Table of Contents - idmedicaid.com

1 Idaho MMIS Provider Handbook General Billing Instructions Table of Contents 1. Section Modifications .. 1. 2. General Billing Information .. 8. Online Portal Access .. 8. Participant Responsibility .. 8. Co-payments .. 8. Share of Cost (SOC) .. 9. Medicaid Billing Policies .. 10. Dental .. 10. Hospice Participants .. 10. Interpretive Services .. 11. 340B Pharmacy Billing .. 11. Prior Authorization (PA) .. 11. Provider Licensing .. 15. Service 15. Telehealth Services .. 16. Wellness Exams .. 16. Timely Filing Limit.

2 17. Documentation to Support Timely 17. Participant Retroactive Eligibility .. 17. Provider Retroactive Eligibility .. 18. Medicare Processing .. 18. Third Party Insurance .. 19. Prior Authorization .. 19. Adjustments of Paid or Denied Claims .. 19. 19. Idaho Medicaid Claim Standards .. 19. National Correct Coding 19. Diagnosis Codes .. 22. Participant Billing Information .. 22. Provider's Billing 23. Billing Procedure for Date Spanning .. 24. Determining How to Bill Units for 15-Minute Timed Codes .. 24. Claims Submission.

3 25. Electronic Claims Submission .. 25. Paper Claim Forms .. 26. Examples of Documentation Necessary for Billing .. 28. Claim Status .. 29. 29. Electronic Adjustments .. 30. Paper Adjustments .. 30. Adjustments Up to Two Years .. 30. Adjustments Beyond Two Years .. 30. Retrospective Review .. 30. March 8, 2018 Page i Idaho MMIS Provider Handbook General Billing Instructions Requests for Reconsideration and Appeals .. 30. Claim Reconsideration and Appeals .. 31. Claim Review Request .. 31. Medicaid Review of Claim Determination.

4 32. Formal Appeal .. 32. Third Party Recovery (TPR) .. 33. Participant Responsibility .. 33. Exclusions .. 33. Determining Other Insurance Coverage .. 33. Coordination of Benefits (COB) .. 35. Processing Third Party Recovery (TPR) Claims .. 39. Claims for Dually Eligible 40. Injury Liability .. 44. Third Party Recovery (TPR) Inquiries .. 45. Table of Figures Figure 2-1: Retroactive Eligibility Letter/Notice of Action .. 18. Figure 2-2: Example of Date Spanning .. 24. Figure 2-3: Units for 15-Minute Timed Codes.

5 24. Figure 2-4: Claim Mailing Addresses .. 27. Figure 2-5: Claim with 28. Figure 2-6: Examples of Documentation Required for Billing .. 28. Figure 2-7: Third Party Recovery (TPR) Coverage Codes .. 34. Figure 2-8: Third Party Recovery (TPR) Fields on Paper Claim Forms .. 40. March 8, 2018 Page ii Idaho MMIS Provider Handbook General Billing Instructions 1. Section Modifications Publish Version Section Update SME. Date All Published version 3/8/18 TQD. Procedure Corrected ICD-10-PCS definition 3/8/18 W Deseron Codes D Baker E Garibovic Service Updated information for policy limitations 3/8/18 W Deseron Limitations D Baker E Garibovic All Published version 2/9/18 TQD.

6 Coordination of Changed members to participants 2/9/18 W Deseron Benefits D Baker Litigation E Garibovic Cases Modifiers Added Medical Waste of Drugs and 2/9/18 W Deseron Biologicals and added heading for D Baker Separate Encounters and Distinct E Garibovic Procedures . Procedure Updates to documentation requirements 2/9/18 W Deseron Codes without a Price D Baker on the Fee Schedule E Garibovic All Published version 1/29/18 TQD. All Document restructured and updated 1/29/18 W Deseron throughout E Garibovic D Baker C Loveless All Published version 1/6/18 TQD.

7 Co-payments Updated for TPA upgrade 1/6/18 T Humpherys Discrepancy D Baker Contact Information E Garibovic Signature on File Overview Medicaid Prior Authorization All Published version 12/29/17 TQD. Overview Updated for MMCP expansion 12/29/17 F Clarke E Garibovic All Published version 10/20/17 TQD. Medicaid Billing Added statement to indicate revenue codes 10/20/17 D Baker Policies not listed in UB04 Instructions are not E Garibovic covered All Published version 9/21/17 TQD. Resubmitting Added reference to exception for services 9/21/17 D Baker Crossover Claims matching MRN E Garibovic All Published version 9/7/17 TQD.

8 Medicaid Prior Removed reference to PAD list and added 9/7/17 E Garibovic Authorization (PA) reference to Fee Schedule All Published version 6/5/17 TQD. Retrospective New sections 6/5/17 W Deseron Review, and D Baker subsections E Garibovic Overview and Requests for Reconsideration and Appeals All Published version 5/26/17 TQD. March 8, 2018 Page 1 of 45. Idaho MMIS Provider Handbook General Billing Instructions Publish Version Section Update SME. Date Claim Review Changed original claim ID to most 5/26/17 C Van Zile Request current claim ID D Baker E Garibovic Procedure Updated statement about claims submitted 5/26/17 C Van Zile Codes without a Price without required attachments D Baker on the Fee Schedule E Garibovic All Published version 3/29/17 TQD.

9 2. General Billing Updated dental vendor information 3/29/17 C Loveless Information All Published version 3/23/17 TQD. Timely Filing Limit Clarified requirement is for start date of 3/23/17 D Baker Additional service E Garibovic Services on a Resubmitted Claim Resubmissions of Denied Claims All Published version 2/27/17 TQD. Paper Removed zero from CMS 1500 frequency 2/27/17 D Baker Adjustments codes E Garibovic All Published version 2/1/17 TQD. Wellness Exams New section 2/1/17 D Baker Medicaid Billing Added statement regarding cost centers 2/1/17 T Lombard Policies D Baker E Garibovic All Published version 12/30/16 TQD.

10 Interpretive Updates to documentation and payment 12/30/16 C Brock Services information D Baker E Garibovic Telehealth Changes regarding updated policy effective 12/30/16 C Brock Services 1/1/2017 D Baker E Garibovic All Published version 8/31/16 TQD. Overview [PA] Updated QIO information due to vendor 8/31/16 D Boyle QIO PA change D Baker Requests for Reconsideration and Appeals All Published version 8/25/16 TQD. Attachments Changed manufacturer's invoice to 8/25/16 D Baker manufacturer's MSRP ; added bullet about cost and shipping Procedure Added listing procedure code and plus 8/25/16 D Baker Codes without a Price shipping as applicable.