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Alabama Medicaid Update Tina G Pippin Dental Program Director Alabama Dental Association Annual Sess

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Title: Alabama Medicaid Update Tina G Pippin Dental Program Director Alabama Dental Association Annual Sess


1
Alabama Medicaid Update Tina G Pippin Dental
Program Director Alabama Dental Association
Annual Session June 16, 2006
2
Medicaid Overview
3
Medicaid Rules
  • Medicaid was established in 1965 by federal law
    to provide medical assistance to low income and
    resource individuals.
  • States may choose to have a Medicaid program, but
    must comply with all federal Medicaid
    requirements once a program has been implemented.
  • Funded through a federal and state partnership
    (generally 70/30 in Alabama)

4
Rules continued
  • Federal law sets minimum eligibility and benefit
    levels.
  • With few exceptions, Alabamas program is at the
    federal minimum level for eligibility.
  • Alabama has one of the most conservative benefit
    packages in the country.
  • Medicaid cannot make any more program cuts and
    still be in compliance with federal regulations.

5
Dont be confused…
  • Medicaid is a federal and state program and
    provides medical assistance to low income and
    resource individuals.
  • Medicare is a federal program to provide medical
    insurance generally to individuals aged 65 and
    older.

6
Who Determines Eligibility
  • Three Alabama agencies certify individuals for
    Medicaid.
  • Agencies certify certain groups of individuals
    for Medicaid based on their circumstances.
  • These agencies are
  • The Social Security Administration
  • The Department of Human Resources
  • The Alabama Medicaid Agency

7
The Face of Medicaid
8
Demographics FY 2005
  • Medicaid covers
  • 20.7 of Alabamas total population (includes
    all eligibility categories)
  • 46 of all deliveries in Alabama
  • 37.9 of Alabamas children (under 19)
  • 19.7 of Alabamas elderly (65 and above)
  • 74 of nursing home days in Alabama

9
Total Medicaid Eligibles As a Percentage of
Alabamas Population
FY
Note Includes individuals eligible for Plan
First
10
Medicaid Children Under age 19 as a Percent of
Alabamas Child Population
FY
11
Children in Working Families As of September 2005
Source Obtained for MLIF and SOBRA populations
based on information from Medicaid applications
as filed.
12
What are the sources of health insurance coverage
in Alabama?
13
AL Uninsurance Rates by Age
All rates reflect point in time data.
14
Eligible and Payment Distribution By Age FY 2005
15
Medicaid Eligibles by Aid Category FY 2005
16
Eligibles Percent Distribution by Race FY 2005
17
Cost Per Eligible FY 2005
By Category
By Gender
By Age
18
Economic Impact
Hospital Care
Pharmacy
MEDICAID
Primary Care
Maternity Care
19
High Medicaid Counties FY 2005
These 12 counties have the highest concentration
of Medicaid eligibles across the general
population (30 or greater). Bullock
35 Lowndes 33 Butler 33 Macon
31 Conecuh 31 Marengo 30 Dallas 41
Perry 43 Greene 40 Sumter 39 Hale
32 Wilcox 46
20
High Medicaid Counties FY 2005
These 11 counties have the highest concentration
of Medicaid eligibles across the childrens
population (50 or greater). Bullock 66
Lowndes 55 Butler 56 Macon 50 Conecuh
56 Perry 63 Dallas 65 Sumter 65
Greene 66 Wilcox 71 Hale 50
21
Economic Impact
  • In FY 2004, Medicaid paid approximately 3.7
    billion to providers for various health care
    services rendered 2.7 billion represents
    federal funds brought into the State.
  • In FY 2005, Medicaid paid approximately 3.9
    billion to providers for various health care
    services rendered 2.8 billion represents
    federal funds brought into the State.

22
Economic Impact (continued)
  • Medicaid expenditures supported more than 84,323
    jobs in various industries within the state.1

1 Economic Impact of the Alabama Medicaid Agency
on the Economy of the State of Alabama and its
Counties, Amy K. Yarbrough, MSHA, MBA,
Administrative Fellow, University of Alabama at
Birmingham
23
Financial Impact by County
  • Medicaid payments
  • 5 counties receive in excess of 100 million
  • Jefferson 520 million
  • Mobile 252 million
  • Tuscaloosa 144 million
  • Madison 127 million
  • Montgomery 315 million
  • 8 counties receive payments in excess of 60
    million.
  • 16 counties receive payments in excess of 40
    million.
  • 31 counties receive payments in excess of 20
    million.

FY 2005
24
Financial Impact by Hospital
  • Without Medicaid revenue, critical components of
    Alabamas healthcare infrastructure could not
    continue to exist.
  • 52 of the patient days at The Childrens
    Hospital of Alabama are paid for by Medicaid.
  • 77 of the patient days at USA Childrens and
    Womens Hospital are paid for by Medicaid.
  • Source Information obtained from Medicare Cost
    Reports as filed.

25
Program Funding
26
Where It Comes From, Where It Goes
Administrative Costs 2.0
State Funds 29.17
Federal Funds 70.83
Benefit Payments 98.0
FY 2005
27
Distribution of Payments Excluding Hospital
Disproportionate Share Payments FY 2005
28
Dental Care Expenditures FY 1998-2005
Millions

FY
29
Medical Care Expenditures FY 1994-2005
Billions

FY
Excludes DSH payments, enhancements, and pharmacy
rebates
30
History of Unfunded Mandates
  • Medicare Modernization Act, 2003
  • Health Insurance Portability and Accountability
    Act
  • (Currently implementing NPI)
  • Pryor Amendment, 1990 (Mandated open drug
    formulary)
  • OBRA 1989 (Mandated the EPSDT program)
  • CCA 1988 (Mandated coverage of QMB)

31
General Fund Contributions Medicaid as a Percent
of the GF

FY
32
Medical Services Update
33

Town Hall Presentation to Provider Support
Personnel
34
Goal
  • Improve health care outcomes for Medicaid
    recipients through creation of a medical home
    while containing the escalating cost of quality
    health care.

35
Basic Program Concepts
  • Providers enroll as a Primary Medical Provider
    (PMP)
  • Patients are assigned to a PMP
  • Services must be provided directly or through
    referral (NO REFERRAL needed for Dental Services)
  • PMPs are paid a monthly case management fee based
    on signed contract

36
Who Can Be A PMP?
  • Pediatricians
  • Internists
  • Family Practitioners
  • General Practitioners
  • OB/GYNs
  • FQHC
  • RHC
  • Specialists (ex special needs child)

37
Who Is IN Patient 1st?
  • SOBRA Children
  • MLIF Eligibles
  • Infants Of SSI Mothers
  • Aged
  • Blind
  • Disabled

38
Who is NOT In?
  • Foster Children
  • SOBRA Adults
  • Dual Eligibles
  • Institutionalized (nursing homes, group homes, MR
    facilities, DYS) Lock-Ins
  • Enrollees of Private HMO
  • Medically Exempt

39
Real World Numbers
  • 1,018 PMPs Enrolled
  • 944 Physicians
  • 74 Clinic Based
  • 448,708 Total Enrollees
  • 84,247 Over 21
  • 364,461 Under 21
  • As of 4/20/06

40
Program Redesign . . .
  • This time around …
  • A cost effective model
  • More program accountability
  • Have ability to demonstrate success
  • More focus on affecting behavior
  • Effective patient management tools through
    program enhancements
  • Patient information

41
Moving Into the 21st Century Tools to Help the
PMP Manage the Patient
In-Home Monitoring InfoSolutions ePrescribing
42
In-Home Monitoring aka Disease Management
  • Partnership with USA Hospital and the Alabama
    Department of Public Health (ADPH)
  • Telemetry concept
  • Targets chronic diseases through claims
    utilization
  • Diabetics initial phase
  • Can monitor blood sugars, weight and blood
    pressure
  • Coordination with Primary Physician
  • Supported with case management
  • Web based with real-time reporting available

43
InfoSolutions
  • Purpose is to inform providers of prescription
    activity based on Medicaid paid claims data.
  • Desktop or PDA tool for physicians
  • Download patient prescription information

44
e-Prescribing Component of InfoSolutions
  • Download prescription history
  • Automatically alerted to potential drug-to-drug
    interactions
  • Prescribe/refill multiple medications
  • Print prescriptions up to 30 feet away using
    Bluetooth technology
  • Establish favorites list of frequently
    prescribed medications
  • View both Blue Cross/Medicaid formulary

45
Plan f irst
  • Different from regular family planning
  • Have to use enrolled providers
  • Providers dispense birth control pills and the
    patch
  • Nuva Ring is not covered
  • Women will have to recertify each year

46
Successful … very
  • 95,448 women enrolled (3/06)
  • Teen enrollment grew by 21 during 1st five
    years
  • 9,014 births averted in DY 4 (10/03-9/04)
  • Approximately 25 of women utilize private
    providers (in addition or instead of public)
  • Enrollees were 42 more likely to use
    contraceptives and 33 more likely to use
    effectively

47
Pharmacy Update
48
Prescription Utilization FY 2005
49
Pharmacy Expenditures Percent Change from
Previous Year Net of Rebates
50
Program Update
  • The Preferred Drug List (PDL), monthly brand
    limit, and system edits continue to be important
    management tools.
  • These programs are estimated to save 20 of the
    pharmacy program expenditures in FY 2007.

Projected FY 2007 expenditures with program
initiatives - 443.6 without initiatives -
554.5 before rebates. Medicaid Fiscal
Division
51
Monthly Brand Limit
  • July 1, 2004 a monthly brand limit was
    implemented, allowing 4 brand prescriptions per
    month with unlimited generic and OTC
    prescriptions.
  • Children and nursing home patients are excluded.
  • Anti-psychotic and anti-retroviral drugs are
    allowed up to total of 10 brand prescriptions.
  • Allowances are made for additional brands per
    month for certain classes if a physician needs
    to switch a patient from one brand to another
    in the event of adverse or allergic reactions.

52
PDL Update
  • November 1, 2003 a Preferred Drug List (PDL) was
    implemented, requiring that drug classes be
    reviewed by our Pharmacy and Therapeutics (PT)
    Committee for clinical recommendations for
    inclusion into the PDL.
  • Medicaid is currently re-reviewing implemented
    classes into our PDL to ensure up-to-date
    clinical information is taken into consideration
    for PDL clinical decisions.

53
Medicare Part D Update
54
a
55
Medicare Prescription Drug Coverage
  • What Do You Need To Know?

56
Medicare Basics
  • Part A
  • Hospital Insurance
  • Part B
  • Medical Insurance (doctor visits)
  • Part C
  • Medicare Advantage
  • Part D
  • NEW Medicare Prescription Drug Benefit

57
Eligibility and Enrollment
  • Entitled to Part A and/or enrolled in Part B
  • Must reside in the plans service area
  • Program voluntary (for most)
  • Must enroll with the drug plan
  • Monthly fees apply (for most)

58
Prescription Drug Benefit
  • Available to everyone with Medicare
  • Provides coverage for brand-name and generic
    drugs
  • Medicare contracts with private companies
  • Benefit started January 1, 2006
  • Extra help with drug cost available for many
    people with limited income and resources

59
Initial Enrollment Period
  • November 15, 2005 through May 15, 2006
  • Penalty of 1 per month added to monthly fee if
  • Enrollment is delayed and
  • Beneficiary is without creditable coverage

60
Coverage Varies by Plan
  • Select the Plan that meets your needs
  • Plans may not cover all drugs
  • Plans must give a 60-day notice if they decide
    not to cover a drug
  • Plans must have Appeals process

61
What to do if your Prescription Plan will not
pay for your medicine?
  • Check with your doctor to see if he/she can
    switch you to a medicine that the plan will cover
  • Change Plans
  • If your medicine can not be changed ask your
    doctor to request an appeal on your behalf

62
Requesting a Coverage Determination or Appeal
  • Beneficiary can request
  • Appointed representative
  • Prescribing physician can request
  • Others can assist with form completion, letter
    writing, etc.

63
Need Help With Medicare Part D?
  • Call 1-800-MEDICARE (1-800-633-4227)
  • Visit www.medicare.gov
  • For extra help
  • - Social Security Administration
  • - 1-800-772-1213
  • - www.socialsecurity.gov
  • - 1-800-AGELINE (1-800-243-5463)
  • Questions regarding Medicaid (1-800-362-1504)
    Visit www.medicaid.state.al.us

64
Resources
  • Enrollment and Appeals Guidance
    http//www.cms.hhs.gov.gov/PrescriptionDrugCovCont
    ra/06_RxContracting_EnrollmentAppeals.asp
  • How to File a Complaint, Coverage Determination,
    or Appeal http//www.medicare.gov/Publications/
    Pubs/pdf/1112.pdf

65
Dental Program
66
Premise
  • Good oral health prevents pain, suffering,
  • missed days of school or work and
  • unnecessary costs due to dental treatment.

67
Why Is Good Oral Health Important?
  • Dental related illness causes poor children to
    miss 12 times more school days than children
    from higher income families
  • Poor oral health has been associated with other
    medical problems including heart disease and
    premature births

68
Is There An Oral Health Problem In Alabama?
  • Two out of five Alabama schoolchildren are
    estimated to have untreated tooth decay
  • Almost 70 of low-income children in Alabama did
    not visit a dentist last year

69
Is There An Oral Health Problem In Alabama?
  • Alabama has 30 fewer dentists per capita than
    the nation and our dentists are not distributed
    evenly (38 dentists in Alabama versus 54 per
    100,000 population nationally)
  • One-third of all Alabamians over age 65 have no
    teeth, the 9th highest percentage in the country

70
Dental Program Vision Statement
  • To ensure every child in Alabama enjoys optimal
    health by providing equal and timely access to
    quality, comprehensive oral health care, where
    prevention is emphasized promoting the total
    well-being of the child.

71
Alabama Medicaid Dental Program
  • Approximately 450,000 Medicaid eligible children
    with limited access to dental services
  • 8 counties with no Medicaid dentists or one
    Medicaid dentist
  • Limited participation in other counties with most
    not accepting new Medicaid patients

72
Currently…..
  • Increased dental rates to 100 of BCBS 2001
    rates
  • More procedure codes covered
  • Increased provider assistance
  • Made case management services available
  • Increased enrolled dentists to over 700

73
Where to begin?
  • Where do I find ______?

74
Alabama Medicaid Provider Manual
  • Updates Quarterly
  • Provides All Information on Policy and Billing
  • Now Available on CD Rom
  • You are responsible for policies listed in the
    manual.

75
Chapters you need….
  • Chapter 1 Introduction Chapter 2
    Enrollment Chapter 3 Eligibility Chapter 4
    Prior Authorization Chapter 5 Filing
    Claims Chapter 6 Receiving
    Reimbursement Chapter 7 Rights and
    Responsibilities Chapter 13 Dental

76
Appendix
  • Appendix B Electronic Media Claims (EMC)
    Guidelines
  • Appendix E Medicaid Forms
  • Appendix G Non-Emergency Transportation (NET)
  • Appendix I Outpatient Hospital and ASC
    Procedures
  • Appendix J Explanation of Benefit Codes
  • Appendix K Third Party Carrier Codes
  • Appendix L AVRS Quick Reference Guide
  • Appendix N Medicaid Contact Information

77
Come On Board!!!
  • How do I become a provider?
  • For an enrollment application Contact
  • EDS provider enrollment unit 1-888-223-3630
  • Medicaids dental program 1-334-242-5997
  • EDS issues a 9 digit provider number (effective
    the first day of the month the application is
    received)
  • You must receive a provider number for each
    physical location where you perform
    services

78
Providers Rights
  • Keep records for 3 years plus current
  • Provide same services to Medicaid patients as all
    other patients
  • Can bill recipients when services are non-covered
    or patient exceeded limits
  • Can limit number of patients seen, days seen or
    ages

79
Chapter Three--Eligibility Who is eligible?
  • Three important questions to ask…
  • Are they eligible?
  • Are they under the age of 21?
  • Do they have full Medicaid benefits?

80
Verifying Eligibility
  • Three Primary Ways 1. Provider Electronic
    Solutions Free Software provided by EDS.
    Quick response time one at time or in
    batches 2. Automated Voice Response Toll free
    Number 1-800-727-7848 Available 23 hrs/day, 7
    days per week 3. Secure Website
  • https//almedicalprogram.alabama-medicaid.com/s
    ecure/logon.do

81
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82
Provider Assistance Center
  • Toll free number 1-800-688-7989
  • Speak with a representative
  • Verify up to 6 recipients at a time
  • NOTE If you want claims history information, you
    must ask for a provider representative.

83
Dental Benefit Information
  • Provides last two PAID dates of service for the
    following codes
  • Panoramic X-rays D0330
  • Full Series X-rays D0210
  • Oral Exams D0120 or D0150
  • Prophylaxis/Fluoride D1110, D1120, D1201,
    D1203, D1204, D1205
  • Space Maintainers D1510, D1515, D1520, D1525,
    D1550

84
Third Party Liability (TPL)
  • Verify at each visit
  • Apply all payments received toward services
    rendered
  • If incorrect - update recipient file by calling
  • A-G 334-242-5280 H-P 334-242-5254 Q-Z
    334-242-5279

85
Prior Authorization
  • Who…
  • What…
  • When …
  • Where?

86
How to Obtain a Prior Authorization
  • Use the Prior Authorization Dental Request Form
    (form 343) in provider manual Chapter 4 (can
    copy)
  • Mail to EDS PO Box 244032 Montgomery, AL
    36124-4032
  • Note X-rays must be mailed in a separate sealed
    envelope
  • and be of diagnostic quality

87
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88
Prior Authorization
  • Some of the services requiring Prior
    Authorization
  • Complete Bony Extractions
  • Periodontics
  • Space Maintainers after the first two
  • Look in Chapter 13 for complete list.

89
Inpatient and Outpatient Hospitalization
  • Required for children ages 5 through 20 when
    medical criteria is met
  • Not required for children under age 5
  • Reimbursed for recipients older than 21 when
    dental problems have exacerbated underlying
    medical condition

90
Hospital Care
  • Dentists must have all procedures loaded to prior
    authorization file to get paid
  • Use correct place of service
  • Hospitals use D9420 for payment for facility fee
  • Must receive prior authorization number from
    dentists for children 5 or greater

91
Emergency Prior Authorization
  • Call the Dental Program at 334-242-5997
  • Talk with staff or leave a voice message with
    the following information
  • Recipients name and Medicaid number
  • Provider number of dentist
  • Phone number of dentist
  • Fill out Prior Authorization Request Form 343
    and mail that day

92
Chapter 13 Dental Program
  • Examinations
  • D0120 Periodic Once every six months (not to
    the date/within the same month)
  • D0140 Limited oral Problem focused, once per
    recipient per provider per year and cannot be
    billed in conjunction with periodic or
    comprehensive. Need to document what done.
  • D0150 Comprehensive Once per recipient per
    provider, must document!

93
Prophylaxis and Fluoride Billing
  • When billing for prophylaxis and fluoride
    treatment performed on the same date of service
    for a recipient, use the appropriate combined
    code
  • D1201 Topical fluoride with prophylaxis - Child
    (up to and including age 12)
  • D1205 Topical fluoride with prophylaxis Adult
    (over 12 years of age)

94
Radiology
  • Full mouth and panoramics are covered every three
    years at age 5 (exceptions by report)
  • Posterior bitewing and single anterior can be
    taken every six months
  • BW-4 Films limited to age 13 and older
  • Must be of diagnostic quality

95
Space maintainers
  • Non-covered for premature loss of primary
    incisors and placed greater than 180 days after
    the premature loss of a primary tooth
  • Non-covered for permanent tooth
  • Limited to one per recipients lifetime for a
    given space to be maintained
  • Bill the space where tooth was extracted
  • If extraction of tooth is not is Medicaid paid
    claim history, you must send in for override

96
Endodontics
  • Pulp caps without a protective dressing are
    non-covered
  • D3120 - Indirect pulp caps covered for deep
    carious lesions on permanent teeth only
  • D3220 - Therapeutic pulpotomy covered for primary
    teeth only not billable with other endo codes
  • Criteria for pulpal therapy and root canals

97
Incomplete Procedures
  • Applies to multiple appointment procedures i.e.
    root canals and crown
  • Effective July 1, 2003, payment is made to the
    provider that started the procedure
  • Must have documentation in record of multiple
    attempts to complete procedures (letters, phone
    calls)
  • Subsequent provider should know that procedure
  • is considered non-covered

98
Crowns and Core Buildups
  • Covered following root canal therapy ONLY
  • Crowns limited to permanent teeth
  • Recipients must be 15 years of age
  • Cast post and core must be radiographically
    visible, one-half length of canal
  • Must have post-op x-ray after crown inserted

99
What if the root canal is not in paid claims
history?
  • Send in for an administrative review with a
    clean claim and x-ray showing completed root
    canal therapy and crown inserted (DO NOT send in
    for a prior authorization.)
  • Only send claim with procedures needed for
    review
  • Send to the Medicaid Dental Program

100
Periodontics
  • Only codes covered include D4341 scaling and root
    planing, D4355 full mouth debridement and D4910
    periodontal maintenance
  • All require prior authorization with periodontal
    charting and/or radiographs
  • Criteria listed in Chapter 13-22 and 13-23

101
Oral Surgery
  • Primary teeth limited to D7140 unless by report
    for valid indications
  • Prior authorization required for D7240 and
    D7241 (by report)
  • Surgical extractions require documentation listed
    in Chapter 13-24
  • Extractions due to crowding to facilitate
    orthodontics are non-covered

102
Palliative (Emergency) Treatment D9110
  • This must not be billed with definitive treatment
    or emergency procedures.
  • These procedure codes
  • include
  • -D0210 -D0350 -D0470 -D9220
    -D9610 -D1110 through D7971

103
Non-Covered Services
  • These include, but are not limited to dental
    implants, prosthetic treatment (bridgework,
    partials or dentures), all porcelain crowns,
    esthetic veneers and adult dental care.
  • Refer to Provider Manual Chapter 13 for details.

104
  • Reimbursment

Show me the money!
105
Paper Claims
  • Only ADA-approved claim forms are
    acceptable Version 2002,2004
  • OCR Scannable form recommended
  • CDT2005 codes must be used (D-codes)
  • There will be a release of CDT2007 in January

106
When it is required to send a paper claim?
  • When filing
  • Accident Form XIX-TPD-1-76
  • Third Party Denial
  • Administrative Review/ Override

107
Why bill electronically?
Enhances effectiveness and efficiency
  • Less than two week turn-around on claims
  • Immediate claim correction
  • Enhanced online adjustment functions
  • Improved access to eligibility information

108
Enhancements
  • Can now use LAN, ISP or DSL connection
  • View EOP within software
  • Claim status
  • Send adjustments/reversals electronically

109
Important Facts to remember…
  • Tooth numbers 1-9 must have a
  • 0 in front when billing (example 01)
  • Primary teeth - use letters
  • Supernumerary teeth NEW VALUES!
  • Place of service codes include
  • 11 office
  • 22 outpatient, requires prior authorization
  • 21 inpatient, requires prior authorization
  • 31 nursing facility, requires prior authorization

110
Oral Cavity Codes
  • 00 Full Mouth
  • 01 Upper Arch
  • 02 Lower Arch
  • 10 Upper Right Quadrant
  • 20 Upper Left Quadrant
  • 30 Lower Left Quadrant
  • 40 Lower Right Quadrant

111
Filing Limit
  • Medicaid requires all claims for Dental
    providers be filed within one year of date of
    service.
  • Providers should process claims for payment as
    soon as service is completed.
  • 120 days from other insurance EOP date
  • 120 days from adjustment, if past the filing
    limit

112
Administrative Review
  • Must be received within 60 days of the date the
    claim became outdated
  • Must have documentation showing attempts to get
    claim paid (see Chapter 7-6)
  • Mail to Alabama Medicaid Agency Dental Program
    Administrative Review PO Box 5624 Montgomery,
    AL 36103-5624

113
Changes to MMIS - 2007
114
Introducing interChange, The New Alabama
Medicaid System
115
Medicaid Modernization
  • Improvement/ Focus Areas
  • Create an NPI compliant system
  • Improve Technology for AMA
  • Improved Provider Access
  • Faster Claims Processing

116
What Will Change With The New System?
  • New Interactive Web Portal
  • Interactive Claims Submission
  • Immediate claim correction capabilities
  • Improved EOP Retention
  • Provider Electronic Solutions
  • Upgrade Only
  • NPI Numbers Utilized

interChange
Alabama Medicaid
Provider Community
117
interChange Highlights
  • System Features
  • Real-time claims processing
  • Interactive claims submission
  • Browser-based screens
  • Eligibility verification
  • Providers can correct and resubmit claims
    immediately
  • 24x7 Provider access
  • Claim Status Inquiry

118
interChange Highlights
Eligibility
119
interChange Highlights
Claims Submission
120
interChange Highlights
Claims Inquiry
121
interChange Highlights
Explanation of Payment
122
interChange Highlights
Viewing Submitted Claims
123
Upcoming Events
  • Claims processing will continue in current system
    as performed today
  • Send your NPI information to EDS when requested
    (ALERT will be sent/read Provider Insider)
  • Training Classes for providers will be conducted
    in Spring 2007

124
Smile Alabama!
Medicaids Dental Outreach Initiative
  • Primary goals
  • Increase number of Medicaid dental providers
  • Increase number of children receiving dental
    care
  • Other goals
  • Provider training and support
  • Patient education
  • Assistance with claims processing
  • Patient education tools/resources

125
Targeted Case Management
  • Case management by social workers and nurses
  • available through the EPSDT program
  • Assistance with patient education, follow-up on
    missed appointments, coordination of services,
    transportation.
  • http//www.medicaid.alabama.gov/documents/Program-
    Pt1st/Care_Coord_ContactList_1-19-06.pdf

126
Available Tools
  • Alabama Medicaid Provider Manual
  • Available on CD-Rom
  • Policy/procedure information on all Medicaid
    Programs
  • Provider Insider Newsletter
  • Published bimonthly
  • Policy changes and clarification on existing
    policy
  • Alert Bulletins
  • Urgent information published as needed

127
More Tools
  • Mini Messages
  • Part of EOP statements
  • Gives status of system problems/claims issues
  • Notice of any recoupments/ re-processing of
    claims
  • Medicaid Web site (www.medicaid.alabama.gov)
  • Contains contact information
  • Forms
  • Provider Notices
  • Fee Schedules

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Important Numbers To Remember
  • Medicaid
  • Dental Program (Policy Questions) 334-242-5997
    Fax 334-353-5027
  • Recipient Inquiry Unit (Toll-free) 1-800-362-1504
  • Outreach/Education (Educational Materials)
    334-353-5203
  • EDS
  • Provider Assistance Center (Billing
    Issues) 1-800-688-7989
  • Provider Enrollment (Enrollment Issues)
    1-888-223-3630
  • EMC (Electronic Claims Submission Issues)
    1-800-456-1242

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NET Non-Emergency Transportation
  • Requires Prior Authorization
  • Provides transportation vouchers to patients
    (like a check)
  • Vouchers must be signed by dentist
  • Covers one escort for recipients under 21
  • Must be done 5 days prior to appointment,
    unless urgent
  • Call 1-800-362-1504, press 3

130
Whats happened since last year…
131
Health Watch Technologies (HWT)
  • Medicaid is working with Health Watch
    Technologies (HWT) to further insure payment
    integrity.
  • HWT will provide a cross functional team to
    include professionals in medicine, law, public
    policy, hospital administration, nursing, mental
    health, and data analysis.

132
Review Algorithms
  • Examples of review algorithms
  • CDT and HCPC coding guidelines to insure
    appropriate billing of comprehensive codes,
    mutually exclusive codes, and modifier use
  • Regulation and policy based rules to include
    coverage limitations and non-covered services
  • Unbundling review of lab and ER services,
    surgical procedures and procedures

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Review Algorithms
  • Examples continued
  • Unreasonable volume to indicate excessive units
    of a service
  • Duplicate billings of the same claim or same
    service by multiple providers
  • Recipient utilization of narcotics, or other
    services that indicate potential drug seeking
    behavior

134
National Provider Identifier…NPI
  • Covered providers can begin applying for NPIs
    May 23, 2005
  • Compliance date applicable to most entities is
    May 23, 2007
  • By this date, covered entities must use only the
    NPI to identify providers in standard electronic
    transactions.
  • http//nppes.cms.hhs.gov
  • www.ada.org

135
NPI The Concept
  • Provides the ability to bill all health plans
    uniformly no longer necessary to use different
    identifiers for different health plans,
    contracts, locations
  • Billing will be simplified
  • COB payments will come sooner
  • If 100 paper, does not apply

136
Its All About
Healthy Smiles for Healthy Children
137
AND you call who?
  • Medicaid Dental Program
  • Tina Pippin
  • 334-242-5472
  • tina.pippin_at_medicaid.alabama.gov
  • Iola Dow
  • 334-353-8473
  • Iola.dow_at_medicaid.alabama.gov
  • EDS
  • Cyndi Crockett
  • Provider Relations Supervisor
  • 334-215-4170
  • Cyndi.crockett_at_eds.com

138
Questions….
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