This revised Provider Manual was prepared for the Idaho Department of Health and Welfare by Qualis Health in February 2006 and will be updated periodically.
Updated Idaho Medicaid Provider Manual — Effective July 1, 2008
The purpose of this manual is to provide information to providers regarding the Medicaid Review Programs for Idaho Medicaid clients. The following is a list of the chapters:
- Section I: Purpose of the Qualis Health Care Management Program
- Section II: Communicating with Qualis Health
- Section III: URAC Time Frames
- Section IV: Health Insurance Portability and Accountability Act (HIPAA)
- Section V: Provider Billing Concerns
- Section VI: Categories of Eligibility
- Section VII: Web-Based Utilization Review (iEXCHANGE)
- Section VIII: Pre–service Review
- Section IX: Concurrent Review
- Section X: Late Certification Reviews
- Section XI: Psychiatric and Chemical Dependency Review
- Section XII: Physical Rehabilitation Review
- Section XIII: Out of State (Non–Bordering County) Review
- Section XIV: Quality of Care Reviews
- Section XV: Retrospective Review — Retroactive Eligibility
- Section XVI: Retrospective Review (“Late” Review)
- Section XVII: Focused Case Reviews
- Section XVIII: Procedure for Weekends and Holidays
- Section XIX: Leave of Absence
- Section XX: Administratively Necessary Days (“AND's”)
- Section XXI: Appeal Procedure
- Section XXII: Case Management
- Appendix A: Select Pre–Authorization List of Diagnoses and Procedures
- Appendix B: Glossary
- Appendix C: Key Contact Personnel
- Appendix D: Provider Bulletins/Informational Release
- Appendix E: Exhibits
