Update information on Medicaid and CMOs

Hope everyone is enjoying the holiday season as this year comes to a close.

A few things I've learned from the Medicaid conference, phone calls, and words passed along the way recently I thought I would pass along

Peachstate, BCBS, and Humana will be the policies in Georgia for the affordable health care act that begins in January. Peachstate owns most of the policies, BCBS a few, and Humana has the most expensive. If you are in network with any of these, you can take those patients, no matter what age the patient is. Medicare rate will be paid for those claims. You do not have to be in Medicare to participate. This information was given by the Peachstate manger Robin in credentialing.

Peachstate also said that unless you send a letterhead giving notice to remove yourself from network (such as Wellcare), they can keep you on a list showing you are a provider for their system. Once you send in a letterhead giving notice, you will be active 90 days from that date. Therefore by not signing the new contracts with Wellcare does not help keep Wellcare from contacting you asking to continue to see patients.

Wellcare reps said at the Medicaid fair that once you are termed from network with Wellcare, your authorization lasts 90 days from the termed date. For example, if you are told you are out of network with Wellcare as of 11/1/13, yet had an auth on a child that lasted until 3/1/14, you can see that child 2/1/14 only. Not til the end of the authorization. Remember as long as you are in network with a company, you are under obligation to see patients within that network...unfortunately. The insurance company will contact you if reported to ask why you turned away a client.

With Medicaid, you have 60 days from the date you discover an issue with a claim to fix the problem (this was discussed at the Medicaid Fair in November in the auditors class). I have the General Auditor for Medicaid's information for anyone that needs to report fraud. Most fraud reports are coming from patients now.

Medicaid re-coupment from September was due to be completed by 12/13/13 (last Friday). Any claims that have been adjusted can be appealed within 30 days of adjustment.

Amerigroup hearing screens for speech patients is a large topic at the moment. Many speech pathologists are complaining about not being able to get parents to get their children to an audiologist for the screening, and Amerigroup is arguing PCPs are paid for the hearing screens at the wellcheck. When I find more information I will pass along what is happening with this issue.

Amerigroup has been assigned the foster kids starting January 1st. Straight Medicaid kids will consist only of SSI/disability.

Any child that needs to change CMO policies are only allowed to do so during the 30 days of their anniversary date when they signed up or within the first 90 days of signing up. https://www.georgia‐families.com/GASelfService/en_US/choosing.htm#changing To change, contact Georgia Families at: 1‐888‐423‐6765 or https://www.georgia‐families.com/GASelfService/en_US/home.htm

PCP referrals for patients on the Medicaid web portal ‐ if you have the provider's NPI, you can put that into the Provider ID and click search to present a list of the physician who referred the patient to the provider. Go with the correct address location that you know the patient sees their PCP. If you are unaware of which REF number you should select, you can call the PCP office and ask for their Medicaid provider number.

Medicaid uses a report from DFCS each month to update eligibility on patients. If the patient has not updated their primary insurance information with their DFCS caseworker, Medicaid is unaware of this information. You can fax in their primary insurance information to Medicaid on a form DMA‐410 to report the change. However, if DFCS is not updated by the patient or Medicaid, the next month the patient could have their information changed back to reflect no primary insurance in the system. Be careful that even though a patient might not reflect the information in Medicaid to show that the patient has primary insurance, you still must bill that insurance company and report that information to Medicaid via form and claim.

Remember secondary claims for Medicaid can be filed via the web portal. For more information on how to file such claims, feel free to contact me and I can go over it with you.

If you have anything you want to add to the list, or have questions, feel free to let us know!