Idaho Medicaid contracts with Gainwell Technologies for the MMIS claims processing center, provider training, billing, and operational support for all Medicaid providers.
Idaho Medicaid offers four different plans to meet the individual needs of participants:
- Standard – Provides only federally mandated benefits. All participants have the option to select this Standard Plan.
- Basic – Benefits include preventive as well as medical, dental, and vision services for participants who meet income standards.
- Enhanced – Benefits include Basic Plan benefits plus long-term, developmental disability, and behavioral health services and supports for participants who are eligible due to disabilities or have special health needs.
- Medicare-Medicaid Coordinated – For participants 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.
Effective June 7, 2010, Idaho Medicaid contracted with Gainwell Technologies external-link, formally known as Molina Medicaid Solutions and DXC to be the MMIS claims processing center as well as provide provider training, billing, and operational support for all Medicaid providers.
Magellan Medicaid Administration is providing 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 Optum Idaho. For more information, please contact Optum at www.OptumIdaho.com.
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 Gainwell Technology 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 Gainwell Technology website.
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 Gainwell Technology at 1-866-686-4272, for more information.
Anesthesia Fee Schedule- effective 7/1/2018
Codes specific to Anesthesia providers are billed to Medicaid where the total units for time are equal to 1 unit per minute at a rate of $1.00. 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, rates, and assigned level can be found to the right under the "Current Fee Schedules".
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:
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 in the Hospital Prospective Payment System: DRG and APC library.