General Payment Procedures

01. Provided Services. (7-1-26) a. Providers must obtain the required information from the Electronic Verification System (EVS) by using the Medicaid number on the identification card from the EVS and transfer the required information onto the appropriate claim form. (7-1-26) b. Upon providing the care and services to a participant, the provider or their agent must submit a properly completed claim to the Department including their usual and customary charge, which is the lowest charge by the provider to the general public for the same service including advertised specials. Each claim submitted by a provider constitutes an agreement to accept and abide by the Department’s requirements. (7-1-26) c. The Department is to process each claim received and make payment directly to the provider. (7-1-26) d. The Department will not supply claim forms. Form examples needed to comply with the Department's unique billing requirements are included in the Idaho Medicaid Provider Handbook. (7-1-26) 02. Provider Reimbursement. (7-1-26) a. The Department will pay the provider the lowest of: (7-1-26) i. The provider's actual charge for service; or (7-1-26) ii. The maximum allowable charge for the service as established by the Department on its pricing file and Idaho Medicaid Provider Handbook; or (7-1-26) iii. The Medicaid-allowed amount minus the Medicare payment or the Medicare co-insurance and deductible amounts added together when a participant has both Medicare and Medicaid. (7-1-26) b. Services and items without a Medicare price on file are priced for the maximum allowable charge at the Department’s discretion per the following: (7-1-26) i. Historical cost or regional reimbursement data. (7-1-26) ii. Percent of charge. (7-1-26) IDAHO ADMINISTRATIVE CODE IDAPA 16.03.26 Department of Health & Welfare Medicaid Plan Benefits Section 030 Page 27 iii. A copy of the manufacturer’s suggested retail pricing (MSRP) or an invoice or quote from the manufacturer or wholesaler. Reimbursement will be seventy-five percent (75%) of MSRP or quote. If the pricing documentation is an invoice for items, reimbursement will be at cost plus ten percent (10%), plus shipping. (7-1-26) vi. An invoice with the usual and customary charges of the provider, and documentation in the form of operation reports, chart notes or medical records. (7-1-26) v. HCBS are priced in accordance with approved service criteria. (7-1-26) 03. Services Normally Billed Directly to the Patient. If a provider bills services directly to patients, the provider must submit a claim form to the Department for reimbursement. (7-1-26) 04. Other Noninstitutional Services. The Department will reimburse for noninstitutional services unless otherwise specified. (7-1-26) 05. Cost Reporting. Providers subject to filing a Medicaid cost report must use the Department designated reporting forms, unless the Department approves an exception. Requests to use alternate forms must be sent to the Department in writing, with samples attached, ninety (90) days prior to the report due date. Requests are not a reason for late filing. (7-1-26) 06. For Providers Subject to Retrospective Cost Settlement. Following receipt of a finalized Medicare cost report and timely receipt of other requested information to fairly cost settle with a provider, the Department sends a certified letter with return receipt requested to the provider setting forth the underpayment or overpayment amounts made to the provider. The notice of results of a final retroactive adjustment are sent even when a provider intends to appeal or has appealed the Medicare Intermediary's determination of cost settlement. When the determination shows that a provider owes Medicaid because total interim and other payments exceeded cost limits, the state takes the necessary action to recover overpayments, including suspending interim payments sixty (60) days after the provider receives the notice. Recovery or suspension actions continue even after the state receives a request for an informal conference or hearing is filed with the state. If the hearing results in a revised determination, appropriate adjustments are made to the settlement amount. (7-1-26) a. The Department makes every effort to issue a notice of program reimbursement within twelve (12) months of receiving a cost report. (7-1-26) b. A Medicaid completed cost settlement may be reopened by a provider or the state within a three (3) year period from the date of the notice of program reimbursement. The issues must have been raised, appealed, and resolved by reopening the Medicare Intermediary’s cost report. Issues previously addressed and resolved by the state’s appeal process are not cause to reopen a finalized cost settlement. (7-1-26) 07. Procedures for Medicare Cross-Over Claims. (7-1-26) a. If a Medicaid participant is eligible for Medicare, the provider must first bill Medicare for the services before billing the Department. (7-1-26) b. If a provider accepts a Medicare assignment, the Department will forward payment to the provider automatically based upon the Medicare Summary Notice (MSN) that is received from the Medicare Part B Carrier. (7-1-26) c. If a provider does not accept a Medicare assignment, an MSN must be submitted with a claim to the Department. (7-1-26) d. For all other services, an MSN must be submitted to the Department with a claim. (7-1-26) e. The Department will pay the provider for the services up to the Medicaid allowable amount minus the Medicare payment. (7-1-26) 08. Appeals Process. Reimbursement for services originally denied by the Department will be made if IDAHO ADMINISTRATIVE CODE IDAPA 16.03.26 Department of Health & Welfare Medicaid Plan Benefits Section 031 Page 28 such decision is reversed by the appeals process. (7-1-26)