personal care services (pcs) documentation... · 2020. 7. 16. · overview 2 • eligibility •...

Idaho Department of Health & Welfare

Personal Care Services (PCS)


Overview

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• Eligibility

• Prior Authorization

• Fee Schedule (Personal Care)

• Resources


Eligibility


Participant Eligibility

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Why should you verify eligibility?

• To verify a participant has Medicaid coverage on actual date of service

• To review a participant’s eligibility plan, coverage codes, and healthy connections provider

Note: Medicaid card does not guarantee current Medicaid coverage.


Verifying Eligibility

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Three ways to verify eligibility:

• MACS — Medicaid Automated Customer Service 1(866)686-4272

• HIPAA compliant vendor software• Health PAS-OnLine Trading Partner

To obtain eligibility information from one of these systems, submit two pieces of identifying information from the following list:

• Medicaid ID number (ten digits)• Social Security Number (SSN) • Last Name, First Name • Date of Birth


Navigating the Secure Portal

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Note: Two pieces of identifying information required; MID and DOB recommended.


Verifying Eligibility | Patient and PCP Roster

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Coverage

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Medicaid offers several coverages that are aligned with health needs and include an emphasis on prevention and wellness.

Coverage codes:

• Basic Coverage• Enhanced Coverage (includes Katie Beckett)• Pregnant Women Coverage (PW)• Otherwise Ineligible Noncitizens (OINC)• Part B Premium Coverage (SLMB)• Medicare Co-insurance & Deductible (QMB)• Medicare and Medicaid • MMCP and IMPlus Coverage• INPATIENT ONLY Coverage


Enhanced Coverage

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The Medicaid Enhanced Coverage is for qualified participants with disabilities or special health needs.

• Includes all benefits in Basic Coverage, plus additional benefits:

o Nursing Facilityo Intermediate Care Facility for the Individuals

with Intellectual Disabilities (ICF/IID)o Private Duty Nursingo Home & Community Based Waiver Serviceso Service Coordination

• Many of the services in this plan have medical eligibility and prior authorization requirements


Enhanced Coverage Example

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Medicare-Medicaid Coordinated Plan

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The Medicare-Medicaid Coordinated Plan (MMCP) is for participants who:• Are 21 years old or older• Enrolled in Medicare Part A and Part B • Eligible for full Medicaid• Reside in an MMCP coverage area

The qualified participant can voluntarily enroll into MMCP, and choose their administrator.


MMCP Example

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Idaho Medicaid Plus (IMPlus)

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The Idaho Medicaid Plus (IMPlus) is for participants who: • Are 21 years old or older • Enrolled in Medicare Part A and Part B • Eligible for full Medicaid • Reside in an IMPlus coverage area• Are not an excluded or exempt population

participant • Do not enroll into MMCP – Participants are

mandatorily enrolled into IMPlus, and an administrator for coverage will be assigned if one is not chosen


IMPlus Example

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Claim Submission


Claim Submission

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Patient Roster | Submit Claim

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Claim Submission

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Authorizations


Authorizations

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• Prior to rendering PCS services, verify that Regional Medicaid Services has issued a PA for the services you are providing

• All PCS must be provided in accordance with a written plan of care.


View Authorizations

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Authorization Search

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Authorization Details

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Fee Schedule


Fee Schedule

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Information found on the fee schedule:

• PCS codes

• Medicaid rate


Reference Material | Fee Schedules

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Fee Schedule

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Provider Relations Consultants

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Region 1 and the state of [email protected]



Region 4 and all other states [email protected]




mailto:[email protected]








Thank you for attending our Personal Care Services

Training.

Please take a few minutes to complete the survey that will be emailed following this presentation. This

provides us with valuable information for future trainings.

personal care services (pcs) documentation... · 2020. 7. 16. · overview 2 • eligibility •...

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