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 .. 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.

2 24. Determining How to Bill Units for 15-Minute Timed Codes .. 24. Claims Submission .. 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 .. 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.

3 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 .. 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. 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.

4 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. 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. 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.

5 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. 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.

6 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. 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 . on the Fee Schedule All Published version 7/14/16 TQD. 340B Pharmacy New section 7/14/16 J Siroky Billing D Baker All Published version 7/1/16 TQD.

7 Crossover Errors Changed six months to 365 days 7/1/16 D Baker All Published version 6/2/16 TQD. Third Party Added 0016 6/2/16 K McNeal Recovery (TPR) D Baker Coverage Codes All Published version 5/19/16 TQD. Participant Clarified information on supporting 5/19/16 R Natal Eligibility documentation for timely filing D Baker All Published version 3/1/16 TQD. Medicaid Billing Add section Provider Licensing 3/1/16 D Baker Policies L Windham All Published Version 1/22/16 TQD. March 8, 2018 Page 2 of 45. Idaho MMIS Provider Handbook General Billing Instructions Publish Version Section Update SME. Date Processing TPR Removed information concerning MRN 1/22/16 D Baker Claims requirement C Loveless Telehealth New Section added 1/22/16 D Baker Services C Loveless Medicaid Billing Added information on no-show or missed 1/22/16 D Baker Policies appointments C Loveless All Published version 12/1/15 TQD. Medicaid Removed section 12/1/15 C Coyle Participation D Baker Participant Updated for December 2015 COB changes 12/1/15 C Coyle Responsibility D Baker Coordination of Updated for December 2015 COB changes 12/1/15 C Coyle Benefits D Baker Medicaid Billing Updated for December 2015 COB changes 12/1/15 C Coyle Policies D Baker All Published version 9/25/15 TQD.

8 Medicaid Prior Additional information added for PAs and 9/25/15 C Brock Authorization (PA) modifiers; removed bullet indicated a PA J Siroky request must include HC referral number D Baker All Published version 9/10/15 TQD. Medicaid Prior Clarification regarding modifiers 9/10/15 C Brock Authorization (PA) C Taylor Overview Clarification for EPSDT services 9/10/15 C Brock C Taylor All Published version 8/28/15 TQD. Procedure Codes Updated for ICD-10 8/28/15 A Coppinger Split Claims J Siroky C Taylor D Baker All Published version 8/14/15 TQD. Claim Review Updates for overpayment process 8/14/15 C Taylor Request D Baker C Loveless Adjustments New section 8/14/15 C Taylor Beyond Two Years D Baker C Loveless Adjustments Up New section 8/14/15 C Taylor to Two Years D Baker C Loveless Overview Clarified amount of time for adjustments 8/14/15 C Taylor D Baker C Loveless All Published version 6/26/15 TQD. Paper Corrected frequency codes for CMS 1500 6/26/15 C Van Zile Adjustments D Baker Electronic Updated link to CARC/RARC list 6/26/15 D Baker Third Party Claims Third Party Updated name of carrier codes document 6/26/15 D Baker Recovery (TPR) Carrier Codes Completing the Removed reference to ADA Dental 6/26/15 D Baker Claim Form Instructions All Published version 6/4/15 TQD.

9 Exclusions Added prenatal care 6/4/15 C Taylor All Published version 5/21/15 TQD. Exclusions Updated list of services excluded from TPR 5/21/15 C Coyle requirements C Taylor All Published version 1/29/15 TQD. March 8, 2018 Page 3 of 45. Idaho MMIS Provider Handbook General Billing Instructions Publish Version Section Update SME. Date National Correct Section added 1/29/15 J Siroky Coding Initiative, and C Taylor subsections D Baker All Published version 12/18/14 TQD. Timely Filing Changed six months to 365 days 12/18/14 C Van Zile Limit; Medicare D Baker Processing; Timely Filing Documentation Interpretation Updated for clarity 12/18/14 F Trenkle- Services MacAllister C Taylor D Baker All Published version 9/25/14 TQD. Trading Partner Updated TPA User Guide link 9/25/14 H McCain Agreement C Taylor Documentation Added bullet for County Indigent Fund 9/25/14 C Taylor to Support Timely Filing Notification All Published version 08/08/14 TQD. Exclusions Changed Prenatal Care to Normal 08/08/14 C Taylor pregnancy diagnoses.

10 Overview Added PA requirement for claim 08/08/14 C Taylor All Published version 08/01/14 TQD. Timely Filing Changed AS OF date to notice date ; 08/01/14 C Taylor Limit; removed figure 2-4: Retroactive Eligibility Participant Eligibility; Letter/Notice of Action Figure 2-4: Timely Filing Chart All Published version 7/7/14 TQD. Figure 2-5: Timely Denials: deleted a remittance advice or a 7/7/14 C Taylor Filing Chart letter from EDS saying that they are no D Baker longer processing claims.. Documentation Updated to reflect current requirements 7/7/14 C Taylor to Support Timely Filing D Baker All Published version 7/2/14 TQD. Part A Dually Removed duplicate information 7/2/14 F Clarke Eligible Claims T Kinzler Hospital Billing Medicare Updated for clarity 7/2/14 F Clarke T Kinzler Overview Updated for clarity and MMCP 7/2/14 F Clarke T Kinzler Co-payments Removed sentence that amount would be 7/2/14 A Coppinger adjusted annually and Hospital bullet C Taylor All Published version 5/23/14 TQD.