1 the iowa working together for a healthier iowa medicaid enterprise part two

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The Iowa Working Together for a Healthier Iowa

Medicaid Enterprise

Part Two

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IME Contact Information

Mailing Address for Claims

Iowa Medicaid Enterprise

P. O. Box 150001

Des Moines, Iowa 50315

(Begin Using 6/27/05)

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IME Contact Information

Visit the IME Website to access even more information:

www.ime.state.ia.us

(Effective 5/10/05)

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IME Contact Information

ELVS(Eligibility Verification System)

800-338-7752515-323-9639 (Local)

• Verify member eligibility• Verify if there is a primary insurance• Verify member enrollment with HMO, MediPASS, and the Iowa

Plan• Access your last payment amount and date• Verify if the member has a spend down amount remaining• Verify if the member has other restrictions (Lock-in or Iowa Plan)

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IME Contact Information

PROVIDER SERVICES

7:30 AM – 4:30 PM

800-338-7909

515-725-1004 (Local)

515-725-1155 (Fax)

(Effective 6/30/05)

• Speak personally to knowledgeable IME staff• Check status of a claim• Press “2” to speak directly to IME Enrollment staff

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IME Contact Information

PHARMACY PRIOR

AUTHORIZATION

8:00 AM – 6:00 PM(after-hours on-call available)

Provider PA Hotline

877-776-1567

515-725-1106 (Local)

• Ask questions about prior authorizations•Ask questions about the Preferred Drug List

Prior Authorization Requests

800-574-2515 (Fax Only)

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IME Contact Information

PHARMACY POS HELP DESK8:00 AM – 6:00 PM

(after-hours on-call available)

877-463-7671515-725-1107 (Local)

• Ask questions about your claims• Check status of claims• Get assistance with adjustments• Drug coverage issues• DUR overrides

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IME Contact Information

MEDICAL SERVICESMedical Support

8:00 AM – 4:30 PM800-383-1173

515-725-1008 (Local)(Effective 6/30/05)

• Ask questions about Medical Prior Authorization• Ask questions about authorization for MR/DD Targeted Case

Management• Ask questions about the Lock-in program

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IME Contact Information

MEDICAL

PRIOR AUTHORIZATION (PA)

8:00 am – 4:30 PM

888-424-2070

515-725-1009 (Local)

515-725-1356 (Fax)

(Effective 6/30/05)

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IME Contact Information

MEMBER SERVICES8:00 AM – 5:00 PM

800-338-8366515-725-1003 (Local)

(Effective 6/30/05)

Refer Members here if they have questions about:• Medicaid Policy• Unpaid bills for Medicaid services• Managed Care enrollment• Publication requests

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IME Contact Information

PROVIDER AUDITS AND

RATE SETTING

8:00 AM – 5:00 PM

866-863-8610

515-725-1108 (Local)

State MAC Help Line

800-591-1183

(Effective 6/30/05)

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IME Contact Information

SURS(Surveillance & Utilization Review Subsystem)

8:00 AM – 5:00PM

877-446-3787

515-725-1346 (Local)

(Effective 6/30/05)

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IME Contact Information

REVENUE COLLECTION(Effective 6/30/05)

Estate Recovery

7:30 AM – 5:30 PM

Third Party Liability (TPL)

8:30 AM – 5:00 PM

Lien Recovery

8:30 AM – 5:00 PM

877-463-7887

515-725-1005

(Local)

866-810-1206

515-725-1006

(Local)

888-543-6742

515-725-1007

(Local)

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IME HIPAA Transactions

• 837 Professional, Dental, Institutional• 835 Electronic Remittance Advice

(Available 6/30/05)• 278 Prior Authorization Request• 276 Claims Inquiry• 270 Eligibility Inquiry

Register at www.ime.state.ia.us

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IME Provider Web Pagewww.ime.state.ia.us

• Provider Manuals• Provider Enrollment Forms• Fee Schedules• Electronic Provider Directory• Electronic Claims Information• E-mail Questions –

imeproviderservices@dhs.state.ia.us

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Claims Submission Changes

• HIPAA transactions only for electronic claims• No black and white claim copies• You must use the original “Drop-out” red and white

CMS-1500 and UB-92 claim forms.• Do not high-light Medicare EOMBs• Do not use red ink• New credit and adjustment form

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Medical Services

Overview

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Effective June 30, 2005, the IME Combines Programs Previously Performed by ACS, the

IFMC, and DHS

• Pharmacy Prior Authorization

• Medical Prior Authorization

• MR/DD Targeted Case Management

• Medical Support• Quality of Care

• Home Health Prior Authorization for Early, Periodic, Screening Diagnosis and Treatment (EPSDT)

• Elderly Waiver• Lock-in• Psychiatric Medical

Institutions for Children (PMIC)

• Pharmacy POS

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Iowa Medicaid Enterprise

  Effective June 30, 2005

Iowa Medicaid Enterprise Implements the Following NEW Programs:

• Disease Management• Expanded Primary Care Case Management• Long Term Care Assessments

• Nursing Facility • ICF/MR• All Waivers Programs Excluding Elderly Waiver Services

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Pharmacy

Operational January 15, 2005 • Supplemental rebates • Preferred Drug List • Prior Authorizations• Recommended drug list

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Medical Prior Authorization

• Verify medical necessity and compliance with Medicaid guidelines for medical services that require prior authorization

• No changes in current process for providers• Providers continue to use same phone numbers for inquiries

• 1-888-424-2070• 515-725-1009 (Local)• 515-725-1356 (Fax)

• Complete authorization requests will be processed within 5 working days

• Authorizations requiring peer review will be processed within 10 working days

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MR/DD Targeted CaseManagement

• Effective July 1, 2005, requests for MR/DD TCM (Targeted Case Management) previously completed by DHS will be reviewed by Medical Services

• Requests for Targeted Case Management for persons with:• Mental Retardation• Developmental Disability• Chronic Mental Illness (Over 65 or Medically Needy)

• TCM providers will continue to send requests by email to same email address: tcmauth@dhs.state.ia.us

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Early and Periodic Screening, Diagnosis and Treatment

(EPSDT)

• Process requests for home health services for special needs children following prior authorization procedures

• Coordinate care for special needs children

• Remind case managers of prior authorizations needed

• Complete reports for program support

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Elderly Waiver

There are no changes to the Elderly Waiver review program in FY 06-07

• Assessments are completed by area agency on aging staff• Assessments are reviewed by medical services to determine

level of care• Level of Care decisions are documented in the Individualized

Services Information System (ISIS)

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Medical Support

Involves a Broad Range of Continuing Activities:

• Prepay claims review

• Pre-Procedure review

• Retrospective review of inpatient and outpatient services

• MDS automation education

• Make policy recommendations and consulting for specific concerns on behalf of the Department of Human Service (DHS)

• Provide medical expertise to assist DHS in the evaluation of requests for new or unusual services or treatment modalities

• Assist in the adjudication of any provider claim that is suspended or pended for medical review

• Participate in the certification of new outpatient programs, make recommendations to DHS, and determine the coverage criteria

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Lock-in and Member Health Education

• Review member utilization of medical services to identify • Over utilization• Duplication of services• Medication misuse and abuse• Possible drug-to-drug interaction

• Provide education to identified members• Enroll members in program restricting access to providers• Recruit primary care providers to provide oversight to enrolled members• Improve care and health of members, reduce wasteful and duplicative

services, promote reduction of health care spending, • Providers continue to use same phone number for inquiries and referrals

• 1-800-383-1173• 515-725-1008 (Local)

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Quality of Care

• The Quality of Care program monitors care provided to Iowa Medicaid members

• The focus is care delivered by MediPASS, the HMO and the Iowa Plan providers.

• A comprehensive” Report Card” will be developed to assist in evaluating:

• The health status of the members in the program.• Providers compliance with service agreements.• Federal requirements for managed care contracting are

met

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Disease Management

• Disease management is a program for improving care and outcomes for individuals with specific disease conditions

• Disease management programs use indicators reflective of guidelines for the specific disease processes to evaluate positive outcomes

• Disease management includes services designed to enhance patient management and adherence to a treatment plan

• Functions of disease management are to:• Improve the health status of enrolled members • Reduce costs• Support recognized evidence-based practice guidelines• Enlist primary care providers to be actively involved in the

management of the member enrolled in the program• DHS policy staff will select the specific diseases included in the

program

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Enhanced Primary Care Case Management

• The function of enhanced primary care case management is to improve access to needed care and to reduce unnecessary or inappropriate utilization and costs

• The program staff perform the following:• Accept referrals for case management• Perform a prescreening assessment on each enrolled

member• Enlist the primary care provider to be actively involved in

the management of the member enrolled in the program • Develop care plans for each member receiving case

management and disseminate to involved entities• Monitor the performance of the case management

process

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Long Term CareAssessment Program

• Face to face pre-screening assessments will be completed by healthcare professionals with expertise in the institutional and community based services

• Services requiring pre-screening assessment are:• Nursing Facility• Intermediate Care Facility for Mentally Retarded• Brain Injury Waiver• Ill and Handicapped Waiver• Mental Retardation Waiver• Aids Waiver• Physical Disability Waiver

• Pre-screening assessments will be completed prior to placement or service initiation

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Long Term CareAssessment (Cont.)

• Assessments will be conducted within five days of the request for services

• A preliminary care plan may be developed at the time of the assessment for members requiring immediate services

• The pre-screening assessment decision will be documented in the Individualized Services Information System (ISIS)

• The Medicaid Medical Director will provide medical leadership and guidance to staff conducting assessments

• Follow-up pre-screening assessments will be conducted periodically to determine continuing need for Long Term Care (LTC) services