MEDICAID INFORMATION RELEASE MA22-19
Customize your policy alerts
Sign up for Idaho Department of Health and Welfare Policy MA22-19 alerts
Get alerted when Policy MA22-19 changes without checking for updates manually.
Monitor payer policy activity
This document provides informational updates, coding and billing guidance (NCCI edits, APC fee schedule updates, CPT/HCPCS code configuration), provider contacts, audit procedures, and administrative reminders for Idaho Medicaid providers.
No material clinical or coverage changes in this revision.
Coverage, Billing & Audit Criteria
NCCI-based coverage and reporting criteria
Coding and billing must follow AMA CPT guidance and NCCI policy and edits; many services are included in the medical/surgical global/package and are not separately reportable except in specified circumstances.
ALL of the following
Examples of non-separately reportable services
- Anesthesia services performed by the same physician performing a surgical or medical procedure are generally not separately reportable.
- Endoscopic procedures performed during the same encounter as non-endoscopic procedures to verify no intraoperative injury are not separately reportable.
- Cardiopulmonary monitoring integral to a procedure is not separately reportable.
- Exposure and exploration of the surgical field is integral and not separately reportable.
- Services required to obtain access through diseased tissue (e.g., debridement, incision and drainage) when integral to the primary procedure are not separately reportable.
- When treatment of a complication requires return to the operating room, modifier 78 may be appropriate to report the separate procedure; otherwise postoperative complication care that does not return to the OR is included in the global package.
Claim submission and fee schedule update guidance
Fee schedule updates and code configuration affect claim processing; submit claims with current codes to preserve timely filing even if lines may initially deny pending system configuration.
Eligibility verification requirement
Providers must verify eligibility and maintain documentation at the time of service; failure to verify may affect reimbursement.
Telligen audit operational criteria
Operational criteria for Telligen audits: how to submit records, timelines for submission, appeal windows, notifications, and options for rebilling/resubmission.
DRG-related administrative actions
Administrative actions required related to the October 1, 2022 APR DRG updates.
Code Configuration, Fee Schedules & Modifiers
| Configuration for new codes covered as of January 2022 has been underway; several codes are still pending configuration. Claims should be submitted with the new codes, however those claim lines may deny as non-covered and will be reprocessed once configuration is finished. |
| APC Prep - Fee Schedule Paid Procedure Codes list updated to remove expired and informational procedure codes effective for dates of service on or after July 1, 2022. Acute care hospitals (except in-state CAH, IMDs, and State-Owned Hospitals) must bill a CPT or HCPCS code on each outpatient hospital claim line where procedure codes are required under national billing guidelines. |
| NCCI policy: component elements of pre-, intra-, and post-procedure work are included in the procedure. Many services (including certain anesthesia, monitoring, endoscopy, access procedures, exploration, and treatment of complications that do not require return to the OR) are not separately reportable. E&M services are separately reportable with major procedures only in limited circumstances (modifier 57) and with minor procedures only if a significant, separately identifiable E&M is performed (modifier 25). Examples of PTP modifiers: 24, 25, 27, 57, 58, 59, 78, 79. Services billed that do not comply with NCCI edits may be subject to recoupment and/or civil monetary penalties. |
| Telligen reviews only the paid claim and does not regroup to review the paid claim. Telligen will regroup the claim only if coding revisions affect the DRG. |
Required Provider Actions & Submission Instructions
Use NCCI modifiers only for separate encounters/sites/specimens
Modifiers should be used only when appropriate for separate patient encounters, separate anatomic sites, or separate specimens; examples of NCCI PTP associated modifiers include 24, 25, 27, 57, 58, 59, 78, and 79. Services billed that do not comply with NCCI edits may be subject to recoupment and/or civil monetary penalties.
- Use modifiers only for separate encounters, anatomic sites, or specimens.
- Examples of associated modifiers: 24, 25, 27, 57, 58, 59, 78, 79.
- Noncompliant services may be subject to recoupment or civil monetary penalties.
Verify and document participant eligibility before service
Verify and document the participant’s eligibility and Healthy Connections enrollment status on the date of service before rendering services; maintain proof of the eligibility check as required by Idaho Medicaid policies and IDAPA rule.
- Verify eligibility on date of service per Provider Handbook section 7.2.
- Maintain proof that eligibility was checked.
- Providers may not require participants to check eligibility for them.
Submit medical records via Qualitrac, mail, or confidential fax
Submit requested medical records via the Telligen Qualitrac web portal (preferred). If Qualitrac is unavailable, send records by mail to Telligen at 1776 West Lakes Parkway, West Des Moines, IA 50266, Attn: Idaho Medicaid, or fax to Telligen’s confidential line at (866) 539-0365.
- Preferred method: Telligen Qualitrac portal.
- Mail: Telligen Attn: Idaho Medicaid, 1776 West Lakes Parkway, West Des Moines, IA 50266.
- Fax: confidential fax line (866) 539-0365.
Rebill or resubmit corrected claims within 365 days
If you agree with Telligen’s recommendation, rebill or resubmit a corrected or new outpatient claim within 365 days of the first day of service.
- You have 365 days from the first day of service to submit a new outpatient claim.
- Resubmit corrected coding within the same 365-day window.
Timely request reconsideration and Department appeals
Request a reconsideration (first‑level appeal) within 30 calendar days of the notice by submitting additional clinical documentation via Qualitrac, fax, or mail. You may request a Department appeal with DHW within 28 days of the date the notice was mailed; instructions are provided on Telligen outcome letters.
- Reconsideration (first‑level) deadline: 30 calendar days from notice; submit via Qualitrac, fax, or mail.
- Department appeal deadline: 28 days from date notice was mailed; follow instructions on Telligen outcome letters.
Sign and submit updated Medicaid Provider Agreement for APR DRG
Sign the updated Medicaid Provider Agreement reflecting the 3M APR DRG updates and submit the signed agreement to the Department by mail, email, or fax using the provided contact information.
- Mail signed agreement to Idaho Department of Health and Welfare Division of Medicaid, PO Box 83720, Boise, ID 83720-0009, Attn: Reimbursement Unit.
- Or submit via email to MedicaidReimTeam@dhw.idaho.gov or by fax to 208-287-1170.
- Updated agreement available via mass mailing and online under 'Additional Terms - Reimbursement for Hospital Services October 2022'.
Key Terms & Acronyms
OpenPayer is powered by Trek Health's payer performance platform. Trek continuously ingests, validates, and normalizes Transparency in Coverage data alongside payer policies and other commercial payer data to create a structured payer intelligence foundation. OpenPayer uses this foundation to deliver personalized search results, dynamically generated policy pages, and tailored policy monitoring based on each user's payers, specialties, billing codes, and areas of interest. The same intelligence powers broader payer performance workflows, including reimbursement benchmarking, contract evaluation, payer negotiations, and financial decision-making.