agenda general policies & procedures break questions & answers 2
TRANSCRIPT
Agenda
General Policies & Procedures
Break
Questions & Answers
2
Iowa Medicaid provides health care coverage for
children, financially-needy parents with children, people
with disabilities, elderly people, and pregnant women.
Purpose of Iowa Medicaid?
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Iowa Medicaid StatisticsOver 559,000 members will be served
SFY 2011 (18% of Iowa’s population)
Iowa Medicaid is the 3rd largest health care payer in Iowa, following Wellmark and Medicare
51,468 enrolled Iowa Medicaid Providers
SFY 2009 total Iowa Medicaid expenditures were $2.8 billion.
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Iowa Medicaid- Enrollment
As of January 2010:
Total Medicaid enrollment was 405,912; compared to 389,305 in January 2009
MediPASS enrollment was 178,566; compared to 157,709 in January 2009
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Iowa Medicaid- Distribution54% Medicaid members are
children, accounting for only 17% of the expenditures
9% are elderly, accounting for 20% of the expenditures
21% are disabled, accounting for 52% of the expenditures.
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IME FactsIn January 2010Provider Services call center received 29,089 phone calls with an average wait time of less than 20 seconds.
Member Services received 13,172 calls with an average wait time of 17 seconds.
An average of 1.2 million claims processed each month.
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Medical Assistance CardMedical assistance card is “good” as
long as the individual has Iowa MedicaidLost, damaged or stolen cards can be
replaced
No specific eligibility month or program will be indicated on the card
Providers must verify eligibility through ELVS or the Web Portal
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Retroactive EligibilityMay receive a Notice Of Decision (NOD)
from DHS granting retroactive eligibility
Claims must be submitted with a copy of the Notice of Decision within 365 days of the NOD issue date
Please see reference materials online at: http://www.ime.state.ia.us/Providers/Training
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IowaCare and IowaCare Card
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IowaCareThe IowaCare provider network currently includes:University of Iowa Hospitals and Clinics
Broadlawns Medical Center
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IowaCare ExpansionExpansion tentatively scheduled to
begin October 1, 2010
Will expand to include Hospitals for emergency services onlyFederally Qualified Health Clinics
(FQHC)One or two FQHC’s will be phased in Beginning on the western side of the
state16
Lock-InFor members who have misused
Medicaid
Members can be restricted to:
One Primary Care Provider (PCP)
One specialty care provider
One hospital
One pharmacy
Referrals must be obtained from the member’s lock-in PCP before services are rendered
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Medically NeedyMedicaid program that helps individuals
with medical bills if they have high medical bills that use up most or all of their income
May qualify for a spenddown
Typically 2 month certification period
Claims must be billed to the IME- IME does the accounting
Medical Assistance Cards
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QMB/SLMBQMB (Qualified Medicare Beneficiary)QMB with SpenddownSLMB (Special Low Income Medicare Beneficiary)
SLMB with Spenddown
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Iowa Family Planning NetworkCovers only specifically identified
family planning services
Members may receive family planning services from any Iowa Medicaid provider
Members can have IowaCare and IFPN
See Informational Letters 483 and 485
Request the covered services list from IME Provider Services
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Overview of MediPASSPurpose
Assure access to services
Assure coordination & consolidation of care
Educate members to access medical care from the most appropriate point
Mandatory in many counties
IME pays administrative fee of $2.00 per member per month.
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MediPASS ProvidersProvider types that provide primary
care services:
Provider specialties:
•MD •ARNP •RHC
•DO •Midwives •FQHC
• Family practice • Obstetrics
• General Practice • Internal Medicine
• Pediatric
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MediPASS ProvidersCan fine tune their agreement to suit their
own practiceOpen or closed panelMaximum number of members acceptedGender of enrolleesAge range of enrollees
Can alter agreements at any time with written notification
Can disenroll members for good cause
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MediPASS MembersChildren, families with children, pregnant
womenSent enrollment packet outlining programMust make 1st choice within 10-45 daysCan continue to make choices for 90 daysClose enrollment for 6 months after end of
open periodNot required of:
American IndiansChildren receiving comprehensive Title V
servicesElderly and Disabled
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MediPASS ReferralsTreating provider must obtain a referral
from the MediPASS provider
Paper referrals not required by the IME
Referrals should be solicited prior to serviceMediPASS provider must either treat or
referIME staff can mediate when necessary
If solicited after service, then choice is up to MediPASS provider; no mediation available
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MediPASS ReferralsIt is not appropriate to maintain a list of
NPI numbers rather than contacting MHC provider
Exempt from referral: •Vision •Emergent diagnosis•Dental •EPSDT screenings•Ambulance •Childhood immunizations•Family Planning •Prescription drugs•Skilled nursing care
•Other misc programs
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What is the Iowa Plan?State wide plan that covers most
Medicaid members
Most services are billed to the Iowa Plan contractor, currently Magellan Behavioral Health Services
Members that are not enrolled with the Iowa Plan have services paid through the IME
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Magellan will begin managing Medicaid enrollees 65 and over beginning July 1, 2010
Magellan staff are partnering with IME staff to ensure a smooth transition of services
Medicaid enrollees will have access to services under the Iowa Plan that Magellan manages
Members aged 65 & older
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• Partner with primary care for mental health/substance abuse referrals
• Transition of care during June 2010 to ensure all current services/providers are continued
65+ Priorities
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SeniorConnect team in place March 2010
Team lead for outreach/coordination Follow up specialist for implementation of
community-based services Intensive care managers following members
by region
Dedicated Magellan SeniorConnect team for members, families and providers for information/referral
65+ Resources
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Key clinical focus on increasing access to services through community/home-based services:
community support services, mobile counseling, psychiatric in home nursing, assertive community treatment, intensive psychiatric rehabilitation, substance abuse services and peer support
New Services
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Contacting MagellanProviders call:
Toll-free (800) 638-8820Local Des Moines area (515) 223-
0306
Website: www.magellanofiowa.com
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Adult Routine PhysicalsPayable for both regular Medicaid
and IowaCare adult (19+)members Members may receive annual
preventative physicals from any enrolled Medicaid provider
See Informational Letters 640 and 789 for complete details
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Updating TPL to the IMEMembers can call Member Services to update their
insurance information
Complete the Insurance Questionnaire (IQ) found at http://www.ime.state.ia.us/Providers/Forms.html
Form #470-2826
The IQ form can be emailed to [email protected] or faxed to 515-725-1352
It can take 10 days for TPL to be updated
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Release of Medical RecordsMay release member’s bills and medical
records if member requests themRelease medical bills if a subpoena is
receivedDo not release bills or records on trauma-
related claims to the member or the member’s representative until IME has authorized releaseProviders should notify the IME Lien
Recovery Unit of trauma related incidents by calling 888-543-6742 or locally (Des Moines area) at 515-256-4620.
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Correct Coding Initiative Providers must use the NCCI
coding convention effective 2-1-10Allows IME to more closely follow
national standards/MedicareEnhanced prospective &
retrospective reviews were delayed but will be part of FY 2011
Refer to IL 875, 882, 912
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Iowa Medicaid Health Information Technology
Federal ‘incentive grants’ to Medicaid providersTo encourage adoption and meaningful use of
EHRs (electronic health records) Administered by the State Medicaid Program Eligible providers must meet minimum patient
volume thresholds90% federal matching funds for statewide
initiatives that promote the adoption and use of HIT
Up to $63,750 is available to each eligible professional over a six year period
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Medicaid Integrity ProgramCMS audit program to combat Medicaid
fraud & abuseEffective 11/1/09Iowa contractor is Health Integrity, LLCCommunication is between Health
Integrity and the provider Failure to comply with request from
Health Integrity can cause claim recoupment
Refer to IL 841
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Prior Authorization ImagingRequest made through Clear
Coverage-Prior Authorization Management Portal http://prod.cue4.com/
PA required for MRI, CT, CTA, PET, MRA
Program will suggest alternatives if PA denied or pended
Effective 3/1/10Refer to IL 876, 911
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EFT/Debit card paymentsEffective with 8/23/10 payment cycleSign up for EFT, call Provider ServicesDebit cards can be used at retailer,
banks, ATMSpecial toll-free number for balance &
account infoWeb access to balance & account info
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HIPAA 5010 & ICD-10
Contract awarded to Chicago Systems Group, Inc. (CSG)
Assisting the IME in meeting the goals established by CMS
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Iowa Administrative Code 441
79.9(4) Recipients must be informed before the service is provided that the recipient will be responsible for the bill if a non-covered service is provided.
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Top Claim Denial ReasonsDuplicate claimMember not eligibleMissing or invalid MediPASS referral
numberThird-party insurance, or Medicare,
should have been billed primaryConcurrent careProcedure/provider type conflict
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Electronic Claim SubmissionOver 83% of all claims are
submitted electronically.
Home Health has been able to bill electronically since early 2009.
ETPs can be billed electronically. See IL 757.
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Electronic Claim Submission
Providers must enroll with EDISS through their Total OnBoarding program
PC-ACE Pro32- Free software available through DHS
Link to PC-ACE Pro32 Instructions on the IME Provider Home page under Quick Links
Providers must check ALL confirmation reports to insure that the claims have not rejected
…continued…
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Timely Filing GuidelinesClaims must be filed within 365 days of the
through date of service (DOS).
If a claim is filed timely but denied, an additional 365 days from the denial date is allowed, up to 2 years from the DOS.
Claims up to 2 years from the date of service may be submitted electronically, as it is no longer required to attach the remittance advice denial.
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Timely Filing Guidelines
Claim AdjustmentsRequests for claim adjustments must be
made within 365 days of the payment date
Claim credits are not subject to a time limit
Discussion of adjustment form will follow
…continued…
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Exceptions to the Timely Filing Guidelines
Retroactive eligibility
Needs to be billed with the Notice of Decision (NOD)
Submit claims within 365 days of the date on the NOD
Third-party related delays
Need to include reason for delay
Within 365 days of TPL payment
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Guidelines for Medicare CrossoversMedicaid will pay coinsurance and
deductibles (unless SLMB)
Necessary information must be added to the EOMB copySee Informational Letters 638, 658, 687 and 693
for information needed on EOMB
TPL payment declaration (if applicable)
IME will now automatically reprocess electronic Medicare cross-over claims that Medicare denied for reasons PR-96 & PR-204
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Medicare Cross-over Template
Can submit this form rather than submitting the Medicare/HMO EOB
Cleaner claim processing
Template and instructions are located on the Provider home page of the IME website
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Exception to PolicyWhat is an Exception to Policy? (ETP)Request an Exception to Policy at:
http://www.dhs.state.ia.us/dhs/appeals/ask_exception.html
If an Exception to Policy has been approved:
Submit claim with a copy of the Exception to Policy approval letter to the address on the approval letter
Submit claim electronically, see IL 757.
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Credits and AdjustmentsWhen to credit vs. adjust?
The Credit/Adjustment form is located on the IME provider website. Form # 470-0040
Use most recently paid TCN
If crediting with this form , do not send a refund check
Include either a new corrected claim or a copy of the remittance advice with corrections
Include appropriate documentation
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Provider InquiryForm found on IME provider
website. Form # 470-3744
When to use:To initiate an investigation into a claim
denial
To request Medical Services review
When not to use:To add documentation to a claim
To update/change/correct a paid claim58
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Fraud
To report instances of possible fraud or abuse, contact one of the following telephone numbers:
Medicaid Fraud Control Unit800-831-1394
Medicaid Surveillance & Utilization Review877-446-3787 or515-256-4615(Des Moines area)
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Addresses and phone numbers
Claims address: IMEPO Box 150001Des Moines, IA 50315
Correspondence address:IME PO Box 36450Des Moines, IA 50315
IME Provider Services800-338-7909515-256-4609
(Des Moines area)
ELVS800-338-7752
515-323-9639 (Des Moines area)
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How can you receive information from the IME?
IME Website- www.ime.state.ia.us
Provider Services phone line
Remittance Advice comments
Email Updates
Informational Letters
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www.ime.state.ia.usDownload forms
Access provider manuals
Access Informational Releases
Find links to the Web Portal for claims submission and eligibility information
Provider training documents & Webinars
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ELVSVoice response systemEligibility information available 24/7Providers can verify:
Monthly eligibilitySpenddownTPL insuranceManaged Health Care informationCurrent check amountsLimited vision and dental historyIowa Plan
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EDISS WebportalAvailable 24/7
Check member eligibility
Check claim status
Submit batch claims
Enroll with EDISS through Total OnBoarding
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I-MERSIowa Medicaid Electronic Records
System
Web-based patient management tool
Billed diagnosis, drugs and procedures
Name and phone of rendering provider
Quick link on Provider Home page at www.ime.state.ia.us
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https://secureapp.dhs.state.ia.us/impa/
Remittance Advice
View weekly remittance advice online 24/7
History going back 2 yearsIowa Medicaid discontinued paper
remittance advices March 1, 2010As of 7/5 this tool replaces
imeservices.org for RA retrievalSee IL 890 for direction to IMPA
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HCBS Waiver Authorization
Providers can view Waiver Program information: Number of authorized unitsServices RatesProcedure Codes
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Presumptive Eligibility NEW – Presumptive Eligibility for Children
Currently only hawk-i outreach workers are eligible to enter applications into IMPA for this group
Online tool for Presumptive eligibility for Woman with breast or cervical cancer (BCCT) & pregnant presumptive will be available on IMPA beginning Summer 2010.
ILs will be mailed as soon as more information becomes available
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Provider Incident Reporting
Providers can report, track & monitor incidents in "real time"
Required of HCBS waiver & habilitation providers
online forms, instructions, & tutorial are available on Provider home page of the IME website
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Provider Reenrollment 2010Provider must designate:
Provider AdministratorProvider SignatoryProvider Reenrollment
Ownership Control Disclosure Background Checks Disclosure
Coming Soon…
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Provider Services Outreach Staff
Outreach Staff provides the following services:
On-site trainingPC-Ace trainingEscalated claims issuesPlease send an email to
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