CurrentIdaho Department of Health and WelfarePolicy N/A
Idaho Medicaid: Provider Operational and Administrative Bulletin
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Summarizes operational clarifications and administrative policy updates for Idaho Medicaid providers, affecting billing, documentation, enrollment, and service coverage procedures.
Policy Summary
PayerIdaho Department of Health and Welfare
PolicyIdaho Medicaid: Provider Operational and Administrative Bulletin
Policy CodePolicy N/A
Change TypeAdministrative/Operational updates
Effective DateN/A
Next Review DateN/A
Key ActionSubmit prior authorization requests using the Idaho Medicaid Surgery & Procedure PA form and fax to 877-314-8779 when routine services associated with clinical trials or certain procedures require PA.
SourceLink
POLICY UPDATE CHANGES
No material clinical or coverage changes in this revision.
~20 topicstopics listed in this bulletin
4molecular tests/month
4rapid antigen tests/month
2serologic tests/year
May 11, 2023PHE end date referenced
1YES respite usage required/yr
Coverage Criteria and Program Requirements
Urine drug testing coverage and documentation
Laboratory urine drug testing is covered only when medically necessary and supported by a valid order and documentation. Laboratories must maintain required records prior to billing.
Tests must be medically necessary (e.g., altered mental status, possible overdose, substance use treatment, chronic pain treatment) and are not covered for routine physicals, sports participation, legal/criminal justice, employment, or administrative purposes.
Orders must be by a licensed or certified healthcare professional who: has performed a face-to-face evaluation of the participant (telehealth may satisfy this if telehealth policy requirements are met); is treating the participant for the condition the test is being ordered for; and is enrolled with Idaho Medicaid and/or the IBHP.
Blanket or standing orders and orders specifying presumptive and confirmatory testing will be performed simultaneously are not allowed.
Specimen validity testing is included in reimbursement for the test.
Confirmatory (quantitative) testing (e.g., LCMS/MS or GC-MS) should be reserved for disputed presumptive results or when the drug of concern cannot be tested by immunoassay; majority of testing should be presumptive.
Documentation that laboratories must maintain prior to billing includes: the practitioner order; documentation supporting medical necessity; specimen identification number; means of identifying the specimen's owner; ordering provider name; date specimen collected; date specimen received; test performed; date test performed; test results; name and address of referred laboratory (if applicable); and referring laboratory that submitted the specimen (if applicable).
Clinical trial routine cost coverage
Routine participant costs associated with qualifying clinical trials are covered when they would otherwise be covered under the state plan or waiver; investigational items that are the subject of the trial are not covered.
Routine costs include items or services to prevent, diagnose, monitor, or treat complications resulting from participation in the qualifying clinical trial to the extent they would be covered outside the trial under the state plan or waiver.
Investigational items or services that are the subject of the clinical trial are excluded from coverage; services required solely for data collection not used in direct clinical management and not covered under the state plan or waiver are excluded.
Routine participant costs are covered regardless of where the clinical trial is conducted (including out-of-state) and regardless of whether the principal investigator or treating provider is outside the participant's MCO network; usual requirements for rates, billing, and prior authorization for out-of-state care and services still apply.
Idaho Medicaid requests an attestation form be completed and faxed to the Medical Care Unit at 877-314-8782 before participants start receiving services through a clinical trial; the attestation must be signed by the principal investigator (or delegated authority) and the participant's healthcare provider providing care during the trial.
Participation in a qualifying clinical trial itself does not require prior authorization; however, routine services associated with the trial may still have PA requirements and, when required, PA requests must be submitted using the Idaho Medicaid Surgery & Procedure PA form (fax 877-314-8779).
Present-on-Admission (POA) requirement limited to CMS HAC list diagnoses
Idaho Medicaid will require Present-on-Admission (POA) reporting only for diagnoses on the CMS Hospital-Acquired Conditions (HAC) list; providers may submit blank POA for other diagnoses.
POA is defined as present at the time the order for inpatient admission occurs; medical record documentation from any provider involved in the patient's care may be used to support POA determination; providers must resolve inconsistent, missing, conflicting, or unclear information.
Idaho Medicaid will require a POA indicator only for diagnoses on the CMS HAC list; for diagnoses not on the HAC list providers may submit claims with a blank POA.
Idaho Medicaid is adding '1' as a POA indicator; if a diagnosis requires a POA indicator and it is not present (or indicates N or U), the claim may be denied.
To reduce administrative burden for HAC claims with a diagnosis of N or U, providers may split billing by submitting one inpatient claim with covered services and a second bill type 0110 (Non-Payment/Zero Claim) for services with HAC diagnoses of N or U, both with the same admission-to-discharge date range and noting 'Split Claim' in Field/Box 80 of the UB-04.
Coverage criteria and program requirements
Coverage positions for telehealth, COVID-19 testing, and vaccinations after the Public Health Emergency (PHE) end date are specified below.
Telehealth: Any covered service may be delivered via telehealth when the service can be safely and effectively delivered via the medium; the service meets the code definition when provided via telehealth; the service is billed with FQ or GT modifier; and all other existing coverage criteria are met.
Telehealth documentation: Individual treatment records must include written documentation of the evaluation process, services provided, participant consent, outcomes, and that services were delivered via telehealth; documentation quality must match an in-person visit.
Telehealth claims: Use place of service 02 (other than patient's home) or 10 (patient's home). Include modifier FQ for audio-only or GT for audio-visual telehealth. FR may be used additionally when a supervising practitioner is present via real-time two-way audio/video.
Reporting of test results only is not covered as a telehealth service.
COVID-19 testing: Idaho Medicaid continues to reimburse medically necessary CDC-recommended SARS-CoV-2 testing (molecular, rapid antigen, serologic) after the PHE ends; an individualized test result for diagnostic or screening services is required to support reimbursement.
COVID-19 testing limits: Molecular and rapid antigen tests are limited to four per participant per month; serologic (antibody) tests are limited to two per participant per year without prior authorization. Prior authorization for additional SARS-CoV-2 tests is available through Telligen.
COVID-19 vaccinations: Vaccines recommended by ACIP are reimbursed; vaccines supplied at no cost by state/federal government must be billed with the SL modifier. Vaccine administration by RHC/FQHC/IHS may be included in encounter rate if a qualified health professional is seen; otherwise bill fee-for-service using vaccine administration codes.
99211-GT for vaccine outreach will no longer be covered after May 11, 2023; outreach for vaccination reminders is considered included in Healthy Connections case management payment.
YES Program eligibility, cost sharing, and ASC dental billing criteria
Requirements and consequences for YES Program enrollment, plus ASC dental billing changes and cost-sharing rules.
PCSP requirement: Complete a Person-Centered Service Plan (PCSP) within 90 days of YES Program enrollment and update the PCSP at least annually within 364 days of the previous plan.
SED assessment requirement: Complete an annual independent assessment for Serious Emotional Disturbance (SED) within 364 days of the previous assessment.
Service utilization requirement: Utilize at least one 1915(i) service (currently respite) one time per eligibility year with a Medicaid-enrolled provider; respite must be listed in the PCSP.
Consequence for noncompliance: Failure to meet the above requirements may result in disenrollment from the YES Program; members who qualify via other Medicaid pathways will remain enrolled under those pathways.
Cost sharing: No sooner than Sept 1, 2023, members with family income between 185% and 300% FPG may be required to pay a $15/month premium (not to exceed 5% of family income). Members above 133% FPG may be subject to a $3.65 copay per visit for certain outpatient services. Bureau of Financial Services will invoice families and provide instructions for hardship waivers.
ASC dental billing change: Ambulatory Surgical Centers must use CDT codes for dental procedures without an applicable CPT code effective May 1, 2023; prior authorizations for dental services are handled through Idaho Smiles administered by MCNA Dental and ASCs must verify the performing provider has an approved prior authorization when applicable.
Reimbursement and limits for listed dental procedures
The following dental procedure codes list reimbursements and any stated limits.
D7210 — Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth; reimbursement $102.51; limitation: N/A.
D7220 — Removal of impacted tooth - soft tissue; reimbursement $98.31; limitation: N/A.
D7230 — Removal of impacted tooth - partially bony; reimbursement $114.68; limitation: N/A.
D7240 — Removal of impacted tooth - completely bony; reimbursement $148.49; limitation: N/A.
D7250 — Removal of residual tooth roots (cutting procedure); reimbursement $78.85; limitation: N/A.
D7280 — Exposure of an unerupted tooth; reimbursement $153.60; limitation: N/A.
D7510 — Incision and drainage of abscess - intraoral soft tissue; reimbursement $42.66; limitation: N/A.
D9230 — Inhalation of nitrous oxide/anxiolysis, analgesia; reimbursement $24.46; limitation: 1 per day.
D9420 — Hospital or ambulatory surgical center call; reimbursement $92.27; limitation: 1 per day.
Coding, Billing Examples, and Limits
Multiple delivery billing examplesCPTCovered
| 59400 | Vaginal delivery, first baby (1 unit as first baby) |
| 59409 | Vaginal delivery of additional baby(ies) with Modifiers 51 and 59 per additional baby |
| 59510 | Cesarean delivery for multiple babies (one CPT with one unit for multiple cesareans) |
| 59514 | Cesarean delivery code used for additional babies with Modifiers 51 and 59 when mixed delivery methods |
Telehealth places of service and modifiersmixed
| 02 | Telehealth provided other than in patient's home (place of service) |
| 10 | Telehealth provided in patient's home (place of service) |
| FQ | Modifier for telehealth furnished using real-time audio-only communication technology |
| GT | Modifier for telehealth furnished using real-time audio-visual communication technology |
| FR | Modifier when supervising practitioner present via real-time two-way audio/video technology |
Selected CDT codes and reimbursements for ASC billingCDTCovered
| D0120 | Periodic oral evaluation - established patient; reimbursement $19.24; limitation 1 per 6 months or 1 per 12 months (document lists both) |
| D0140 | Limited oral evaluation - problem focused; reimbursement $27.15; limitation 1 per 6 months |
| D0150 | Comprehensive oral evaluation - new or established patient; reimbursement $27.90; limitation 1 per 6 months or 1 per 12 months (document lists both) |
| D0210 | Intraoral - comprehensive series of radiographic images; reimbursement $59.17; limitation 1 per 36 months |
| D1110 | Prophylaxis - adult; reimbursement $41.68; limitation 1 per 6 months |
| D1120 | Prophylaxis - child; reimbursement $29.17; limitation 1 per 6 months |
Dental procedure codes and reimbursementsCPTCovered
| D7210 | Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth; includes elevation of mucoperiosteal flap if indicated (reimbursed $102.51) |
| D7220 | Removal of impacted tooth - soft tissue (reimbursed $98.31) |
| D7230 | Removal of impacted tooth - partially bony (reimbursed $114.68) |
| D7240 | Removal of impacted tooth - completely bony (reimbursed $148.49) |
| D7250 | Removal of residual tooth roots (cutting procedure) (reimbursed $78.85) |
| D7280 | Exposure of an unerupted tooth (reimbursed $153.60) |
| D7510 | Incision and drainage of abscess - intraoral soft tissue (reimbursed $42.66) |
| D9230 | Inhalation of nitrous oxide/anxiolysis, analgesia (reimbursed $24.46; limit: 1 per day) |
| D9420 | Hospital or ambulatory surgical center call (reimbursed $92.27; limit: 1 per day) |
COVID-19 testing limits
Molecular testingLimited to 4 tests per participant per month without prior authorization; additional tests require prior authorization through Telligen (https://idmedicaid.telligen.com).
Rapid antigen testingLimited to 4 tests per participant per month without prior authorization; at‑home rapid antigen tests require a prescription and are billed at the pharmacy point‑of‑sale; additional tests require prior authorization through Telligen.
Serologic testingLimited to 2 tests per participant per year without prior authorization; serologic tests are not for diagnosing acute infection; additional tests require prior authorization through Telligen.
prior authorization thresholds
Dental prior authorization for ASCsSome dental services have limits that, if exceeded, require prior authorization through Idaho Smiles (administered by MCNA Dental); ASCs must verify the provider performing the procedure has an approved prior authorization.
Prior authorization for additional COVID-19 testsIf molecular, rapid antigen, or serologic test limits are exceeded, providers can submit a prior authorization request to Telligen (https://idmedicaid.telligen.com).
Out‑of‑state routine clinical trial servicesUsual requirements regarding rates, billing processes, and prior authorization for out‑of‑state care apply to routine clinical trial participant costs.
D9230 limit
D9230 description & reimbursementInhalation of nitrous oxide/anxiolysis, analgesia; reimbursed $24.46.
D9230 limitLimit: 1 per day.
Prior authorization noteSome dental services may require prior authorization through Idaho Smiles; verify authorizations to be eligible for reimbursement.
D9420 limit
D9420 description & reimbursementHospital or ambulatory surgical center call; reimbursed $92.27.
D9420 limitLimit: 1 per day.
ASC billing requirementASC providers must bill CDT codes for dental procedures without an applicable CPT code starting May 1, 2023; verify prior authorization requirements with Idaho Smiles.
Provider Actions, Prior Authorization, and Administrative Steps
Prior Authorization
Clinical trial prior authorization guidance
Participation in a clinical trial itself does not require prior authorization; however, routine services associated with the trial may still have PA requirements. Submit completed PA requests using the Idaho Medicaid Surgery & Procedure PA form and fax to 877-314-8779 (MCO participants follow the MCO process).
- Clinical trial participation alone is not subject to PA.
- Routine trial-related services may still require PA and must use the standard Surgery & Procedure PA form.
- Fax completed PA form and documentation to 877-314-8779; follow MCO-specific processes for MCO participants.
Prior Authorization
Prior authorization for additional COVID‑19 tests
Molecular and rapid antigen SARS‑CoV‑2 tests are limited to four tests per participant per month and serologic tests are limited to two per year without prior authorization; if additional tests are needed providers may submit a prior authorization request to Telligen at https://idmedicaid.telligen.com/.
- Molecular testing: limited to 4 tests per participant per month; additional tests require PA through Telligen.
- Rapid antigen testing: limited to 4 tests per participant per month; additional tests require PA through Telligen.
- Serologic testing: limited to 2 tests per year without PA; additional tests require PA through Telligen.
Documentation Required
Re‑acknowledge Additional Terms in Provider Enrollment Application
Hospitals and long‑term care facilities must re‑acknowledge and electronically sign the Additional Terms presented on the Documents tab in the Provider Enrollment Application during their next maintenance; re‑acknowledgement is also required if a change of ownership is reported (provider impact anticipated by May 1, 2023).
- Electronically sign the Additional Terms on the Documents tab during next PEA maintenance.
- Re‑acknowledgement required upon change of ownership.
- Expected provider impact date: May 1, 2023.
Prior Authorization
ASC dental prior authorization process and verification
Some dental services provided in Ambulatory Surgical Centers may require prior authorization through Idaho Smiles (administered by MCNA Dental); codes that always require prior authorization do not require the ASC to obtain it directly, but the ASC must verify the performing provider has an approved authorization to be eligible for reimbursement.
- Request prior authorizations for dental services through Idaho Smiles (call 1‑855‑235‑6262 or visit the Idaho Smiles website).
- If a code always requires PA, the ASC need not obtain it directly, but must verify the performing provider holds the approved PA.
- No reimbursement will be paid to the dental provider or ASC if a required prior authorization was not obtained.
Billing Rule
Dental procedure reimbursement amounts and limits (ASC billing)
The bulletin lists allowed dental CDT procedure codes with associated reimbursement amounts and any stated limits (e.g., D7220, D7230, D7240, D7250, D7280, D7510, D9230, D9420); ASCs must bill CDT codes for dental procedures without an applicable CPT code effective May 1, 2023.
- Effective May 1, 2023 ASCs must use CDT codes when no CPT code exists; do not use T1015 for those services.
- Reimbursements include: D7220 $98.31; D7230 $114.68; D7240 $148.49; D7250 $78.85; D7280 $153.60; D7510 $42.66; D9230 $24.46 (limit 1 per day); D9420 $92.27 (limit 1 per day).
- Verify any prior authorization requirements through Idaho Smiles to ensure reimbursement eligibility.
Definitions and Key Terms
Qualifying Clinical Trial
DefinitionA 'qualifying clinical trial' is a trial related to the prevention, detection, or treatment of any serious or life‑threatening disease or condition; includes trials funded by NIH, CDC, or other federal‑approved entities.
Routine costs coverageRoutine participant costs (preventing, diagnosing, monitoring, or treating complications from trial participation) are covered under the state plan or waiver; investigational items/services that are the subject of the trial are not covered.
Attestation requirementIdaho Medicaid requests an attestation form signed by the principal investigator (or delegated authority) and the participant's healthcare provider; fax to Medical Care Unit at 877-314-8782 before services begin.
POA indicator
POA definitionPresent on Admission (POA) is defined as present at the time the order for inpatient admission occurs; medical record documentation from any provider involved may support the determination.
Scope of POA requirementIdaho Medicaid will only require a POA indicator for diagnoses that appear on the CMS hospital‑acquired conditions (HAC) list.
Claiming guidanceIdaho Medicaid is adding '1' as a POA indicator; providers may submit a blank POA for diagnosis codes not on the HAC list; claims requiring a POA will be denied if missing.
Telehealth
DefinitionTelehealth means providing medically necessary healthcare services remotely via real‑time video or telephone interactions between participant and provider.
Billing requirementsServices delivered via telehealth must be billed with modifier FQ or GT and place of service 02 or 10; FR may be used additionally when a supervising practitioner is present via two‑way audio/video.
Documentation standardsThe individual treatment record must include written documentation of evaluation, services provided, participant consent and outcomes, and that services were delivered via telehealth; quality must match an in‑person visit.
Molecular testing
DefinitionMolecular testing detects SARS‑CoV‑2 viral RNA and is the definitive method to diagnose active infection.
Monthly limitMolecular tests are limited to 4 per participant per month without prior authorization.
Prior authorization for excess testsIf additional molecular tests are needed beyond the limit, submit a prior authorization request to Telligen (https://idmedicaid.telligen.com).
Rapid antigen testing
DefinitionRapid antigen testing provides quicker results (15–30 minutes) but is less sensitive than molecular testing and may be less effective after five days of symptom onset or in asymptomatic individuals.
Monthly limitRapid antigen tests are limited to 4 per participant per month without prior authorization; at‑home rapid antigen tests require a prescription and are billed at the pharmacy point‑of‑sale.
Follow‑up guidanceNegative rapid antigen tests with high clinical suspicion should be followed by molecular testing and isolation while awaiting results; additional tests beyond limits require prior authorization through Telligen.
Serologic testing
DefinitionSerologic testing detects antibodies indicating prior infection and is not recommended for diagnosing acute infection, quarantine decisions, or assessing immunity after vaccination.
Annual limitSerologic tests are limited to 2 per participant per year without prior authorization.
Confirmation recommendationGiven risk of false positives, a second serologic test is recommended to confirm a positive result alongside clinical history and diagnostic tests; additional tests require prior authorization through Telligen.
PCSP
DefinitionPerson‑Centered Service Plan (PCSP) — a plan that documents services the member and family may use and guides treatment planning.
Timing requirementComplete initial PCSP within 90 days of YES Program enrollment and update at least annually within 364 days of the previous plan.
Responsible partiesPCSPs may be completed by Target Care Coordinators enrolled in the IBHP provider network, DD Case Managers, Wraparound Coordinators, or other designated entities.
SED assessment
DefinitionSerious Emotional Disturbance (SED) independent assessment — an annual assessment required to evaluate SED status.
Timing requirementAn annual independent SED assessment must be completed within 364 days of the previous assessment.
Scheduling supportMedicaid's contracted Independent Assessor (currently Liberty Healthcare) will send reminder letters starting 90 days prior to the renewal date to schedule the assessment.
CDT
DefinitionCDT — Code on Dental Procedures and Nomenclature used for billing dental procedures not represented by CPT codes.
ASC billing changeEffective May 1, 2023, ASCs must bill appropriate CDT codes when no applicable CPT code exists; services must be medically necessary to be eligible for reimbursement.
Prior authorization processPrior authorizations for dental services are requested through Idaho Smiles (MCNA Dental); codes that always require prior authorization do not require the ASC to obtain it directly but ASCs must verify authorizations.
guidance
Nature of documentGuidance document that interprets existing law to provide clarity; not new law but an interpretation prepared by the Idaho Department of Health and Welfare.
Contact for inputFor additional information or to provide input, contact the Idaho Division of Medicaid at medicaidcommunications@dhw.idaho.gov or call 208‑334‑5747.
ApplicabilityThis guidance does not bind the public except as authorized by law or incorporated into a contract.
Policy Summary
PayerIdaho Department of Health and Welfare
PolicyIdaho Medicaid: Provider Operational and Administrative Bulletin
Policy CodePolicy N/A
Change TypeAdministrative/Operational updates
Effective DateN/A
Next Review DateN/A
Key ActionSubmit prior authorization requests using the Idaho Medicaid Surgery & Procedure PA form and fax to 877-314-8779 when routine services associated with clinical trials or certain procedures require PA.
SourceLink
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