Information for Medicaid Providers

Idaho Medicaid contracts with Gainwell Technologies for the MMIS claims processing center, provider training, billing, and operational support for all Medicaid providers.

About Idaho Medicaid

Idaho Medicaid offers four different plans to meet the individual needs of members:

  • Standard – Provides only federally mandated benefits. All members have the option to select this Standard Plan.
  • Basic – Benefits include preventive as well as medical, dental, and vision services for members who meet income standards.
  • Enhanced – Benefits include Basic Plan benefits plus long-term, developmental disability, and behavioral health services and supports for members who are eligible due to disabilities or have special health needs.
  • Medicare Medicaid Coordinated – For members who are eligible and enrolled in both Medicare and Medicaid. This plan includes the same benefits identified in the Enhanced Plan but include an option to receive services through a Medicare Advantage Plan of their choice.

Idaho Medicaid contracts with Gainwell Technologies, to provide claims processing, provider training, billing, and operational support for all Medicaid providers.

Prime Therapeutics provides these services for the pharmacy program.

  • If you are a provider that renders behavioral health services, who is enrolling, or has enrolled with Gainwell Technologies, you may also be required to enroll and maintain your provider record with Magellan of Idaho. For more information, please contact Magellan of Idaho.
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Gainwell Health PAS
To login to Idaho Medicaid Health PAS, please visit their portal.
Provider Handbooks
For information about billing, provider requirements and guidelines.
Medicaid Provider Exclusion List
This is a list of providers, individuals, and entities that are excluded from participation in the Idaho Medicaid Program.
Health Care Provider Self-Report
Use this form to self-report things such as services being incorrectly coded, services were provided by an unlicensed or excluded individual, services were not rendered, or services are outside the two-year period for adjusting claims.

Resources

Medical provider authorization forms

Find provider prior authorization forms to request services such as Durable Medical Equipment, Chiropractic Services, and others.

Medicaid newsletter for providers

The MedicAide newsletter is a monthly publication that communicates information to Medicaid providers and other interested parties.

Information Releases

Idaho Medicaid issues Information Releases (IR) to providers to update them on policy, billing, and/or processing changes.

Fee schedules

For most services, Idaho Medicaid reimburses providers the lesser of the billed amount or the maximum allowable fee established by the 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 the Provider Services team at Gainwell Technologies.

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 the Provider Handbook for more information.

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.
  • If you find a code not listed, contact the Provider Services team at Gainwell Technologies for more information.
Idaho Medicaid Public Schedule of Premiums and Cost-Sharing

In accordance with federal regulations at 42 CFR 447.57, the Department of Health and Welfare is making available a public schedule describing current Medicaid premiums and cost-sharing requirements. See the full document below:

Idaho Medicaid Public Schedule of Premiums and Cost-Sharing

Hospital Prospective Payment System: DRG and APC

Frequently Asked Questions (FAQ), provider trainings, and payment calculators are resources for acute care hospitals subject to reimbursement through 3M TM All Patient Refined DRG (APR DRG) Software.

Acute care hospitals will be subject to reimbursement through Ambulatory Payment Classifications (APCs) starting July 1, 2024.  The list of procedure codes that are paid at the fee schedule rate starting July 1, 2022, to prepare for APCs is listed under APC Prep – Fee Schedule Paid Procedure Codes.

The resources related to 3M APR DRG reimbursement and the APC transition preparation can be found in the Hospital Prospective Payment System: DRG and APC library.

Medicaid Notice of Property Transfer Forms

Prior Authorizations for Therapy (PT, OT, Speech)

Effective January 1, 2026, physical therapy (PT), occupational therapy (OT), and speech-language pathology (SLP) services will require a prior authorization when the total number of visits exceed 20 in a calendar year per discipline (therapy type). 

  • Each member will be allowed 20 visits per calendar year for PT, OT, and SLP services before prior authorization is required.
  • Any request for services beyond the initial 20 visits must be submitted for prior authorization. All requests will be reviewed by clinical staff in the Idaho Medicaid Medical Care Unit to ensure medical necessity.
  • Services provided by home health agencies, the Infant Toddler Program, and school-based providers are exempt from the 20 visit threshold.

Please review Idaho Medicaid Information Release MA26-05 Therapy Service Limitations for additional information. 

Provider Frequently Asked Questions

How do providers submit requests for prior authorization?

Complete the Idaho Medicaid Therapy Service Prior Authorization Form, available on the Gainwell Technologies website (under Reference Material - DHW Forms). The form includes required documentation and how to submit the request. 

Can a provider submit a prior authorization request before the 20 initial visits have been exhausted? If so, is there a particular visit requirement that must be met before submitting?

A provider may submit a prior authorization request once they can complete the form and send in all required documentation in its entirety. It is recommended that providers do not send in a request more than 60 days in advance to ensure the request is reflective of the member's current status.

Required documentation:

  • Completed prior authorization form
  • Current therapy evaluation
  • Current Plan of Care to include measurable short and long-term goals, frequency, and duration of the recommended therapy
  • Orders: All therapy services must be ordered by a physician, nurse practitioner, or physician assistant
  • Last five treatment notes (needed for requests for continuation of care only)
Will prior authorization be allowed for blocks of care, such as intensive therapy programs?

Providers should submit the plan of care that identifies the need of the member (including how many days per week, for the number of weeks necessary, as well as the appropriate documentation to ensure medical necessity.

Can one prior authorization be done for both intensive care and regular care, when they are two separate plans of care, or are two prior authorizations required for the intensive care vs regular care?

Two plans of care within the same discipline can be requested on one prior authorization form. The two types of therapy and the number of visits per week, for the number of weeks necessary can be identified on the prior authorization request form.

Do the prior authorizations have to be sent individually, or can they be sent together in bulk?
  • Due to HIPAA, requests for multiple members can't be submitted in one request. This means requests can't be submitted together for multiple members in one single fax submission, or one single portal upload.
Do providers need to submit separate prior authorization requests for SLP, OT, and PT or can they all be submitted on one request form?

For quicker turnaround times, and to ensure proper documentation has been received, it is preferred that a provider submit one request form per discipline. 

Will providers be limited to the exact units requested on the authorization for each CPT code?
  • The prior authorization requests will be reviewed for medical necessity for the number of visits based on the request and supporting documentation. Authorizations may be approved in full or may receive partial approval, they won't be approved for more than the plan of care identifies or more than is requested.
  • The requests should include the necessary frequency and duration requested per discipline (PT/OT/Speech) and not per CPT code within those visits.
Should therapy services continue while the prior authorization request is under review, or must services pause until approval is issued?
  • It is recommended that providers plan and account for review times when submitting requests. Providers can submit a prior authorization request up to 60 days in advance of the anticipated start date. To avoid interruptions to care, retroactive authorizations may be granted in certain circumstances.
  • To account for potential delays in review times, Medicaid will authorize visits from the date the request is received through the date the review is completed regardless of the determination.
Is it possible to submit the request more than 60 days before the request date?

This is allowable, but not recommended. Please keep in mind that requests must reflect the dates indicated within the plan of care.

Is requesting authorized visits by discipline, rather than listing all potential CPT codes acceptable?

The prior authorization request should indicate the number of visits and number of weeks being requested per discipline. The request does not need to include each CPT code.

What does this process look like for members who have secondary or supplemental insurance coverage?

This would be determined by the primary plan

  • If the primary insurance is a private insurance, the provider must submit a prior authorization to Medicaid as well
  • If the primary insurance is Medicare, no prior authorization requests need to be submitted to Medicaid
  • If the member is a dually eligible Medicaid member (UHC or Molina), the provider must follow the prior authorization requirement as determined by UHC or Molina.
If a provider submits a claim to Medicaid, even if Medicaid is secondary and pays $0.00, will the claim count against the 20-visit threshold?

If a claim is submitted for OT/PT/ST visit, it will count as a visit towards the 20-visit threshold.

Are we able to authorize diagnoses for multiple treatment areas (i.e. left knee, neck, and low back) in a single authorization? Or are authorizations limited to a single treatment area?

The prior authorization will be authorized by discipline and by visits, regardless of treatment area

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