Idaho Medicaid Provider Handbook, Home Health and Hospice Services § 3.7

Providers must be enrolled to receive reimbursement from Idaho Medicaid. Providers have

the burden of proof to establish entitlement to payment. Idaho Medicaid reimburses home

health services on a per visit basis, which includes the cost of mileage. Interim payment

amounts are found on the Home Health Fee Schedule. Interim payment is based on the lesser

of the Medicaid cost caps established by Idaho Medicaid on a state fiscal year basis or billed

amount. Interim payments are made for:

•

Skilled nurse visit;

•

Home health aide;

•

Occupational therapy;

•

Physical therapy; and

•

Speech-language pathology services.

Finalized payments are based on the provider’s usual and customary fees for services and

paid up to the reasonable cost as determined by a finalized Medicare cost report or the

Medicaid percentile cap. The Medicaid percentile cap is revised annually on July 1st. Rates are

determined by data from the most recent finalized Medicare cost reports 30 days prior to the

effective date. Home health providers are subject to the Overpayments and Underpayments

section of the General Billing Instructions, Idaho Medicaid Provider Handbook.

Durable medical equipment and supplies (DME and DMS) are paid up to the Medicaid allowed

amount per the Durable Medical Equipment, Prosthetics, Orthotics and Supplies, Idaho

Medicaid Provider Handbook, and the Numerical Fee Schedule.

Participants with Medicare eligibility will have all services paid for by Medicare. The

department will cover any remaining coinsurance and deductible.

Reimbursement for therapy services is not reduced when provided by an assistant and does

not require the CO, CQ or HM modifiers.

Payment for the initial nursing evaluation visit depends upon the participant’s need for home

health services. The provider should bill according to the following requirements:

•

If the participant needs further home health services, bill the evaluation visit as a

skilled nursing visit; or

•

If the participant does not require home health services, the visit must be charged to

the agency administration cost center.

All claims that aren’t for DME and DMS are subject to Electronic Visit Verification (EVV) and

may pend up to 10 days before processing. EVV requires all data elements be submitted to

the state’s aggregator before claims are billed. All home health services, including DME and

DMS must be billed by the home health provider on the UB-04 claim form using the

appropriate revenue and type of bill codes. See the Home Health Billing Appendix for more

information on allowed revenue codes and bill types. It’s important to bill all services on the

same date of service in a single claim when possible. If multiple claims for the same date of

service are submitted, the claim processing system counts each one separately against the

100 visit limitation.

See the General Billing Instructions, Idaho Medicaid Provider Handbook regarding billing, prior

authorization, and requirements for billing all other third party resources before submitting

claims to Medicaid. See the Participant Financial Responsibility section of the General

Information and Requirements for Providers, Idaho Medicaid Provider Handbook for

information on when billing a participant is allowable including co-payments.