Idaho Admin. Code r. 16.03.09.230 - GENERAL PAYMENT PROCEDURES

01. Provided Services.

a. Each participant may consult a participating physician or provider of their choice for care and receive covered services by presenting their identification card to the provider, subject to restrictions imposed by participation in Healthy Connections or enrollment in a PAHP.

b. The provider must obtain the required information by using the Medicaid number on the identification card from the Electronic Verification System (EVS) and transfer the required information onto the appropriate claim form. Where the EVS indicates that a participant is enrolled in Healthy Connections, the provider must comply with referral or follow-up communication requirements under Section 210 of these rules.

c. Upon providing the care and services to a participant, the provider or their agent must submit a properly completed claim to the Department.

d. The Department is to process each claim received and make payment directly to the provider.

e. The Department will not supply claim forms. Forms needed to comply with the Department's unique billing requirements are included in the Idaho Medicaid Provider Handbook.

02. Individual Provider Reimbursement. The Department will not pay the individual provider more than the lowest of:

a. The provider's actual charge for service; or

b. The maximum allowable charge for the service as established by the Department on its pricing file, if the service or item does not have a specific price on file, the provider must submit documentation to the Department and reimbursement will be based on the documentation; or

c. The Medicaid-allowed amount minus the Medicare payment or the Medicare co-insurance and deductible amounts added together when a participant has both Medicare and Medicaid.

03. Services Normally Billed Directly to the Patient. If a provider delivers services and it is customary for the provider to bill patients directly for such services, the provider must complete the appropriate claim form and submit it to the Department.

04. Reimbursement for Other Noninstitutional Services. The Department will reimburse for all noninstitutional services that are not included in other Department rules, but allowed under Idaho's Medical Assistance Program under 42 CFR Section 447.325.

05. Review of Records.

a. The Department, the U.S. Department of Health and Human Services, and the Bureau of Compliance have the right to review records of providers receiving Medicaid reimbursement for covered services.

b. The review of participants' medical and financial records must be conducted for the purposes of determining:

i. The necessity for the care; or

ii. That treatment was rendered under accepted medical standards of practice; or

iii. That charges were not in excess of the provider's usual and customary rates; or

iv. That fraudulent or abusive treatment and billing practices are not taking place.

c. Refusal of a provider to permit the Department to review records pertinent to medical assistance will constitute grounds for:

i. Withholding payments to the provider until access to the requested information is granted; or

ii. Suspending the provider's number.

06. Lower of Cost or Charges. Payment to providers, other than public providers furnishing such services free of charge or at nominal charges to the public, is the lesser of the reasonable cost of such services or the customary charges with respect to such services. Public providers that furnish services free of charge, or at a nominal charge, are reimbursed fair compensation that is the same as reasonable cost.

07. Procedures for Medicare Cross-Over Claims.

a. If a medical assistance participant is eligible for Medicare, the provider must first bill Medicare for the services rendered to the participant.

b. If a provider accepts a Medicare assignment, the Department will pay the provider for the services, up to the Medicaid allowable amount minus the Medicare payment, and forward the payment to the provider automatically based upon the Medicare Summary Notice (MSN) information that is received from the Medicare Part B Carrier on a weekly basis.

c. If a provider does not accept a Medicare assignment, an MSN must be attached to the appropriate claim form and submitted to the Department. The Department will pay the provider for the services, up to the Medicaid allowable amount minus the Medicare payment.

d. For all other services, an MSN must be attached to the appropriate claim form and submitted to the Department. The Department will pay the provider for the services up to the Medicaid allowable amount minus the Medicare payment.

08. Services Reimbursable After the Appeals Process. Reimbursement for services originally identified by the Department as not medically necessary will be made if such decision is reversed by the appeals process required in IDAPA 16.05.03, "Contested Case Proceedings and Declaratory Rulings."

Notes

Idaho Admin. Code r. 16.03.09.230

Effective July 1, 2024