Presented by: Xerox State Healthcare, LLC Provider Relations

1. IntroIntroduction to NM Medicaid Medicaid Presented by: Xerox State Healthcare, LLC Provider Relations

2. Resources • When online use: Ask Service Representative • HIPAA.Desk.NM@xerox.com • NMPRSupport@xerox.com • Call Center 505-246-0710 or 800-299-7304 • New Mexico Web Portal • Provider Information section • Links and FAQ section • Provider Login section

3. Important State Websites STATE WEBSITE: PROGRAM POLICY MANUAL • http://www.hsd.state.nm.us/mad/policymanual.html • BILLING INSTRUCTIONS • http://www.hsd.state.nm.us/mad/billinginstructions.html • REGISTERS AND SUPPLEMENTS: • http://www.hsd.state.nm.us/mad/registers/2012.html

4. IMPORTANT!Electronic Funds Transfers (EFT) Step One: Click on Email EFT Administration Step Two: Enter EIN (Federal Tax ID) or SSN and click on submit

5. IMPORTANT!Electronic Funds Transfers (EFT) Step Three: You will need to fill out your account type, account number and bank routing transit number, you will also need to enter your email address then click on submit This e-mail address will also provide a security purpose for EFT because a provider will be notified whenever a change is made to the banking information associated with EFT.

6. IMPORTANT!Electronic Funds Transfers (EFT) Step Four: You receive confirmation

7. Glossary of Terms

8. Glossary of Terms • Visit the link below for a list of frequently used abbreviations. • http://www.hsd.state.nm.us/mad/Glossary.html

9. History of Medicaid • As he campaigned in 1964 Lyndon B. Johnson declared a “The War on Poverty.” He challenged Americans to build a “Great Society” that eliminated the troubles of the poor. • Medicaid was created by the Social Security Amendment of 1965 which added Title XIX to the Social Security Act.

10. What is Medicaid? • U.S. health coverage program for individuals and families with low incomes/resources. • Medicaid is jointly funded by the federal and state governments and administered by the States. • Largest funding source for health related services for low income people.

11. It All Fits Together ISD Medical Assistance Division Molina\TPA PROVIDER DentaQuest Managed Care Providers Xerox FEE-FOR-SERVICE SCI

12. New Mexico Medicaid Program

13. New Mexico Medicaid Program • The Medical Assistance Division (MAD) of the Human Services Department (HSD) administers the Medicaid program for the State of New Mexico and establishes policies around benefits and claims processing. • Medical Assistance Division (MAD) is comprised of the Director’s Office and several bureaus or units. To find out more about each office, bureau, or unit go to the following link • http://www.hsd.state.nm.us/mad/HBureauListing.html

14. Medicaid Policy Manual • Medicaid Policy Manuals are available for reference. • Each manual contains basic Medicaid policy as well as specific provider type policy and billing instructions. • Billing providers should become familiar with their manual and refer to it. • http://www.hsd.state.nm.us/mad/RPolicyManual.html

15. What Is HIPAA?:

16. HIPAA is?: • The Administrative Simplification provisions of the Health Insurance Portability and Accountability Act of 1996 (HIPAA, Title II) required the Department of Health and Human Services (HHS) to establish national standards for electronic health care transactions and national identifiers for providers, health plans, and employers.

17. HIPAA is?: • The security and privacy of health data was also addressed. As the industry adopts these standards for the efficiency and effectiveness of the nation's health care system, the use of electronic data interchange will improve. • NPI (National Provider Identifier) • Electronic Billing (Payer Path, Clearing Houses) • NM Medicaid Web Portal

18. New Mexico Medicaid Program • Eligibility: Who qualifies? • Client eligibility is determined by the Income Support Division (ISD) of HSD or Social Security Office • Eligibility is based upon family size, income, assets and other criteria (Often in association with the disability or age of an individual) • Clients qualify for Medicaid under a specificcategory of eligibility (COE). The COE can also indicate a benefit package (full benefits, limited benefits, full benefits but may owe co-pays, etc.)

19. How to Apply for Medicaid Benefits • In order to apply, clients must provide information about family, income, and assets to the ISD office in their local county, or if their eligibility is determined by the Social Security Department, the information is reported to the Social Security Department.

20. How to Apply for Medicaid Benefits Continued • Once approved clients receive a blue plastic Medicaid ID card upon their eligibility being sent to Xerox. • *The card itself is not proof of eligibility. Rather the card contains information that enables a provider to check on eligibility. In addition, a provider should always ask to see other recipient identification in order to assure that the patient is who he or she claims to be. • Remember to verify that eligibility is current. • Clients must inform their caseworker of any status changes.

21. NM Medicaid Blue Card

22. Ways to Check Eligibility • On-Line Eligibility Inquiry—Web Portal • https://nmmedicaid.acs-inc.com • Automatic Voice Response System (AVRS) (800) 820-6901 • Xerox Eligibility Help Desk: (800)-705-4452 • Monday, Tuesday, Wednesday and Friday8:00 a.m. - 5:00 p.m. • Thursday (Mountain Time) 8:00 a.m. - 4:00 p.m.

23. Medicaid RecipientCOE examples • 072: Medicaid full benefits • 035: Pregnancy-related services only • 029: Family Planning Benefits • 074: Working Disabled Individuals • 041: QMB - Age 65 and Over • 044: QMB - Under 65 • For a COE & description listing, go to: http://www.hsd.state.nm.us/mad/pdf_files/GeneralInfo/Eligpamphlet.pdf

24. New Mexico Medicaid Program Structure New Mexico Human Services Department/Medical Assistance Division Medicaid Program Physical Health Program Behavioral Health Program Fee-for Service Managed Care Statewide Entity for Behavioral Health – OptumHealth Fiscal Agent Xerox SALUD! CoLTS Lovelace Amerigroup Utilization Review Third Party Assessor Contractor Molina Presbyterian UnitedHealthcare Community plan Molina DentaQuest Contracted by Molina Blue SALUD!

25. NM Medicaid Managed Care Organizations

26. SALUD! • The managed care contracts provide for the delivery of medically necessary physical and behavioral health services to approximately 300,000 children and adults in New Mexico.

27. SALUD! • Native Americans are not automatically enrolled in SALUD!, however, they can choose to be in SALUD!. • Visit the link below for additional details regarding the Native American opt-in policy. • http://www.hsd.state.nm.us/mad/PNaoptin.html • Medicaid clients who are dual eligible (covered by Medicare and Medicaid) are enrolled in CoLTS and not SALUD!.

28. SALUD! • Medicaid clients qualified under COE 029 – Family Planning Services Only are not in SALUD!. • Medicaid clients in nursing homes or intermediate care facilities for the developmentally disabled are enrolled in CoLTS.

29. SALUD! • Clients not excluded from SALUD! are enrolled in SALUD! about 4-6 weeks after they’ve qualified for Medicaid. During that 4 - 6 week interval, most recipients are in the Medicaid Fee-For-Service Program with claims processed by Xerox. • The client receives a notice that they will be enrolled in SALUD! and have an opportunity to select their MCO. • If they do not select a MCO by a certain date, they are automatically assigned to a MCO. The client has 90 days after assignment to change their SALUD!.

30. SALUD! • Clients in SALUD! become members of a SALUD! Managed Care Organization (MCO) and receive their physical health care services from doctors, hospitals, pharmacies, and others who work with that MCO. • Once enrolled in an MCO, the client is issued a member card by that MCO. • This card is NOT their Medicaid eligibility card. It indicates they are a member of that MCO and has their MCO member ID on it.

31. SALUD! • A newborn baby is enrolled in the same MCO as the mother, if the mother was enrolled in SALUD! on the baby’s date of birth. • The baby’s birth must be reported to the ISD office for the enrollment to take place.

32. SALUD! Managed Care Organizations (MCO) • Lovelace Healthcare: 800-808-7363 • Molina Healthcare: 800-580-2811 • Presbyterian Healthcare: 888-977-2333 • Blue Cross Blue Shield of NM: 866-689-1523

33. Coordination of Long Term Services (CoLTS) • CoLTS covers primary, acute, and long-term services in one coordinated and integrated program that incorporates Medicare and Medicaid services. • Clients who are also eligible for Medicare and are in nursing facilities, or receive certain services such as Personal Care Option services in their home, are enrolled in a CoLTS MCO, not in Salud! • CoLTS MCO: • United Healthcare: 800-851-1878 • Amerigroup: 800-600-4441

34. Important Reminder • In all cases, providers must be enrolled in the MCO in order to be paid by the MCO. • Providers must follow MCO requirements and submit claims to the MCO for clients who are enrolled in SALUD! or CoLTS on the date(s) of service (DOS). • Xerox cannot pay physical health claims for clients enrolled in SALUD! or CoLTS on the claim’s DOS.

35. NM Medicaid Structure:Fee-for-Service (FFS)

36. NM Medicaid Structure:Fee-for-Service (FFS) • Xerox is the Fiscal Agent for the New Mexico Medicaid Fee for Service program.

37. NM Medicaid Structure:Fee-for-Service (FFS) • Clients who are not enrolled in SALUD! or CoLTS may obtain health care services from any provider who accepts Medicaid. • This part of the Medicaid program is referred to as Medicaid “fee-for-service”.

38. NM Medicaid Structure:Fee-for-Service (FFS) • Terms you may hear describing clients in the Medicaid fee-for-service program: • “exempt” • “Medicaid fee-for-service” • “In regular Medicaid” • “Medicaid traditional”

39. As the Fiscal Agent: • Enrolls providers into the FFS Medicaid program. • Processes health care claims for New Mexico’s Medicaid FFS program. • Claims are processed according to the policies of the New Mexico Medicaid program. • Issues payment to Medicaid providers.

40. As the Fiscal Agent Does Not: • Make Medicaid Policy. • Make exceptions to Medicaid Policy.

41. Full Medicaid Covered Services through Fee for Service (FFS) Medicaid. • Inpatient Hospitalization • Outpatient Hospital Services • Physician Services • Lab & Radiology Services • Home Health • Nursing Facilities • Early and Periodic Screening, Diagnostic and Treatment (EPSDT) Services for Children • Prescription Drugs • Vision and Hearing Services • Organ Transplants • Behavioral Health Services • Podiatrist Services • Dental Services • Physical, Occupational and Speech Therapies • Rehabilitative Services • ICF/MR • Case Management • Emergency Hospital Services • Hospice • Transportation Services • Prosthetic Devices • Personal Care **Some procedure codes within these services may not be covered and some may require prior authorization**.

42. Insure New Mexico Programs

43. 2012 Federal Poverty Level Guidelines

44. Behavioral Health Services

45. Behavioral Health Services • Services provided by a Behavior Health Provider are administered by Optumhealth. • Prescription drugs prescribed by a Behavioral Health Provider are also administered by OptumHealth. • It is the provider type, not the service or the diagnosis that is used to determine if it is Behavioral Health Service. • For clients enrolled in CoLTS, Medicare crossovers are paid by the CoLTS MCOs (Amerigroup, UnitedHealthcare).

46. Behavioral Health Services • Behavioral Health Providers should access Optumhealth’s website for information. https://www.optumhealthnewmexico.com

47. NM Medicaid Utilization Review

48. Utilization Review (UR) • Prior Authorization (PA) • Some services in the Fee For Service program require prior authorization in order for the claim to be eligible for payment. • The PA is issued based upon medical necessity, but does not guarantee the client’s Medicaid eligibility. (Eligibility must still be verified).

49. Utilization Review (UR) • The UR contractor for New Mexico is Molina TPA (Third Party Assessor) • All claims for Waiver and PCO providers require an authorization. • Waiver providers – Contact the Case Manager to obtain or follow up on a Prior Authorization. • PCO providers – Contact Molina TPA (Third Party Assessor). (505) 348-0311 ( in Albuquerque) (866) 916-3250 (Toll free)

50. Utilization Review (UR) • How do you determine if/when a Prior Authorization (PA) is required? • Call Molina. They can tell you if a PA is required and the procedures for getting a Prior Authorization. • Molina TPA (Third Party Assessor)         • (505) 348-0311 ( in Albuquerque) • (866) 916-3250 (Toll free) • Also, consult the Medicaid program and policy manuals and billing manuals for prior authorization requirements. • Authorizations for EMSA Emergency Medical Service for Aliens (review contact Molina TPA.).