Preferred Agents for Drug Classes Reviewed at July 21, 2006 and August 18, 2006 Pharmacy and Therapeutics Committee Meetings

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NEW DDA PROCEDURE CODE EFFECTIVE OCTOBER 1, 2006

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INCREASES IN REIMBURSEMENT RATES FOR CERTAIN NURSING

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HOME HEALTH MEDICAID CAPS

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STERILIZATION CONSENT FORM REQUIREMENTS

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TRANSITION OF PARTICIPANTS FROM BASIC TO ENHANCED DEVELOPMENTAL DISABILITIES AGENCIES (DDA) SERVICES

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TRANSITION OF PARTICIPANTS FROM BASIC TO ENHANCED MEDICAID MENTAL HEALTH SERVICES

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Preferred Agents for Drug Classes Reviewed at May 19, 2006 Pharmacy and Therapeutics Committee Meeting

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TRANSITION OF PARTICIPANTS FROM MEDICAID BASIC PLAN TO MEDICAID ENHANCED PLAN FOR SERVICE COORDINATION

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CHANGES TO MEDICAID COVERAGE AND REIMBURSEMENT

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CHANGES TO MEDICAID REIMBURSEMENT RATES

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NEW DDA PROCEDURE CODES EFFECTIVE JULY 1, 2006

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REIMBURSEMENT FOR HEARING AID BATTERIES

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CHANGES TO BILLING FOR INDIVIDUALS WITH A CLIENT CONTRIBUTION

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RATE INCREASE DEVELOPMENTAL DISABILITY SERVICES AND RESIDENTIAL HABILITATION SERVICES EFFECTIVE JULY 1, 2006

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ELIGIBILITY AND BENEFIT PLAN COVERAGE UNDER MEDICAID MODERNIZATION

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EPSDT RATE INCREASES AND EXPANDED COVERAGE FOR ADULT PREVENTIVE MEDICINE SERVICES EFFECTIVE JULY 1, 2006

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EXCLUSIONS AND LIMITATIONS OF MEDICAID BASIC PLAN BENEFITS

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PROVIDER QUALIFICATIONS

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Clarification of Medicaid Coverage for Children

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NOTICE OF CHANGE IN CODES FOR PSYCHOLOGICAL TESTING

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CLARIFICATION OF USE OF REGISTERED NURSE AND LICENSED PRACTICAL NURSE FOR SUPERVISORY VISIT AND ASSESSMENT AND EVALUATION

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HOURLY RESIDENTIAL HABILITATION (SUPPORTED LIVING) DAILY MAXIMUM

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NOTICE OF PHYSICIAN BILLING INSTRUCTIONS

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DAILY DOSAGE EDIT AND UNIT OF MEASURE EDIT

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72 HOUR EMERGENCY FILL FOR PRESCRIPTION MEDICATIONS

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INFORMATION REQUEST RELATED TO PCS WAGE DETERMINATION

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NOTICE OF 2006 MEDICAID RATES FOR SWING-BED DAYS AND ADMINISTRATIVELY NECESSARY DAYS (AND)

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CHANGES TO REIMBURSEMENT FOR MEDICARE PART B PSYCHIATRIC CROSSOVER CLAIMS FOR DUAL-ELIGIBLES

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School Based Services Rate Increase in three procedural areas    

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  Change in Medicaid Policy for Bariatric Surgeries

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  Change in Policy on billing for Immunizations

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  WAIVER COMMERCIAL TRANSPORTATION REIMBURSE

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Cancellation of Claim Cutback Policy

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MEDICAID BILLING POLICY FOR REHABILITATIVE SERVICES PROVIDED IN SCHOOLS

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Pharmacy billing when Medicaid is not the primary payer.

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Change in Adult Developmental Disabilities (DD) Transportation Prior Authorization (PA) Requirements for Commercial and Agency Transportation Providers

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CHANGES IN PRIOR AUTHORIZATION REQUIREMENTS FOR SPINAL NEUROSTIMULATORS

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Reimbursement Rate Increase-Transportation Providers

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NEW CONTACTS FOR REQUESTING NON-EMERGENT Transportation Prior Authorization

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ADDITIONAL TERMS to the MEDICAID PROVIDER AGREEMENT

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DENTAL: DOCUMENTATION REQUIREMENTS FOR BILLING BEHAVIOR MANAGEMENT (D9920)

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HOSPICE RATES

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PRIOR AUTHORIZATION CRITERIA FOR SKELETAL MUSCLE RELAXANT DRUG CLASS

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Replacing information in IR 2004-45: NEW PRIOR AUTHORIZATION CRITERIA FOR LONG ACTING OPIOID DRUG CLASS

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REPLACEMENT OF INFORMATION RELEASE 99-47: COLLECTION OF THE CLIENT CONTRIBUTION

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SUPPORTED LIVING (RESIDENTIAL HABILITATION) REIMBURSEMENT/SERVICE CHANGES EFFECTIVE SEPTEMBER 1, 2005

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Replacing information in IR 2005-11 for this drug class only: NEW PRIOR AUTHORIZATION CRITERIA FOR PROTON PUMP INHIBITOR DRUG CLASS

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PRIOR AUTHORIZATION CRITERIA FOR ALZHEIMER’S DRUG CLASS

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Replacing information in IR 2004-46 for this drug class only: NEW PREFERRED AGENTS FOR URINARY INCONTINENCE DRUG CLASS

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PRIOR AUTHORIZATION CRITERIA FOR LEUKOTRIENE DRUG CLASS

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PRIOR AUTHORIZATION CRITERIA FOR INHALED CORTICOSTEROID DRUG CLASS

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PRIOR AUTHORIZATION CRITERIA FOR INHALED BETA-2 AGONIST DRUG CLASS

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NEW PCS PAYMENT RATES EFFECTIVE JULY 1, 2005

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CHANGE IN MEDICAID COVERAGE FOR MALE CIRCUMCISION

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HOME HEALTH COST SETTLEMENT PROCESS

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CLARIFICATION OF DD and EPSDT SERVICE COORDINATOR AND PARAPROFESSIONAL RESPONSIBILITIES

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CHANGES TO ADULT DEVELOPMENTAL THERAPY CODES

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CHANGES IN REIMBURSEMENT METHODOLOGY FOR HOSPITAL-BASED AMBULANCE SERVICES

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NEW PRIOR AUTHORIZATION CRITERIA FOR 2ND GENERATION ANTIDEPRESSANT DRUG CLASS

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NEW PRIOR AUTHORIZATION CRITERIA FOR 2ND GENERATION ANTIHISTAMINE DRUG CLASS

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NEW PRIOR AUTHORIZATION CRITERIA FOR ANTIEPILEPTIC DRUG CLASS

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REPLACEMENT OF INFORMATION RELEASE 2004-35: New Prior Authorization Criteria for Ace Inhibitors Drug Class

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EVALUATING NURSING FACILITY’S LOWER OF COSTS OR CHARGES LIMITATION

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REPLACEMENT OF INFORMATION RELEASES 2004-14 & 2004-22: New Preferred Agents for Proton Pump Inhibitor and Triptan Drug Classes

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NOTICE OF 2005 MEDICAID RATES FOR SWING-BED DAYS AND ADMINISTRATIVELY NECESSARY DAYS (AND

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CHANGE IN BILLING PROCEDURES FOR PRESUMPTIVE ELIGIBILITY (PE) CLIENTS WHO ARE PREGNANT

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IDAHO MEDICAID DISPROPORTIONATE SHARE HOSPITAL (DSH) SURVEY

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High Risk Pregnancy Case Management

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NEW PRIOR AUTHORIZATION CRITERIA FOR ANGIOTENSIN II RECEPTOR ANTAGONISTS AND BETA ADRENERGIC BLOCKER DRUG CLASSES

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CLIENT NAME/NUMBER MISMATCHES

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BILLING CLARIFICATION AND INFORMATION CONCERNING HOW TO PROPERLY BILL IDAHO MEDICAID FOR RADIONUCLIDE/CONTRAST MEDIA

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ELECTRONIC BILLING INSTRUCTIONS

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REQUIREMENT OF NATIONAL DRUG CODE (NDC) FOR OUTPATIENT CLAIMS

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Effective August 1, 2003 the Idaho Medicaid program will reinstate the electronic edit process that ensures that all other known insurances have been billed for clients with other pharmacy insurance coverage.

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Immunization Guidelines Public Health DEPARTMENT Local/State CODES

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Effective for dates of service on or after August 1, 2002, any client living in an ICF/MR in need of a wheelchair may obtain one from a qualified Medicaid supplier and have the purchase billed to Medicaid.

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On July 1, 2004, Idaho Medicaid implemented the new Children’s Health Insurance Program-Part B (CHIP-B).

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Release was not issued.

On May 5, 2003, the Idaho Medicaid program will begin accepting pharmacy claims from retail pharmacies using NCPDP software Version 5.1 (which replaces the current versions ) or the new Idaho Medicaid billing software, PES (Provider Electronic Solutions).

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Effective for dates of service on or after October 20, 2003, Idaho will be converting the following state-only codes to the appropriate HCPCS or CPT codes in the table below. Please be aware that some codes will require a modifier to be attached when billing the appropriate code.

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Release was not issued.

Release was not issued.

Correction to July DME information release #MA02-20

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As a result of these audits, the Department is issuing this information release to clarify record keeping and program requirements for all pharmacy providers when dispensing prescriptions to Medicaid clients.

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The Division of Medicaid will continue to hold commercial transportation rates to the April 2000 fee schedule on file with the Medicaid Transportation Unit.

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GUIDELINES ON REPORTING AND TESTING DAY TREATMENT SERVICES PERFORMED FOR PARTICIPANTS IN A LICENSED DEVELOPMENTAL DISABILITY CENTER

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SURGICAL CODES FOR PRIOR AUTHORIZATION REVIEW

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Temporary rules have been instituted effective July 1, 2001 to include Licensed Marriage and Family Therapists as a reimbursable Medicaid provider in a Mental Health Clinic, and Rehabilitation Option for Mental Health Services agency.

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Effective November 1, 2001, the following State-only codes will be deleted.

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Effective October 1, 2001, Idaho Medicaid will adopt specific sections of coverage criteria that have been established by Cigna Medicare in regards to Positron Emission Tomography Scans (PET Scans).

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Effective October 1, 2001, Medicaid will increase its reimbursement for Personal Assistance Services (personal care and attendant services) for dates of service on or after October 1, 2001.

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HOSPICE RATES--Effective for dates of service on or after 4/1/2001

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NOTICE OF 2001 MEDICAID RATES FOR EACH SWING-BED DAY AND ADMINISTRATIVELY NECESSARY DAYS (AND)

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DENTAL PROCEDURE CODE ADDITIONS/DELETIONS/LIMITATIONS/FEE UPDATES

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HCPC CODE G0169 DISCONTINUED

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CODE CHANGES FOR PRIOR AUTHORIZATION

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Effective July 1, 2001 all Medicaid fees for the above providers will be increased by 3.2% per Idaho Code, Title 1, Chapter 56, Section 136.

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NEW PAYMENT RATES EFFECTIVE JULY 1, 2001

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INTESTINAL TRANSPLANTS AND CHANGES TO RETROSPECTIVE REVIEW REQUEST ATTACHMENTS

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Effective January 1, 2002, the following definition for prior authorization and valid prior authorization request will be applicable for durable medical equipment and supplies.

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Effective August 1, 2001, Medicaid will allow for Physician’s to bill for Locum Tenens and Reciprocal billing arrangements using the following guidelines

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C-PAP supplies are separately billable items that do not require prior authorization from the Department.

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Effective for dates of service on or after April 01, 2002, the Department now requires prior authorization for HCPCS code E0147, Heavy duty, multiple breaking system, variable wheel resistance walker. “Medicare covers “safety roller” walkers only in patients with severe neurological disorder or restricted use of one hand. In some cases, coverage will be extended to patients with a weight exceeding the limits of a standard wheeled walker.” (HCPCS Level II Expert 2002)

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IDAHO MEDICAID DISPROPORTIONATE SHARE HOSPITAL (DSH)

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NEW REIMBURSEMENT METHODOLOGY FOR MEDICARE PART B CROSSOVER CLAIMS

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INFORMATION REQUEST RELATED TO PCS WAGE DETERMINATION

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EXPANSION OF MEDICAID PHARMACEUTICAL PRIOR-AUTHORIZATION

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ELIMINATION OF INDEPENDENT RESIDENTIAL HABILITATION SUPPORTED LIVING PROCEDURE CODES

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Audits of Mental Health Clinic services found that some providers are providing partial care (mental health day treatment) services outside the clinic facility. Some clinic providers were taking clients on field trips, outings or other community activities.

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POLICY EXCEPTION FOR DENTAL SERVICES PROVIDED TO RESIDENTS IN ICF/MR FACILITIES

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POLICY EXCEPTION FOR DENTAL SERVICES PROVIDED TO RESIDENTS IN ICF/MR FACILITIES

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Medicaid policy for reimbursement of anesthesia services has been changed.

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Effective August 1, 2002, the following state-only codes will be deleted.

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Effective for dates of service on or after July 1, 2002, the billing procedure for Newborn Screening Kits (PKU) will be billable to the Idaho Medicaid program.

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Effective for dates of service on or after July 1, 2002, Medicaid will make some changes to its reimbursement for Personal Assistance Services (personal care and attendant services).

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Effective for dates of service on or after August 19, 2002, the Medicaid Pharmacy Program will change the process for quantity override requests. Currently override requests are billed to EDS on a paper claim with the prescription attached. The new procedure will require you to request the quantity override from the Medicaid Pharmacy Program prior to dispensing.

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In order to be compliant with the Health Insurance Portability and Accountability Act (HIPAA) and Medicaid's effort to align reimbursement rates with Medicare, the billing procedure for anesthesia will change.

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As published in the June 2002 issue of Medic/Aide, Medicaid Information Release MA-02-16 stated that clinic services are reimbursable only when provided in the actual clinic setting. This definition is clearly established in the Code of Federal Regulations at 42 CFR 440.90, which specifically defines Clinic Services as those services furnished to outpatients “at the clinic”.

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Any review received on or after September 30, 2002, by Qualis Health (formerly PRO-West), Idaho Medicaid's Quality Improvement Organization, will be reviewed utilizing InterQual® clinical appropriateness criteria. This criteria will be used to review for prior authorization of procedures and diagnoses on Idaho Medicaid’s Select Pre-Authorization List and for the length of stay reviews.

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In conjunction with the beginning of the 2002/2003 Respiratory Syncytial Virus (RSV) infection season, effective dates of service on or after September 1, 2002, Idaho Medicaid will no longer require prior authorization for Synagis to be reimbursed.

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A recent court ruling that has interpreted an amendment to statute has changed the requirements for state-funded abortions. For abortions performed with dates of service on or after July 1, 2002, the following rules apply:

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We would like to clarify our DME program guidelines regarding spacers, nutritional products, and diabetic test strips. The items mentioned below do not require prior authorization.

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Medicaid Information Release #2002-11 outlined the new reimbursement methodology for the processing of Medicare/Medicaid crossover claims effective May 1, 2002. Based on further clarification from CMS (Center for Medicare/Medicaid Services) and comments from providers, the system has been changed to insure that, for claims submitted electronically, the total payment will not exceed the Medicare allowed amount.

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Revised Policy of the Idaho Medicaid Dental Program

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The Idaho Medicaid Provider Handbook has been updated to include the current Hospice service guidelines. The most prominent revisions as of November 1, 2002, include the following:

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Effective immediately Medicaid point of sale (POS) pharmacy claims will allow the electronic billing of a 72-hour emergency supply of medication that requires prior authorization.

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Effective December 1, 2002, several changes in reimbursement and policy for Medicaid programs will be implemented.

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Effective for dates of service on or after November 1, 2002, cesarean section deliveries will be allowed a four-day inpatient length of stay before a continued stay review is required with the Department’s Quality Improvement Organization, Qualis Health.

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Release was not issued.

Effective for dates of service on or after December 1, 2002, Idaho Medicaid is adopting specific sections of the 2002 coverage criteria that have been established by Cigna Medicare for the following PET scan codes (2002 Cigna Medicare Coverage Issues Manual).

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When billing the procedure code, S5140, Certified Family Home Providers need to use the following modifiers based on the resident’s waiver program.

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1. Change in the Prior Authorization and Reimbursement Process for Clients Residing in Supported Living Arrangement 2. Change in documentation requirements for ESC/TSC authorization for crisis assistance hours.

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You recently received Information Release MA02-39 regarding program changes resulting from the need to meet a balanced state budget.

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Effective for dates of service on or after December 1, 2002, the following changes have been made to reimbursement for procedure code 0501P.

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Effective January 1, 2003, Medicaid will no longer accept claims for which providers have not accepted assignment when the electronic transmittal is received from CIGNA/Medicare.

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STREAMLINING OF THE INDIVIDUAL SUPPORT PLAN (ISP) AND ADDENDUM PROCESS FOR PERSONS WITH DEVELOPMENTAL DISABILITIES

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The Department, in accordance with the Rules Governing the Medical Assistance Program IDAPA 16.03.09.121.03a and b, is providing a list of approved procedures to all participating ASCs. We have updated the ASC and Hospital Provider Handbooks with the new codes, changes in level of reimbursement, and deleted codes.

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Outpatient Hemodialysis Billing Information and Home Dialysis Supplies and Equipment

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Effective for dates of service on or after 6/1/03, procedure code 5999I, Health Encounter will be obsolete. It will be replaced by the following Healthcare Common Procedure Coding System (HCPCS) codes:

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Effective for dates of service on or after March 1, 2003, Medicaid will change how we treat the payment for coinsurance and deductible for Medicare Part A nursing facility crossover claims.

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IDAHO MEDICAID DISPROPORTIONATE SHARE HOSPITAL (DSH) SURVEY

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CLARIFICATION OF GUIDELINES FOR SPECIAL RATES FOR NURSING FACILITIES

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Effective March 17, 2003, Medicaid is requesting all providers prescribe the preferred agents within the following classes of medications

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Effective for dates of service on or after October 20, 2003, Idaho will be converting the following PWC (Pregnant Women and Children) state-only codes to the appropriate HCPCS codes in the table below.

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Effective for dates-of-service on or after August 1, 2003, surgical trays, HCPCS code A4550 will be reimbursed in compliance with the Medicare reimbursement methodology. Separate payment for surgical trays (A4550) may be made if billed in conjunction with the following procedure codes only:

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This is a clarification regarding the billing of encounters.

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Beginning July 1, 2003, the hours for Targeted Case Management are being redistributed to five (5) hours monthly of non-crisis ongoing case management and three (3) hours monthly of crisis ongoing case management. This change was initiated by the Legislature with the addition of $147,900 in General Funds.

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Effective September 1, 2003, Idaho will be converting the following hearing aid state/local code to the appropriate HCPCS code in the table below.

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State-Only DME Codes Medical Necessity Documentation Format Lifetime Limits of DME Upgrades for DME Rolling Month Billing Cycle

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Idaho Medicaid is changing the current ground ambulance reimbursement methodology and rates to align more closely with Medicare’s bundled reimbursement rates for non-hospital based ground ambulance services.

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INFORMATION REQUEST RELATED TO PCS WAGE DETERMINATION

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Effective for dates-of-service on or after January 1, 2003, Medicaid will pay the following rates:

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In an effort to be consistent with Medicare policy and to avoid overpayments Medicaid is instructing providers to bill in the following manner

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MOBILE IMAGING UNIT BILLING FOR TECHNICAL RADIOLOGY SERVICES

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The new Federal Regulations called HIPAA (Health Insurance Portability and Accountability Act) Privacy become effective April 14, 2003.

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Children’s Dental Program Pregnant Women and Children (PWC) Program Adult Emergency Dental Program Services for High-Risk Adults Prior Authorization Billing changes for code D0460

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Effective May 5, 2003, the Idaho Medicaid Program will begin accepting pharmacy claims using NCPDP Version 5.1 format for electronic drug claims.

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Idaho Medicaid, by becoming HIPAA compliant, will no longer be accepting the reporting of state-only code 0714V for eyeglass fitting.

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EPSDT (Early and Periodic Screening, Diagnostic, and Treatment) Codes

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REIMBURSEMENT RATE CORRECTION

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ADULT DENTAL POLICY EFFECTIVE JULY 1, 2003 DENTURIST CDT-4 CHANGES

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IDAHO STATE-ONLY PROCEDURE CODES MODIFIER FP FAMILY PLANNING DIAGNOSES BILLING INSTRUCTIONS FOR ORTHO-EVRA AND NUVARING

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Some providers have received incorrect payments when billing according to instructions provided in Information Release #2002-32. Modifications have been made to the claims processing system to solve these problems and the following instructions are effective immediately

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MEDICAID PROVIDER NUMBERS FOR CERTIFIED FAMILY HOMES

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ENROLLMENT OF INDEPENDENT RESIDENTIAL HABILITATION PROVIDERS WHO PROVIDE ONLY “ALTERNATE CARE” AND CERTIFIED FAMILY HOME (CFH) OPERATORS

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The process for updating staff affiliation rosters has been changed. Previously, Mental Health Clinics and Mental Health Case Management providers were instructed to send in periodic updates of their Clinical Staff Affiliation Rosters, as part of their provider applications, to the Division of Medicaid’s Alternative Care Coordinator for Mental Health Services.

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Effective July 1, 2003, Medicaid will make some changes to its reimbursement for Personal Assistance Services (personal care and attendant services).

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AFFILIATION FEE RATE INCREASE

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RATE INCREASE

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Effective September 1, 2003, Idaho will be terminating the following vision state-only code. Effective for dates-of-service on or after May 1, 2003, the state-code 0702V was converted to the appropriate CPT code in the table below.

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State-Only Billing Codes for Transportation Services

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DEVELOPMENTAL DISABILITY AND IDAHO STATE SCHOOL AND HOSPITAL WAIVER State-Only procedure codeS

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Idaho State-Only EPSDT (Early Prevention, Screening, Diagnosis, and Treatment) Program Modifiers

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Effective for dates of service on or after October 20, 2003, Idaho will be converting the following state-only code, 0515D unable to deliver full denture, to the appropriate CDT-4 code in the table below.

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IDAHO STATE-ONLY DENTURIST PROCEDURE CODES

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Idaho State-Only Program Specific Procedure Codes for Exams When Requested by the Department for Program Requirements

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DME State-Only Procedure Codes

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Reporting Family Planning Services With New Modifier FP Family Planning Diagnoses

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NEW MODIFIER FOR FAMILY PLANNING SERVICES FAMILY PLANNING DIAGNOSES

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ENCOUNTER CODE T1015 NEW FAMILY PLANNING MODIFIER FAMILY PLANNING DIAGNOSES

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Effective for dates of service on or after October 20, 2003, Idaho will be converting the following state-only codes to the appropriate HCPCS codes in the table below.

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Requirement of National Drug Code (NDC)

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IMPLEMENTATION OF CARE MANAGEMENT FOR ADULTS WITH DEVELOPMENTAL DISABILITIES

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Reporting of Prescriber License Number Prior Authorized Medications – Update New Prior Authorization Procedure & ICD-9 Diagnosis Codes

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This Information Release will summarize the negotiation process used to update rules, highlight key changes, and provide clarification regarding requirements in Medicaid mental health service benefits.

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ENHANCED PRIOR AUTHORIZATION PROGRAM FOR MEDICAID PHARMACY PROGRAM

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Effective August 8, 2004, the Idaho Department of Health and Welfare (DHW) will update the State Maximum Allowable Cost (SMAC) program. The Idaho Department of Health and Welfare has contracted with Myers and Stauffer to provide assistance in establishing and maintaining the State Maximum Allowable Cost (SMAC) program for generic pharmaceuticals.

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NEW PRIOR AUTHORIZATION CRITERIA FOR LONG ACTING OPIOID DRUG CLASS Drug/Drug Class: LONG ACTING OPIOID Implementation Date: Effective for dates of service on or after October 1, 2004

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Effective July 1, 2004, Medicaid will make some changes to its reimbursement for Personal Assistance Services (personal care and attendant services). As required by Idaho Code and IDAPA 16.03.09.148, the Department conducted a salary survey to calculate the new rates. The maximum allowable amounts are based on wages and salaries paid for comparable positions within nursing facilities and intermediate care facilities for the mentally retarded (ICF/MRs). NOTE: Service provided on or before June 30, 2004,

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1. REVISED ISP FORMAT (Plan of Service): Information Replaces IR# 2003-05 dated January 17, 2003 2. PROVIDER STATUS REVIEW process begins September 1, 2004 for plans dated March 2004 as defined in IDAPA 16.03.13.06-07 available online at: http://www2.state.id.us/adm/adminrules/rules/idapa16/0313.pdf 3. PLAN MONITOR SUMMARIES are required for all Plans of Service developed on or after March 1, 2004

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HOSPITAL-BASED AMBULANCE SERVICES PROVIDER BILLING CLARIFICATION

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CONTRACEPTIVE COVERAGE

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NOTICE OF 2002 MEDICAID RATES FOR EACH SWING-BED DAY AND ADMINISTRATIVELY NECESSARY DAYS (AND)

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CORRECT BILLING PROCEDURES FOR OBSTETRIC CARE

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Effective December 1, 2002, several changes in reimbursement and policy for Medicaid programs will be implemented.

[Read the rest of this article...]

The Idaho Medicaid Provider Handbook has been updated to include the current Hospice service guidelines.

[Read the rest of this article...]

Revised Policy of the Idaho Medicaid Dental Program

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We would like to clarify our DME program guidelines regarding spacers, nutritional products, and diabetic test strips.

[Read the rest of this article...]

Effective for dates of service on or after November 1, 2002, cesarean section deliveries will be allowed a four-day inpatient length of stay before a continued stay review is required with the Department’s Quality Improvement Organization, Qualis Health.

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ADDITIONAL CHANGES IN STATE-ONLY CODES AND PROGRAM CHANGES/REMINDERS

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NEW PRIOR AUTHORIZATION CRITERIA FOR ESTROGEN, ORAL HYPOGLYCEMIC, AND URINARY INCONTINENCE DRUG CLASSES

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Effective for dates of service on or after 10/01/04, Medicaid has revised its hospice rates.

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RESIDENTIAL HABILITATION SUPPORTED LIVING REIMBURSEMENT/SERVICE LEVEL CLARIFICATION

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The Department would like to clarify the definition of D9430 to accomplish correct billing of this code

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DISENROLLMENT OF HEALTHY CONNECTIONS ENROLLEES FROM YOUR PRACTICE

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CLARIFICATION OF MEDICAID REIMBURSEMENT POLICY FOR BILLING THE COMPONENTS OF THE GLOBAL SURGICAL PROCEDURE CODES: PRE-OPERATIVE, INTRA-OPERATIVE AND POST-OPERATIVE

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Idaho Medicaid is pleased to announce that we are now able to accept Type of Bill 721, 722, 723, and 724 for dialysis claims. This will facilitate the crossover billing from Medicare.

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1. RESIDENTIAL HABILITATION SUPPORTED LIVING BILLING INSTRUCTIONS FOR DD AND ISSH WAIVER PARTICIPANTS ATTENDING PUBLIC SCHOOL 2. BILLING AND ADDENDUM PROCESS CLARIFICATIONS FOR MEDICAID INFORMATION RELEASE MA04-50

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Effective 7/1/04, pharmacies will be able to receive a returned drug fee of $6.00 each time they accept the return of unused medication from an Idaho Medicaid prescription (IDAPA 16.03.09. 817.07).

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MEDICAID MEDICAL NECESSITY REQUIREMENTS FOR THE ADMINISTRATION OF FLUMIST

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CORRECTION TO INFORMATION RELEASE 2003-87 CONCERNING AMERICAN DENTAL ASSOCIATION (ADA) 1999 (2000) RED INK CLAIM FORM

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This Information Release was not issued.

Informational Letter #2004-44 issued by Care Management.

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Informational Letter 2004-47 issued by Care Management

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Informational Letter 2004-49 issued by the Reimbursement Unit

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Effective for dates of service on or after April 1, 2004, optometrists may receive Idaho Medicaid reimbursement for corneal pachymetry, CPT code 76514

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This information release was not issued.

This release was not issued.

This information release was not issued.

Bariatric Surgery, Panniculectomy/Abdominoplasty

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Expansion of the UM/CM Neonate Program to All Hospitals

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EXPEDITED MEDICAID ELIGIBILITY FOR CERTAIN NEWBORNS

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This information release describes billing and service requirements for providing limited Medicaid mental health services through telemedicine technology.

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CLARIFICATION OF TIMELY FILING REQUIREMENTS

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Change in Medical Transportation Prior Authorization Requirements

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IDAHO MEDICAID DISPROPORTIONATE SHARE HOSPITAL (DSH) SURVEY

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ADDITION OF LIMITED INPATIENT MENTAL HEALTH SERVICES FOR CHIP-B PARTICIPANTS

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NEW SERVICES AND BILLING CODES FOR ADULTS WITH DEVELOPMENTAL DISABILITIES

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REPLACEMENT OF INFORMATION RELEASES 2004-14 & 2004-22: New Preferred Agents for Proton Pump Inhibitor and Triptan Drug Classes

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NEW PRIOR AUTHORIZATION CRITERIA FOR ACE INHIBITORS and CALCIUM CHANNEL BLOCKERS DRUG CLASS

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REPLACEMENT OF INFORMATION RELEASE 2003-76

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NEW PRIOR AUTHORIZATION CRITERIA FOR PROTON PUMP INHIBITORS

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CLARIFICATION OF DD and EPSDT SERVICE COORDINATOR AND PARAPROFESSIONAL RESPONSIBILITIES

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Home Health Cost Settlement Process

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CHANGE IN MEDICAID COVERAGE FOR MALE CIRCUMCISION

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PRIOR AUTHORIZATION CRITERIA FOR INHALED BETA-2 AGONIST DRUG CLASS

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PRIOR AUTHORIZATION CRITERIA FOR INHALED CORTICOSTEROID DRUG CLASS

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PRIOR AUTHORIZATION CRITERIA FOR LEUKOTRIENE DRUG CLASS

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Replacing information in IR 2004-46 for this drug class only: NEW PREFERRED AGENTS FOR URINARY INCONTINENCE DRUG CLASS

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PRIOR AUTHORIZATION CRITERIA FOR ALZHEIMER’S DRUG CLASS

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Replacing information in IR 2005-11 for this drug class only: NEW PRIOR AUTHORIZATION CRITERIA FOR PROTON PUMP INHIBITOR DRUG CLASS

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CHANGES IN REIMBURSEMENT METHODOLOGY FOR HOSPITAL-BASED AMBULANCE SERVICES

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Scope of Service Changes

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IDAHO MEDICAID DISPROPORTIONATE SHARE HOSPITAL

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INFORMATION REQUEST RELATED TO PCS WAGE DETERMINATION

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NOTICE OF 2006 MEDICAID RATES FOR SWING-BED DAYS AND ADMINISTRATIVELY NECESSARY DAYS

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ADULT DAY CARE PROVIDER BILLING

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NEW PCS PAYMENT RATES EFFECTIVE JULY 1, 2006

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EXCLUSIONS AND LIMITATIONS OF MEDICAID BASIC PLAN BENEFITS

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ELIGIBILITY AND BENEFIT PLAN COVERAGE UNDER MEDICAID MODERNIZATION

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NOTICE OF MATCH PAYMENT INSTRUCTIONS

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EPSDT RATE INCREASES AND EXPANDED COVERAGE FOR ADULT PREVENTIVE MEDICINE SERVICES EFFECTIVE JULY 1, 2006

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Preferred Agents for Drug Classes Reviewed at May 19, 2006 Pharmacy and Therapeutics Committee Meeting

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All medical care provided outside the state of Idaho is subject to the same utilization review and other Medicaid coverage requirements and restrictions as medical care received within Idaho.

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All medical care provided outside the state of Idaho is subject to the same utilization review and other Medicaid coverage requirements and restrictions as medical care received within Idaho.

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Referals from HC physicians

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Guidelines for crisis assistance hours

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TSC AND ESC Guidelines For Use of Crisis Assistance Hours

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Dental Guidelines section will contain instructions on how to properly fill out both the 1994 and the 1999 ADA claim forms.

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Requirements for authorization of admission to Institutions

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Drug/Drug Class: STATIN Implementation Date: Effective for dates of service on or after August 1, 2004

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Information Release 2003-78 was previously sent to providers to inform them of the state-only code conversions to the appropriate CPT and HCPCS codes. The large number of system changes at one time resulted in some errors that need to be corrected. Additionally, a few system adjustments were implemented to ensure accurate payment processing. Medicaid Information Release MA04-16 supersedes Medicaid Information Release 2003-78.

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Information Release 2003-79 was previously sent to providers to inform them of the state-only code conversions to the appropriate CPT and HCPCS codes. The large number of system changes at one time resulted in some errors that need to be corrected. Additionally, a few system adjustments were implemented to ensure accurate payment processing. Medicaid Information Release MA04-17 supersedes Medicaid Information Release 2003-79.

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Information Release 2003-76 was previously sent to providers to inform them of the state-only code conversions to the appropriate CPT and HCPCS codes. The large number of system changes at one time resulted in some errors that need to be corrected. Additionally, a few system adjustments were implemented to ensure accurate payment processing. Medicaid Information Release MA04-12 supersedes Medicaid Information Release 2003-76.

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DSH Survey

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Case-Mix Weights and Limit Percentages

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EDS will return or deny any claims that have unidentified Medicare EOBs attached

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The purpose of this Information Release is to clarify: billing for evaluations (History and Physicals - H&Ps) for DD Waiver clients, and determining need for nursing services for the DD Waiver client.

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3/1/00 sample letter to assist in meeting 3/1/00 "Medical Care guidelines for DD and ISSH Waiver Participants" and Certified Family Home rules for Specialized Family Home residents

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Guidelines for Medical Care Arrangements for DD and ISSH Waiver Participants

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The Guidelines for Medical Care Arrangements for individuals on the Developmental Disabilities (DD) and Idaho State School and Hospital (ISSH) waivers have been modified to clarify the process of planning for the medical care of individuals on these waivers. These new guidelines are effective March 1, 2000.

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Information release 2000-02 and 2000-06 concern out-of-state admissions.

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Effective May 1, 1999, Medicaid eliminated the state-only codes of 0100J, 0200J, and 0300J and replaced them with the new 1999 CPT codes 90471 and 90472. The 2000 CPT book has changed the description of procedure code 90472 to be for each additional vaccine instead of for two vaccines or more.

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the Department has developed a special rate for consumers who have long term care needs beyond the scope of facility services

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Each year, the Department gathers information from all Nursing Facilities (including those which are hospital-based) and Intermediate Care Facilities for the Mentally Retarded in order to determine wage data for select employees within the nursing home industry

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2000 MEDICAID RATES FOR EACH SWING-BED DAYS

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PROSPECTIVE PAYMENT SYSTEM

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As an agency provider you cannot allow your staff to use their personal vehicles to transport clients to your program and bill under your agency provider specialty.

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1. OXYGEN CERTIFICATE OF MEDICAL NECESSITY 2. CLARIFICATION OF PHYSICIAN’S ORDERS FOR DURABLE MEDICAL EQUIPMENT AND SUPPLIES

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Effective immediately, the Department will be establishing Nursing Facility (NF) level of care based on the procedures identified below.

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This Information Release is a corrected version of Information Release 2000-17. The original release is missing vital information; please discard it. We apologize for any inconvenience or confusion this may have caused.

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Medicaid Non-Emergent Transportation Update

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MODIFICATION OF GUIDELINES FOR DURABLE MEDICAL EQUIPMENT SUPPLIES (DME), SPECIALIZED MEDICAL EQUIPMENT AND SUPPLES (SME), AND HOME MODIFICATIONS FOR THE DEVELOPMENTAL DISABILITY (DD) AND IDAHO STATE SCHOOL AND HOSPITAL WAIVERS (ISSH)

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Idaho Medicaid is establishing the following criteria and limitations for the rental of Bilirubin Lights for newborns

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1. RESOURCE BASED RELATIVE VALUE SCALE (RBRVS) 2. NEUROSURGERY

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Effective July 1, 2004, there was a rate increase for code S5140-U2 (Adult Residential Care) for Certified Family Homes and Residential and Assisted Living Facilities that bill this code. All Residential Care providers will receive a letter notifying them of the new rate for each of their clients. If you do not receive a letter for a participant living in your facility, please notify your local Regional Medicaid Services unit. Billing system changes for claims with dates of service on or after July 1, 200

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TO: All Non-Commercial Medicaid Transportation Providers (Agency/ Individual) FROM: KATHLEEN...

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REVISION OF THE GUIDELINES TO EVALUATE COST EFFECTIVENESS OF PLANS FOR THE DEVELOPMENTAL DISABILITY (DD) AND IDAHO STATE SCHOOL AND HOSPITAL (ISSH) WAIVER, AND TIMEFRAMES FOR INDIVIDUAL SUPPORT PLAN SUBMISSION

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1. SHORT-TERM WHEELCHAIR RENTAL 2. REIMBURSEMENT RATES FOR DURABLE MEDICAL EQUIPMENT AND SUPPLIES

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Effective May 15, 2000 the Third Party Liability claims will be accepted without an Explanation of Benefits (EOB) if the other insurance payment amount is 40% or more of your billed charges.

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Effective July 1, 2000, Medicaid will change its reimbursement for personal care services (PCS) and other related services.

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Annual Rate Increase

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The attached guidelines for supported living were developed to assist targeted service coordinators and person-centered planning teams when consumer’s individual support plans exceed the cost effectiveness level determined for the Developmental Disability waiver and the Idaho State School and Hospital waiver.

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Senate Bill 1365 was passed by the Idaho Legislature, and becomes effective on July 1, 2000. While the Department is currently in the process of developing rules to implement this legislation, one major effect of this legislation is the requirement of all hourly Personal Care Service providers to become either employees of a PCS or Aged and Disabled Waiver agency, or an employee of record of a fiscal intermediary.

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The Department of Health and Welfare will be performing system maintenance beginning at 10:00 p.m., July 7, 2000, and ending at 7:00 a.m., July 11, 2000.

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CHANGES IN MEDICAL TRANSPORTATION - SENATE BILL 1530 – UNDUE HARDSHIP CRITERIA

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Effective July 1, 2000, two major changes are being made to the payment for Attendant Care under the Aged and Disabled Waiver

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CHANGE FOR HOURLY PERSONAL CARE AND RN VISIT

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Modification of guidelines for durable and specialized medical equipment and supplies and development of guidelines for environmental modifications for the developmental disability waivers, aged and disabled waiver and traumatic brain injury waiver.

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DEBRIDEMENT

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The Department has revised the Special Rate guidelines included in information release #2000-16 dated March 15, 2000. This change is the result of additional comments from a negotiated process.

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Prior Authorization for Physical Therapy Visits

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Effective September 1, 2000, Medicaid will no longer require prior authorization for the following dialysis supplies.

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This Information Release is a corrected version of Information Release 2000-35. The original release is missing vital clarifying information, please discard it. We apologize for any inconvenience or confusion this may have caused.

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The Department has received information indicating providers may be performing "co-therapy" or "co-treatments", defined as multiple therapies with a client during a single time period.

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NEW RULES AND REIMBURSEMENT FOR COMMERCIAL VS. NON-COMMERCIAL NON-EMERGENCY TRANSPORTATION PROVIDERS

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We wanted to remind you of a very important change that occurs Friday, September 1, 2000. Effective that date, all independent Personal Care Attendants are required to join or bill through an agency.

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Effective September 15, 2000, retrospective review requests will no longer be required to be sent to the Department for approval before PRO-West performs the review.

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Effective October 1, 2000, all requests for prior authorization of Durable Medical Equipment and supplies should be submitted to the Department at the address and fax number below. PRO West will no longer be processing these requests.

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The Department will pay school districts and other public agencies for covered rehabilitative and health related services pursuant to IDAPA 16.03.09, 560 "Rules Governing Medical Assistance."

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On October 1, 2000, Department staff will replace PROW as the entity that authorizes medical equipment and supplies for the Idaho Medicaid program. To assist in this transition, effective immediately, please use the following guidelines when submitting DME and supplies requests.

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The Department has recently responded to a number of provider requests for information regarding the changes in the Medicaid Transportation program, which will occur on or after October 1, 2000. The following items will hopefully provide clarification to the majority of the questions

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Effective for dates of service on or after 10/01/2000, Medicaid has revised its hospice rates

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BILLING FOR GLOVES AND ORAL NUTRITIONAL PRODUCTS OXYGEN MEDICAL NECESSITY DOCUMENTATION

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Billing procedures

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The Department of Health and Welfare (DHW), Division of Medicaid, is pleased to announce that effective January 1, 2001, information currently sent to Idaho Medicaid Providers utilizing the Information Release process, will now be included in the monthly MedicAide Newsletter. Information Releases, in their present format, will only be sent on an exception basis.

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NEW BRAND NAME VS. GENERIC POLICY FEDERAL UPPER LIMIT (FUL) AND STATE MAXIMUM ALLOWABLE COST (SMAC) – EFFECTIVE DECEMBER 7, 2000

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Due to changes in Idaho law, the Department has been working with various public and private transportation representatives to redesign and improve Medicaid transportation services. As you know, part of this process was the re-enrollment of providers to designate a provider type, which occurred in September of this year. In addition, temporary rules were developed with an effective date of October 1, 2000. These were published as Docket Number 16-0309-0011 in the October 4, 2000 Idaho Administrative Bulleti

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Published in the MedicAide, 3/01. See page 8

Effective for inpatient admissions that begin on or after February 3, 2002, a new length of stay (LOS) criteria will be used to determine when the admission requires a PRO-West re-certification review.

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Effective February 3, 2002, approximately half of all CPT codes will be brought into alignment with the 2002 Idaho Medicare Fee Schedule.

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EARLY REFILL EDIT AFTER HOURS EMERGENCY MEDICATION ANTI-EMETIC PRIOR AUTHORIZATION FEDERAL UPPER LIMIT (FUL) CHANGES

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During the 2002 session, the Idaho Legislature attached language to the Medicaid appropriation bill directing the Department of Health and Welfare to reduce Medicaid dental coverage for adults to emergency services only.

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Effective April 1, 2002, Idaho Medicaid will cover, without prior authorization (PA), up to four prescription drugs or drug products per calendar month for eligible persons 21 years of age and older, beginning the calendar month following their 21st birthday.

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Effective August 15, 2003, Intensive Behavioral Intervention Services billed by a school-based provider, regardless of who delivers the service, will no longer require prior authorization from the Medicaid Central Office.

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Revenue Code 400 for PET Scans until October 20, 2003 Cesarean Sections Length of Stay Policy Effective September 1, 2003

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CHANGES FOR BEHAVIORAL HEALTH CARE MANAGEMENT FOR ADULTS WITH A DEVELOPMENTAL DISABILITY FOR DATES OF SERVICE ON OR AFTER APRIL 1, 2004. 1. Prior-Authorization by dollars rather than units. 2. Prior-Authorization for Medical Social History performed by a DDA. 3. Contents and Distribution of the ISP Packet. 4. Billing for Plan Development (G9007) and Plan Monitoring (G9012). 5. Modifications to the Durable Medical Equipment and Specialized

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NEW DENTAL PRIOR AUTHORIZATION PROCESS REIMBURSEMENT CHANGES FOR D9230 MANDATORY USE OF ADA 1999 (2000) CLAIM FORM

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Effective October 1, 2003, the following new ICD-9-CM procedure codes have been added to the Idaho Medicaid Select Pre-Authorization List.

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Effective October 1, 2003 for Medicaid clients, nursing homes must file claims with other insurances that cover long-term care services prior to filing claims to Medicaid for payment.

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Hospital Revenue Code Changes Hospital-Based Ambulance Services

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All of the criteria listed below must be met before services can be provided.

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Effective for dates of service on or after October 20, 2003, Idaho will be converting the following state-only codes to the appropriate HCPCS codes in the table below.

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Each year, the Department gathers information from all Nursing Facilities (including hospital-based facilities) and Intermediate Care Facilities for the Mentally Retarded to determine wage data for select employees in the nursing home industry

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Effective March 1, 2004, participant services authorized through the Adult DD Care Management business model follow the process below to obtain evaluations required by IDAPA 16.04.11.

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The Department recently met with representatives of the Case Management Association of Idaho and the Mental Health Providers Association of Idaho to discuss the need for the provision of crisis case management. Through this collaborative effort, the group was able to develop language and criteria for the provision of crisis case management services to adults with severe and persistent mental illness. This new language and criteria will appear in an amendment to temporary rule that will be published in the M

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Effective October 7, 2002, the State of Idaho will begin using the National HIPAA Adjustment Reason Codes.

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Idaho Medicaid has recently identified significant opportunities for improving the prescribing of long-acting opioid analgesics for chronic pain. Long-acting opioid analgesics are frequently prescribed for Medicaid clients for use in non-malignant chronic pain such as chronic back pain, headaches, osteoarthritis, and neuropathic pain.

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Effective for dates of service on or after 10/01/02, Medicaid has revised its hospice rates.

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Clozapine is a psychotropic medication that requires coordination and close medical oversight. Currently Clozapine is the only medication for which Medicaid makes a separate payment for care coordination.

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On May 5, 2003, the Idaho Medicaid program will implement the standard HIPAA eligibility transaction ASC X12 270/271, version 4010A1.

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Currently, Idaho Medicaid rents certain DME that is considered outside of the nursing facility Content of Care. Medicaid will now determine if the DME will be a rental or purchased item. Some equipment to be considered for purchase may include, but are not limited to, specialized hospital beds, specialized pressure relieving mattresses or overlays, and highly specialized wheelchairs.

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On April 15, 2003 an incorrect version of Information Release 2003-25 was mailed out. This document replaces the previous document.

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Effective May 1, 2003, Medicaid is requesting all providers prescribe the preferred agents within the following classes of medications

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Non-Citizen Emergency Medical Documentation for Labor and Delivery and Other Emergency Medical Requests

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The new Federal Regulations called HIPAA (Health Insurance Portability and Accountability Act) allow the use and disclosure of identifying or protected health information between “covered entities” to provide treatment, payment or health care operations (45 CFR Part 164.506).

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CHANGE IN NON-HOSPITAL-BASED AIR AMBULANCE REIMBURSEMENT METHODOLOGY

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1. Prior authorization for plan development hours (G9007) 2. Distribution of medical care evaluation form

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Effective for dates of service on or after 7/1/2004, use these guidelines to bill ultrasound and fetal stress/non-stress test procedures for a multiple pregnancy

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Information Release 2003-75 was previously sent to providers to inform them of the state-only code conversions to the appropriate CPT and HCPCS codes. The large number of system changes at one time resulted in some errors that need to be corrected. Additionally, a few system adjustments were implemented to ensure accurate payment processing. Medicaid Information Release MA04-11 supersedes Medicaid Information Release 2003-75.

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Effective for dates of service on or after 10/01/03, Medicaid has revised its hospice rates

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Effective July 1, 2004, Idaho Medicaid will implement the new Idaho Title XXI Children’s Health Insurance Program-Part B (CHIP-B).

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The CHIP-B program offers limited medical coverage to qualified applicants.

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Drug/Drug Class: Cox-2 Inhibitors Implementation Date: Effective for dates of service on or after March 1, 2004

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DSH Survey

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Information Release 2003-77 was previously sent to providers to inform them of the state-only code conversions to the appropriate CPT and HCPCS codes. The large number of system changes at one time resulted in some errors that need to be corrected. Additionally, a few system adjustments were implemented to ensure accurate payment processing. Medicaid Information Release MA04-15 supersedes Medicaid Information Release 2003-77.

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Effective 7/1/04, pharmacies will be able to receive a returned drug fee of $6.00 each time they accept the return of unused medication from an Idaho Medicaid prescription (IDAPA 16.03.09. 817.07).

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AUTOMATED PRIOR AUTHORIZATION PROCESS AND CALL CENTER FOR MEDICAID PHARMACY CLAIMS

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CLARIFICATION OF INFORMATION RELEASE MA02-19: BILLING SEPARATE ANESTHESIA SESSIONS ON THE SAME DAY

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ENHANCED PRIOR AUTHORIZATION PROGRAM FOR MEDICAID PHARMACY PROGRAM

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NEW PRIOR AUTHORIZATION CRITERIA FOR STIMULANT MEDICATIONS

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PROCEDURE CODE CHANGES FOR RESIDENTIAL HABILITATION - SUPPORTED LIVING

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Effective for dates of service on or after October 20, 2003, Idaho will be converting the following state-only codes to the appropriate HCPCS or CPT codes in the table below. Please be aware that some codes will require a modifier to be attached when billing the appropriate code.

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Effective for dates-of-service on or after January 1, 2003, the following DME items are a benefit of Idaho Medicaid program.

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Effective for dates of service on or after October 20, 2003, Idaho will be converting the following state-only codes to the appropriate HCPCS or CPT codes in the table below.

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MEDICAL CARE EVALUATION FOR ASSESSMENT OF ADULTS WITH DEVELOPMENTAL DISABILITIES

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Effective for dates-of-service on or after May 1, 2004, the HCPCS code for Surgical Trays, A4550, will be reimbursable only when the following CPT codes are billed with a Place of Service Code - 11 (office), on the CMS-1500 form

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Starting July 1, 2003, the following rates will be effective for personal care services

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Effective August 1, 2003, the new code to use for Language and Deaf Interpretation which encompasses all sign language or oral interpretive services is state-only code 8296A (Interpretive Services).

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NOTICE OF 2004 MEDICAID RATES FOR SWING-BED DAYS AND ADMINISTRATIVELY NECESSARY DAYS (AND)

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HIPAA ELECTRONIC PRIOR AUTHORIZATION (PA) TRANSACTION AVAILABLE FEBRUARY 23, 2004

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As you are aware, providers are required to use the International Classification of Diseases 9th Revision, Clinical Modification (ICD-9-CM), Volumes 1, 2 and 3 for medical claim billing to Idaho Medicaid. Included in these code sets are E codes, which are supplementary classification of external causes of injury and poisoning (E800-E999).

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Effective for dates of service on or after April 1, 2004, optometrists may receive Idaho Medicaid reimbursement for corneal pachymetry, CPT code 76514.

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CORRECTION TO INFORMATION RELEASE 2003-87 CONCERNING AMERICAN DENTAL ASSOCIATION (ADA) 1999 (2000) RED INK CLAIM FORM

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Additional information concerning Medicaid Information Release MA03-69, “Requirement of National Drug Code (NDC)”

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