|Idaho Medicaid will Remove the MUE Columns from Fee Schedule |
Medically Unlikely Edits (MUEs) defines the maximum Units of Service (UOS) that a provider would report for each HCPCS/CPT code, under most circumstances for a single participant on a single date of service. The purpose of the MUE is to detect and deny unlikely claims on a pre-payment basis to stop inappropriate payments. MUEs are coding edits, not medical necessity edits and they do not exist for all HCPCS/CPT codes. Medicaid MUEs are applied separately to each line of a claim. The values are updated by CMS quarterly. For more information please see NCCI for Medicaid | CMS
Although CMS publishes most Medicaid MUE values on its website, other MUE values are confidential. The State is required to use confidential MUE files to process claims and is not able to release any information from those files.
Effective 04/01/2023, Idaho Medicaid will remove the MUE columns from fee schedule because we can only publish the same values that are made publicly available by CMS. The State is restricted from publishing the MUE values it is required to use. Providers are encouraged to check publicly available MUE values on the following site Filtered NCCI Medically Unlikely Edits (MUEs) (medicaid.gov).
|May Workshops in Lewiston and Twin Falls!|
Please join your Gainwell Provider Relations Consultants (PRC) in-person if you're in the Lewiston or Twin Falls area for a Workshop presentation that will cover a comprehensive overview of how and when to submit Provider Maintenance to reflect changes to an existing Provider record using the Gainwell Provider Enrollment Application system. The Idaho Medicaid Provider Enrollment Application system helps simplify processes for maintenance requests, features dynamic screens, electronic signature options, and less paper transactions. We will share tips on navigating the maintenance process. Join us to learn more!
Limited spaces are available, so please register here today by signing in, searching the Catalog for ID – PRV PEA 2.0 Workshop and enrolling into the session that fits your location. Email your PRC if you need any support with the registration process.
|Attention: Hospice Program Audit and Claims Reprocessing|
The Department completed an analysis of paid claims between 2/1/2022 to 2/1/2023 that may have paid incorrectly. Claims were paid when participants were receiving hospice care, but the Department had not been notified. Claim reprocessing will begin on 3/3/2023.
Hospice agencies are required to communicate and coordinate all services included in the patient’s plan of care. This includes working with ancillary service providers so claims are billed correctly. If ancillary service providers have questions about a claim reversal, they may contact their Gainwell Provider Relations Consultant
or the Medical Care Unit and request the hospice agency name for the participant. It is the responsibility of the hospice provider to work with the ancillary service provider on the claim(s) in question.
The Hospice Services, Idaho Medicaid Provider Handbook
requires the hospice provider to notify the Medical Care Unit (MCU) of all hospice elections or recertification for Medicaid participants, regardless of other insurance coverage. The provider is required to notify the MCU of the election or recertification within 15 working days. Election requests received after the first 15 days will be evaluated on a case-by-case basis; or election start date will begin the date of the faxed hospice election documentation is received.
Thank you for the continued service you provide to Idaho Medicaid participants; we look forward to correcting these impacted claims and appreciate your patience.
|Idaho Health Care Conference 2023 – Save the Date!|
Gainwell Technologies is eager to invite providers and their staff personnel to the 30th annual statewide Idaho Health Care Conference (IHCC) in May. This year’s conference will be held in-person only at the locations noted below. We will be presenting a comprehensive overview of how and when to submit Provider Maintenance to reflect changes to an existing Provider record using the Gainwell Provider Enrollment Application system. The Idaho Medicaid Provider Enrollment Application system helps simplify processes for maintenance requests, features dynamic screens, electronic signature options, and less paper transactions. We will share tips on navigating the maintenance process. Join us to learn more!
Join us at the 2023 Idaho Health Care Conference from 8:00 AM to 4:00 PM on the following dates:
- May 11, 2023: North Idaho—Red Lion Templin's Hotel on the River, Post Falls
- May 16, 2023: Eastern Idaho—Shoshone Bannock Casino Hotel, Fort Hall
- May 18, 2023: Treasure Valley—Nampa Civic Center, Nampa
We hope you’ll attend the conference at a location near you!
|Attention All Hospital and Long Term Care Facility Provider Types! Additional Terms Documentation|
An enhancement to the Provider Enrollment Application and the current process in collecting Additional Terms documentation for Hospitals reimbursed using 3MTM All Patient Refined DRG (APR DRG) Software and Long Term Care Facility provider types is moving through our implementation process and we anticipate this change to have provider impact by 05/01/2023. Many providers have already completed the Additional Terms documentation, however, we must require Hospital and Long Term Care Facilities to repeat their acknowledgement and electronically sign the terms that are presented on the Documents tab in the application during their next maintenance. If a change in ownership is reported the Additional Terms will require re-acknowledgement. Thank you for your cooperation in this matter.
|Gainwell Provider Survey |
Gainwell Technologies is excited to invite providers to respond to our Provider Satisfaction Survey starting in February. Our Provider Feedback Team will email providers who have had recent interactions with Gainwell Technologies for Idaho Medicaid. The email will include a short survey, which should take 5 minutes or less to complete, and you can simply return it back to us via email. Provider Satisfaction Survey results will be supplied to the State. Thank you in advance for your valuable time and insight. We are looking forward to hearing from you.
|Provider Enrollment Application or Maintenance Case with "Needs More Info" Status|
If any items need to be corrected on your enrollment or maintenance case, a letter will be generated and emailed to the address on file outlining what actions must be taken in order for the enrollment or maintenance case to be processed and the application will be returned in a “Needs More Info (NMI)” status. All items outlined on the letter must be addressed before you resubmit the case and only the changes requested should be made during this case.
All communications from the Gainwell Provider Enrollment department are sent via email to the email address on file; be sure to check your junk folder in situations when you’re expecting correspondence or a response from the enrollment department.
|Provider Request for Alternate Effective Date Form Reminder!|
Gainwell Technologies and IDHW worked jointly in 2022 to enhance the alternate effective date process and reduce burdens on the provider community when needing to elect a backdate of up to 365 days prior to the current date during the enrollment process. Any applicable license, certification or other required credential must be valid on or before the requested date.
In extremely unique situations, with supporting documentation, an alternate effective date of more than 365 days prior to the current date may be requested utilizing the current version of the Provider Request for Alternate Effective Date form
. A claim and chart notes that reflect the requested alternate effective date are required in addition to the form. When requesting an alternate effective date, Gainwell and IDHW will not review or process the request if the current form is not utilized, or the claim and chart notes are missing. A rejection letter will be delivered via email to the email address associated to the case with additional instruction and information.
|Attention Home Health and PCS Providers – Claim Processing Timeframe|
All claims that are subject to Electronic Visit Verification (EVV) may pend for up to 10 days, in order to identify a correlating visit that was submitted through your aggregator, however 90% of these claims process within three days. It’s best practice to submit claims earlier in the week to allow the necessary time for the visit search to be completed. Claims submitted on Thursday will not have enough time to pend, search for the visit and be picked up and included in the financial cycle by Thursday evening. Please note that all claims may pend for up to 30 days for reasons other than EVV, if manual review and intervention is necessary.
|Administrator Update and Gaining Access to the Secure Trading Partner Account (TPA) |
The Idaho Medicaid Provider Portal is a secure tool that allows providers full access to claim and eligibility information, direct communication with Gainwell through secure messaging, maintaining the enrollment record, management of the account and much more.
When the Trading Partner Account is set-up, the individual who establishes the account is made the administrator, who then has full access to the account, and is expected to manage security and access for each additional user within their practice. The TPA administrator(s) are also expected and required to be listed on the Ownership information, at a minimum, as a Managing Employee. These individuals are granted full access to all areas of the Trading Partner Account and have security clearance to grant/terminate access to all other users.
We understand that in rare circumstances the account administrator may part ways from the practice, leaving the Trading Partner Account unmanaged or at times, inaccessible. Gainwell understands the need and urgency you may have to gain access to the account again. It is critical for security reasons that we follow strict measures when assisting any user with gaining access to an already established account.
To request this level of support, all of the following criteria must be provided and emailed to firstname.lastname@example.org:
- A request letter on company letterhead, including the following details, with physical signature and date, signed by an individual who is listed on the ownership form:
- Reason for update (previous administrator is no longer employed, change in ownership, new manager, etc.)
- Old admin information (name, username and email address)
- New admin information (name, username and email address)
- Pay-to NPI, Trading Partner ID and name that is on record with Gainwell Technologies
- Only an individual who is listed as an owner, board member or managing employee on the Ownership information is eligible to become the new account administrator and the request itself must be signed by either this individual or another individual on the Ownership information.
- If you do not know who is listed on the Ownership information for the provider’s record, you may request to update the Ownership details to add the new account administrator by completing this form and including it with your request and email. Once account access is reestablished, the individual must be added to the electronic Ownership information within their application. Note: At least one individual person must be listed on the Ownership document and their DOB and SSN.
|Dial 1 When You Call!|
It is very important that you dial a 1 when calling us. Please call 1(866) 686-4272. Thank you!