General Medicaid News as of July 2016
Early and Periodic Screening, Diagnostic, and Treatment (EPSDT)
Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) benefit includes a comprehensive array of preventive, diagnostic, and treatment services for Medicaid eligible infants, children and adolescents under age 21, as specified in Section 1905(r) of the Social Security Act (the Act). The EPSDT benefit is also available to PeachCare for Kids® members up to 19 years of age. The EPSDT benefit is designed to assure that children receive early detection and care, so that health problems are averted or diagnosed and treated as early as possible.
The goal of the EPSDT benefit is to assure that individual children get the health care they need when they need it. The EPSDT benefit also covers medically necessary diagnostic services. When a screening examination indicates the need for further evaluation of a child’s health, the child should be appropriately referred for diagnosis without delay. States are required to arrange for and cover under the EPSDT benefit any Medicaid covered service listed in Section 1905(a) of the Act if that treatment or service is determined to be medically necessary to correct or ameliorate defects and physical and mental illnesses or conditions. This includes physician, nurse practitioner and hospital services; physical, speech/language, and occucupational therapies; home health services, including medical equipment, supplies, and appliances; treatment for mental health and substance use disorders; treatment for vision, hearing and dental diseases and disorders, and much more. This broad coverage requirement results in a comprehensive, high-quality health benefit for children under age 21 enrolled in Medicaid.
Reviewing your Health Check Record Although Health Check Record Reviews are currently not available as a service through the Chapter, it is important to periodically review your charts for Health Check accuracy. The goal of the Health Check program is to make certain a child’s health needs are met through initial and periodic exams and evaluations, so that health problems are found, diagnosed and treated early.
Billing Tips for Health Check
The Health Check manual is updated quarterly in January, April, July and October and can be downloaded off the Medicaid web portal under the tab Provider Manuals. The following are tips to guide you when billing for Health Check Services with FFS.
1. Use the AAP/Bright Futures Periodicity Schedule.
2. Review quarterly updates within the Health Check EPSDT manual posted on the Medicaid webportal.
3. If you have any concerns with denials for EPSDT services, please contact the Chapter office
Health Check Referral Codes-
When completing the Health Insurance Claim Form [CMS-1500 ], the EPSDT Referral Codes must be entered in the shaded area of box 24H. (See Appendix L)
Example 1: If the EPSDT screening is normal, the referral code is NU (No follow up visit needed)
Example 2: If the EPSDT screening indicates the need for further diagnostic and treatment services and a follow-up visit is necessary, use the applicable referral code(s):
AV Available, Not Used: Patient refused referral
S2 Under Treatment: Patient is currently under treatment for health problem and has a return appointment.
ST New Services Requested: Referral to another provider for diagnostic or corrective treatment/scheduled.
Reimbursement available Developmental Screens in EPSDT - In order to be reimbursed for the developmental screenings required by Georgia Medicaid at the 9, 18, and 30 months visits, members are to bill code 96110 with the EP modifier and the appropriate ICD-10 diagnosis code -Z00.121 or Z00.129 OR Z02 – Z02.89- in order to receive reimbursement for the Developmental Screening. Only one (1) Developmental Screening will be reimbursed at each of these intervals. The reimbursement rate is $11.74.
A few of the tools that meet the Medicaid requirement for this code include the Ages & Stages Questionnaire (ASQ II and ASQ III), Parents Evaluation of Developmental Status (PEDS), Child Development Inventory (CDI) - 18 months to 6 years, and the Infant Development Inventory – Birth to 18 months. The child’s medical record should include a note indicating the date on which the test was performed, the standardized tool used, and the screening result result/score.
If the child is not seen at the 9, 18, or 30 month visit, a developmental screening should be performed during the Catch-Up visit for the missed periodic visit. This Catch-Up Developmental Screening should be billed, using the EP and the Medicaid Program specific “HA” modifiers along with the 96110 CPT code and the appropriate ICD-10 code. Only one (1) Catch-Up Developmental Screening during any one (1) Catch-Up interval is allowed.
Reimbursement of Depression and Alcohol Drug Screening -An annual depression screening and an annual alcohol/substance abuse risk assessment should be performed for members ages 11 years through 20 years during the EPSDT periodic screening visit. When completed during the periodic visit, the depression screening and alcohol/substance risk assessment can be reported as brief emotional/behavioral assessments. Providers must bill code 96127 with the EP modifier, POS 99 and the appropriate ICD-10 diagnosis code - Z00.121 or Z00.129 Z00.00 or Z00.01 or Z02 – Z02.89 - in order to receive reimbursement.
Vision Screening - Effective April 1, 2016, the updated AAP/Bright Futures Periodicity Schedule changed the routine vision screening at age 18 to a risk assessment. Footnote 7 was updated to read “A visual acuity screen is recommended at ages 4 and 5 years, as well as in cooperative 3 year olds. Instrument based screening may be used to assess risk at ages 12 and 24 months, in addition to the well visits at 3 through 5 years of age. See 2016 AAP statement, “Visual System Assessment in Infants, Children, and Young Adults by Pediatricians and “Procedures for Evaluation of the Visual System by Pediatricians”.
Oral Health - Oral Health- A subheading has been added for fluoride varnish, with a recommendation from 6 months through 5 years. Footnote 25 wording has been edited and also includes reference to the 2014 clinical report, “Fluoride Use in Caries Prevention in the Primary Care Setting” and 2014 policy statement, “Maintaining and Improving the Oral Health of Young Children." Footnote 26 has been added to the new fluoride varnish subheading: See USPSTF recommendations. Once teeth are present, fluoride varnish may be applied to all children every 3-6 months in the primary care or dental office. Indications for fluoride use are noted in the 2014 AAP clinical report “Fluoride Use in Caries Prevention in the Primary Care Setting."
Georgia Health Partnership – Fee-for-Service (FFS) Medicaid - Hewlett Packard Enterprise Services (HP) is an electronic healthcare administrative system. Effective 11/1/2011, HP became the DCHs third party administrator for Georgia Medicaid and PeachCare for Kids that are excluded from the Georgia Families (GF) program.
The Medicaid Managed Care Act: This piece of legislation (also known as HB1234), was passed during the 2008 Georgia Legislative Session and signed into law by the Governor. A few of the areas it focuses on include claim submissions, 72 hour eligibility rule, reimbursement of emergency care, and dental services provided by the Care Management Organizations (CMOs). Click here for full details.
ICD-10 has been updated into the Medicaid System. The Georgia Department of Public Health reviewed all unspecified ICD10 codes and selected certain unspecified codes that would be denied by Medicaid Fee for Service. Please visit the Medicaid webportal and view the Provider Notice dated July 15, 2016 for a list of these codes.
Coordination of Benefits - Georgia Medicaid Fee for Service (FFS) and the CMOs are referred to as "payors of last resort" under federal law. This means that if there is other third party or private insurance available, it must cover the child's medical care. The exceptions to this rule are preventive and pediatric services including Health Check and non-institutionalized pregnancy related services. Refer to the plan's Coordination of Benefits section for details on claims submission. However, if you have billed Peach State and Amerigroup for a sick visit and your patient was later shown to have third party coverage, these plans will contact the third party plan to obtain reimbursement. If you have billed WellCare for a sick visit and your patient is later shown to have third party coverage, WellCare will recoup payment from your office and you will need to bill your patient's third party payor.
Who are the Managed Care Organizations?
Centene Corporation DBA Peach State Health Plan
With corporate headquarters in St. Louis, they currently operate in Indiana, Kansas, Missouri, New Jersey, Ohio, Texas and Wisconsin. To identify the local provider representative for your area, contact Provider Services at 1-866-874-0633.
Based in Virginia Beach, Virginia they operate as a Medicaid only managed care organization. They currently operate in the District of Columbia, Florida, Illinois, Maryland, New Jersey, New York and Texas. To identify the local provider representative for your area, contact Provider Services at 1-800-454-3730.
WellCare of Georgia, Inc.
They are a provider of only government sponsored health products. They are based in Tampa, Florida and currently operate in Connecticut, Illinois, Indiana, Florida, Louisiana and New York. To identify the local provider representative for your area, contact Provider Services at 1-866-231-1821.
DCH is in the process of revising its credentialing process and will begin to announce these changes as they occur. Current plans are to utlize HP to work with an NCQA approved vendor to manage the credentialing process. Click here for details.
Checking Medicaid CMO Eligibility:
With the implementation of HB 1234 in 2008, there have been some changes to the way you verify member eligibility. Previously, you would go to the CMOs websites to determine eligibility by plan affiliation; however, due to the bill the only acceptable verification of plan affiliation for a member is via the GHP web portal. You may notice that all the CMOs have a link to the GHP web port for plan affiliation verification. You may still utilize the CMO eligibility verification for PCP assignment.
Who is eligible for the Georgia Families Managed Care Program?
Individuals who are eligible to enroll in Georgia Families include low-income families, children, and pregnant women, women eligible for Medicaid due to cervical cancer and PeachCare for Kids to managed care. Aged, Blind and Disabled (ABD) population are included in the managed care program at this time. Children in foster care must opt out in order to not be transfered to Amerigroup's Georgia Family 360.
How can your patients can enroll in Georgia Families?
Maximus, the enrollment broker for GA Families, works with Medicaid members who are eligible to participate in the GF program. Members are encouraged to do the following to enroll:
1. By calling 1-888-GA-ENROLL (1-888-423-6765) or click here for the on line enrollment process.
2. By completing an enrollment packet and mailing it to GF
3. Attending an assisted enrollment session
Once a member has enrolled into a plan, they will have 90 calendar days to change their health plan or PCP. After the 90-day period, they will not be able to make any changes to their health plan affiliation without cause until the open enrollment period begins the following year.
To assist you and your patient in the enrollment process, there are a few thing you should know:
• Maximus has also developed a brochure and CMO comparison sheet that you can download from their website (https:www.georgia-families.com) for distribution to your patients in the office.
• Providers can tell their patients which plans(s) they are participating with, but they cannot advise their patients’ which plan to choose. The patients need to chose a plan based on their own decision making process.
Please be reminded that CMO Medicaid members have the option during their open enrollment period (once per year) to change their CMO and PCP assignment. Open enrollment is continuous, based on the individual member’s enrollment date. Members will receive a letter from Georgia Families 30 days prior to their enrollment anniversary date. If the member does not make a choice during the 30-day window they will remain in their CMO.
Planning for Healthy Babies
Planning for Health Babies (P4HB) - Planning for Healthy Babies (P4HB) is a waiver program developed by the DCH with the goal of reducing the number of low birth weight (LBW) and very low birth weight (VLBW) births in Georgia. Effective January 1, 2011, this two year program began providing Family Planning, Inter-Pregnancy Care (IPC) and Recourse Mother (case management) services to members 18 through 44, who would otherwise not be eligible for Medicaid.
- Family planning initial exam and annual exam
- Contraceptive (birth control) services and supplies
- Follow-up family planning visits
- Pregnancy tests and pap smears
- Testing, medicine and follow up for sexually transmitted infections found during the family planning exam (does not include HIV/AIDS and hepatitis)
- Counseling and referrals to social services and primary health care providers
- Tubal ligation (sterilization)
- Family planning pharmacy visits
- Vitamins/folic acid
- Select immunizations for participants ages 19 and 20. Participants age 18 receive vaccines at no cost
If you have a patient who is a Low Birth Weight or Very Low Birth Weight, you can refer the mother to www.P4HB.org for further details on how to apply for this program.