For most services, Idaho Medicaid reimburses providers the lesser of the billed amount or the maximum allowable fee established by the Idaho Department of Health and Welfare Division of Medicaid, whichever is lower.

Reimbursement rates may change during the year without update to the Internet fee schedule information. See Reminders Section below for additional information.

How to Read It

The Fee Schedule lists for each:

• Procedure Code — Numerical identifier (generally CPT or HCPCs) for medical services or supplies.
• Procedure Description — Description of the procedure. For additional details, refer to the most current CPT or HCPCS code books.
• Reimbursement Allowable information for dates of service July 1, 2003, through the present. If a Professional or Technical Component is involved, the percentage is indicated in the appropriate column, if applicable. Percentage is based on Allowable Amount.

NOTE: A zero price does not mean it is not a covered service. It could be a manually priced service, or reimbursement is based on invoice. Refer to Section 3 of your provider handbook for more information.

• For more information, see Reminders below.

How to Search

The Fee Schedule list is searchable based on procedure code. To search:

1. Open the Numerical Fee Schedule (Acrobat Reader is required. If you do not have Adobe Acrobat Reader 5.0 to view this file, click on the icon to download.)
2. Go to the tool bar and click the binoculars icon.
3. Enter Procedure code you are looking for.
4. Click on Find Next.

Reminders

When using the fee schedule, remember:

• Idaho Medicaid requires all providers to bill their usual and customary charge for services provided to Medicaid recipients. Therefore, providers should not use the fee schedule to set their rates. "Usual and customary charge" means the provider's charge for providing the same service to persons not eligible for Medicaid benefits.
• If you find a code not listed, contact Idaho’s Fiscal Agent, EDS at (800) 685-3757, for more information.
• Any code listed may have a service limitation associated with it or need prior authorization from Medicaid or its designee. For more information, refer to your specific provider handbook section 3 at Handbooks or contact EDS at (800) 685-3757.
• Different areas of a provider's office, such as billing and medical services, may have different uses for fee schedule information. Share schedule and handbook information with appropriate staff.
• Questions? Visit our FAQ section.

How to Obtain a Copy

Numerical List — Sorted by procedure code. Does not include State Only or Anesthesia codes.

1. Go to the section below titled CURRENT INFORMATION to open and print: 

• Anesthesia List — Codes specific to Anesthesia providers. Anesthesia codes are billed as base units (Medicare standard) plus time reported in minutes and reimbursed at $1.00 per minute.
• Dental List — Codes specific to dental providers.
• Idaho Medicaid ASC Codes — Codes accepted by Idaho Medicaid, if performed in an Ambulatory Surgical Center (ASC).
• Provider Specific Reimbursement Rates - Idaho Medicaid reimburses ASC providers based on levels. Below are the most current rates for each ASC level:
  • Level 1 = $293.88
  • Level 2 = $393.49
  • Level 3 = $451.28
  • Level 4 = $555.88
  • Level 5 = $634.58
  • Level 6 = $789.00
  • Level 7 = $879.66
  • Level 8 = $923.80
  • Level 9 = $1022.65
    
    
• Historical Information — Information prior to latest update. 

2. Electronic copies: Contact EDS at (800) 685-3757 for a diskette. There is a fee.

 

 

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