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1 The Iowa Working Together for a Healthier Iowa Medicaid Enterprise Part Two.

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Presentation on theme: "1 The Iowa Working Together for a Healthier Iowa Medicaid Enterprise Part Two."— Presentation transcript:

1 1 The Iowa Working Together for a Healthier Iowa Medicaid Enterprise Part Two

2 2 IME Contact Information Mailing Address for Claims Iowa Medicaid Enterprise P. O. Box 150001 Des Moines, Iowa 50315 (Begin Using 6/27/05)

3 3 IME Contact Information Visit the IME Website to access even more information: (Effective 5/10/05)

4 4 IME Contact Information ELVS (Eligibility Verification System) 800-338-7752 515-323-9639 (Local) Verify member eligibility Verify if there is a primary insurance Verify member enrollment with HMO, MediPASS, and the Iowa Plan Access your last payment amount and date Verify if the member has a spend down amount remaining Verify if the member has other restrictions (Lock-in or Iowa Plan)

5 5 IME Contact Information PROVIDER SERVICES 7:30 AM – 4:30 PM 800-338-7909 515-725-1004 (Local) 515-725-1155 (Fax) (Effective 6/30/05) Speak personally to knowledgeable IME staff Check status of a claim Press 2 to speak directly to IME Enrollment staff

6 6 IME Contact Information PHARMACY PRIOR AUTHORIZATION 8:00 AM – 6:00 PM (after-hours on-call available) Provider PA Hotline 877-776-1567 515-725-1106 (Local) Ask questions about prior authorizations Ask questions about the Preferred Drug List Prior Authorization Requests 800-574-2515 (Fax Only)

7 7 IME Contact Information PHARMACY POS HELP DESK 8:00 AM – 6:00 PM (after-hours on-call available) 877-463-7671 515-725-1107 (Local) Ask questions about your claims Check status of claims Get assistance with adjustments Drug coverage issues DUR overrides

8 8 IME Contact Information MEDICAL SERVICES Medical Support 8:00 AM – 4:30 PM 800-383-1173 515-725-1008 (Local) (Effective 6/30/05) Ask questions about Medical Prior Authorization Ask questions about authorization for MR/DD Targeted Case Management Ask questions about the Lock-in program

9 9 IME Contact Information MEDICAL PRIOR AUTHORIZATION (PA) 8:00 am – 4:30 PM 888-424-2070 515-725-1009 (Local) 515-725-1356 (Fax) (Effective 6/30/05)

10 10 IME Contact Information MEMBER SERVICES 8:00 AM – 5:00 PM 800-338-8366 515-725-1003 (Local) (Effective 6/30/05 ) Refer Members here if they have questions about: Medicaid Policy Unpaid bills for Medicaid services Managed Care enrollment Publication requests

11 11 IME Contact Information PROVIDER AUDITS AND RATE SETTING 8:00 AM – 5:00 PM 866-863-8610 515-725-1108 (Local) State MAC Help Line 800-591-1183 (Effective 6/30/05)

12 12 IME Contact Information SURS (Surveillance & Utilization Review Subsystem) 8:00 AM – 5:00PM 877-446-3787 515-725-1346 (Local) (Effective 6/30/05)

13 13 IME Contact Information REVENUE COLLECTION (Effective 6/30/05) Estate Recovery 7:30 AM – 5:30 PM Third Party Liability (TPL) 8:30 AM – 5:00 PM Lien Recovery 8:30 AM – 5:00 PM 877-463-7887 515-725-1005 (Local) 866-810-1206 515-725-1006 (Local) 888-543-6742 515-725-1007 (Local)

14 14 IME HIPAA Transactions 837 Professional, Dental, Institutional 835 Electronic Remittance Advice (Available 6/30/05) 278 Prior Authorization Request 276 Claims Inquiry 270 Eligibility Inquiry Register at

15 15 IME Provider Web Page Provider Manuals Provider Enrollment Forms Fee Schedules Electronic Provider Directory Electronic Claims Information imeproviderservices@dhs.state.ia.usE-mail Questions –

16 16 Claims Submission Changes HIPAA transactions only for electronic claims No black and white claim copies You must use the original Drop-out red and white CMS-1500 and UB-92 claim forms. Do not high-light Medicare EOMBs Do not use red ink New credit and adjustment form

17 17 Medical Services Overview

18 18 Effective June 30, 2005, the IME Combines Programs Previously Performed by ACS, the IFMC, and DHS Pharmacy Prior Authorization Medical Prior Authorization MR/DD Targeted Case Management Medical Support Quality of Care Home Health Prior Authorization for Early, Periodic, Screening Diagnosis and Treatment (EPSDT) Elderly Waiver Lock-in Psychiatric Medical Institutions for Children (PMIC) Pharmacy POS

19 19 Iowa Medicaid Enterprise Effective June 30, 2005 Iowa Medicaid Enterprise Implements the Following NEW Programs: Disease Management Expanded Primary Care Case Management Long Term Care Assessments Nursing Facility ICF/MR All Waivers Programs Excluding Elderly Waiver Services

20 20 Pharmacy Operational January 15, 2005 Supplemental rebates Preferred Drug List Prior Authorizations Recommended drug list

21 21 Medical Prior Authorization Verify medical necessity and compliance with Medicaid guidelines for medical services that require prior authorization No changes in current process for providers Providers continue to use same phone numbers for inquiries 1-888-424-2070 515-725-1009 (Local) 515-725-1356 (Fax) Complete authorization requests will be processed within 5 working days Authorizations requiring peer review will be processed within 10 working days

22 22 MR/DD Targeted Case Management Effective July 1, 2005, requests for MR/DD TCM (Targeted Case Management) previously completed by DHS will be reviewed by Medical Services Requests for Targeted Case Management for persons with: Mental Retardation Developmental Disability Chronic Mental Illness (Over 65 or Medically Needy) TCM providers will continue to send requests by email to same email address:

23 23 Early and Periodic Screening, Diagnosis and Treatment (EPSDT) Process requests for home health services for special needs children following prior authorization procedures Coordinate care for special needs children Remind case managers of prior authorizations needed Complete reports for program support

24 24 Elderly Waiver There are no changes to the Elderly Waiver review program in FY 06-07 Assessments are completed by area agency on aging staff Assessments are reviewed by medical services to determine level of care Level of Care decisions are documented in the Individualized Services Information System (ISIS)

25 25 Medical Support Involves a Broad Range of Continuing Activities: Prepay claims review Pre-Procedure review Retrospective review of inpatient and outpatient services MDS automation education Make policy recommendations and consulting for specific concerns on behalf of the Department of Human Service (DHS) Provide medical expertise to assist DHS in the evaluation of requests for new or unusual services or treatment modalities Assist in the adjudication of any provider claim that is suspended or pended for medical review Participate in the certification of new outpatient programs, make recommendations to DHS, and determine the coverage criteria

26 26 Lock-in and Member Health Education Review member utilization of medical services to identify Over utilization Duplication of services Medication misuse and abuse Possible drug-to-drug interaction Provide education to identified members Enroll members in program restricting access to providers Recruit primary care providers to provide oversight to enrolled members Improve care and health of members, reduce wasteful and duplicative services, promote reduction of health care spending, Providers continue to use same phone number for inquiries and referrals 1-800-383-1173 515-725-1008 (Local)

27 27 Quality of Care The Quality of Care program monitors care provided to Iowa Medicaid members The focus is care delivered by MediPASS, the HMO and the Iowa Plan providers. A comprehensive Report Card will be developed to assist in evaluating: The health status of the members in the program. Providers compliance with service agreements. Federal requirements for managed care contracting are met

28 28 Disease Management Disease management is a program for improving care and outcomes for individuals with specific disease conditions Disease management programs use indicators reflective of guidelines for the specific disease processes to evaluate positive outcomes Disease management includes services designed to enhance patient management and adherence to a treatment plan Functions of disease management are to: Improve the health status of enrolled members Reduce costs Support recognized evidence-based practice guidelines Enlist primary care providers to be actively involved in the management of the member enrolled in the program DHS policy staff will select the specific diseases included in the program

29 29 Enhanced Primary Care Case Management The function of enhanced primary care case management is to improve access to needed care and to reduce unnecessary or inappropriate utilization and costs The program staff perform the following: Accept referrals for case management Perform a prescreening assessment on each enrolled member Enlist the primary care provider to be actively involved in the management of the member enrolled in the program Develop care plans for each member receiving case management and disseminate to involved entities Monitor the performance of the case management process

30 30 Long Term Care Assessment Program Face to face pre-screening assessments will be completed by healthcare professionals with expertise in the institutional and community based services Services requiring pre-screening assessment are: Nursing Facility Intermediate Care Facility for Mentally Retarded Brain Injury Waiver Ill and Handicapped Waiver Mental Retardation Waiver Aids Waiver Physical Disability Waiver Pre-screening assessments will be completed prior to placement or service initiation

31 31 Long Term Care Assessment (Cont.) Assessments will be conducted within five days of the request for services A preliminary care plan may be developed at the time of the assessment for members requiring immediate services The pre-screening assessment decision will be documented in the Individualized Services Information System (ISIS) The Medicaid Medical Director will provide medical leadership and guidance to staff conducting assessments Follow-up pre-screening assessments will be conducted periodically to determine continuing need for Long Term Care (LTC) services

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