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December 03, 2016

Medicaid Fee Schedule

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.

Any code listed may have a service limitation associated with it or need prior authorization from Medicaid or its designee. For more information, contact Molina Medicaid Solutions at 1 (866) 686-4272.

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 numerical fee schedule contains at least the following:

  • 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 Dollar Amount - 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 the General Information Section of your provider handbook for more information. This information can be found on the Molina website.

Anesthesia Fee Schedule

Codes specific to Anesthesia providers are billed to Medicaid where the total units for time are equal to 1 unit per minute. Base units will be added by the system automatically and should not be billed separately.

Ambulatory Surgical Center Fee Schedule 

Idaho Medicaid reimburses ASC providers based on levels. The current ASC code and assigned level can be found to the right under the "Current Fee Schedules". Below are the most current rates for each ASC level:

  • Level A = $100.00 

  • Level B = $150.00 

  • Level C = $200.00 

  • 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 

Reminders 

When using the fee schedule, remember the following:

  • 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. 

  • 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.

  • If you find a code not listed, contact Molina Medicaid Solutions at 1 (866) 686-4272, for more information.