Idaho MMIS Provider Handbook
Allopathic and Osteopathic Physicians
Table of Contents
1.
Section Modifications ............................................................................................ 1
2.
Allopathic and Osteopathic Physician ...................................................................... 4
2.1. General Policy................................................................................................ 4
2.2. Reimbursement ............................................................................................. 4
2.2.1. Site of Service Differential ......................................................................... 4
2.3. Referrals ....................................................................................................... 5
2.4. Physician Service Policy .................................................................................. 5
2.4.1. Overview ................................................................................................ 5
2.4.2. Physician Employees ................................................................................ 5
2.4.3. Misrepresentation of Services .................................................................... 5
2.4.4. Health Acquired Conditions (HAC) .............................................................. 5
2.4.5. Out-of-State Care .................................................................................... 5
2.4.6. Locum Tenens and Reciprocal Billing .......................................................... 6
2.5. Allergy Injections ........................................................................................... 6
2.6. Anesthesiology .............................................................................................. 7
2.6.1. Overview ................................................................................................ 7
2.7. Consultations ................................................................................................ 7
2.8. Emergency Department .................................................................................. 7
2.9. Critical Care Services ...................................................................................... 8
2.9.1. Other Procedures ..................................................................................... 8
2.10.
Prolonged Services ...................................................................................... 8
2.11.
Diabetes Education and Training ................................................................... 9
2.11.1.
Participant Qualifications for Diabetes Education ....................................... 9
2.12.
Examinations - Wellness ............................................................................ 10
2.12.1.
Wellness Exams for Children Up to the Age of 21 .................................... 10
2.13.
Excluded Services ..................................................................................... 10
2.14.
Immunization ........................................................................................... 11
2.14.1.
State-Supplied Free Vaccines ............................................................... 11
2.15.
Laboratory Coverage ................................................................................. 12
2.15.1.
Physician Office Laboratories ................................................................ 12
2.15.2.
Independent Laboratories .................................................................... 13
2.15.3.
Pathology Laboratory Procedures .......................................................... 13
2.15.4.
Special Services.................................................................................. 13
2.15.5.
Blood Lead Screening for Early and Periodic Screening, Diagnosis, and
Treatment (EPSDT) ............................................................................. 13
2.15.6.
PKU Testing ....................................................................................... 13
2.16.
Obstetrics and Gynecology ......................................................................... 14
2.16.1.
Obstetrics Overview ............................................................................ 14
2.16.2.
Family Planning .................................................................................. 18
2.16.3.
Abortions ........................................................................................... 19
2.16.4.
Hysterectomy Overview ....................................................................... 20
2.17.
Sterilization Procedures Overview ............................................................... 21
2.17.1.
Participant Consent ............................................................................. 21
January 15, 2015
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Idaho MMIS Provider Handbook
Allopathic and Osteopathic Physicians
2.17.2.
Waiting Time Exceptions ...................................................................... 21
2.17.3.
Interpreter’s Statement ....................................................................... 22
2.17.4.
When Not to Obtain Consent ................................................................ 22
2.17.5.
Signature Requirements ...................................................................... 22
2.17.6.
Statement of Person Obtaining Consent ................................................. 23
2.17.7.
Physician’s Statement ......................................................................... 23
2.18.
Ophthalmologist ....................................................................................... 23
2.18.1.
Overview ........................................................................................... 23
2.19.
Oral Treatments........................................................................................ 24
2.20.
Oral and Maxillofacial Surgery .................................................................... 24
2.21.
Physician-Administered Drugs (PAD) ........................................................... 24
2.21.1.
Reporting National Drug Code (NDC) for Drugs Billed with HCPCS Codes ... 24
2.21.2.
Compound Drugs ................................................................................ 25
2.22.
Psychiatric Care ........................................................................................ 25
2.22.1.
Outpatient Psychiatric Care .................................................................. 25
2.22.2.
Inpatient Psychiatric Care .................................................................... 26
2.23.
Radiology ................................................................................................. 26
2.23.1.
Overview ........................................................................................... 26
2.23.2.
Technical Component .......................................................................... 26
2.23.3.
Professional Component....................................................................... 27
2.23.4.
Place-of-Service (POS) Codes ............................................................... 27
2.23.5.
Place-Of-Service (POS) Office ............................................................... 27
2.23.6.
Diagnosis Codes ................................................................................. 27
2.24.
Surgery ................................................................................................... 27
2.24.1.
Global Fee Concept ............................................................................. 27
2.24.2.
Complications ..................................................................................... 27
2.24.3.
Modifiers............................................................................................ 28
2.24.4.
Hospital Admissions ............................................................................ 28
2.24.5.
Abdominoplasty or Panniculectomy ....................................................... 28
2.24.6.
Bariatric Surgery ................................................................................ 29
2.24.7.
Circumcisions ..................................................................................... 29
2.25.
Tobacco Cessation..................................................................................... 29
2.26.
Transplants .............................................................................................. 30
2.26.1.
Overview ........................................................................................... 30
2.26.2.
Coverage Limitations ........................................................................... 30
2.26.3.
Re-Transplants ................................................................................... 30
2.26.4.
Multi-Organ Transplants ...................................................................... 31
2.26.5.
Transplant Authorization ...................................................................... 31
2.26.6.
Non-Covered Transplants ..................................................................... 31
2.26.7.
Follow-Up Care ................................................................................... 31
2.27.
Qualis Prior Authorization and Medical/Surgical Review .................................. 31
2.27.1.
Overview ........................................................................................... 31
2.27.2.
Penalties ............................................................................................ 32
2.27.3.
Prior Authorization (PA) ....................................................................... 32
2.27.4.
Third Party Recovery (TPR) .................................................................. 33
January 15, 2015
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Idaho MMIS Provider Handbook
Allopathic and Osteopathic Physicians
1. Section Modifications
Section/
Version
21.0
20.1
20.0
19.1
19.0
18.1
18.0
17.1
Column
Modification Description
All
2.2.1 Site of Service
Differential
All
2.19 Oral Treatments
Published version
Added list of places of service that
receive site of service differential
Published version
Added CPT code 99188 to replace
D1206 and D1208
All
2.17.2 Waiting Time
Exceptions
All
2.2.1 Site of Service
Differential
Published version
Removed statement about paper forms
Published version
In the last sentence, updated link to
Site of Service Reduction Codes and
changed Reference to Links.
Published version
Removed Medicare reference and added
link to Surgical Review Corporation
Date
1/15/15
1/15/15
12/29/14
12/29/14
9/25/14
9/25/14
TQD
C Taylor
08/15/14
08/15/14
TQD
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D Baker
C Taylor
TQD
C Taylor
TQD
J Siroky
C Taylor
TQD
R Sosin
C Taylor
C VZile
C Taylor
D Baker
All
2.24.6 Bariatric Surgery
16.0
15.1
15.0
14.1
All
2.27.3.1 PA Notification
All
2.21. Physician-Administered
Drugs (PAD)
All
2.4.4 Health Acquired
Conditions
2.17.2 Waiting Time
Exceptions; 2.17.3
Interpreter’s Statement;
2.17.6 Statement of Person
Obtaining Consent
All
2.19 Oral Treatments
Published version
Added “or adjusted” in first sentence
Published version
Clarified information and location of the
PAD list
Published version
Removed date
Published version
Added section
4/25/14
4/25/14
2.16.1.5 Billing Ultrasounds
and Stress Tests for Multiple
Pregnancies
2.16.1.1 Total Obstetric (OB)
Care
2.27.3.1 Prior Authorization
(PA) Notification
2.4.4 Health Acquired
Conditions
All
2.16.4 Hysterectomy
Overview
Added to use ICD-10 diagnosis code
4/25/14
Clarified using date of delivery as the to
and from date.
Added new requirement and information
for adding PA number to claim
Added new section
4/25/14
13.1
13.0
12.5
12.4
12.3
12.2
12.1
12.0
11.1
Removed statements that Medicaid will
not accept corrected or altered consent
forms.
11.0
10.1
All
2.24 Tobacco Cessation
Published version
Added that the sterilization form can
also be used and the required
information that needs to be included
Published version
New section
10.0
9.2
9.1
9.0
All
2.16.3
2.25.3.3
All
Published version
Removed procedure codes
Reordered paragraphs for clarity
Published version
TQD
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09/02/14
09/02/14
17.0
16.1
14.0
13.2
SME
08/08/14
08/08/14
07/07/14
07/07/14
07/01/14
07/01/14
07/01/14
4/25/14
4/25/14
03/07/14
03/07/14
01/24/14
01/24/14
12/20/13
12/20/13
12/20/13
09/20/13
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TQD
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C Taylor
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TQD
C Taylor
A Coppinger
TQD
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TQD
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Idaho MMIS Provider Handbook
Section/
Version
8.1
Column
Allopathic and Osteopathic Physicians
Modification Description
Date
SME
New section (2.16.1.5); updated
2.16.3.1 for clarity
09/20/13
A Coppinger
C Taylor
8.0
7.1
2.16.1.5 Billing Ultrasounds
and Stress Tests for Multiple
Pregnancies
2.16.3.1 Participant Consent
All
2.20.1-2
Published version
Added new information to align with
current policy
08/30/13
08/30/13
TQD
C Burt
D Baker
7.0
6.1
All
All
05/31/13
05/31/13
6.0
All
Published version
Removed outdated information and
added updated information for current
policies
Published version
10/02/12
C Taylor
J Siroky
A Farmer
A Coppinger
TQD
Removed last procedure code table.
This table is available under the
Reference Section of the Handbook,
Qualis Health Pre-Authorization List
Updated for clarity
Updated for clarity
Updated with modifier information.
10/02/12
C Taylor
10/02/12
10/02/12
10/02/12
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10/02/12
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10/02/12
C Taylor
5.10
5.9
5.8
5.7
5.6
2.21.7 Follow-Up Care
2.20.3 Modifiers
2.20.2 Complications
2.19.3 Professional
Component
2.18.3.3 PA by the Medicaid
MCU
5.5
2.18.3.1 PA Notification
5.4
2.14.3.2 Waiting Time
Exceptions
2.14.1.6 Billing for Twin
Deliveries
2.14.1.4 Billing for Incomplete
Antepartum Care
2.9.1.3 Individual Diabetic
Counseling
All
2.14.5 Hysterectomies
Overview
5.3
5.2
5.1
5.0
4.1
4.0
3.1
All
2.1.3 Procedure Codes
3.0
2.22
2.21
All
2.1.3 Procedure Codes
2.21 Transplants
2.20
2.20 Surgery
2.19
2.19 Radiology
2.18
2.18 Prior Authorization and
Medical / Surgical Review
2.17 Physician-Administered
Drugs
2.17
2.16
2.15
2.16 Oral and Maxillofacial
Surgery
2.15 Ophthalmologist
Added outpatient. Updated phys
therapy, speech & lang, & occupational
therapy. Updated procedure code table
Updated to indicate to not include PA
number on claim
Added additional information about
sterilization forms
Added modifier 59 and clarified this is
for multiple deliveries
Clarified information on split billing
10/02/12
10/02/12
C Taylor
10/02/12
C Taylor
10/02/12
C Taylor
05/23/12
05/23/12
TQD
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01/18/12
01/18/12
TQD
C Taylor
11/23/11
11/23/11
11/23/11
TQD
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J Siroky
New subsections added, other sections
updated for clarity
New subsections added, other sections
updated for clarity
New section
11/23/11
J Siroky
11/23/11
J Siroky
11/23/11
J Siroky
New section
11/23/11
J Siroky
A Farmer
Updated for Clarity
11/23/11
J Siroky
Updated for Clarity
11/23/11
J Siroky
Clarified “CDEs services are to augment
not substitute”
Published version
Deleted part of sentence “and the PA
number entered on the claim from in
field 23 of the CMS-1500 claim from, or
field 63 of the UB-04 claim form.” From
the last paragraph
Published version
Removed section; Information is found
in General Billing Instructions
Published version
Added section
New Section
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Page 2 of 33
Idaho MMIS Provider Handbook
Section/
Version
2.14
Column
Allopathic and Osteopathic Physicians
Modification Description
Date
SME
2.14 Obstetrics and
Gynecology
2.13 Laboratory Coverage
2.12 Immunization
2.11 Excluded Services
2.10 Examinations - Wellness
2.9 Diabetes Education and
Training
2.8 Prolonged Services
2.7 Critical Care Services
2.6 Emergency
Department/Critical Care
Services
2.5 Consultations
2.4 Anesthesiology
New subsections added, other sections
updated for clarity
New section
New section
New section
New section
New section
11/23/11
New section
New section
New section
11/23/11
11/23/11
11/23/11
J Siroky
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New section
Updated for clarity
11/23/11
11/23/11
New section
11/23/11
2.2
2.3
Allergy Injections
2.2 Physician Service Policy
Updated for clarity
11/23/11
2.1
2.1 Introduction
11/23/11
2.0
1.2
1.1
All
All
All
08/27/10
08/27/10
08/27/10
1.0
All
New subsections added, other sections
updated for clarity
Published version
Replaced member with participant
Updated numbering for sections to
accommodate Section Modifications
Initial document – published version
J Siroky
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J Siroky
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J Siroky
A Farmer
J Siroky
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TQD
TQD
TQD
5/7/2010
TQD
2.13
2.12
2.11
2.10
2.9
2.8
2.7
2.6
2.5
2.4
2.3
11/23/11
11/23/11
11/23/11
11/23/11
11/23/11
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Idaho MMIS Provider Handbook
Allopathic and Osteopathic Physicians
2. Allopathic and Osteopathic Physician
General Policy
2.1.
This section covers Medicaid services provided by all physician specialties. It addresses the
following:
•
•
•
•
•
Idaho Medicaid’s general physician policy
Service limitations
Medical/surgical review process
Specific medical services
Prior authorization (PA)
Reimbursement
2.2.
Idaho Medicaid reimburses physician services on a fee-for-service basis. Medicaid
reimbursement will be either the lowest of the provider’s actual charge for the service, the
other insurance allowable, or Medicaid’s established maximum allowable reimbursement
from its pricing file, minus the payment from Medicare or other insurance.
Providers must accept Medicaid payment as payment in full for covered services. Providers
may only bill non-covered services to the participant if the provider has informed the
participant of their responsibility to pay prior to rendering services.
2.2.1.
Site of Service Differential
Idaho Medicaid reduces physician reimbursement when certain procedures are provided in a
facility setting. For these procedure codes there is a 30 percent reduction of the Idaho
Medicaid fee schedule in the following places of service (POS).
•
•
•
•
•
•
•
•
•
21
22
23
24
25
31
51
52
61
Inpatient Hospital
Outpatient Hospital
Emergency Room - Hospital
Ambulatory Surgical Center
Birthing Center
Skilled Nursing Facility
Inpatient Psychiatric Facility
Psychiatric Facility - partial hospitalization
Comprehensive Inpatient Rehabilitation Facility
If the space and supplies are provided by the hospital, and are included in the hospital's cost
settlement, the physician can bill for POS 22 under his own provider number on the 1500
form, and there is a site of service deduction. The facility fees are billed by the hospital on
their UB-04 form under the hospital provider number. Site of service differential pricing also
applies to POS 23 and 24.
If the physician office space is rented from the hospital and the physician provides his own
supplies, the physician should bill on a CMS-1500 claim form, use POS 11 (office), and use
his own (or group's own) physician provider number. There is no site of service reduction.
The hospital cannot use the same space, etc. to bill for services under their hospital provider
number.
Refer to Site of Service Reduction Codes, in the Links section of the Provider Handbook.
January 15, 2015
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Idaho MMIS Provider Handbook
2.3.
Allopathic and Osteopathic Physicians
Referrals
Check eligibility to see if the participant is enrolled in Healthy Connections (HC), Idaho’s
primary care case management (PCCM) model of managed care, or in Idaho Medicaid Health
Home (IMHH), Idaho’s enhanced primary care case management system. If a participant is
enrolled in one of these programs, a referral may be required from the participant’s primary
care physician (PCP) prior to rendering services. Prior Authorization may be required in
addition to obtaining a referral.
2.4.
Physician Service Policy
2.4.1.
Overview
Physicians in any state are eligible to participate in the Idaho Medicaid Program. They must
be licensed in the state where the services are performed, and enroll as an Idaho Medicaid
provider with Idaho Medicaid prior to submitting claims for services.
See General Provider and Participant Information for more information on enrolling as an
Idaho Medicaid provider.
2.4.2.
Physician Employees
Services provided by employees of a physician may not be billed directly to Idaho Medicaid.
However, psychological testing services provided by a licensed psychologist or social worker
who are employees of the physician, may be billed under the physician’s provider number.
This exception applies to testing only.
Therapy services that are provided by a physician may be billed with that physician’s
provider number. If services are provided by a licensed therapist employed by the physician,
the therapist must apply for a separate Medicaid provider number and the services billed
with that number.
2.4.3.
Misrepresentation of Services
Any representation that a service provided by a nurse practitioner, nurse midwife, physical
therapist, physician assistant, psychologist, social worker, or other non-physician
professional was rendered as a physician service is prohibited.
2.4.4.
Health Acquired Conditions (HAC)
An edit in the claims processing system will look at CMS-1500 claims for HAC and will deny
all claims with the modifiers of PA, PB, or PC.
When submitting a claim to indicate a HAC, one of the following modifiers is required.
Modifier
PA
PB
PC
2.4.5.
Description
Surgical or other invasive procedure on wrong body part
Surgical or other invasive procedure on wrong patient
Wrong surgery or other invasive procedure on patient
Out-of-State Care
Out-of-state providers who are enrolled in the Idaho Medicaid Program and have an active
Idaho Medicaid provider number may render services to Idaho Medicaid participants without
receiving out-of-state prior approval.
January 15, 2015
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Page 5 of 33
Idaho MMIS Provider Handbook
Allopathic and Osteopathic Physicians
All medical care provided outside the state of Idaho is subject to the same utilization review,
coverage requirements, and restrictions as medical care provided within Idaho.
2.4.6.
Locum Tenens and Reciprocal Billing
Idaho Medicaid allows for physicians to bill for Locum Tenens and Reciprocal Billing.
Definition of Locum Tenens and Reciprocal Billing
The practice of physicians retaining substitute physicians to cover their professional
practices when the regular physician(s) is absent for reasons such as illness, vacation, or
continuing medical education, and the absent physician continues to bill and receive
payment for the substitute physician’s services as though they were performed by the
regular physician.
2.4.6.1.
Duration of Locum Tenens
Locum tenens occurs when the substitute physician covers the regular physician during
absences not to exceed a period of 90 continuous days.
2.4.6.2.
Duration of Reciprocal Billing
Reciprocal billing occurs when the substitute physician covers the regular physician during
absences or on an on call basis not to exceed a period of 14 continuous days.
Requirements and procedures for billing:
•
•
•
•
•
The regular physician is unavailable to provide the services.
The Medicaid participant has arranged or seeks to receive services from their regular
physician.
The regular physician pays the locum tenens for their services on a per diem, or
similar fee-for-time basis.
The substitute physician does not provide the services to Medicaid participants over a
continuous period of longer than 14 days for reciprocal billing.
The regular physician identifies the services as substitute physician services meeting
the requirements of this section by appending the appropriate modifier to the
procedure code.
The regular physician must keep on file a record of each service provided by the substitute
physician, associated with the substitute physician’s National Provider Identifier (NPI), and
make this record available to DHW upon request.
If the only substitution services a physician performs are in connection with an operation
and are post-operative services furnished during the period covered by the global fee, those
services should not be reported separately on the claim as substitute services.
A physician may have locum tenens/reciprocal billing arrangements with more than one
physician. The arrangements do not need to be in writing.
2.5.
Allergy Injections
Reimbursement for office visits is included in the reimbursement for allergy injections.
Office visits may only be billed if there is a separately identifiable service, such as treatment
for an ear infection.
January 15, 2015
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Idaho MMIS Provider Handbook
2.6.
Allopathic and Osteopathic Physicians
Anesthesiology
2.6.1.
Overview
Medicaid accepts anesthesia codes from the anesthesia section of the Current Procedural
Terminology (CPT) Manual. Anesthesia claims must include the CPT anesthesia code that
relates to the surgical procedure performed.
Anesthesia time begins when the anesthesiologist physically starts to prepare the
participant for the induction of anesthesia in the operating room and ends when the
anesthesiologist is no longer in constant attendance.
A second separate anesthesia session may be reimbursed when a patient is returned to
surgery after spending time in another unit of the hospital. In these cases, Medicaid will
reimburse both CPT anesthesia codes plus the total time for both sessions, with adequate
documentation.
Medicaid does not pay for supervision of anesthesia services. The provider who administers
the anesthesia, either a physician or Certified Registered Nurse Anesthetist (CRNA), is paid
100 percent of the allowed amount for the procedure.
2.6.1.1.
Billing Anesthesia
Enter the CPT anesthesia code for the surgical procedure that was performed on the
participant, total amount of time in one (1) minute increments, and any necessary
modifiers.
Idaho Medicaid limits reimbursement for anesthesia procedures to once per day. A repeat
anesthesia procedure on the same day that is billed with the CPT modifier 76 or 77 will be
paid at $0.00. Medicaid considers that a second separate session of anesthesia has occurred
when a patient is returned to surgery after spending time in another unit of the hospital. In
these cases, Medicaid will reimburse both CPT anesthesia codes plus the total time for both
sessions, with adequate documentation.
2.7.
Consultations
Idaho Medicaid does not recognize or reimburse for the Current Procedural Terminology
(CPT) codes for consultation services (CPT codes 99241– 99245 and 99251–99255). For
office or outpatient visits, Medicaid will not recognize CPT codes 99241–99245 but will
instead require providers to bill these services as new (99201–99205) or established
(99211–99215) office/outpatient visits.
For inpatient visits, providers should bill initial inpatient patient visits (99221–99223).
2.8.
Emergency Department
Emergency departments are defined as organized hospital-based facilities for the provision
of unscheduled temporary services to participants who come in for immediate medical
attention. The facilities must be available 24 hours a day.
Idaho Medicaid pays hospitals for six emergency department visits in any calendar year for
participants who do not have Healthy Connections.
January 15, 2015
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Idaho MMIS Provider Handbook
Allopathic and Osteopathic Physicians
Use codes 99281-99285 to report evaluation and management services provided in the
emergency department. No distinction is made between new and established participants in
the emergency department.
Critical Care Services
2.9.
Critical care includes the care of critically ill participants, in a variety of medical emergencies
that requires the constant attention of the physician. Critical care is usually, but not always,
given in a critical care area, such as the Coronary Care Unit, Intensive Care Unit,
Respiratory Care Unit, or the Emergency Department.
The following services are included in the global reporting and billing of critical care when
performed during the critical period by the physician providing critical care:
•
•
•
•
•
•
•
•
Interpretation of cardiac output measurements.
Interpretation of chest x-rays.
Pulse oximetry.
Blood gases and information data stored in computers (e.g., electrocardiogram
[ECG]), blood pressure, hematologic data.
Gastric intubation.
Temporary transcutaneous pacing.
Ventilator management.
Vascular access procedures.
The critical care codes are used to report the total duration of time spent by a physician
providing constant attention to a critically ill participant.
Use code 99291 for critical care, including the diagnostic and therapeutic services and
direction of care of the critically ill or multiple injuries or comatose participant, requiring the
prolonged presence of the physician.
This code is used to report the first 30 - 74 minutes of critical care on a given day. Code
99291 is only billed as one unit. It should be used only once per day even if the time spent
by the physician is not continuous on that day. Code 99291 is paid to a physician once per
day.
Use code 99292 to bill each additional 30 minutes of critical care. This code is used to report
each additional 30 minutes beyond the first 74 minutes. Bill 99292 in 30 minute units.
2.9.1.
Other Procedures
Other procedures that are not directly connected to critical care management (the suturing
of laceration, setting of fractures, reduction of joint dislocations, lumbar puncture, peritoneal
lavage, bladder tap, etc.) are not included in the critical care and should be reported
separately.
2.10. Prolonged Services
Use codes 99354-99357 when a physician provides prolonged service involving direct (faceto-face) participant contact that is beyond the usual service in an inpatient or outpatient
setting.
Use code 99354 or 99356 to report the first hour of prolonged service on a given date,
depending on the place of service. Prolonged service lasting less than 30 minutes on a given
date is not separately reported, because the work involved is included in the evaluation and
management codes.
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Use code 99355 or 99357 to report each additional 30 minutes beyond the first hour,
depending on the place of service. Prolonged service of less than 15 minutes beyond the
first hour or less than 15 minutes beyond the final 30 minutes is not reported separately.
2.11. Diabetes Education and Training
Medicaid covers individual and group counseling for diabetes education and training. The
physician is responsible to furnish basic diabetic care and instruction to the participant and
may not use the formally structured program, or a Certified Diabetes Educator, as a
substitute. Physician responsibility includes the disease process and pathophysiology of
diabetes mellitus, and dosage administration of agents for glycemic management.
2.11.1.
•
•
•
Participant Qualifications for Diabetes Education
The participant has a recent diagnosis of diabetes (within 90 days) and has not had
prior diabetes education.
The participant has uncontrolled diabetes manifested by two or more fasting blood
sugar levels of greater than one hundred forty milligrams per decaliter (140 mg/dal),
hemoglobin A1c greater than eight percent (8%), or random blood sugar levels
greater than one hundred, eighty milligrams per decaliter (180 mg/dal), in addition
to the manifestations.
The participant has recent manifestations resulting from poor diabetes control
including neuropathy, retinopathy, recurrent hypoglycemia, repeated infections, or
non-healing wounds.
2.11.1.1.
Provider Qualifications for Diabetes Education
Providers must operate an American Diabetes Association (ADA) Recognized Diabetes
Education Program to provide group diabetes counseling/training.
•
•
•
Only Certified Diabetes Educators (CDE) may provide individual counseling through a
recognized program, a physician’s office, or outpatient hospital counseling.
The billing provider must submit and maintain proof of the CDE’s current diabetic
counseling certification with Molina provider enrollment.
Counseling services must be billed under the provider number of their employer
(e.g., the hospital, or physician’s clinic provider number).
More information can be found in IDAPA 16.03.09.640-645 Medicaid Basic Plan Benefits.
2.11.1.2.
Individual Diabetic Counseling
To bill these services, use procedure code G0108, and bill in 30 minute increments to
comply with standard coding requirements. Individual counseling services must be face-toface services between a CDE and the participant. The CDE’s services are to augment, not
substitute, for the services a physician is expected to provide to diabetic participants.
Medicaid allows 12 hours, per participant every five years for individual diabetic counseling.
2.11.1.3.
Group Diabetic Counseling
Group counseling is billed with procedure code G0109 and is billed in 30 minute increments
to comply with standard coding requirements. Only hospitals operating an ADA recognized
program may bill for group counseling. Medicaid allows 24 hours, per participant, every five
years for group diabetic counseling.
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2.12. Examinations - Wellness
See General Provider and Participant Information for more information.
2.12.1.
Wellness Exams for Children Up to the Age of 21
Health risk assessment physicals for children are covered based on child wellness exams
(also referred to as EPSDT) periodicity requirements. See the General Provider and
Participant Information handbook for more information.
Routine physicals such as pre-school, school, summer camp, Special Olympics, or sports
examinations for individuals up to the age of 21 are covered with diagnosis V70.3 as long as
one of the above reasons is listed on the claim form. The provider must use the preventive
medicine procedure codes and diagnosis code V20.1, V20.2, V20.31, or V20.32 when billing
for wellness physical exams.
2.13. Excluded Services
2.13.1.1.
Acupuncture
Acupuncture is not covered.
2.13.1.2.
Biofeedback Therapy
Biofeedback therapy is not covered.
2.13.1.3.
Complications
The treatment of complications, consequences, or repair of any excluded medical procedure
is not covered, although Medicaid may authorize treatment if the resultant condition is
determined by Medicaid to be life threatening.
2.13.1.4.
Cosmetic Surgery
All surgery which is generally cosmetic in nature is excluded from payment unless it is found
to be medically necessary and is prior authorized.
2.13.1.5.
Fertility Related Services
Fertility-related services, including testing, are not covered.
2.13.1.6.
Investigational/Unproven/Experimental Procedures
New procedures of unproven value and established procedures of questionable current
usefulness as identified by the Public Health Service and which are excluded by the Medicare
Program and/or the Federal Drug Administration (FDA) are excluded from payment by
Medicaid.
2.13.1.7.
Laetrile Therapy
Laetrile therapy is not covered.
2.13.1.8.
Naturopathic Services
Naturopathic services are not covered.
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2.14. Immunization
Vaccine administration should conform to the Advisory Committee on Immunization
Practices (ACIP) guidelines for vaccine use.
2.14.1.
State-Supplied Free Vaccines
The Vaccine for Children (VFC) program offers a free-vaccine program for children who have
not reached their 19th birthday. When a free vaccine(s) is administered, the Medicaid claim
must include the following information:
•
•
The CPT code for the vaccine with modifier SL billed at a zero dollar amount ($0.00).
The CPT code that accurately reflects the administration of the vaccine(s).
2.14.1.1.
Administration of State-Supplied Free Vaccine with
Evaluation and Management (E/M) Visit
If there is a significant, separately identifiable service performed at the time of the vaccine
administration, an E/M visit may also be billed, and the Medicaid claim must include the
following information.
•
•
•
The CPT code for the vaccine with modifier SL billed at a zero dollar amount ($0.00).
The CPT code that accurately reflects the administration of the vaccine(s).
The CPT code for the E/M visit with modifier 25.
Note: In order to bill the E/M code, documentation in the participant’s record must reflect
that additional services were rendered at the time the vaccine was given.
2.14.1.2.
Administration of a Provider Purchased Childhood
Vaccine With or Without an Evaluation and Management
(E/M) Visit
This should only occur when a free vaccine is not available. Services provided should be
billed at the usual and customary rate. When a provider-purchased childhood vaccine is
administered to a child less than 19 years old, the Medicaid claim must include the following
information:
•
•
The CPT or HCPCS code for the injectable vaccine.
The CPT code that accurately reflects the administration of the vaccine(s).
If there is a significant, separately identifiable service performed at the time of the vaccine
administration, an appropriate E/M code may also be billed with modifier 25.
Note: In order to bill the E/M code, documentation in the participant’s record must reflect
that a significant, separately identifiable service was rendered at the time the vaccine was
given.
See General Provider and Participant Information, Periodicity Schedule for the complete
schedule of age-appropriate health history and health screening services.
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2.14.1.3.
Allopathic and Osteopathic Physicians
Administration of a Provider Purchased Adult Vaccine
With or Without an Evaluation and Management (E/M)
Visit
When an injection or adult vaccine is administered, the Medicaid claim must include the
following information:
•
•
•
The CPT code for the vaccine(s) without a modifier.
The CPT code that accurately reflects the administration of the vaccine.
If applicable, the appropriate CPT code for the E/M visit with modifier 25.
Note: In order to bill the E/M code, documentation in the participant’s record must reflect
that a significant, separately identifiable service was rendered at the time the vaccine was
given.
2.14.1.4.
Administration of an Injection that is Part of a Procedure
When an injection is administered that is part of a procedure (i.e., allergy injections,
therapeutic, and diagnostic radiology, etc.), Medicaid will not pay the administration fee(s).
2.14.1.5.
Administration Only of an Injectable Vaccine to a
Participant with Medicare or Other Primary Payer and
Medicaid
When billing for a participant who has either Medicare or private insurance in addition to
Medicaid, bill Medicare/private insurance first using its billing instructions. If Medicare or the
other primary payer combines payment for the administration with the cost of the
injectable, a separate administration fee may not be charged.
2.15. Laboratory Coverage
2.15.1.
Physician Office Laboratories
Physician office or group practice office laboratories must hold a current Clinical Laboratory
Improvement Amendments (CLIA) certificate on file with Molina before Medicaid will
reimburse for testing performed in the laboratory. Payments will be denied to any laboratory
submitting claims for services not covered by their CLIA certificate. Claims for services
rendered outside the effective dates of their CLIA certificate will be denied or may be
recouped.
Physicians can bill Medicaid for clinical diagnostic laboratory services they personally
performed or supervised. Those services are reimbursed at the rate established by
Medicaid.
Physician-owned laboratories may not bill for tests sent to independent laboratories or
pathology laboratories. Medicaid only pays the actual provider of service.
An office visit cannot be billed when a participant comes in for a blood draw by a lab
technician and does not see the doctor. The lab technician’s cost is included in the lab
procedure payment.
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2.15.2.
Allopathic and Osteopathic Physicians
Independent Laboratories
Independent laboratories are not affiliated with a specific physician’s office and have a
separate provider number. They are able to do testing for multiple groups of physicians.
Independent laboratories must bill Idaho Medicaid directly for the services they render.
2.15.3.
Pathology Laboratory Procedures
Certain pathology lab codes can be broken out into professional and technical components.
When billed with place of service 21 (Inpatient), 22 (Outpatient), or 23 (Emergency), a 26
modifier is required, unless the procedure code says, Supervision and Interpretation Only.
The hospital will bill for the technical component on its UB-04 claim form.
If a pathologist has their own office and equipment, they may bill and be paid for the
complete test including those that cannot be broken out into the professional and technical
components.
2.15.4.
Special Services
Handling and conveyance of specimens for transfer from the participant to a place other
than a physician’s office/place of service 12 (Residence) or 32 (Nursing Home) to a
laboratory is covered by Medicaid when billed with procedure code 99001.
2.15.5.
Blood Lead Screening for Early and Periodic Screening,
Diagnosis, and Treatment (EPSDT)
Federal regulation requires that a screening for lead poisoning be a component of an EPSDT
screen. Current Centers for Medicare and Medicaid Services (CMS) policy requires a
screening blood lead test for all Medicaid eligible children at 12 months and 24 months of
age. In addition, children over the age of 24 months, up to 72 months of age, should receive
a screening blood lead test if there is no record of a previous test.
The Department of Health and Welfare (DHW) will reimburse providers for lead testing (CPT
83655) performed by a venous blood draw or by capillary test. DHW will provide a LeadCare
Analyzer machine to providers at no cost. This machine tests for lead by a simple capillary
test (finger prick). The results are available immediately. Please contact the Medical Care
Unit at 1 (208) 364-1835, or see www.medunit.dhw.idaho.gov, for more information on lead
screening.
2.15.6.
PKU Testing
Newborn screening kits (PKU) are a covered benefit of the Idaho Medicaid Program. Use
HCPCS procedure code S3620. Test kits are ordered through the Idaho Newborn Screening
Program and must be purchased in advance from this program provider:
Idaho Newborn Screening Program
450 West State Street, 4th floor
PO Box 83720
Boise, ID 83720-0036
1(208) 334-4927 in the Boise calling area
Note: Follow-up PKU testing for participants diagnosed with PKU can be done in a
laboratory.
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Nutritional services are available for children and pregnant women on the PW Program and
are limited to two nutritional services visits per calendar year or per pregnancy. The services
must meet the following criteria:
•
•
•
Determined to be medically necessary.
Ordered by a licensed physician, physician assistant, or nurse practitioner.
Performed by a registered dietician or an individual who has a baccalaureate degree
from a U.S. regionally accredited college or university, and who has met the
academic and professional requirements in dietetics as approved by the American
Dietetic Association.
2.16. Obstetrics and Gynecology
2.16.1.
Obstetrics Overview
Obstetric (OB) care must be billed as a global charge unless the attending physician (or
another physician working in the same practice) did not render all components of the care.
Antepartum and postpartum care may be billed separately from the delivery only when the
services were rendered by a different physician or group.
High risk pregnancy case management services are now available to support providers in
caring for Idaho Medicaid participants. Pregnant women who are at risk for premature labor
or congenital issues of the fetus may be referred to a Qualis Health Case Manager, who will
telephonically assist with the coordination of in-home and community support services. To
make a referral, contact Qualis Health at 1 (800) 783-9207 and request Case Management
Services.
A nurse case manager will send a packet of information to the participant with information
about the voluntary, no-cost service. If the participant wishes to participate, they will return
the signed form to Qualis Health.
2.16.1.1.
Total Obstetric (OB) Care
Total OB care includes cesarean section or vaginal delivery, with or without episiotomy, with
or without forceps, or breech delivery.
Charges for total OB care must be billed after the delivery using the date of delivery as the
to and from date. The initial office examination for diagnosis of a pregnancy may be billed
separate from the total OB charges if that is the provider’s standard practice for all OB
participants. If the participant is new to the office, a new patient office visit code should be
used. The initial examination must be identified as such and billed with the appropriate
Evaluation and Management (E/M) CPT code.
Prenatal diagnostic laboratory charges, such as a complete urinalysis, should be billed as
separate charges using appropriate CPT codes. If an outside laboratory, not the clinic, did
services, the lab must bill Medicaid directly.
Resuscitation of the newborn infant is covered separately if billed under the child’s name
and Medicaid identification (MID) number.
2.16.1.2.
Place-of-Service (POS) Code
The POS code for total OB care is normally 21 (Inpatient), and must be in field 24B on the
CMS-1500 claim form, or in the appropriate field of the electronic claim.
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2.16.1.3.
Allopathic and Osteopathic Physicians
Antepartum Care
Antepartum care includes the following usual prenatal services:
•
•
•
Recording weight, blood pressure, and fetal heart tones.
Routine dipstick urinalyses.
Maternity counseling.
2.16.1.4.
Billing for Incomplete Antepartum Care
If the physician sees the participant for part of the prenatal care but does not deliver,
submit charges only for the services rendered.
When billing for the initial physical examination and the second or third follow up visit, use
the appropriate E/M CPT code.
Any laboratory services not previously submitted can be billed using the appropriate CPT
code. Do not bill for lab charges sent to an outside laboratory. Bill only for the services
rendered.
When billing for four to six prenatal visits, use CPT code 59425 with the total charge for all
visits on one line. Do not split out each visit. Enter the first date the participant was seen in
both the from and to date fields on the CMS-1500 claim form. If billing a paper CMS-1500
claim form, note the date for each additional visit in field 19.
When billing for seven or more prenatal visits with or without an initial visit, use CPT code
59426 with the total charge and the description, Antepartum Care Only, on one line with
one charge. Do not split out each visit. Enter the first date the participant was seen in both
the from and to date fields on the CMS-1500 claim form. If billing a paper CMS-1500 claim
form, note the date for each additional visit in field.
2.16.1.5.
•
•
Billing Ultrasounds and Stress Tests for Multiple
Pregnancies
Use the following guidelines to bill for each occurrence of a Primary Code
Always document a multiple pregnancy with an appropriate ICD-9/ICD-10 diagnosis
code
PRIMARY CODES
Ultrasounds, Biophysical Profiles, and
Stress/Non-Stress Testing
Modifier 59 is not subject to CCI edits;
Modifier 59 may be used for the Primary Codes
below, if all of the following requirements are
met:
•
Patient’s record includes documentation of
medical necessity for a repeat primary
procedure on the same day and at least 15
minutes apart.
•
The two services are not ordinarily provided on
the same day.
•
No other modifier better describes the
circumstances.
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ADD-ON CODES FOR ADDITIONAL
FETUSES
Modifier 51 - Multiple procedures.
Modifier 51 should not be appended to the four
“Add-on” codes below:
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PRIMARY CODES
Ultrasounds, Biophysical Profiles, and
Stress/Non-Stress Testing
Allopathic and Osteopathic Physicians
ADD-ON CODES FOR ADDITIONAL
FETUSES
76801 Ultrasound, pregnant uterus, first
trimester, single or first gestation.
(See modifier 59 note above if more than one
76801 is done same day.)
76802 Add-on code, each additional
gestation.
Bill 76802 on one separate line after 76801;
Indicate total number of additional fetuses in
quantity field. (Do not use modifier 51.)
76805 Ultrasound, pregnant uterus, after first
trimester, single or first gestation.
(See modifier 59 note above if more than one
76805 is done same day.)
76810 Add-on code, each additional
gestation.
Bill 76810 on one separate line after 76805;
indicate total number of additional fetuses in
quantity field. (Do not use modifier 51.)
76811 Ultrasound, pregnant uterus, with
detailed fetal anatomic exam, single or first
gestation.
(See modifier 59 note above if more than one
76811 is done same day.)
76812 Add-on code, each additional
gestation.
Bill 76812 on one separate line after 76811;
indicate total number of additional fetuses in
quantity field. (Do not use modifier 51.)
76813 Ultrasound, pregnant uterus, real time
with imaging, trans-abdominal or transvaginal, single or first gestation.
(See
modifier 59 note above if more than one 76813 is
done same day.)
76814 Add-on code, each additional
gestation.
Bill 76814 on one separate line after 76813;
indicate total number of additional fetuses in
quantity field. (Do not use modifier 51.)
76815 Ultrasound, pregnant uterus, real time
with image documentation, limited, fetal
position and/or fluid volume, one or more
fetuses.
(See modifier 59 note above if more than one
76815 is done same day.)
Use 76815 only once per exam and not per fetus.
76816 Ultrasound, pregnant uterus, real time
w/image documentation, follow-up, transabdominal approach, per fetus.
(See modifier 59 note above if more than one
76816 is done same day.)
Report 76816 with modifier 59 on a separate line
for each additional fetus examined in a multiple
pregnancy.
76817 Ultrasound, pregnant uterus, real time
w/image documentation, trans-vaginal.
(See modifier 59 note above if more than one
76817 is done same day.)
Use 76817 only once per exam and not per fetus.
If 76817 is done in addition to trans-abdominal OB
ultrasound exam, use 76817 in addition to the
trans-abdominal exam code.
76818 Fetal biophysical profile with nonstress testing.
(See modifier 59 note above if more than one
76818 is done same day.)
Bill 76818 with modifier 59 on a separate line for
each additional fetus.
76819 Fetal biophysical profile without nonstress testing.
(See modifier 59 note above if more than one
76819 is done same day.)
Bill 76819 with modifier 59 on a separate line for
each additional fetus.
59020 Fetal contraction stress test.
Bill the first fetus on one detail line without
modifiers 51 or 59. (See modifier 59 note above if
more than one 59020 is done same day.)
Bill the same code on separate lines for each
additional fetus, with modifiers 51 and 59 on each
line, and enter quantity of “1” for each line.
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PRIMARY CODES
Ultrasounds, Biophysical Profiles, and
Stress/Non-Stress Testing
59025 Fetal non-stress test.
Bill the first fetus on one detail line without
modifiers 51 or 59. (See modifier 59 note above if
more than one 59025 is done same day.)
2.16.1.6.
Allopathic and Osteopathic Physicians
ADD-ON CODES FOR ADDITIONAL
FETUSES
Bill the same code on separate lines for each
additional fetus, with modifiers 51 and 59 on each
line, and enter quantity of “1” for each line.
Postpartum Care
Postpartum care includes hospital and office visits in the 45 days following vaginal or
cesarean section delivery. Postpartum care also includes contraceptive counseling.
2.16.1.7.
Billing for Multiple Deliveries
Delivery of the first baby should be billed with the appropriate CPT code (59400 or 59510),
one (1) unit, and only the charges for the first delivery. Delivery of any additional babies
should be billed with a delivery code (59409, 59514, 59612, or 59620), modifier 51 and 59,
one (1) unit. All antepartum or postpartum care should be included in the delivery code for
the first baby.
2.16.1.8.
Presumptive Eligibility (PE)/Pregnant Women (PW)
Services
The PE and the PW Programs are outlined in the General Provider and Participant
Information, Presumptive Eligibility (PE) and Pregnant Women (PW). Services for
participants in this eligibility category have limited benefits. Please refer to Excluded
Services, under these sections for more information.
2.16.1.9.
Billing Presumptive Eligibility (PE) Determinations
To bill for the completion of a PE determination, follow these procedures:
•
•
•
•
•
Participant and provider complete program questions and determine if participant is
eligible for the PE Program. Provider sends the application for services to the
participant’s regional field office.
Participant’s local field office processes the application for services and issues a
Medicaid number for the participant’s PE period.
Participant’s PE period ends after a maximum coverage period of 45 days or sooner if
the candidate is eligible for PW or another Medicaid program.
Participant’s eligibility must be verified by the provider using Medicaid Automated
Customer Service (MACS) or electronic software. See General Provider and
Participant Information for instructions on verifying eligibility.
Use HCPCS code T1023 to bill for PE determination. Include the participant’s full
name, MID number, and date of birth.
Note: The PE Program covers only outpatient ambulatory pregnancy related services. A
delivery cannot be billed under the PE Program, regardless of the setting.
2.16.1.10. Billing for Presumptive Eligibility (PE) or Pregnant
Women (PW) Services
Claims submission for PE or PW participants should follow the same billing practices as
those for any pregnant Medicaid participant. Services for PW participants must be pregnancy
related. Services are only covered if they are needed to promote a positive outcome for
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mother and/or baby, or failure to provide the services could affect the outcome of the
pregnancy for mother and/or baby, or the services are needed to treat a condition caused by
or exacerbated by the pregnancy.
PE prenatal clinics can bill only the special services procedure codes and laboratory services
under the prenatal clinic provider number.
2.16.1.11.
Medical Necessity Form
The PE and PW Programs are for pregnancy related services only. Diagnosis codes must
include the appropriate V diagnosis code to indicate pregnancy or postpartum status. All
services that are not clearly pregnancy related must have supporting documentation to
justify the service. Providers may use a Medical Necessity form and attach the form to their
claim. Forms are available under Forms on the Molina Medicaid website, or as paper copies
by request from Provider Services.
Each claim is reviewed on a case by case basis by the Molina consultant. If a claim is
denied, an Explanation of Benefits (EOB) code that states the reason for a denial will be
provided and the provider may request further review from Medicaid. Please refer to the
Appeals section in the General Billing Instructions.
2.16.2.
Family Planning
Family planning services are covered postpartum as long as the woman is eligible under the
PW Program. A Healthy Connections referral is not required for family planning if the service
is billed with the FP modifier. If the FP modifier is not used, an HC referral is required for
billing.
2.16.2.1.
Contraceptive Supplies
Medicaid will pay for contraceptive supplies, including prescription diaphragms, intrauterine
devices (IUDs), implants, injections, contraceptive patches, and oral contraceptives. Plan B
is not covered by Idaho Medicaid.
Payment for oral contraceptives is limited to the purchase of a three month supply when
purchased through a pharmacy.
Payment to providers of family planning services is limited to Department of Health and
Welfare (DHW) fee schedule. Medicaid does not pay a physician’s office for take-home
contraceptives, except those inserted or fitted by the provider, such as an IUD, Norplant, or
diaphragm.
2.16.2.2.
Intrauterine Device (IUD)
When billing for IUDs, use the appropriate procedure codes (with modifier FP). When billing
J codes, the appropriate NDC must be billed with the procedure code. Medicaid pays for the
IUD insertion, but does not cover any separate fees for the office exam.
The only time that an office exam may be billed at the time of insertion is if the participant
was treated for an unrelated diagnosis. Attach modifier 25 to the evaluation and
management (E/M) CPT code.
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2.16.2.3.
Allopathic and Osteopathic Physicians
Implantable Contraception
Implantable contraceptive services must be billed using the appropriate insertion or removal
procedure codes along with the FP modifier. If there is a corresponding NDC, that
information must be included on the claim.
2.16.2.4.
Depo-Provera and Lunelle Injectables
Depo-Provera and Lunelle injectables must be billed using the appropriate procedure codes
(with modifier FP).
When billing J codes, the product NDC must be billed with the procedure codes. When DepoProvera is used for any purpose other than contraception or for dosages up to 100 mg, use
J3490 (Unclassified Drug) and indicate the NDC, quantity dispensed, and units of measure.
2.16.2.5.
Diaphragm
When billing for a diaphragm, use the following codes (with modifier FP).
A4266
57170
Diaphragm for contraceptive use
Diaphragm or cervical cap fitting with instructions
Note: Medicaid will not reimburse for drugs often described as “The Morning-after Pill,”
such as Plan B.
2.16.3.
2.16.3.1.
Abortions
Overview
Medicaid will cover abortions only under circumstances where the abortion is necessary to
save the life of the woman, or in cases of rape or incest as determined by the courts, or,
where no court determination has been made, if reported to a law enforcement agency.
Note: Medicaid does not pay for any type of abortion for participants on the Presumptive
Eligibility (PE) Program. Also, PE participants are not covered for any delivery services.
In the case of rape or incest, the following documentation must be provided to the
Department with the physician’s claim:
a.
b.
c.
A copy of the court determination of rape or incest must be provided; or
Where no court determination has been made, documentation that the rape or
incest was reported to a law enforcement agency.
Where the rape or incest was not reported to a law enforcement agency, a
licensed physician must certify in writing that, in the physician's professional
opinion, the woman was unable, for reasons related to her health, to report the
rape or incest to a law enforcement agency. The certification must contain the
name and address of the woman.
When the abortion is necessary to save the life of the woman, the following
information must be included with the physician’s claim. A licensed physician must certify in
writing that the woman may die if the fetus is carried to term. The certification must contain
the name and address of the woman. See section 2.16.3.2 Sample Documentation for
Abortions for an example.
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2.16.3.2.
Allopathic and Osteopathic Physicians
Sample Documentation for Abortions
I,
(Name of physician), attending physician to
(Name of participant), certify that in my professional
judgment, allowing this participant’s present pregnancy to be carried to term will endanger
her life.
Date:
Signature of physician:
Name of participant:
Address of participant:
2.16.3.3.
Hospitalization
Hospital charges for a therapeutic abortion are subject to the same restrictions as the
physician’s charges. The physician should send a copy of the documentation with the claim,
as required in section 2.16.3.1 Overview.
2.16.4.
Hysterectomy Overview
Medicaid only pays for a hysterectomy if the following criteria are met:
• Prior authorization (PA) by Qualis Health is on file.
• Rendering the participant permanently incapable of reproducing was not the sole
purpose of the surgery.
• Participant was advised both verbally and in writing that the hysterectomy would
result in permanent sterility and that she will no longer be able to bear children.
• The Authorization for Hysterectomy form, or the sterilization form (HW0034 or
HW0034S), must be signed by the participant, regardless of the participant’s age or
reproductive capabilities.
The Authorization for Hysterectomy form may be signed either before or after the surgery
has been performed. If the form is signed after the surgery has been performed, the
participant must sign a statement clearly stating that she was informed, both verbally and
in writing, before the surgery was performed, that the hysterectomy would render her
sterile. See Section 2.16.4.1 Sample Consent for Hysterectomy Form for an example.
If using the sterilization form under Consent to Sterilization, the field for operation known as
should be completed with “hysterectomy” and the form should be signed and dated by the
participant.
Approval from the Quality Improvement Organization (QIO), Qualis Health, must be
obtained.
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2.16.4.1.
Allopathic and Osteopathic Physicians
Sample Consent for Hysterectomy Form
I have been informed orally and in writing that the hysterectomy will render me
permanently incapable of reproducing. I was informed of these consequences prior to the
surgery being performed.
Signature:
Patient’s Medicaid ID number or birth date: ___________
Date:
_
___________________
2.17. Sterilization Procedures Overview
Sterilizations (tubal ligations/vasectomies) do not require prior authorization from the
Department or Qualis Health; however, participant information and consent require strict
adherence in accordance with federal regulations.
2.17.1.
Participant Consent
The participant must be at least 21 years of age at the time the consent form is signed and
prior to performing the procedure.
The participant must be mentally competent in order to give consent.
There must be a lapse of 30 days between the time the participant signs the consent form
and the time the sterilization is performed. However, not more than 180 days can lapse
after the participant signs the consent and the procedure is performed. In other words, the
time span looks like this:
Date signed
Day 1
Day 31
Day 180
Participant signs form. This does not count as the first day.
Count begins and 30 days must lapse. This counts as the first day.
First day surgery can be performed.
Last day surgery can be performed.
The intent of the rules and the federal requirements that 30 days must lapse are to allow
the participant time to think about the decision to be sterilized. The physician who performs
the surgery does not need to be the physician who obtains the consent from the participant.
However, the physician who performs the surgery must also sign the consent form, but the
30 day lapse need not be met again, as long as the participant signed a consent form at
least 30 days prior to surgery. Diagnosis code V25.2 must be used for sterilizations.
Note: A valid consent form must be on file before payments can be made.
2.17.2.
Waiting Time Exceptions
If premature delivery occurs or emergency abdominal surgery is required, the physician
must certify that the sterilization was performed because of the premature delivery or
emergency abdominal surgery less than 30 days, but no less than 72 hours after the date of
the participant’s signature on the consent form. The surgeon must certify the following
information in paragraph two of the physician’s statement of the consent form.
•
•
The expected delivery date and provide written details of the premature delivery.
The emergency nature of the abdominal surgery in writing.
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Under no circumstance can the period between consent and sterilization exceed 180 days.
Failure to properly complete the physician’s statement of the consent form will result in
claim denial.
An interactive sterilization consent form can be downloaded from the Molina Medicaid
website. The form can be downloaded, filled out online, printed, signed and attached to a
claim. The form is available in English (HW0034) and Spanish (HW0034S). Three copies are
needed – one for the patient, one for the physician, and one is the required claim
attachment.
Although this form is not required to be used, any form that is submitted must have at a
minimum all of the same information as the HW0034/HW0034S form.
2.17.3.
Interpreter’s Statement
When necessary, an interpreter must be provided to ensure that information is effectively
communicated to any individual to be sterilized who is blind, deaf, or otherwise
handicapped. An interpreter must also be provided if the participant does not understand
either the language used on the consent form or spoken by the person obtaining the
consent. Providers may bill Medicaid for reimbursement for oral or sign language interpreter
services that they provide for participants. Interpreters may not bill Medicaid directly for
their services.
The interpreter must sign and date the consent form the same day the participant’s
signature and date is obtained.
The interpreter certifies:
•
•
•
The information and advice was accurately translated and verbally presented to the
participant.
The consent form was read and accurately explained to the participant.
To the best of their knowledge and belief, the participant understood the interpreter.
If the interpreter fails to complete the statement correctly, all claims regarding the
sterilization, including physician, hospital, and anesthesiologist charges, will be denied.
See General Provider and Participant Information for additional information about billing for
interpretive services.
2.17.4.
When Not to Obtain Consent
Informed consent must not be obtained while the participant is in any of the following
conditions:
•
•
•
In active labor or childbirth.
Seeking to obtain or obtaining an abortion.
Under the influence of alcohol or other mind altering substances.
2.17.5.
Signature Requirements
The participant must voluntarily sign and date the consent form in the presence of the
person obtaining the consent.
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2.17.6.
Allopathic and Osteopathic Physicians
Statement of Person Obtaining Consent
Before the participant signs and dates the consent form, they are advised federal benefits
would not be withheld regardless of their decision to be sterilized or not to be sterilized.
•
•
The requirements on the consent form were verbally explained to the participant.
To the best of the witness’ knowledge and belief, the participant appeared mentally
competent and knowingly and voluntarily consented to the sterilization.
The person obtaining consent may sign the form any time on or after the date the person
giving consent signed the form. If the physician obtains the participant’s signature, then the
physician must sign both statements on the form, once as the person obtaining the consent
and again as the physician performing the surgery.
If the person obtaining consent fails to complete the statement correctly, all claims
regarding the sterilization, including physician, hospital, and anesthesiologist charges, may
be denied. Corrections to the participant signature and signature date are not allowed. The
providers of service may not bill the participant if this error is made.
2.17.7.
Physician’s Statement
The physician must sign the consent form certifying that the requirements per the IDAPA
16.03.09.681 Medicaid Basic Plan Benefits have been fulfilled.
The signature of the physician performing the sterilization must be obtained not more than
three days prior to surgery or any time after the surgery. A copy of the completed consent
form must be submitted with the claim form.
2.18. Ophthalmologist
2.18.1.
Overview
Effective July 1, 2011, vision services for adult participants age 21 and older are limited to:
•
•
Services necessary to treat or monitor a chronic condition, such as diabetes, that
may damage the eye.
Services necessary to treat an acute conditions that, if left untreated, may cause
permanent or chronic damage to the eye.
Participants under the age of twenty-one (21) are eligible to receive one complete visual
examination annually (every 365 days) to determine the need for eyeglasses to correct a
refractive error. If more visits are necessary, please submit claim with the KX modifier and
attach supporting documentation.
General policy, covered services, limitations, and exclusions can be found in the Eye and
Vision Services Guidelines.
Note: Evaluation and management procedures are paid only for an eye injury or disease.
Medicaid requires the appropriate eye exam procedure code to be billed for all other eye
exams.
If the participant requests a copy of the prescription, it must be provided to the participant.
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Order all vision supplies (frames, lenses, contact lenses) from Idaho Medicaid’s vision
product contractor, Classic Optical, who bills Medicaid for the supplies. Products obtained
through any other lab cannot be reimbursed.
View and order from the Classic Optical catalog online at www.classicoptical.com, or fax
orders to 1 (888) 522-2022.
Providers who do not have access to the internet or fax service can mail eyeglass and
contact lens orders to the following address.
Classic Optical
P.O. Box 1341
Youngstown, OH 44501
Phone: 1(888) 522-2020
2.19. Oral Treatments
For dates of service through 12/31/2014, for participants up to the age of 21, physicians
may provide the following topical oral treatments.
•
•
D1206 - Topical application of fluoride varnish.
D1208 – Topical application of fluoride.
For dates of service 1/1/2015 and forward, physician should use CPT® code 99188:
Application of topical fluoride varnish by a physician or other qualified health care
professional.
Effective 1/1/2015, D1206 and D1208 will no longer be covered for physicians and will be
denied.
2.20. Oral and Maxillofacial Surgery
A dental provider that is also enrolled as an oral surgeon performing surgical procedures is
required to bill the appropriate CPT code on the CMS-1500 claim form with their physician
provider number and submit to Molina.
Extractions must be billed on an ADA claim form under the provider’s dental provider
number, with the appropriate common dental terminology, dental code, and tooth number.
Claims on the ADA Dental Claim form must be submitted to Idaho Smiles. Idaho Smiles may
require authorization for some extractions. Please call Idaho Smiles provider services at 1
(800) 936-0978 for more information.
2.21. Physician-Administered Drugs (PAD)
Certain PADs require prior authorization by the Idaho Medicaid Pharmacy Unit. Please refer
to the Physician Administered Drugs (PAD) Requiring Prior Authorization list in the Links
section of the Provider Handbook. The pharmacy request forms can be found at
www.medicaidpharmacy.idaho.gov. If there is no PA form listed for the specific drug given,
use the Universal PA form. At the top of the form please write “Physician Administered
Drug” so that your PA is directed to the correct authorizing entity.
2.21.1.
Reporting National Drug Code (NDC) for Drugs Billed
with HCPCS Codes
Federal mandates require that professional claims for drugs reported with HCPCS must
include the appropriate NDC of the drug supplied, units dispensed, and basis of
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measurement for each HCPCS drug. This requirement applies to drugs with HCPCS codes,
whether submitted electronically, on a paper CMS-1500 claim form, or as a Medicare crossover claim.
The HCPCS drugs that require NDC information are listed in the current HCPCS Manual,
Appendix 1, and are listed alphabetically by generic, brand, or trade name with
corresponding HCPCS codes. Claims with incomplete NDC information will be denied.
2.21.2.
Compound Drugs
Paper Claims: Attach the NDC Compound Detail Attachment.
Electronic Claims: To designate the claim as a compound drug claim combining two or
more ingredients (one of which is a covered Medicaid product), a compound indicator value
of two (2) is required.
If one or more of the ingredients being billed is a non-covered item and the pharmacy has
chosen to be paid for the covered ingredients only, use a submission clarification code equal
to eight (8). This will post a zero payment to the non-covered ingredient(s) and process the
rest of the covered ingredients to pay at the applicable allowed amount.
Required for All Compound Claims:
• National Drug Code for each individual ingredient
• Drug name and strength
• Quantity of each ingredient
• A unit of measure for each individual ingredient of the compound
o Each (EA)
o Grams (GM)
o Milliliters (ML, CC)
• Ingredient cost for each ingredient (if no value is entered, no payment will be made)
2.22. Psychiatric Care
Medicaid covers preventive, diagnostic, therapeutic, rehabilitative, or palliative services
provided by a psychiatrist in an inpatient or outpatient setting. A psychiatrist billing for
these services will use their own physician provider number.
Refer to the Current Procedural Terminology® (CPT) Manual for procedure codes to bill
psychotherapy services.
2.22.1.
Outpatient Psychiatric Care
Effective September 1, 2013, Medicaid participants who are eligible for the basic plan are
automatically enrolled in the Idaho Behavioral Health Plan to obtain outpatient behavioral
health services administered by Optum Idaho. Physicians are not required to enroll as
network providers in order to provide and bill for Medicaid-reimbursable outpatient
psychiatric services.
2.22.1.1.
Telehealth
Limited mental health services may be provided via telemedicine technology if the
telecommunications permit real-time communication between the physician and the
participant. For additional information, refer to the telehealth policy.
Physicians providing services via telehealth must bill Medicaid utilizing their physician
provider number. The service may occur wherever the telehealth equipment is located.
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Medicaid allows for payment for a transmission fee for the “originating site” - code Q3014
(where the participant is located) and a transmission fee for the “distant site” – code T1014.
Telehealth delivered services must be billed with the GT modifier in addition to the
procedure code.
2.22.2.
Inpatient Psychiatric Care
All urgent admissions for inpatient psychiatric care must be authorized by Qualis Health
within one business day of the admission.
All non-urgent admissions for inpatient psychiatric care must be authorized by Qualis Health
one business day prior to the admission.
A non-urgent admission is defined as an admission that is planned and scheduled in
advance and is not urgent in nature OR is an urgent admission during regular business
hours. An urgent (emergency) admission is defined as: The sudden onset of acute
psychiatric symptoms of such severity that the absence of immediate medical attention
could reasonably be expected to result in serious dysfunction of any bodily organs or part or
death of the individual or harm another person. The Department of Health and Welfare
(DHW) will pay for prior authorized medically necessary inpatient psychiatric hospital
services in a free-standing psychiatric hospital for participants under the age of 21 who have
a DSM V diagnosis with substantial impairment in mood, perception, or behavior.
All admissions require a QIO authorization, which includes review for less restrictive services
by the Office of Mental Health and Substance Abuse. See the Qualis Health Idaho Medicaid
Provider Manual for more information.
2.23. Radiology
2.23.1.
Overview
Radiology procedures include:
•
•
Performance or supervision of the procedure (technical component).
Interpretation and writing of an examination report, and consultation with referring
physician (professional component).
2.23.2.
Technical Component
The technical component includes charges for the following.
•
•
•
•
Personnel
Material, including usual contrast media* and drugs
Film or xerograph
Space, equipment, and other facility charges
To bill for the technical component, use the appropriate CPT code with a TC modifier.
* The technical component does not include radioisotopes or non-iodine contrast media.
List the separate charges for radioisotopes with the appropriate HCPCS (Healthcare Common
Procedure Coding System) code. Attach an invoice to your claim identifying the cost of the
radioisotope, the manufacturer, and the strength and dosage administered. Because of the
wide variations in costs to providers and the radioisotopes billed, this information is
necessary to price each claim.
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2.23.3.
Allopathic and Osteopathic Physicians
Professional Component
The professional component represents services of the physician (radiologist) to interpret
and report on the procedure. To identify a charge for the professional component, use the
appropriate 5-digit CPT procedure code with a 26 modifier. This component is applicable in
any situation in which the physician does not provide the technical component as described
above.
The professional component does not include the cost of personnel, material, space,
equipment, or other facilities.
2.23.4. Place-of-Service (POS) Codes
X-ray procedure codes billed in POS 21 (Inpatient), 22 (Outpatient), or 23 (Emergency)
should be billed with a 26 modifier, Professional Component, unless there is a procedure
code with a description that says, Supervision and Interpretation Only. The TC (Technical
Component) is billed by the facility that owns the equipment.
2.23.5.
Place-Of-Service (POS) Office
In POS 11 (Office), if the physician owns the x-ray equipment, and also supervises and
interprets the x-ray, the physician may bill for the complete procedure without a modifier. If
the physician uses their equipment but sends the x-ray to a radiologist for interpretation,
they must use the TC modifier.
2.23.6. Diagnosis Codes
When billing for either the professional or technical component, the correct diagnosis code
should be used. If the provider is unable to obtain the diagnosis from the primary physician,
it is acceptable to use V72.5, except for sterilizations or abortions.
2.24. Surgery
2.24.1.
Global Fee Concept
Medicaid pays all surgical fees based on the global fee concept as defined in the Current
Procedural Terminology (CPT) Manual. The following services are always included in the
global fee payment for the procedure:
•
•
•
•
•
•
Local infiltration, metacarpal/metatarsal/digital block, or topical anesthesia.
Subsequent to the decision for surgery, one related Evaluation and Management
(E/M) encounter on the date immediately prior to or on the date of the procedure
(including history and physical).
Immediate postoperative care, including dictating operative notes and talking with
the family and other physicians.
Writing orders.
Evaluating the patient in the postanesthesia recovery area.
Typical postoperative follow-up care.
If a provider only delivers part of the global components listed above, he/she must bill the
appropriate CPT code for the actual services delivered with the appropriate modifier.
2.24.2. Complications
Complications are not considered part of a global procedure and additional services for the
treatment of complications should be billed accordingly.
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Use appropriate CPT codes, modifiers, and diagnosis codes for the billing of post-operative
complications.
2.24.3.
Modifiers
Modifiers are mandatory in certain circumstances. Refer to the most recent Current
Procedural Terminology (CPT) Manual for specific guidance using modifiers.
In order to recognize assistant-at-surgery services provided by a physician assistant or
nurse practitioner (mid-level practitioners), surgical codes should be billed under the midlevel practitioner number with an AS modifier.
The following surgical modifiers pay a percentage of the Idaho Medicaid fee schedule.
Modifier
Percentage
of Fee
Schedule
54
55
58
80%
20%
100%
62
78
62.5% each
80%
80
81
82
20%
20%
10%
Modifier Description
Surgical care only
Post-op management only
Staged or Related Procedure or Service By the Same Physician During
the Postoperative Period
Two surgeons
Unplanned return to operating room for a related procedure following
initial procedure for related procedure during post-op period
Assistant surgeon
Minimum assistant surgeon
Assistant surgeon when qualified resident surgeon not available
Note: Correct CPT modifier use is required and is an important part of avoiding fraud and
abuse or noncompliance issues.
When billing an E/M code on the same day as a surgical code, append modifier 25
(Significant separately identifiable E/M service by the same physician on the same day of
the procedure) or 57 (Decision for surgery) to the E/M code when appropriate. This is
regardless of whether both services were provided by the same or different providers.
2.24.4.
Hospital Admissions
If the surgery is elective or non-trauma, the hospital admission is included in the fee for
surgery. If the surgery is the result of an emergency or trauma situation, the hospital
admission can be paid in addition to the surgery. Indicate in field 24C of the CMS-1500
claim form or in the electronic claim form emergency indicator when the admission is
trauma or emergency related.
2.24.5.
Abdominoplasty or Panniculectomy
Abdominoplasty or panniculectomy is covered only with PA from Qualis Health. Medicaid
does not cover procedures for cosmetic purposes. The documentation that must accompany
a request for PA includes, but is not limited to, the following:
•
•
•
•
•
Photographs of the front, side, and underside of the participant’s abdomen.
Documented treatment of the ulceration and skin infections involving the panniculus.
Documented failure of conservative treatment, including weight loss.
Documentation that the panniculus severely inhibits the participant’s walking.
Documentation that the participant is unable to wear a garment to hold the
panniculus up.
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•
Allopathic and Osteopathic Physicians
Documentation of other detrimental effects of the panniculus on the participant’s
health such as severe arthritis in the lower body.
2.24.6. Bariatric Surgery
Medicaid will only cover bariatric surgeries that are performed in an approved bariatric
surgery center (BSC) or bariatric surgery center of excellence (BSCE). A list of facilities for
bariatric surgery is available online from the Surgical Review Corporation.
Any surgery for the correction of obesity is covered only if prior authorized by Qualis Health.
All participants must meet the criteria for morbid obesity as defined in Medicaid Basic Plan
Benefits, IDAPA 16.03.09.431 Surgical Procedures for Weight Loss-Participant Eligibility,
through IDAPA 16.03.09.434, Surgical Procedures for Weight Loss - Provider Qualifications
and Duties, including the following.
•
•
•
•
•
The participant must meet criteria for clinically severe obesity with a Body Mass
Index (BMI) equal to or greater than 40.
BMI equal to or greater than 35 with comorbid conditions such as type 2 diabetes,
hypothyroidism, atherosclerotic cardiovascular disease, or osteoarthritis of the lower
extremities.
The serious comorbid medical condition must be documented either by the primary
physician who refers the patient for the procedure, or by a physician specializing in
the participant's comorbid condition. The physician who refers the participant must
not be associated by a clinic or other affiliation with the surgeons who will perform
the surgery.
The obesity is caused by the serious comorbid condition, or the obesity could
aggravate the participant’s cardiac, respiratory, or other systemic disease.
The participant must have a psychiatric evaluation to determine the stability of
personality at least 90 days prior to the date a request for PA is submitted to
Medicaid.
Administrative rules specific to Medicaid coverage for bariatric surgery are found in IDAPA
16.03.09.431 Surgical Procedures for Weight Loss-Participant Eligibility, through IDAPA
16.03.09.434, Surgical Procedures for Weight Loss - Provider Qualifications and Duties.
2.24.7.
Circumcisions
Claims billed with CPT (Current Procedural Terminology) circumcision codes 54150, 54160,
or 54161, and related charges are only paid if one of the following diagnosis codes is used
or the physician has attached notes or documentation that this was medically necessary.
187.1
222.1
607.81
187.4
233.6
878.0
187.8
605
878.1
187.9
607.1
959.14
198.82
607.2
2.25. Tobacco Cessation
Effective January 1, 2014, tobacco cessation benefits are available to all eligible Medicaid
participants, including those who are dually eligible for both Medicare and Medicaid. These
benefits are no longer available through the Preventive Health Assistance (PHA) program.
Tobacco cessation products are now covered under the Medicaid Pharmacy program when
prescribed by a physician.
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For more information, call the Medicaid Pharmacy Unit at 1 (208) 364-1829 or refer to the
Medicaid Pharmacy program website.
2.26. Transplants
2.26.1.
Overview
Department of Health and Welfare may purchase organ transplant services for bone marrow,
kidneys, hearts, intestines, and livers when:
•
•
•
It is provided by a hospital that has been approved by Centers for Medicare and
Medicaid Services (CMS) for Medicare transplants for the type of transplant
requested.
That facility has completed a provider agreement with DHW.
The transplant has a PA by the QIO, Qualis Health.
Department of Health and Welfare may purchase cornea transplants for conditions where
such transplants have demonstrated efficacy. Cornea transplants do not require QIO PA.
The following transplants are covered.
•
•
Heart or Liver Transplants
o Note: A liver transplant from a live donor is not covered.
Kidney Transplants will be covered only in a renal transplantation facility
participating in the Medicare Program after meeting the criteria specified in 42
CFR 405 Subpart U. Facilities performing kidney transplants must belong to one of
the End Stage Renal Dialysis (ESRD) network of Health and Human Services for
Medicare certification.
o Living Kidney Donor Costs - The transplant costs for actual or potential living
kidney donors are fully covered by Medicaid and include all reasonable
preparatory, operation, and post operation recovery expenses associated with
the donation. Payments for post operation expenses of a donor will be limited
to the period of actual recovery.
o Coverage Limitations - When the need for transplant of a second organ such
as a heart, lung, liver, bone marrow, pancreas, or kidney represents the
coexistence of significant disease, the organ transplants will not be covered. If
medically necessary, otherwise non-covered transplants may be prior
authorized through EPSDT for children under the age 21. Each kidney or lung
is considered a single organ for transplant. Lung transplants are not covered
for participants age 21 and older.
2.26.2. Coverage Limitations
When the need for transplant of a second organ such as a heart, lung, liver, bone marrow,
pancreas, or kidney represents the coexistence of significant disease, the organ transplants
will not be covered. If medically necessary, otherwise non-covered transplants may be prior
authorized through EPSDT for children under the age 21. Each kidney or lung is considered a
single organ for transplant.
2.26.3. Re-Transplants
Re-transplants will be covered only if the original transplant was performed for a covered
condition and if the re-transplant is performed in a Medicare/Medicaid approved facility.
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2.26.4. Multi-Organ Transplants
Multi-organ transplants such as heart/lung or kidney/pancreas and the transplant of artificial
hearts or ventricular assist devices are not covered unless it is for an EPSDT participant, it is
medically necessary, and is prior authorized.
2.26.5.
Transplant Authorization
Except for cornea transplants, all organ transplants are excluded from Medicaid payment
unless a PA is obtained through the QIO and performed for the treatment of medical
conditions where such transplants have a demonstrated efficacy.
2.26.6. Non-Covered Transplants
Services, supplies, medications, transportation, or equipment directly related to a noncovered transplant will not be covered by Medicaid. Liver transplants using liver tissue from
live donors are not covered. Lung transplants for participants age 21 and older are not
covered.
2.26.7.
Follow-Up Care
Follow-up care to a participant who received a covered organ transplant may be provided by
a Medicare/Medicaid participating hospital not approved for organ transplantation.
2.27. Qualis Prior Authorization and Medical/Surgical Review
2.27.1.
Overview
Idaho Medicaid contracts with a Quality Improvement Organization (QIO), Qualis Health, to
conduct review on a preadmission basis for selected diagnoses and procedures and a
concurrent length of stay review on all hospital stays that exceed a specified number of
days.
All inpatient admissions must be reviewed by the QIO if the stay exceeds three days, except
for cesarean delivery (admitting or principal diagnosis) which needs review if the stay
exceeds four days. If the patient is not discharged by the end of the third day (count the
day of the admission as day one), a review must be obtained on day four, and thereafter at
intervals determined by the QIO. If the review due date falls on a weekend or a holiday, the
review is due by the next business day. See procedures and instructions detailed in the
Qualis Health Provider Manual or contact Qualis Health.
The QIO conducts 100 percent pre-admission and concurrent review of all admissions with
admitting or primary diagnoses 291.0 through 314.9 to inpatient psychiatric facilities for
Idaho Medicaid participants.
The QIO performs retrospective reviews for services that were not reviewed in a timely
manner (penalties may apply). Retrospective reviews may also be requested from the QIO
for services requiring prior authorization (PA) and for admissions longer than three days
when the patient receives retroactive eligibility. Refer to the Qualis Health Provider Manual.
The participant’s physician or the treating facility may initiate the request for PA. Both
providers are equally responsible for obtaining authorization.
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2.27.2.
Allopathic and Osteopathic Physicians
Penalties
Medicaid assesses a penalty to physicians and hospitals for failure to obtain a timely QIO
review instead of withholding total payment. Information on the penalty amounts are
detailed in the Medicaid Basic Plan Benefits, IDAPA 16.03.09.505 Physician Services Provider Reimbursement and IDAPA 16.03.09.705.03 Inpatient Psychiatric Hospital Services
- Provider Reimbursement; Physician Penalty Schedule, available online or by calling the
Department of Administration, Office of Administrative Rules at 1 (208) 332-1822.
2.27.3.
2.27.3.1.
Prior Authorization (PA)
Prior Authorization (PA) Notification
If a service is approved, a PA number is given to the provider requesting the approval either
by a Notice of Decision (NOD) for Medical Services letter from Medicaid, telephonically, or
via the browser based review application, iEXCHANGE (MEDecision®) from Qualis Health.
All claims submitted or adjusted on or after May 1, 2014 for services that require a prior
authorization, will be denied if the PA number is not on the appropriate claim line. The PA
number is found on the paper NOD letter or online through your Trading Partner Account
(TPA) under Authorization Status. When entering a PA number on a claim, the authorization
number includes “AUTH” plus the numbers that follow.
Please note that Qualis prior authorizations will not contain the letters “AUTH” and will not
require those letters to be entered.
2.27.3.2.
Quality Improvement Organization (QIO) PA
Contact Information
To obtain a Qualis Health provider manual or for additional information regarding the review
process, contact Qualis Health at using the following contact information.
Qualis Health
PO Box 33400
10700 Meridian Avenue North, Suite 100
Seattle, WA 98133-0400
Phone 1 (800) 783-9207 (toll free)
Fax
1 (800) 826-3836
http://www.qualishealth.org/healthcareprofessionals/idaho-medicaid
Provider representatives are available Monday through Friday from 7:30 A.M. - 6:45 P.M. MT
and 6:30 a.m.-5:45 p.m. PT (excluding state holidays).
Quality Improvement Organization (QIO) Diagnosis Codes
Inpatient diagnoses requiring PA for Idaho Medicaid participants are:
Diagnosis Requiring Prior Authorization (PA)
Inpatient Psychiatric or Chemical Dependency Admissions
(use fourth or fifth digit sub-classification): 291.0 - 314.9
Inpatient Physical Rehabilitation Admissions: V57.0 - V57.9
Note: This includes admission to all rehabilitation hospitals, regardless of the diagnosis on
the claim.
Quality Improvement Organization (QIO) Procedure Codes
All surgical procedures on the Qualis Select Pre-Authorization List of Diagnoses and
Procedures require pre-authorization for inpatient and outpatient services. The list is located
January 15, 2015
Page 32 of 33
CPT is a registered trademark of the American Medical Association, Copyright 2013 – AMA
Idaho MMIS Provider Handbook
Allopathic and Osteopathic Physicians
under the Reference area in the Provider Handbook at www.idmedicaid.com. For more
information please call at 1 (800) 783-9207, fax at 1 (800) 826-3836, or refer to the Qualis
Health Provider Manual on the Quails website.
2.27.3.3.
PA by the Medicaid Medical Care Unit
Certain procedures require a Medicaid PA. Physicians must request PA using the appropriate
CPT or ICD-9 CM code. Refer to the List of Surgeries Requiring Prior Authorization from
Medicaid's Medical Care Unit found on the Surgery and Other Medical Procedures website.
Idaho Medicaid authorization is also required for the following inpatient/outpatient
procedures not included on the QIO list (Qualis Select Pre-Authorization List of Diagnoses
and Procedures):
•
•
•
•
•
Reconstructive surgery.
Plastic surgery.
Administratively Necessary Days (AND).
Excluded services found medically necessary in an early and periodic screening,
diagnosis, and treatment (EPSDT) screen.
Molecular pathology (genetic testing) and other laboratory tests may require
authorization.
See Prior Authorization (PA) in the General Billing Instructions for more information.
Send or fax requests for PA and the required documentation to justify the medical necessity
for these services to the following address.
Division of Medicaid
Medical Care Unit
Attn: Surgery Authorizations
PO Box 83720
Boise, ID 83720-0009
Fax 1 (877) 314-8779
Prior Authorization request forms for the Medical Care Unit are available at
www.medunit.dhw.idaho.gov.
Note: Healthy Connections participants require a referral from their PCP for inpatient and
outpatient hospital services in addition to a Medicaid or Qualis Health PA.
2.27.4.
Third Party Recovery (TPR)
A participant who is a Medicare/Medicaid participant will only need to have PA from the
primary carrier, Medicare. Participants who have any other third party coverage, such as a
private insurance company, private individual, corporation, or business, must still obtain PA
when required from Qualis Health or Medical Care Unit.
January 15, 2015
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CPT is a registered trademark of the American Medical Association, Copyright 2013 – AMA

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