74. Prior Authorizations: Otherwise Ineligible Non-Citizens .. 74. References: Otherwise Ineligible Non-Citizens .. 74. The Pregnant Women (PW) Program .. 76. Presumptive Eligibility for Pregnant Women (PW) .. 76. References: Pregnant Women (PW) .. 76. Refugee Medical Assistance Program .. 78. References: Refugee Medical Assistance Program .. 78. Youth Empowerment Services (YES) .. 79. References: Youth Empowerment Services .. 79. Connections (HC) .. 81. Healthy Connections Provider 82. Healthy Connections Primary Care Provider Network Directory.

10 82. Healthy Connections Clinic Panel Limit Entry .. 83. Healthy Connections Clinic Panel Limit Guidelines .. 84. Healthy Connections Tier Requirements .. 85. Healthy Connections Coordinated Care Agreement and Tier Compliance by Tier 86. Healthy Connections Case Management Payment .. 88. Healthy Connections Participant Rosters .. 88. Participant Enrollment .. 89. Voluntary Participant Enrollment in Healthy 89. Participant Enrollment Guidelines .. 89. Enrollment to clinic with panel limitations .. 89. Mandatory Participant Enrollment in Healthy Connections.