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Agenda General Policies & Procedures Break Questions & Answers 2.

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Presentation on theme: "Agenda General Policies & Procedures Break Questions & Answers 2."— Presentation transcript:


2 Agenda General Policies & Procedures Break Questions & Answers 2


4 Iowa Medicaid provides health care coverage for children, financially- needy parents with children, people with disabilities, elderly people, and pregnant women. Purpose of Iowa Medicaid? 4

5 Iowa Medicaid Statistics Over 559,000 members will be served SFY 2011 (18% of Iowas population) Iowa Medicaid is the 3 rd largest health care payer in Iowa, following Wellmark and Medicare 51,468 enrolled Iowa Medicaid Providers SFY 2009 total Iowa Medicaid expenditures were $2.8 billion. 5

6 Iowa Medicaid- Enrollment As of January 2010: Total Medicaid enrollment was 405,912; compared to 389,305 in January 2009 MediPASS enrollment was 178,566; compared to 157,709 in January

7 Iowa Medicaid- Distribution 54% Medicaid members are children, accounting for only 17% of the expenditures 9% are elderly, accounting for 20% of the expenditures 21% are disabled, accounting for 52% of the expenditures. 7

8 IME Facts In January 2010 Provider Services call center received 29,089 phone calls with an average wait time of less than 20 seconds. Member Services received 13,172 calls with an average wait time of 17 seconds. An average of 1.2 million claims processed each month. 8

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11 Medical Assistance Card Medical assistance card is good as long as the individual has Iowa Medicaid Lost, damaged or stolen cards can be replaced No specific eligibility month or program will be indicated on the card Providers must verify eligibility through ELVS or the Web Portal 11

12 Retroactive Eligibility May receive a Notice Of Decision (NOD) from DHS granting retroactive eligibility Claims must be submitted with a copy of the Notice of Decision within 365 days of the NOD issue date Please see reference materials online at: 12


14 IowaCare and IowaCare Card 14

15 IowaCare The IowaCare provider network currently includes: University of Iowa Hospitals and Clinics Broadlawns Medical Center 15

16 IowaCare Expansion Expansion tentatively scheduled to begin October 1, 2010 Will expand to include Hospitals for emergency services only Federally Qualified Health Clinics (FQHC) One or two FQHCs will be phased in Beginning on the western side of the state 16

17 Lock-In For members who have misused Medicaid Members can be restricted to: One Primary Care Provider (PCP) One specialty care provider One hospital One pharmacy Referrals must be obtained from the members lock-in PCP before services are rendered 17

18 Medically Needy Medicaid program that helps individuals with medical bills if they have high medical bills that use up most or all of their income May qualify for a spenddown Typically 2 month certification period Claims must be billed to the IME- IME does the accounting Medical Assistance Cards 18

19 QMB/SLMB QMB (Qualified Medicare Beneficiary) QMB with Spenddown SLMB (Special Low Income Medicare Beneficiary) SLMB with Spenddown 19

20 Iowa Family Planning Network Covers only specifically identified family planning services Members may receive family planning services from any Iowa Medicaid provider Members can have IowaCare and IFPN See Informational Letters 483 and 485 Request the covered services list from IME Provider Services 20


22 Overview of MediPASS Purpose Assure access to services Assure coordination & consolidation of care Educate members to access medical care from the most appropriate point Mandatory in many counties IME pays administrative fee of $2.00 per member per month. 22

23 MediPASS Providers Provider types that provide primary care services: Provider specialties: MD ARNP RHC DO Midwives FQHC Family practice Obstetrics General Practice Internal Medicine Pediatric 23

24 MediPASS Providers Can fine tune their agreement to suit their own practice Open or closed panel Maximum number of members accepted Gender of enrollees Age range of enrollees Can alter agreements at any time with written notification Can disenroll members for good cause 24

25 MediPASS Members Children, families with children, pregnant women Sent enrollment packet outlining program Must make 1 st choice within days Can continue to make choices for 90 days Close enrollment for 6 months after end of open period Not required of: American Indians Children receiving comprehensive Title V services Elderly and Disabled 25

26 MediPASS Referrals Treating provider must obtain a referral from the MediPASS provider Paper referrals not required by the IME Referrals should be solicited prior to service MediPASS provider must either treat or refer IME staff can mediate when necessary If solicited after service, then choice is up to MediPASS provider; no mediation available 26

27 MediPASS Referrals It is not appropriate to maintain a list of NPI numbers rather than contacting MHC provider Exempt from referral: Vision Emergent diagnosis Dental EPSDT screenings Ambulance Childhood immunizations Family Planning Prescription drugs Skilled nursing care Other misc programs 27


29 What is the Iowa Plan? State wide plan that covers most Medicaid members Most services are billed to the Iowa Plan contractor, currently Magellan Behavioral Health Services Members that are not enrolled with the Iowa Plan have services paid through the IME 29

30 Magellan will begin managing Medicaid enrollees 65 and over beginning July 1, 2010 Magellan staff are partnering with IME staff to ensure a smooth transition of services Medicaid enrollees will have access to services under the Iowa Plan that Magellan manages Members aged 65 & older 30

31 Partner with primary care for mental health/substance abuse referrals Transition of care during June 2010 to ensure all current services/providers are continued 65+ Priorities 31

32 SeniorConnect team in place March 2010 Team lead for outreach/coordination Follow up specialist for implementation of community-based services Intensive care managers following members by region Dedicated Magellan SeniorConnect team for members, families and providers for information/referral 65+ Resources 32

33 Key clinical focus on increasing access to services through community/home- based services: community support services, mobile counseling, psychiatric in home nursing, assertive community treatment, intensive psychiatric rehabilitation, substance abuse services and peer support New Services 33

34 Contacting Magellan Providers call: Toll-free (800) Local Des Moines area (515) Website: 34


36 Adult Routine Physicals Payable for both regular Medicaid and IowaCare adult (19+)members Members may receive annual preventative physicals from any enrolled Medicaid provider See Informational Letters 640 and 789 for complete details 36

37 Updating TPL to the IME Members can call Member Services to update their insurance information Complete the Insurance Questionnaire (IQ) found at Form # The IQ form can be ed to or faxed to It can take 10 days for TPL to be updated 37

38 Release of Medical Records May release members bills and medical records if member requests them Release medical bills if a subpoena is received Do not release bills or records on trauma- related claims to the member or the members representative until IME has authorized release Providers should notify the IME Lien Recovery Unit of trauma related incidents by calling or locally (Des Moines area) at

39 Correct Coding Initiative Providers must use the NCCI coding convention effective Allows IME to more closely follow national standards/Medicare Enhanced prospective & retrospective reviews were delayed but will be part of FY 2011 Refer to IL 875, 882,

40 Iowa Medicaid Health Information Technology Federal incentive grants to Medicaid providers To encourage adoption and meaningful use of EHRs (electronic health records) Administered by the State Medicaid Program Eligible providers must meet minimum patient volume thresholds 90% federal matching funds for statewide initiatives that promote the adoption and use of HIT Up to $63,750 is available to each eligible professional over a six year period 40

41 Medicaid Integrity Program CMS audit program to combat Medicaid fraud & abuse Effective 11/1/09 Iowa contractor is Health Integrity, LLC Communication is between Health Integrity and the provider Failure to comply with request from Health Integrity can cause claim recoupment Refer to IL

42 Prior Authorization Imaging Request made through Clear Coverage- Prior Authorization Management Portal PA required for MRI, CT, CTA, PET, MRA Program will suggest alternatives if PA denied or pended Effective 3/1/10 Refer to IL 876,

43 EFT/Debit card payments Effective with 8/23/10 payment cycle Sign up for EFT, call Provider Services Debit cards can be used at retailer, banks, ATM Special toll-free number for balance & account info Web access to balance & account info 43

44 HIPAA 5010 & ICD-10 Contract awarded to Chicago Systems Group, Inc. (CSG) Assisting the IME in meeting the goals established by CMS 44


46 Iowa Administrative Code (4) Recipients must be informed before the service is provided that the recipient will be responsible for the bill if a non-covered service is provided. 46

47 Top Claim Denial Reasons Duplicate claim Member not eligible Missing or invalid MediPASS referral number Third-party insurance, or Medicare, should have been billed primary Concurrent care Procedure/provider type conflict 47

48 Electronic Claim Submission Over 83% of all claims are submitted electronically. Home Health has been able to bill electronically since early ETPs can be billed electronically. See IL

49 Electronic Claim Submission Providers must enroll with EDISS through their Total OnBoarding program PC-ACE Pro32- Free software available through DHS Link to PC-ACE Pro32 Instructions on the IME Provider Home page under Quick Links Providers must check ALL confirmation reports to insure that the claims have not rejected …continued… 49

50 Timely Filing Guidelines Claims must be filed within 365 days of the through date of service (DOS). If a claim is filed timely but denied, an additional 365 days from the denial date is allowed, up to 2 years from the DOS. Claims up to 2 years from the date of service may be submitted electronically, as it is no longer required to attach the remittance advice denial. 50

51 Timely Filing Guidelines Claim Adjustments Requests for claim adjustments must be made within 365 days of the payment date Claim credits are not subject to a time limit Discussion of adjustment form will follow …continued… 51

52 Exceptions to the Timely Filing Guidelines Retroactive eligibility Needs to be billed with the Notice of Decision (NOD) Submit claims within 365 days of the date on the NOD Third-party related delays Need to include reason for delay Within 365 days of TPL payment 52

53 Guidelines for Medicare Crossovers Medicaid will pay coinsurance and deductibles (unless SLMB) Necessary information must be added to the EOMB copy See Informational Letters 638, 658, 687 and 693 for information needed on EOMB TPL payment declaration (if applicable) IME will now automatically reprocess electronic Medicare cross-over claims that Medicare denied for reasons PR-96 & PR

54 Medicare Cross-over Template Can submit this form rather than submitting the Medicare/HMO EOB Cleaner claim processing Template and instructions are located on the Provider home page of the IME website 54

55 Exception to Policy What is an Exception to Policy? (ETP) Request an Exception to Policy at: If an Exception to Policy has been approved: Submit claim with a copy of the Exception to Policy approval letter to the address on the approval letter Submit claim electronically, see IL

56 Credits and Adjustments When to credit vs. adjust? The Credit/Adjustment form is located on the IME provider website. Form # Use most recently paid TCN If crediting with this form, do not send a refund check Include either a new corrected claim or a copy of the remittance advice with corrections Include appropriate documentation 56

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58 Provider Inquiry Form found on IME provider website. Form # When to use: To initiate an investigation into a claim denial To request Medical Services review When not to use: To add documentation to a claim To update/change/correct a paid claim 58

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60 Fraud To report instances of possible fraud or abuse, contact one of the following telephone numbers: Medicaid Fraud Control Unit Medicaid Surveillance & Utilization Review or (Des Moines area) 60


62 Addresses and phone numbers Claims address: IME PO Box Des Moines, IA Correspondence address: IME PO Box Des Moines, IA IME Provider Services (Des Moines area) ELVS (Des Moines area) 62

63 How can you receive information from the IME? IME Website- Provider Services phone line Remittance Advice comments Updates Informational Letters 63

64 Download forms Access provider manuals Access Informational Releases Find links to the Web Portal for claims submission and eligibility information Provider training documents & Webinars 64

65 ELVS Voice response system Eligibility information available 24/7 Providers can verify: Monthly eligibility Spenddown TPL insurance Managed Health Care information Current check amounts Limited vision and dental history Iowa Plan 65

66 EDISS Webportal Available 24/7 Check member eligibility Check claim status Submit batch claims Enroll with EDISS through Total OnBoarding 66

67 I-MERS Iowa Medicaid Electronic Records System Web-based patient management tool Billed diagnosis, drugs and procedures Name and phone of rendering provider Quick link on Provider Home page at 67


69 Remittance Advice View weekly remittance advice online 24/7 History going back 2 years Iowa Medicaid discontinued paper remittance advices March 1, 2010 As of 7/5 this tool replaces for RA retrieval See IL 890 for direction to IMPA 69

70 HCBS Waiver Authorization Providers can view Waiver Program information: Number of authorized units Services Rates Procedure Codes 70

71 Presumptive Eligibility NEW – Presumptive Eligibility for Children Currently only hawk-i outreach workers are eligible to enter applications into IMPA for this group Online tool for Presumptive eligibility for Woman with breast or cervical cancer (BCCT) & pregnant presumptive will be available on IMPA beginning Summer ILs will be mailed as soon as more information becomes available 71

72 Provider Incident Reporting Providers can report, track & monitor incidents in "real time" Required of HCBS waiver & habilitation providers online forms, instructions, & tutorial are available on Provider home page of the IME website 72

73 Provider Reenrollment 2010 Provider must designate: Provider Administrator Provider Signatory Provider Reenrollment Ownership Control Disclosure Background Checks Disclosure Coming Soon… 73

74 Provider Services Outreach Staff Outreach Staff provides the following services: On-site training PC-Ace training Escalated claims issues Please send an to 74


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