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The Implementation Guide for Where Do Providers Get Utah State Medicaid Eob

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Guide of Where Do Providers Get Utah State Medicaid Eob

welcome to the 2018 Utah Medicaid.statewide provider training my name is.Rachel Beecher and I am the Bureau of.Medicaid operations trainer I'm going to.start today's training with some.important information about the provider.enrollment process.as of July 1st 2016.all new applications are submitted.online through the prism system you will.need to have the NPI SSN f ein date of.birth licenses and ownership information.ready for each new application an.application can be started at our.website medicaid Utah gov you will first.click on the tab titled health care.providers and then you will click on the.first link titled become a medicaid.provider a Utah ID will be required to.start a new application and to obtain.one you will visit Magan Utah gov you.will then choose the enrollment type.that is appropriate for the provider a.page will appear asking for the name of.the provider tax ID provider requested.effective date and all fields marked.with an asterisk need to be completed.you will always maximize the windows.that pop up once all of the information.is entered you will press the validate.NPI button and for enrollment types such.as individual group facility agency.organization and Indian Health Services.in the lower right corner of the screen.an error may appear but as long as the.MDI and tax ID are correct you will.press the finish button and move on with.the application you will complete all.required steps the billing provider step.is optional if your provider practices.as part of a group you will need to add.the group mpi to the billing provider.step every new application will need a.provider agreement and provider user.access agreement and these forms can be.obtained at our website medicaid Utah.gov forward slash Utah Medicaid forms if.the application is not submitted within.60 days of the day it was started it.will be removed from the system and at.this point the process would start over.again.all providers are required to wreak.radenso every three to five years.depending on their risk level with CMS.Utah follows CMS guidelines for pre.credentialing and REE credentialing is.done through the prism system a letter.will be mailed to the pay to address on.file when the provider is due to wreak.radenso.providers enrolling in Utah Medicaid.will receive the date their application.is correctly and completely submitted as.their effective date a backdate can be.requested for extenuating circumstances.but an email will need to be submitted.to our provider enrollment team at.provider enroll at Utah gov the email.must include the requested begin date.providers NPI and a detailed.justification of why the request is.needed.all providers enrolled with Medicaid.prior to July 1st 2016 will be required.to validate information converted from.the legacy MMIS system online training.for validations can be found here at our.website medicaid Utah gov /p e training.you will then select validating.converted Medicaid provider information.in prism web-based training.frequent questions when prism.troubleshooting I need to update my EDI.and provider information how do I log.into prism and the answer a validation.letter is required to log into prism for.the first time for providers enrolled.prior to prism go-live you can request.allegation letter by emailing provider.enroll at Utah gov or by calling our.Medicaid hotline at.and another frequent question I am.trying to validate but I am stuck on.step two locations how can I get this.step two complete and the answer click.on the step two locations link you will.then click on the zero zero link that.says in review if there isn't one in.review simply click on the one that is.available.after clicking on the 0-0 link you will.be on the location details page scroll.down to the bottom of the page there.will be a heading labeled address list.and directly above the address list is a.button that says add address and.remember to always maximize new windows.that pop up.once clicking on the add address button.a new window will open asking for an OIG.correspondence if this address is the.same as the mailing address you will.then click copy from mailing address.radio button if you need to manually.input the address you will just click on.the add address button at the end of the.zip code.now that the address is entered and.validated press the next button it will.now ask you for a financial.correspondence address you will fill.this out and select how you would like.overpayments recouped at the bottom then.press ok you will now be able to move on.to step 3.and another frequent question I can't.get the view upload attachments to.complete what am I missing.all new validations require a provider.agreement and provider user access.agreement you can find a list of the.required uploads inside of the step you.first click on the view upload.attachments step and then under the.instructions for upload attachment there.is a link to the provider user access.agreement for lines down.at the top of the page there is a.required credential button you will.click the button to see what is required.the licenses required for upload will be.under 0 1 license click on 0 1 license.select 0 for document type and then.press GO.from this page you will be able to print.the provider agreement and review what.other documents need to be uploaded.close out the window and click on the.upload attachments button to upload all.of the required licenses and documents.in order to complete the validation or.the new enrollment complete the final.step which is submit modification review.or submit enrollment application for.review.now that I have completed the training.section on provider enrollment jeanette.little and i will be moving on to.medicaid 101 where we will discuss.general medicaid information that.includes how to bill dental plans.medicaid members member responsibilities.coordination of benefits and our lookup.tools medicaid uses two different.payment models to reimburse for services.delivered to medicaid eligible members.managed care and fee-for-service.medicaid eligible members may have.fee-for-service or a managed care plan.depending on the county they live in a.managed care organization includes.accountable care organizations and pergi.paid mental health plans providers are.responsible for verifying medicaid.eligibility and determining if a member.is enrolled with an MCO before services.medicaid eligibility can be verified.using our access now eligibility lookup.tool or ANSI to 72 71 a provider who.accepts Medicaid agrees to accept the.MCO payment as payment in full this.includes any deductible coinsurance or.co-payments.a member may not be built for services.unless specific requirements are met if.a medicaid member received a physical.health service and has an ACO send the.claim to the ACO an ACO contracts with.Medicaid to pay for physicals health.services provided to Medicaid members.right now eighty-five percent of.Medicaid members receive their physical.health benefit from an ACO.Utah Medicaid's a COS our health choice.Utah healthy you Molina and select.health enrollment in an ACO is mandatory.in the following counties enrollment in.an ACO for members in other counties is.voluntary the health plan is required to.cover the same services that the.fee-for-service Network covers the eCos.may have their own prior authorization.or other utilization review requirements.if the MCO denies your claim you can.file an appeal with the MCO the appeal.needs to be filed within the timeframe.specified by the MCO and failure to file.your appeal within the required time.frame may prevent you from obtaining.payment we will provide additional.training on Appeals in the future.emergency services program for.non-citizens has been updated and.specific policy for this program can now.be found in an administrative rule r4 14.518 emergency service program for.non-citizens and this defines the scope.of service that is available to.individuals who meet coverage criteria.under the emergency service program for.non-citizens.for the treatment of emergency medical.conditions Utah Medicaid contracts with.Delta Dental and premier access for.pregnant women and children living in.Davis Salt Lake Utah and Weber counties.and if you serve a Medicaid member that.is enrolled in one of these plans then.you would send the claim to the dental.plan dental plans must cover the same.services that the fee-for-service.Network covers adults ages 21 and older.who qualify for Medicaid because of a.disability or blindness are eligible for.dental benefits under fee-for-service.and not through a dental plan.these same members receive the same.dental benefits as pregnant women the.claims for these services will be sent.to you Tom Medicaid and not to a dental.plan these services for members who are.visually impaired or those with.disabilities residing in Salt Lake.County shall be provided services.through the University of Utah School of.Dentistry for Medicaid members who are.visually impaired or those with.disabilities who reside within a nursing.home and are 21 or older covered dental.services are not allowed to reduce the.nursing home liability cover dental.services.be rendered by a Medicaid provider and.billed directly to Medicaid program.coverage and limitations have been.updated and are available in the dental.oral maxillofacial and orthodontists.services provider manual and the Utah.Medicaid coverage and reimbursement code.lookup tool under the p.m. HP Medicaid.contracts with local county mental.health and substance abuse authorities.to provide mental health and substance.abuse services to Medicaid eligible.members prior to delivering services.providers must verify the members p MH p.through access now eligibility lookup.tool or ANSI 270 271 if a member.received a mental health service or.substance abuse disorder service send.the claim to the p MH p all medicaid.members enrolled in the p MH p may also.receive services from a federally.qualified health center p MH p.authorization is not required American.Indian and Alaska native Medicaid.members may receive services from Indian.health care providers that include.Indian Health Program or an urban Indian.organization Medicaid members with.subsidy adoption may disenroll from the.p MH p on a case-by-case basis for.outpatient mental health and substance.use disorder services a Medicaid member.is required to present their eligibility.card before each service every provider.must verify each member's eligibility.every visit before rendering services.and presentation of the Medicaid member.card does not guarantee a member is.eligible for Medicaid you would verify.the members eligibility determine.whether the member is enrolled in a.managed care organization emergency only.program or the restriction program.assigned to a primary care provider.covered by a third party or responsible.for a copay or coinsurance and.eligibility and health plan enrollment.may change from month to month retain.documentation of the verified.eligibility for billing purposes and you.can always verify their eligibility.through our access now eligibility look.up to.or ANSI - 72 71 here is an example of.our eligibility lookup tool which you.can find at Medicaid Utah gov forward.slash eligibility lookup tool to submit.an eligibility inquiry on a specific.member you will enter the provider ID.date of service and a combination of the.following criteria one value from the.unique identifiers column and two values.from the demographics column or all.three values from the demographics.column and only exact matches will.return results remember to print and.file a copy of the eligibility on the.date of service as proof if needed and.providers should also note that the.eligibility lookup tool is currently.showing fee for service network by the.red arrow and when a member is not.enrolled in a managed care plan that's.what it will list fee for service claims.should be billed to State Medicaid.Medicaid members may be billed for.co-payments and coinsurance Medicaid.members may only be billed for broken.appointments if there is a policy in.place for broken appointments for all.patients not just Medicaid members and.the member has also signed an agreement.to pay for broken appointments.traditional and non-traditional Medicaid.members may be built for non-covered.services when all four of the conditions.below are met the provider has an.established policy for billing all.patients for services that are not.covered by a third party the member is.advised prior to receiving a non-covered.service the member agrees to be.personally responsible for the payment.and that agreement is in writing between.the provider and the member which.details the service and the amount to be.paid by the member PCN members may also.be responsible for non covered services.you can see that in the PCN manual for.covered and non-covered services for.complete information regarding our.medicaid members billing please see.section 1 3 - 4 & 3 - 5 located on our.website under forms we have a sample of.the financial agreement form that covers.all four areas that were shown in the.prior slide in order to build the.medicaid member.when billing for emergency services.provided to a non-citizen any payment.made by Medicaid for a service is.considered payment in full once the.payment is made to the provider for.covered services no additional.reimbursement can be requested from the.member because the emergency Medicaid.program for non-citizens.has a very restricted scope of service.it does not have the same restrictions.on billing the member if a provider does.not receive payment from Medicaid.because the provider failed to follow.procedure to get a service covered the.provider is prohibited from pursuing.payment from the member if payment is.not made because the service was not an.emergency or the service is not covered.under the program then the member can be.built for those services if a service is.a covered service and needs the medicaid.definition of emergency Medicaid will.pay for the service however if a.non-citizen eligible for emergency.services only presents at the ER with.symptoms that do not appear to be.emergent in nature the provider would be.prudent to inform the member prior to.the service that that service might not.be covered by Medicaid in that case the.member will be financially responsible.for paying the bill Medicaid members are.responsible for certain charges that.include charges incurred during a time.of in eligibility charges for non.covered services including services.received in excess Medicaid benefit.limitations charges for service which.the member has chosen to receive an.agreed in writing to pay as a private.pay member spend-down liability and.cost-sharing amounts such as premiums.deductibles coinsurance or co-payments.imposed by the Medicaid program some.Medicaid members share the costs for.certain services that include.prescription drugs inpatient hospital.services non-emergent use of the.emergency department services and.cost-sharing in the Medicaid program.that include coinsurance co-payments.deductibles and premiums.some services are exempt from co-payment.even if a member ordinarily has a copay.do not collect a co-payment for the.following services family planning.preventive services that include.vaccinations and health education or.pregnancy related emergency services.non-emergent use of an emergency room.requires a copay and provider.preventable condition services federal.regulations exclude certain services.from cost-sharing and those include.individuals through the age of 18 years.any individual whose medical assistance.for services are furnished in an.institution American Indian and Alaska.native individuals individuals whose.total gross income before exclusions and.deductions is below the temporary.assistance to needy families standard.payment allowance these individuals must.indicate their income status to their.eligibility caseworker on a monthly.basis to maintain their exemption from.the co-payment requirement qualified.Medicare beneficiaries and individuals.who are receiving Medicaid due to having.breast or cervical cancer.other than the cost sharing.responsibilities discussed previously.members are not responsible for a claim.or portion of a claim that is denied for.lack of medical necessity charges in.excess of Medicaid maximum allowable.rate a claim or portion of a claim.denied due to provider error a service.for which a provider did not seek prior.authorization or did not follow up on a.request for additional documentation a.claim or portion of a claim denied due.to changes made in state or federal.mandates after services were performed.the difference between the Medicaid cost.sharing responsibility and the Medicare.or Medicare Advantage copay medicaid.pays the difference between the Medicaid.maximum allowable fee and the total of.all payments that were previously.received by the provider from a third.party liability members aren't.responsible for deductibles co-pays or.coinsurance amounts if the payments were.added to the amounts paid by third.parties equal or exceed the Medicaid.maximum for that service even if the.medicaid amount is zero the member is.also not responsible for private.insurance cost share amounts if the.provider accepted them as a Medicaid.member medicaid pays the difference.between the amount paid by private.insurance and the Medicaid max allowed.amount Medicaid won't make any payment.if the third party pay is equal or.greater than the Medicaid allowable rate.federally qualified health centers and.rural health clinics have two options.for payment they can either bill a.hundred percent billed charges and then.all edits would apply or they can build.by the encounter they would need to.build that T 10 15 they must fill all.CPT codes that apply at least one CPT.code must be an approved encounter code.and if only the T 10 15 or only the CPT.codes are built then the claim would be.denied now let's go over the coverage.and reimbursement look up to.most information on policy and benefits.can be found in the provider manual at.Medicaid dot Utah gov forward slash the.first thing you're going to select on.this page is health care providers then.you will select coverage and.reimbursement on the coverage and.reimbursement lookup tool you can find.information like your coverage status.the charge factor which is your.reimbursement rate doesn't need prior.authorization allowed age range.co-payment information and global period.information.on this screen is where you would select.your provider type so I selected.provider type 20 which is a physician.and I entered code 77080 put in a date.of service and then click on search.after you click on search this is the.page that will come up I want you to.notice the type of service is the.technical part and as you scroll down.you will be able to see the professional.part as well here on these pages will.give you the information you're looking.for is available by you as a provider is.it covered under the benefit plan you're.looking and how much you will be paid.and does it require a prior.authorization now if you want to search.for a Medicaid manual you'll go back to.our home page you will select health.care providers and then you will select.provider resource and information.the next page that comes up will be.where you can select manuals Medicaid.information bulletins forms and other.contact information for providers.so I'm going to select Utah Medicaid.provider manual and then I will select.Medicaid provider manuals or Medicaid.information bulletin after I selected.manuals this is the page that will come.up and you will locate the manual for.your specialty as a note section one.applies to all providers and all.providers are encouraged to read section.one.just as a note the date at the top of.the page is the date applied to the.manual not the page also the table of.contents is hyperlinked before.submitting a claim to Medicaid a.provider must submit and secure payment.from all other liable parties such as.Medicare Part A and B and you can always.get more information on the Medicaid.general information section regarding.this claims denied from Medicare as non.covered services should be submitted to.Medicaid fee-for-service and not to the.crossover mailbox if the primary payer.made line-level payments on the claim.please report line-level data in.addition to the claim level data to.Medicaid Medicaid is the payer of last.resort reimbursement for crossover.claims and other TPL will be limited to.the Medicaid fee schedule for all types.of service which include FQHC and Indian.Health Services the electronic mailbox.for Medicaid fee-for-service ends in.zero zero one and Utah Medicaid.crossovers ends in zero zero five.corresponding EOB for zero pay from.Medicare will be faxed to eight zero one.three two three one five eight four and.for any other corresponding EOB four.zero pay please fax to ORS at eight zero.one five three six eight five one three.providers need to submit their own.Corrections to claims less than three.years old by submitting either a.replacement or void claim the data.elements needed to identify a.replacement or void claim include claim.frequency quote 7 for replacement or 8.for void electronic x12 element 2300 CL.MO 5-3 paper u vo for forum locator for.position CMS 1500 box 22 transaction.control number of original claim to be.replaced or voided electronic.twelve element 2300 re fo two paper ubo.for form locator 37 AC and CMS 1500 box.22 original transaction control number.four issues regarding overpayments and.credit balance on claims over three.years old for fee-for-service there is.an electronic payment adjustment request.form if a payment adjustment is required.on a claim that is less than three years.old our replacement claim must be.submitted and the form is located on our.website the form may be filled out.online before printing one form is.required per claim all required fields.must be appropriately filled out or it.will be returned to the provider checks.for Medicaid operations related to.credit balance TPL for crossover claim.payments and overpayments older than.three years mail them to bureau of.medicaid operations payment adjustments.and the following address and checks for.third-party liability payments excluding.crossover claim adjustments to office of.recovery services team 85 and the.following address.in order should be eligible for.interpretive services a member must be.eligible for Medicaid you can verify.their eligibility by using our.eligibility lookup tool if they are not.eligible they are not eligible for.interpretive services if a member is.enrolled with a managed care plan you.will need to call them directly.when a member is enrolled as fee for.service determined CPT coverage by.referring to our coverage in.reimbursement lookup tool located on our.website and when both the member and the.service qualify then you can call one of.the contractors listed in the general.attachments section interpretive guide.on our website give the required.information below which includes members.first and last name spelled exactly as.on the Medicaid member card the members.date of birth six digits only members.Medicaid ID number your NPI number and.the language requested timely filing for.fee for service all claims and.adjustments for services must be.received by Medicaid within twelve.months from the date of service and new.claims received past the one-year filing.deadline will be denied any corrections.to a claim must also be received or.adjusted within the same twelve month.timeframe if a correction is received.after the deadline then no additional.funds will be reimbursed in the case of.Medicare crossovers all claims and.adjustments must be received within six.months of the Medicare decision the.one-year timely filing period is.determined from the date of service or.from date on the claim the exception to.this is for institutional claims that.include a date of service span the.through date of service on the claim is.used for determining the timely filing.for institutional claims and for any.additional information please see 42 CFR.4 for 7:45.in regards to record-keeping Medicaid.providers must comply with all.disclosure requirements in 42 CFR 455.subpart B such as those concerning.practice ownership and control business.transactions and persons convicted of.fraud or other crimes every provider.must comply with the rules regarding.records noted in Section 1 general.information chapter 4 the provider.manual is found on our website at.Medicaid Utah govt you will click on the.link Medicaid a-to-z you will then click.on the S and after that you will click.on the link for section 1 general.information for providers.hi my name is Janette little and I'm a.Claims Manager here at Medicaid today.I'm going to be going over what's new.with Medicaid.Medicaid is making changes to the.provider manuals we are moving policy.from the provider manuals to the.appropriate Utah administrative rule.within our 414 health health care.financing coverage and reimbursement.policy these changes begin July 1 2017.and will continue until all manuals are.updated moving Medicaid policy to the.administrative rule allows you as a.provider the opportunity to review and.comment on the rural updates we.encourage you to become familiar with.the administrative rule because medicaid.coverage policy will be relocated to the.appropriate rule based on the service.coverage.the manuals are also being streamlined.for example your laboratory services and.women's services are now located in the.Utah Medicaid physician service manual.as part of the manual revision.information regarding specific codes.will be moved from the provide annual to.the Utah Medicaid coverage and.reimbursement lookup tool the provider.manuals will continue to be a reference.for criteria and reporting instructions.providers are encouraged to become.familiar with the updated rules and.manuals noting changes in the structure.format and content of the manuals.providers are required to follow the.coverage policy criteria and prior.authorization.Utah Medicaid submitted a state plan.amendment to the Center for Medicare and.Medicaid Services to update cost-sharing.amounts with an effective date of.October 1st 2017 the new Medicaid.cost-sharing is as follows.eight dollars for each non-emergency use.of the emergency department.$75 for each impatient hospital stay.that is an episode of care four dollars.for each outpatient services this.includes your physicians your podiatrist.your physical therapy etc four dollars.for each outpatient hospital service.with a maximum of one per person per.hospital.per date of service four dollars for.each prescription one dollar for each.chiropractic visit which is one per date.of service and three dollars for each.pair of eyeglasses.my glasses are allowed for pregnant.women and individuals under EPSA check.once every 12 months prior authorization.is required to replace frames sooner.than the 12-month period replacement.lenses do not require prior.authorization so if the lenses just need.to be replaced the provider must use the.existing frames prior authorization may.be issued for a new pair of eyeglasses.even though the 12 months of not passed.since the members last pair was.dispensed when one or more of the.following reasons for medical necessity.at there's a change in the diopter of.0.5 or greater in either sphere or.cylinder power in either eye a.comprehensive or immediate vision exam.shows that the changed in eyeglasses is.medically necessary a change in.recipients head size warrants a new pair.of eyeglasses the recipient has had some.allergic reaction to the previous pair.of eyeglasses or if the original pair is.lost or broken or damaged beyond repair.the dispensing provider must obtain a.written statement explaining this from.the recipient or the recipients.caretaker to send with the prior.authorization documentation.starting November 1st 2017.a prior authorization must be in place.for any impatient or outpatient hospital.service where a PA is required for the.procedure code hospitals should always.verify that the physician received a.prior authorization before they preform.seizure in order to be reimbursed if a.hospital bills a service that requires.prior authorization and one was not.approved the hospital claim will be.denied.if a facility or a hospital submits a.claim for a service requiring a PA and.one was not approved the procedure.required a PA will be denied like an MRI.to review procedures that require a PA.please refer to our coverage and.reimbursement lookup tool on our website.to verify a request of PA please contact.Medicaid and the Salt Lake area call a.tow one five three eight six one fifty.five or toll-free one 800 662.one you can find additional information.related to requesting a PA in our Utah.provider manuals and in the Medicaid.information bulletin on our website.as an entity covered under the Health.Insurance Portability and Accountability.Act of 1996 which is known as HIPAA.Medicaid must comply with HIPAA.standards and their implementation.guides regarding place of service so to.be in full compliance with the national.standards medicaid has added an.additional module to the existing.prepayment editing tool the place of.service module will detect when services.are billed in an inappropriate setting.and this will result in a denial on your.claim the new module took effect as of.October 2017.starting November 1st 2017 Medicaid.expanded to cover targeted adults ages.19 through 64 with no dependent children.the three groups that have been added.are chronically homeless individuals.justice-involved individuals and.individuals needing substance abuse or.mental health treatment this group is.also eligible to receive traditional.Medicaid benefits but they will not be.eligible for dental benefits other than.the limited emergency dental services.in section 1 in general information we.discuss the policy of Medicare crossover.claims when a Medicaid member also has.Medicare a provider may either accept.the member as having dual coverage are.not accept either type of coverage.federal Medicaid regulations do not.permit a provider to reject Medicaid and.accept only Medicare for example when a.member has Medicare a provider cannot.build a member for services that would.have been provided under Medicaid and.accept only Medicare payment.so for an example of a pharmacy Medicare.crossover claim a dual eligible.recipient presents to the pharmacy with.a prescription form that Part B.medication the pharmacy processes the.claim to Medicare and receives backup.payment or a copay or coinsurance of 75.dollars the pharmacy tries to build a.co-payment coinsurance to medicate.through the point of sale and receives a.rejection the pharmacy should dispense.the medication to the member and submit.the claim through coordination of.benefits to the appropriate Medicaid.trading partner number remember there is.no co-payment coinsurance to the dual.eligible Medicare Medicaid crossover.claims coordination of benefit.instructions for electronic claims are.found on our website.20-18 legislative session update the.following bills were passed during the.2018 legislative session House bill 12.family planning services amendments this.bill requires the Medicaid program to.reimburse providers separately for the.insertion of a long-acting reversible.contraception immediately after.childbirth and it Institute's a program.of family planning services to certain.low-income individuals which requires a.Medicaid Waiver House bill 42 Medicaid.Waiver for mental health crisis services.this bill requires the Department of.Health to seek a medicaid waiver for.certain mental health crisis resources.House bill 100 medical inflex children.with disability waiver program this bill.requires ongoing funding for the.medically complex children waivered.program.House bill 139 tell a psychiatric.consultation access amendments this bill.requires the state Medicaid program to.reimburse for telus psychiatric.consultations House bill 435 Medicaid.dental benefits this bill provides.dental benefits to certain adults in the.Medicaid program it also requires a.Medicaid Waiver house fill for seven to.Medicaid expansion revision this bill.requires the Department of Health to.submit a waiver request to provide.Medicaid benefits to eligible.individuals who are below the hundred.percent federal poverty level since.several of these bills require federal.approval prior to the implementation.therefore please read the upcoming meal.as relevant information for the related.programs will be included upon federal.approval if you would like additional.information on the waiver process you.can visit our website at Medicaid Utah.gov forward slash 1115 waiver on our.website.you.welcome to the prior authorization.portion of.2018 Utah Medicaid provider training my.name is Amber Lucero and I am one of the.prior authorization trainers here at.Medicaid I'm going to take a few minutes.today to talk with you about how to know.if you need a prior authorization how to.find and complete the correct forms and.how to know what to send in with a prior.authorization request when you submit it.once you click on the prior.authorization link the page will display.where you will be able to locate all of.the forms that are needed to submit a.prior authorization the first link at.the top is where you will find the.pharmacy PA request and for those of you.that are looking for forms related to.skilled nursing facilities you will.choose the link for resident assessment.forms but the majority of providers will.find the forms that they need under the.link that says general PA forms.once you click on the prior.authorization link the page will display.where you will be able to locate all of.the forms that are needed to submit a.prior authorization the first link at.the top is where you will find the.pharmacy PA request and for those of you.that are looking for forms related to.skilled nursing facilities you will.choose the link for resident assessment.forms but the majority of providers will.find the forms that they need under the.link that says general PA forms once you.click on the link for general PA forms.another screen will open here you will.find all of the general forms that are.used for prior authorizations the form.at the top of the page titled prior.authorization request form is the form.that should be used if you do not see a.form that is more specific to the.services that you will be providing for.example if you are requesting.authorization for an entry formula then.you should choose the form that is.specific for enteral formula but if you.are requesting authorization for a.surgical or imaging service then you.would use the general PA form request.form basics here are some important tips.to remember about the request forms.always use the correct form for the.service you are requesting there are.unique fields that are necessary for.certain services and if the wrong form.is completed you will likely be missing.some essential information that we need.in order to process your request.remember to always use updated request.forms request forms are periodically.updated so be certain to check the.Medicaid website monthly and use the.most current version of the form fill in.all of the required fields on the form.most of the forms have an instruction.page that will inform you of the fields.that are required be sure to use the.spaces provided make sure to always fax.the request to the appropriate number.the fax number will either be directly.on the form or on the instruction page.that goes with each specific form it is.important to remember the minimum.necessary rule in regards to pH I and to.send the least amount of information to.the correct people in or.to accomplish the intended purpose of.the use disclosure or request at the.request of providers all of the request.forms are type a bull and last but not.least it is important to remember that.these are the forms to be used for fee.for service members and for services.that considered carve-outs if the member.has a health plan the provider should.contact the health plan directly.regarding prior authorization.requirements please see the completed.examples of different prior.authorization request forms in the.attachment download section of this.training.prior authorization helpful tips be sure.to check the members eligibility before.sending in any prior authorization.requests equally important is to verify.through the coverage and reimbursement.lookup tool that the code you are.requesting requires authorization submit.clinical documentation that is current.and relevant please include all required.documents forms and consents be sure to.include all required modifiers such as.the ll or RR modifiers used for DME.items or the RT and LT modifiers to.indicate the right or left side of the.body or the Geor GP modifiers that are.required for physical therapy and.occupational therapy if you are unsure.if a modifier is required please review.the manual or contact the prior.authorization staff for questions also.include conservative treatment.documentation for services that require.that type of information.this slide is just a quick recap of.where you can find the eligibility.lookup tool and coverage and.reimbursement lookup tool link under the.health care provider section of the.website for those of you that did not.participate in the earlier portion of.today's training please be advised that.the eligibility lookup tool provides.detailed member eligibility information.including whether the member is enrolled.in a health plan a login is required to.use this tool if you have problems.setting up a login or using the tool.after you have set up your login the.number to contact is located in the.bottom of the gray area on the screen.one thing to be aware of when using this.tool is to make sure not to enter any.spaces or characters at the end of each.area of text that you enter for example.after you type the members first name do.not put a space the system will not find.a match unless it is exact it is also.important to mention that you can verify.the next month eligibility up to 6 days.prior to the end of the month.hi it is a recap of information.presented earlier in the training as.well be sure to always verify that the.code requires prior authorization using.the coverage and reimbursement lookup.tool before you submit a request start.by selecting the provider type that will.be billing for the service enter the.five digit code you are requesting enter.the date of service keep in mind that.you can't enter a future date you should.use the current date for services that.have not been provided yet but remember.that it is the responsibility of the.provider to also verify on the date of.service that coverage has not changed.you are able to inquire on coverage for.the previous two years for requests that.are being authorized retro actively.services that are not covered by.Medicaid will give a system response.that says not billable by provider type.if you enter all information and click.the search button a page will display.that gives you coverage information be.sure to review all information including.whether or not a prior authorization is.required and don't forget to read the.special note if one appears in the.yellow section at the top of the grid.always be sure to scroll all the way to.the bottom of the page and pay.particular attention to the type of.service area above the grid there are.many times when the coverage may be.different depending on the type of.service so be aware of whether you are.looking at the coverage pertaining to a.rental or a purchase with DME items and.also the differences in the technical.and professional and global components.of certain services.you.retroactively authorization there are a.limited number of circumstances when a.prior authorization would be given after.a services rendered the first of these.reasons is when a member is issued.Medicaid program eligibility retro.actively retroactive authorizations must.be requested within 90 days of the.eligibility determination services.provided in a medical emergency or.medical supplies provided in a medical.emergency are also a reason that we.would issue a retroactive prior.authorization these services must be.requested within 90 days of the medical.emergency.we can also issue retroactive requests.for surgical exceptions for example if a.surgical procedure is changed or the.need for an additional procedure is.discovered intraoperatively then a.retroactive authorization can be.submitted these requests must be.submitted within 90 days of the surgical.procedure along with the information.verifying that the procedure changed.from what was originally planned and why.there is also an allowance for.anesthesia providers if a surgeon fails.to obtain prior authorization and the.anesthesia provider cannot get their.claim paid the anesthesia provider can.submit a request for prior authorization.of the anesthesia codes this request.must be submitted within 90 days of the.surgery and must include all required.state and federal consent forms please.be sure to review the section one.Medicaid manual for complete details on.retroactive authorizations and what.information is required.where can I find criteria well there are.a couple of places that you can find.criteria you can click on the link for.medical criteria on the prior.authorization page of the website this.link is found right above the link for.the general PA forms that we discussed.earlier you can also find important.information regarding criteria and.program specific Medicaid manuals by.clicking on the manuals link and.choosing the manual that is specific to.the type of services that you provide.also as we discussed earlier in the.training there is oftentimes code.specific information found in the notes.on the coverage and reimbursement lookup.tool if a service requires prior.authorization and you are not able to.find criteria in any of these places.mentioned you can call the prior.authorization unit or you can send an.email to Medicaid criteria at Utah gov.please allow for a 24 hour response time.and remember not to send any pH I with.criteria requests just let us know the.code or codes that you are requesting.and we will email you back information.regarding what is needed for a prior.authorization now before we wrap up the.prior authorization portion of this.training let's quickly go over what's.new in prior authorizations this year.there are a few new and updated prior.authorization request forms recently we.have updated the general PA form and the.ABA form in addition to those forms.being updated there are new forms for.enteral formula genetic testing and.substance use disorder treatment please.watch for forms coming this year we are.anticipating a new form that is specific.for DME in the next few months we have.also updated our inner quality RIA and.some other PA requirements if any.updates to criteria are more restrictive.they are announced in the Medicaid.information bulletin also before we end.just another quick reminder about an.item that was discussed earlier in the.training today.as of November 1st 2017 facilities now.require prior authorization for codes.that have a PA requirement please review.the article published in the October.2017 Medicaid information bulletin for.more details or refer to the earlier.section of this training.I'd like to thank you all for allowing.us to present this information to you.today we have discussed the most.important things that you should know to.get you on your way to being a.successful prior authorization submitter.to review other frequently asked.questions please click on the frequently.asked questions link from the prior.authorization section of the website and.if you still have questions please don't.hesitate to call us at the number listed.under the contact us link on the website.thank you again and please stay tuned.for the Q&A portion for prior.authorizations.you.hello and welcome to the Utah office of.the inspector general of Medicaid.Services portion of provider training my.name is Jean cockerel and I'm the Utah.inspector general for Medicaid Services.I'm here to talk about the mission of.the office of the inspector general or.OIG and to provide some additional.insight into what we do as an office for.the Medicaid program the OIG is an.independent government agency.legislatively established in 2011 we are.tasked with providing oversight of all.aspects of the Medicaid program in the.state of Utah the primary mission of the.office is to protect taxpayer resources.the office performs both state and.federal responsibilities as such the.primary mission is to is broken down.into two parts oversight which we.accomplished through auditing and.program integrity which we accomplish to.investigations inspections and medical.records reviews the office is organized.into four sections our audit section is.comprised of six auditors that conduct.financial or performance audits on the.efficiencies and effectiveness of the.Medicaid program the Special.Investigations Unit or SIU is comprised.of seven investigators specifically.assigned to conduct investigations of.referrals made to the office and to.identify fraud waste and abuse within.the Medicaid system the SU work and.works in conjunction with our program.Integrity Unit which has four additional.individuals that work closely with.Medicaid to ensure the integrity of the.Medicaid program as a whole.the fourth section is a mission support.section that provides administrative.data mining and policy research support.we accomplish our tasks through sources.of authority first our oversight.responsibility is assigned to us through.Utah State code 63 a dash 13 secondly we.perform program integrity.responsibilities that are defined in the.Code of Federal Regulations in 42 CFR.455 and for 56 those responsibilities.are delegated to us from the Department.of Health who is designated as the.single state agency responsible for the.administration of the state's Medicaid.program the delegation of tasks.associated with program integrity is.accomplished through.a Memorandum of Understanding Medicaid.program is dynamic and very complex it.reaches into other state and federal.governments local counties school.districts medical and dental provider.communities and other entities as the.oversight agency we are tasked to ensure.that Medicaid funds are properly.utilized in all aspects and areas of.Medicaid as our office conducts this.mission we have noted there are various.causes of improper payments these causes.are defined by the state and federal.government this slide depicts what we.have seen over the years and how our.provider can start on one end of the.scale and if not properly checked can.find themselves on the other end a large.portion of the work they owe it does.relates to common errors when we notice.these errors we work with providers to.solve them and help ensure that similar.errors are not being made by similar.peer groups within the Medicaid program.waste on the other hand is when a.provider may not be fully aware that.Billings and processes could be done in.a more efficient manner ways frequently.results in taxpayer dollars being spent.inappropriately ultimately YG's mission.is to protect taxpayer dollars so.anytime we identify areas where waste.may be occurring we work diligently to.identify the problems and then make.recommendations for stopping the waste.from occurring.abuse occurs when providers bend the.rules in their favor when this takes.place a provider may be right on the.edge of intentionally committing fraud.we would encourage all providers that.bending Medicaid rules in your favor is.risky if you have questions please ask.our job is to identify and report such.behavior to the Medicaid program when.that occurs it could result in a.provider being unable to participate in.the Medicaid program.finally fraud is intentional deception.these instances are taken very seriously.and are reported immediately to the.Medicaid fraud control unit which is.responsible for investigating our.referrals and prosecuting the cases if.their investigation leads to criminal.charges any self identified instances of.fraud and abuse should be reported.immediately to the OIG.this slide defines fraud waste and abuse.as they appear in Utah code 63 a - 13 -.102 these are examples of fraud waste or.abuse cases from other states the OIG.monitors activity in other states to.help identify schemes that could take.place in Utah we then watch for.indicators of that activity taking place.in our Medicaid program we are.constantly on the lookout for these and.other schemes the orgies primary focus.is provider billing but we are also very.interested in recipient fraud when an.individual is intentionally deceitful to.obtain Medicaid services they may be.committing recipient fraud.these are just some of the areas the OIG.has seen that directly relate to.Medicaid recipients any instance of.potential recipient fraud should be.reported to the OIG as soon as possible.the Department of Workforce Services.investigates eligibility fraud and the.OIG passes on recipient referrals.especially cases where eligibility is in.question - the DWS investigations unit.next I'll discuss each of our sections a.little more in detail the audit section.receives ideas to perform audits for.many different sources including.legislation Medicaid referrals other.states that have experienced fraud or.difficulties and even referrals from.different providers themselves an audit.will determine the effectiveness of.systems.positive or negative they also help us.identify areas for improvement or.identify gaps in policy from which the.OIG makes recommendations for.improvement to the Utah Department of.Health the audit process consists of.first identifying systems for auditing.then understanding the process.developing an audit plan conducting the.audit and finally developing and sharing.the odd bindings upon completion each.audit is distributed as needed and.publicized on the OIG website Oh IG.audits are performed using generally.accepted government auditing standards.or commonly referred to as gag Asst the.audit cycle is ongoing and starts with.the funding of a program through various.funding sources.the Department of Health through the.division of Medicaid and health.financing then develops and manages the.program through its own oversight of.providers and contractors in conducting.oversight of the entire Medicaid program.the OIG identifies possible policy.contractual and process weaknesses an.auditor evaluates these areas in order.to make recommendations for improvement.to the Department of Health.finally the OIG follows up to ensure.changes are implemented and effective.the Utah Office of Inspector General has.access to a variety of data including.Medicaid claims data Medicaid claims.data contains information regarding what.health care services are being provided.as well as how much they cost this.information is vital for a variety of.functions that the office.the office receives referrals from a.variety of sources that must be reviewed.or investigated data mining can be used.to both confirm and deny allegations.while this may not be responsible for.all referrals for many it can save time.and resources by not having to request.medical records for repute data mining.begins with cleanly extracting raw data.from the Medicaid data warehouse this.takes knowledge about health care data.coding systems as well as Medicaid.claims data warehouse structure there.are millions and millions of lines of.data each year added to the warehouse.auditors and investigators need complete.and accurate data to aid them in their.reviews random samples are utilized so.investigators can look at fewer claims.and get a general understanding of.provider behavior data analysis is used.quite frequently to help identify.patterns of waste fraud and abuse many.different data modeling techniques are.used to look at large data sets to.determine if there are providers that.are behaving differently than their.peers this allows proactive looks at.provider behavior which may include.further investigations by investigators.the goal of the Utah Office of Inspector.General's data team is to assist the.team of investigators and auditors in.their reviews data is not a standalone.pool for fraud detection rather it helps.improve office and.to geisha deficiency and can help.identify fraud otherwise not a parent.without a referral Oh IG audits are.performed using generally accepted.government auditing standards more.commonly referred to as gag Asst the.audit cycle is ongoing and starts with.the funding of a program through various.funding sources the Department of Health.through the division of Medicaid and.health financing then develops and.manages the program through its own.oversight of providers and contractors.in conducting oversight of the entire.Medicaid program the OIG identifies.possible policy contractual and process.weaknesses and audits or evaluates these.areas in order to make recommendations.for improvement to the Department of.Health.finally the OIG follows up to ensure.changes are implemented and effective.the code of federal regulations set.forth requirements for a state fraud.detection and investigation program it.also requires the implementation of a.statewide program to control utilization.of Medicaid Services if these.requirements are not met a state may.risk losing federal funding for their.Medicaid program the Special.Investigations Unit employs multiple.methods to validate the integrity of.Medicaid claims reviews can range from.very simple reviews to complex.investigations sharing information and.training providers corrects most billing.inaccuracies the OIG employs one.full-time staff member that conducts.reviews on Medicaid policies for our.investigations and audits this.individual also conducts reviews on any.changes in Medicaid policies before they.are released to the general public this.slide lists some of the policy resource.links that the office uses and that may.be of interest to the provider community.these links direct you to the main page.of each site from which you can search.for answers to questions you may have.the OIG is available to provide any.additional training providers and.individuals as part of our oversight.responsibilities of the Medicaid program.if there are any questions for which a.provider would like additional training.Oh IG will work with the Medicaid.program to ensure training is provided.please direct questions regarding.training to the OIG training coordinator.whose contact information is included in.an upcoming slide if you suspect fraud.waste or abuse is occurring at any level.of the Medicaid program we encourage you.to report that activity to us referrals.may be made through a number of means.including our fraud hotline and through.our oh I ji website as the Inspector.General I encourage all medical.community members to help us actively.seek out fraud waste and abuse to.preserve taxpayer dollars program.integrity is all of our responsibilities.YG partners closely with these agencies.we work very closely with the Medicaid.fraud control unit or mapuku when there.are credible allegations of fraud if.fraud is suspected we refer the case to.muku muku also receives allegations of.criminal abuse neglect and financial.exploitation when Medicaid recipients.are involved the Department of Workforce.Services is designated as the agency.that determines recipient eligibility YG.investigates all instances of recipient.fraud waste and abuse by instances of.eligibility fraud are ultimately.investigated by the DWS Investigations.Unit Utah Adult Protective Services.investigates complaints and suspected.abuse and neglect of the state's.vulnerable adult population in.particular the elderly please follow the.Utah Office of Inspector General of.Medicaid Services at these online.locations we provide frequent updates.and release results of audits on these.sites thank you for participating in.training today we appreciate your time.and help in accomplishing our mission of.identifying fraud waste and abuse within.the Medicaid system to ensure that.taxpayer dollars are properly spent if.you have any additional questions we.encourage you to ask now or reach out to.us at any time in the future we are here.to provide oversight but we're also here.to help thank you.

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Where Do Providers Get Utah State Medicaid Eob FAQs

Here are the answers to some common misunderstandings regarding Where Do Providers Get Utah State Medicaid Eob. Let us know if you have any other doubt.

Need help? Contact support

How do I fill out the form of DU CIC? I couldn't find the link to fill out the form.

Just register on the admission portal and during registration you will get an option for the entrance based course. Just register there. There is no separate form for DU CIC.

How should I vote on Utah Prop 3 to expand Medicaid?

Vote yes. The more people that are covered - the better. Uninsured people are a tremendous drain on local hospitals. The federal government will pay part of that expansion. We just voted in the expansion for Nebraska. Don’t be fooled by people yelling tax increase. This is actually an investment for the future.

How can I fill out Google's intern host matching form to optimize my chances of receiving a match?

I was selected for a summer internship 2016. I tried to be very open while filling the preference form: I choose many products as my favorite products and I said I'm open about the team I want to join. I even was very open in the location and start date to get host matching interviews (I negotiated the start date in the interview until both me and my host were happy.) You could ask your recruiter to review your form (there are very cool and could help you a lot since they have a bigger experience). Do a search on the potential team. Before the interviews, try to find smart question that you are Continue Reading

How do you know if you need to fill out a 1099 form?

Think of the W-9 as a vehicle between a pay provider or a vendor and an independent contractor. When a W-9 is involved, we typically do not use the terms "employer" or "employee". Rather we use the terms vendor and independent contractor. If you have filled out a W-9, then the person paying for labor sees the worker as an independent contractor, not an employee. In this case you get a 1099-MISC and not a Form W-2 at the end of the year. (People and companies that pay for labor often prefer to pay workers as independent contractors, instead of as employees, because the payor does not have to pa Continue Reading

How many days does Medicaid require you to wait between filling out the Concerta XR?

Since Concerta is a schedule 2 controlled substance, Medicaid will only fill it as the prescription was written. If you had it filled for 30 days, you have to wait until the 30 days are up to get it refilled. They will not fill it earlier, unless the doctor has told you to take more. In that case, you must have your doctor contact the pharmacy to update them on the change so Medicaid will cover it.

Which states have Medicaid expansion?

Because the expansion was not fully funded. It was teasered, so that if you expanded your state Medicare rolls, you could do so at no cost for 2014 thru 2016. So, while the Federal government pays 100 percent of the cost of Medicaid expansion for 2014 through 2016, that share falls to 95 percent in 2017, 94 percent in 2018, 93 percent in 2019, and levels off at 90 percent for 2020 and beyond. The concern is that the state’s 10 percent share of Medicaid expansion spending could represent a significant expenditure that the state could not afford. If taxes were raised to cover the expense, those t Continue Reading

Who pays for Medicaid expansion?

Since its a federal program, the added funding will come mostly from federal taxes. Increased FICA and income tax. Since there is a state government “contribution” (confiscation) they will also be raising taxes somewhere. I expect Missouri to put it in the sales tax. That is the tax which is hardest to avoid.

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