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Provider Workshops
April 2013
Martinsburg Morgantown
Wheeling Flatwoods Huntington
Beckley Charleston
Workshop Agenda Welcome and Introductions
Medicaid
Automated Health Systems
Molina
APS
HMS
WV Health Information Network
Q & A
BMS/Molina 2013 Provider Workshops
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General Updates WV Bureau for Medical Services (BMS) aka WV Medicaid
> Website at ww.dhhr.wv.gov/bms
BMS Relationships
> Molina – Fiscal Agent (FA) – claims processing, provider enrollment
> APS – Utilization Management Contractor (UMC) – prior authorization,
case management
> HMS – Recovery Audit Contractor (RAC) & Third Party Liability
(TPL)
> Medicaid Managed Care Organizations (MCOs)
• The Health Plan of the Upper Ohio Valley
• Unicare of WV
• CoventryCares of WV (formerly Carelink)
> Automated Health Systems – Enrollment Broker
> Other WV DHHR agencies such as EPSDT, Family Planning, Children
with Special Health Care Needs
BMS/Molina 2013 Provider Workshops
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General Updates cont’d. BMS is working with APS to ensure the list of codes that require prior
authorization is consistent with information in Molina’s system
Changes for Tobacco Cessation CPT Codes 99406, 99407
> Effective February 1, 2013, Medicaid may reimburse physicians and/or
APRNs for tobacco cessation counseling to symptomatic members
> Counseling sessions must be face-to-face, are time sensitive and must be
documented in the member’s medical record.
> Sessions are limited to 2 per calendar year
Nerve Conduction Studies
> Effective May 1, 2013, nerve conduction studies require prior authorization
before services are provided
> Covered in place of service “11” (office setting)
Immunization Code 90474
> Open for each additional vaccine (single or combination vaccine/toxoid) by
intranasal or oral route
BMS/Molina 2013 Provider Workshops
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General Updates cont’d. Genetic Testing
> Coverage for BRCA1 and BRCA2 genes is limited to members who meet
the National Comprehensive Cancer Network (NCCN) criteria.
> Prior authorization is required and must be requested by an enrolled
OB/GYN, oncologist or medical geneticist.
> A list of laboratory codes requiring PA is available on the BMS and APS
websites.
2012 ADA Claim Form > Molina evaluating system to accommodate additional fields
> Providers must include the following items on the 2012 ADA Claim Form
for payment consideration:
• Place of Service
• Quantity or number of units
• Diagnosis codes and diagnosis-to-code pointers
• Multiple tooth surfaces
All Medicaid covered dental code descriptions have been updated in
Chapter 505 - Dental Services to match ADA code descriptions.
BMS/Molina 2013 Provider Workshops
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General Updates cont’d. 2013 CPT Coding Changes for Behavioral Health Providers
> Several codes deleted
> Significant change was deletion of 90862 – pharmacologic
management
> Evaluation and Management (E/M) codes must now be billed for
some of the services represented by deleted codes
> BMS provided training via webinar on 2013 coding changes for
behavioral health providers; slides on BMS website
> Additional information on national medical association websites • American Psychiatric Association
• American Academy of Child & Adolescent Psychiatry
Ambulatory Surgery Centers
> Effective June 1, 2013, billing form and fee schedule change • ASC services must be billed on CMS 1500 form
• ASC fee schedule based on 90% of Medicare ASC fee schedule
BMS/Molina 2013 Provider Workshops
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Enhanced Payments for Primary Care Providers Affordable Care Act (ACA) requires that Medicaid reimburse eligible
primary care providers at parity with Medicare rates in CYs 2013 and
2014 for certain E&M and vaccination codes (42 CFR 447.400(a)).
Eligible primary care providers include physicians and advanced practice
professionals (APPs) in certain specialties/subspecialties that meet
specific criteria.
> Includes Medicaid and MCO-contracted providers
Services provided in Federally Qualified Health Clinics (FQHCs), Rural
Health Clinics (RHCs), as well as clinics and Health Departments, to the
extent that they are reimbursed on an encounter or visit rate, are not
eligible for enhanced payments, nor are services provided in nursing
facilities that are reimbursed as part of the per diem rate.
Qualifying codes and their rates will be published on the BMS website.
BMS/Molina 2013 Provider Workshops
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Eligibility for Enhanced Payments for Primary Care
Eligible providers must meet criteria under #1 and #2 below
1. Self-attest to a specialty designation of Family Medicine, Internal
Medicine or Pediatrics, or a related-subspecialty as defined by
American Board of Medical Specialties (ABMS), American
Osteopathic Association (AOA), American Board of Physician
Specialists (ABPS)
2. Be board certified by ABMS, AOA or ABPS in specialty or related
subspecialty to which he/she attests
OR
Have billed E&M and vaccine administration services under the
specified codes that equal at least 60% of all codes billed to Medicaid
during most recent calendar year
Note: If provider has not yet participated in Medicaid for a full year, he/she must self-
attest that 60% of services billed in previous 30-day period were specified codes
BMS/Molina 2013 Provider Workshops
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Self-Attestation for Enhanced Payments Qualifying providers will receive retroactive payments dating back to
January 1, 2013 as long as the completed Self-Attestation Form is sent to
BMS no later than December 31, 2013.
Prior to receiving the enhanced rate, eligible physicians and advanced
practice registered nurses (APRNs) must complete a Self-Attestation
Form.
Physician Assistants (PAs) automatically qualify if their supervising
physician qualifies and self-attests.
A self-attestation form must be completed for 2013 and for 2014.
Self-attestation form, Provider Guide and Newsletter will be on BMS
website
BMS/Molina 2013 Provider Workshops
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Enhanced Payments for Primary Care Enhanced payments will be retroactively paid when CMS approves
WV’s state plan amendment (SPA)
Frequency of payments may vary between Medicaid and MCOs
> Per claim versus quarterly lump sum
May be lag between payments for services submitted on claims that pre-
date SPA approval versus those submitted after approval
Additional information on CMS website
> November 1, 2012, CMS Press Release titled “ Health Care Law Delivers
Higher Payments to Primary Care Physicians”
> CMS Fact Sheet titled “Increased Medicaid Payment for Primary Care”
> http://www.medicaid.gov/AffordableCareAct/Provisions/Provider-
Payments.html
BMS/Molina 2013 Provider Workshops
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General Policy Reminders
For Early Periodic Screening, Diagnosis and Treatment
(EPSDT) services, provider must
> Append -EP modifier to CPT/HCPCS code and
> Enable EPSDT protocol in APS PA system
Maternity Visits
> Procedure code 99213 with modifier -TH (obstetrical
treatment/services prenatal or postpartum) must be billed for each
individual prenatal or postpartum visit.
Mastectomy or Related Reconstructive Procedures
> Prior authorization is not required for individuals diagnosed with or
with history of breast cancer.
> The appropriate breast cancer diagnosis code must be documented on
the CMS 1500 claim form for payment consideration.
BMS/Molina 2013 Provider Workshops
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Updates to BMS Provider Manual BMS Provider Manual
> On BMS website at www.dhhr.wv.gov/bms, under “Providers” section
> Proposed changes posted on BMS website for 30-Day Public Comment
Period
Chapter 514 - Nursing Facility Services
> Updated and published on January 1, 2013
> Changes include:
• Fingerprint-based Criminal Background Checks
• All-inclusive rate services have been defined
• Ancillary services have been defined
• Clarification of cost-reporting used in creating the Medicaid nursing facility rate
• Clarification for dispersing Nurse Aide reimbursement
• Requirement to check National Practitioner Data Bank (NPDB) – HOWEVER
this requirement was recently removed from BMS policy
– Providers must review Federal rules to determine requirements for
reporting to/checking NPDB
BMS/Molina 2013 Provider Workshops
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Updates to BMS Provider Manual cont’d.
Chapter 517 - Personal Care > Will be released for 30-day comment period within next few months
> Proposed changes include:
• Fingerprint-based Criminal Background Checks
• Prior authorization of all hours
– 60 hours/240 units
» Submit Pre-Admissions Screening (PAS) tool and a
physician certification form to APS HealthCare for
approval.
– Prior authorization for 61 hours/244 units to 210 hours/840
units will remain the same
– Authorizations will be a maximum of 12 months.
– Will be phased in for members who are receiving Personal
Care services prior to implementation date
BMS/Molina 2013 Provider Workshops
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Updates to BMS Provider Manual cont’d.
Chapter 519 - Physician and Non-Physician Practitioners
> Under revision and will be released for 30-day comment period in
next few months
> Proposed changes:
• Consolidation of Chapter 504 - Chiropractic Services &
Chapter 520 – Podiatry Services into Chapter 519
– When final version of Chapter 519 is published, these 2 chapters will no
longer exist
• Services subject to nationally-accepted, evidence-based medical
necessity criteria
• Hysterectomy Acknowledgement Form revised
– Includes information from Physician Certification for
Hysterectomy form
– Grace period of 6 months will be granted to allow use of
both new and old forms during the transition period
BMS/Molina 2013 Provider Workshops
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Updates to BMS Provider Manual cont’d.
Chapter 519 – Physician and Non-Physician Practitioner
cont’d.
> Immunizations may be administered via standing orders in local
health departments.
> Drug Screening
• Considered for reimbursement when screening results will alter
patient management decision, deemed medically necessary, and
reasonable within commonly accepted standards of practice.
• Screenings for specific drug(s) must be ordered by treating
practitioner.
• Service limit is 24 screens per calendar year. Prior Authorization
is required for more than 24 screens.
BMS/Molina 2013 Provider Workshops
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Updates to BMS Provider Manual cont’d.
Chapter 519 – Physician and Non-Physician Practitioner
cont’d.
> Pain Management
• Paravertebral Joint/Nerve Block, Paravertebral Joint/Nerve Denervation
and Trigger Point injections require prior authorization before services
are rendered.
– Covered services may be provided in the office, outpatient hospital,
ambulatory surgical center or pain management clinic.
– Enrolled anesthesiologists, neurologists and physicians with board
certification in pain management may provide services.
> Anesthesiologist Assistants (AA)
• Upon completion of accredited AA program and certified by the
National Commission for Certification of Anesthesiologist Assistants
will be eligible for enrollment.
• Must work under the direction of a licensed anesthesiologist.
BMS/Molina 2013 Provider Workshops
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Updates to BMS Provider Manual cont’d.
Chapter 531 - Psychiatric Residential Treatment Facility
(PRTF)
> New Chapter (formerly part of Chapter 510 – Hospital Services)
> Effective May 1, 2013
> Staffing composition and staff ratios
• 1:3 Day Services
• 1:6 Overnight Services
> Detailed explanation of Incident/Accident Reporting and Policy
Requirements
> Fingerprint-based Criminal Background Checks
> Out of State Certification/Review Process
BMS/Molina 2013 Provider Workshops
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WV Medicaid Program - Take Me Home, WV WV’s Money Follows the Person (MFP) Initiative
Program to move eligible participants from long-term care
setting to home or community-based setting
BMS contracted with Metro AAA and their partners to
provide MFP Transition Navigator services
Take Me Home, WV began accepting referrals on
February 1, 2013
Over 50 individuals determined eligible to participate
Several individuals in process for movement to
home/community-based setting
For more information, call Take Me Home, WV’s office
staff at (304) 356-4926
BMS/Molina 2013 Provider Workshops
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WV Medicaid Program - Health Homes Health Homes for members with Chronic Condition
> Program is intended to improve the health of Medicaid members who may
need a variety of services to address primary and acute care, behavioral
health care, and long-term care services.
> BMS has been working with stakeholders across the state
> To be eligible, Medicaid member must have Bipolar Disorder and be at risk
for, or have, Hepatitis B or C.
> Designated primary care physician or advanced practice nurse providers
working with multidisciplinary teams in a variety of possible settings
> Beginning in 6 counties: Cabell, Kanawha, Mercer, Putnam, Raleigh, Wayne
Six defined health home services
> Comprehensive Care Management
> Care Coordination
> Health Promotion
> Comprehensive Transitional Care
> Individual and Family Support Services
> Referral to Community and Social Support Services
BMS/Molina 2013 Provider Workshops
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Background Check Project for Long Term Care Providers
Provision under Affordable Care Act for National Background Check
Program
Grant-funded project
Centralized process for fitness determination of potential employee
> Registry Database Check
> State Criminal History Check
> Federal Criminal History Check
WV is one of 22 State Medicaid Agencies participating at this time
BMS and its partners, WV State Police and WV Office of Inspector
General, working with CMS’ Technical Assistance Vendor on system
development
BMS/Molina 2013 Provider Workshops
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Provider Enrollment and Screening Provider enrollment and screening requirements mandated by ACA
> CMS continues to provide guidance to states
• Guidance remains pending on Criminal Background Check and Fingerprinting
> Enrollment and screening requirements apply to providers, owners,
managing employees, subcontractors
> Database checks
• OIG’s List of Excluded Individuals & Entities (LEIE)
• Excluded Parties List System (EPLS); effective November 2012, exclusion list
now part of the Federal System for Award Management (SAM)
https://www.sam.gov/portal/public/SAM/
• SSA Death Match File (SSA DMF)
• State Medicaid Exclusion Lists
• State Licensing Boards
> Providers must check databases for employees
> Site visits for certain providers as part of enrollment screening
BMS/Molina 2013 Provider Workshops
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Provider Re-Enrollment/Revalidation Update
All WV Medicaid providers must be re-enrolled by end of 2015
Moving to web-based provider enrollment application program (PEAP)
Re-enrollment to begin summer 2013
> Phased-in approach by provider type/risk level
> First phase will be physicians (aka direct provider in Molina’s system)
Phase schedule will be placed on the web portal and banner pages
Providers will receive re-enrollment letter with case number (PEAP access
code) no less than 15 days prior to re-enrollment start date
Provider has total of 60 days from start date to re-enroll
30 days after re-enrollment start date, providers will receive reminder letter
that re-enrollment must be completed within the next 30 days
45 days after re-enrollment start date, providers will receive reminder that if
re-enrollment is not completed within next 15 days BMS may place provider
on pay hold
BMS/Molina 2013 Provider Workshops
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National Correct Coding Initiative (NCCI)
Mandated by the Affordable Care Act of 2010 to incorporate NCCI into
Medicaid claims processing
> Procedure to Procedure (PTP) Edits
> Medically Unlikely Edits
WV Medicaid implemented NCCI edits in summer 2012
Quarterly updates > Approximately 300,000 new edits coming in July 2013 re: same day surgery
Applies to CMS 1500 and outpatient hospital claims
Appeals > Appeals for PTP edits must be directed to CMS
> CMS permits BMS to review appeals for MUEs
> MUE Appeals should be sent to Molina
For more information on Medicaid NCCI, go to
http://www.medicaid.gov/Medicaid-CHIP-Program-Information/By-Topics/Data-
and-Systems/National-Correct-Coding-Initiative.html
BMS/Molina 2013 Provider Workshops
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ICD-10
Providers and Payers must be compliant by October 1, 2014!
Centers for Medicare and Medicaid Services, if non-compliant then:
> Claims may not be paid
> Face possible sanctions and/or penalties from Federal Office of E-Health
Standards and Services (OESS) for non-compliance with HIPAA
BMS workgroup currently assessing system, mapping logic, policy, etc.
CMS has ICD10 website
> Guides for providers and payers recently released
> http://www.cms.gov/Medicare/Coding/ICD10/
Check BMS website and newsletters in future for additional information
BMS/Molina 2013 Provider Workshops
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WV Payment Error Rate Measurement (PERM) 2013
PERM was created and authorized to comply with
> Improper Payments Information Act (IPIA) of 2002 and
> Office of Management and Budget (OMB) guidance
CMS conducts PERM reviews of each State Medicaid Agency every
three (3) years
Last review of WV Medicaid was in 2010
Additional information on PERM 2013 on CMS website at:
http://www.cms.gov/Research-Statistics-Data-and-Systems/Monitoring-
Programs/PERM/index.html
BMS/Molina 2013 Provider Workshops
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WV PERM 2013 cont’d. Two (2) CMS contractors working with WV Medicaid:
> Statistical Contractor (The Lewin Group)
• Gathers all paid claims data for FFY 2013
• Chooses sample of claims to be reviewed
> Review Contractor (A+ Government Solutions)
• Requests and gathers documentation from WV Medicaid providers
• Review documentation for adherence to federal and state policies and
regulations
The Lewin Group currently working with BMS to create
sample of paid claims from the entire universe of paid claims
for FFY 2013.
Once claims sample selected, A+ Government Solutions will
begin sending record requests to providers
BMS/Molina 2013 Provider Workshops
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WV PERM 2013 cont’d.
Review Steps:
> Contractor analyzes documentation and determines appropriateness of paid claims in accordance with applicable policies.
• Additional documentation may be requested from provider
> If payment is not justified BMS is notified of the error.
> If BMS disagrees with findings of Review Contractor, BMS prepares a defense of the billing.
• BMS may request additional documentation from provider at this time
> Once defense is submitted by BMS, Review Contractor will re-review the claim and make a final decision.
> If payment error is upheld by CMS, BMS will inform provider in writing and require reimbursement for billing(s) found in error.
> Providers retain all rights of appeal as stated in BMS Provider Manual.
BMS/Molina 2013 Provider Workshops
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WV PERM 2013 cont’d. In 2010, most claims found in error were due to providers not responding
to documentation requests, or not producing additional documentation
requested by the Review Contractor.
BMS will be working closely with providers in 2013 to ensure that all
document requests are provided to the Review Contractor within required
timeframes.
The documentation request letter in 2013 will contain BMS contact
information in order for providers to have an additional contact person if
they are having difficulty in obtaining requested documentation.
WV Medicaid PERM Contact:
Scott Winterfeld, Office of Quality and Program Integrity
Telephone: 304-558-1700 or email: [email protected]
BMS/Molina 2013 Provider Workshops
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Strengthening and Enhancing West Virginia’s
Medicaid Program:
Overview of the 2013
Managed Care Organization (MCO) Program
Pharmacy Expansion
BMS/Molina 2013 Provider Workshops
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Overview of the Current MCO Program Expansion Overview
Low-income pregnant women, children, and healthy adults in all of West Virginia’s 55 counties are eligible to enroll in the MCO program
Beneficiaries can choose among two or three MCOs in almost every county
The three participating MCOs have demonstrated an ongoing commitment to improving access and quality of care for Medicaid beneficiaries and have developed a strong partnership with the State
MCO Number of Counties
Served
CoventryCares of West Virginia 52
The Health Plan of the Upper Ohio
Valley (THP) 30
UniCare Health Plan of West Virginia
(UniCare) 53
*As of February 2013. In April, CoventryCares will expand to all 55 counties and THP will
expand to six additional counties.
BMS/Molina 2013 Provider Workshops
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Services Covered by the MCO Program Expansion Overview
Services Covered by the MCO Program
• Ambulatory surgical center services
• Children with Special Health Care Needs services
• Clinic services
• Cardiac rehabilitation (children < 21)
• Diabetes education (children < 21)
• Durable medical equipment
• Emergency dental services (adults)
• Early and Periodic Screening, Diagnostic and Treatment
Services (EPSDT)
• Family planning services and supplies
• Hearing services and supplies (children < 21)
• Home health care services
• Hospice
• Hospital services, inpatient
• Hospital services, outpatient
• Laboratory and x-ray services
• Nurse practitioner services
• Speech therapy
• Physical therapy
• Occupational therapy
• Physician services
• Prosthetic devices
• Pulmonary rehabilitation (children < 21)
• Rural health clinic services (including federally qualified
health centers)
• Tobacco cessation programs (children < 21)
• Transportation, emergency services
• Vision services
Services Covered by the Fee-for-Service Program
• Long-term care services
• Non-emergency transportation
• Behavioral health services
• Children’s dental services
• Pharmacy
To date, beneficiaries have been receiving a majority of services through their MCOs:
BMS/Molina 2013 Provider Workshops
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Expansion Overview
Expansion Overview
Medicaid beneficiaries currently enrolled in the MCO program will
begin receiving pharmacy services through their current MCOs as of
April 1, 2013.
Beneficiaries will continue to access the following services through
the fee-for-service Medicaid program:
Non-emergency transportation
Long-term care
Behavioral health
Children’s dental
BMS/Molina 2013 Provider Workshops
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Pharmacy Transition Period
MCO Program Post-Implementation
MCOs networks have 520 of the same pharmacies that were currently in the fee-
for-service network as of December 2012
MCOs will be allowed to continue the pharmacy lock-in program Medicaid
currently uses or develop their own criteria
Mail order pharmacies will not be allowed in the MCO networks
During the 90-day transition period, the MCOs will be required to:
Provide any previously approved prescriptions
Allow members to use out-of-network pharmacies
Assist members with transitioning to a network pharmacy
BMS/Molina 2013 Provider Workshops
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Pharmacy Services
MCO Program Post-Implementation
Almost all prescriptions, including behavioral health prescriptions, will be
included in the MCO benefit package beginning April 1, 2013
Prescriptions will be covered through the member’s MCO regardless of
whether the prescribing provider is included in the MCO’s network
Hemophilia medications will continue to be covered through fee-for-service
BMS/Molina 2013 Provider Workshops
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Impact on Prescribing Providers
MCO Program Post-Implementation MCOs will follow all criteria on the State’s Preferred Drug List (PDL)
Information on the PDL can be accessed at: http://www.dhhr.wv.gov/bms/Pharmacy/Pages/pdl.aspx
Prescribing providers will need to follow the prior authorization and utilization management guidelines of each MCO for drugs not on the PDL
The MCO’s criteria for drugs on the PDL will be the same as the criteria used by BMS for FFS, but the MCO will be responsible for approving any requests. MCO call centers will be available on April 1st to assist prescribing providers with MCO prior authorization requests and procedures
CoventryCares:
Phone: 1-877-215-4100
Fax: 1-877-554-9137
THP:
Phone: 1-800-624-6961 ext. 7914
Fax: 1-888-329-8471
UniCare:
Phone: 1-877-375-6185
Fax: 1-800-601-4829
BMS/Molina 2013 Provider Workshops
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Impact on Pharmacies
MCO Program Post-Implementation
Each of the MCOs will use the same Prescription Benefits Manager – Express
Scripts, Inc. (ESI)
Beginning on April 1st, pharmacies may call ESI’s Eligibility Verification Line at 1-866-641-1112 if they do not know which MCO the member is enrolled in
The central number will route providers based on the member’s plan
Each MCO has slightly different procedures for electronic processing of claims.
Please contact the MCOs for additional details
Pharmacies will be required to provide emergency 3-day prescription fills in
accordance with Federal regulation
No copays will be required for any services
BMS/Molina 2013 Provider Workshops
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CoventryCares Contact Information
MCO Program Post-Implementation
Pharmacy Providers (ESI Help Desk): 1-800-922-1557
Prescribing Providers: 1-877-215-4100
Hours: Calls are answered 24 hours a day, 7 days a week
Additional Information Available at:
www.express-scripts.com/services/pharmacists/
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THP Contact Information
MCO Program Post-Implementation
Pharmacy Providers (ESI Help Desk): 1-800-922-1557
Prescribing Providers: 1-800-624-6961 ext. 7914
Hours: Calls are answered 24 hours a day, 7 days a week
Additional Information Available at:
www.medco.com/rph
BMS/Molina 2013 Provider Workshops
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UniCare Contact Information
MCO Program Post-Implementation
Pharmacy Providers (ESI Help Desk): 1-877-337-1102
Prescribing Providers: 1-877-375-6185
Email: [email protected]
Hours: Calls are answered 24 hours a day, 7 days a week
Additional Information Available at:
www.express-scripts.com/services/pharmacists/
BMS/Molina 2013 Provider Workshops
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Provider Outreach and Education Provider Outreach
Contact Automated Health via the specialists listed below or at 304-345-
0436 or 1-800-449-8466
Region I – John Buzzard
304-552-1426
Region II – Debbie Hon
304-549-9420
Region III – Marjorie Burdick
304-395-0567
Region IV – Michelle Zierer
304-395-0566
BMS/Molina 2013 Provider Workshops
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We appreciate your help and support in ensuring that West Virginia Medicaid beneficiaries have access to
quality health services!
If you have any additional questions on the planned MCO program expansion, you may contact Brandy Pierce at 304-558-1700 or email [email protected]
If you would like to schedule an on-site outreach and education training provided by the State’s enrollment broker, Automated Health Systems, please call 304-345-0436 or 1-800-449-8466.
All pharmacy outreach materials, including this presentation, can be accessed at http://www.dhhr.wv.gov/bms/mco/
Questions?
BMS/Molina 2013 Provider Workshops
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Provider Notifications
Hospice Related Services
Beginning 2/1/2013 denial reasons became more specific for hospice claims related to the terminal illness.
• Claims denied because the service provided is related to the terminal illness of a member enrolled in the Hospice program, will now reflect:
HIPPA compliant Claim Adjustment Reason Code 97 – “The benefit for this service is included in the payment / allowance for another service / procedure that has already been adjucated.”
Transportation Providers
The billing practice of utilizing line 19 for ‘Local Business Use’ on a CMS 1500 Claim form for the transport reason is acceptable for the billing of Medicaid claims.
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Paper Billing Tips
Paper Third-Party Liability (Secondary) Claims
Each claim must have an EOB attached Alternative to paper, Direct Data Entry
(DDE) with Trading Partner Account at: www.wvmmis.com.
Paper Claims Requiring Documentation
Supporting documentation must be printed clearly.
Paper Claims – Most Common Rejected Returns
All claim fields required are complete;
Members Medicaid ID
NPI and taxonomy
Diagnosis codes
Legibility
Alignment of information within claim form fields
BMS/Molina 2013 Provider Workshops
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Electronic Billing Issue Causing Rejected Claim – Return to Provider Letters
Referred to as ‘One to many (OTM)’ provider records
This means one NPI to multiple Medicaid provider ID numbers.
To help ensure that WV Medicaid providers do not experience denials of claims or delays in claims processing and payment, BMS/Molina encourages each of its enrolled health care providers to obtain a unique NPI.
Sub-Part Enumeration
An organization is a subpart, when the lines of business is multi-disciplinary. This is a provider who is enrolled under more than one (1) provider type. An example would be a community mental health center which is owned by the same entity as a behavioral rehabilitation provider.
Separate NPI number can be obtained by NPPES through sub-part enumeration.
https://nppes.cms.hhs.gov/NPPES/NPIRegistryHome.do.
Benefits Eliminates the use of taxonomy.
Reduces delay of claims processing.
Facilitates electronic enrollment.
Electronic Billing Tips
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NEW Molina Medicaid Solutions Web Site & EDI Portal Coming in 2013
BMS/Molina 2013 Provider Workshops
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New Molina Medicaid Solutions Web Site & EDI Portal Molina Medicaid Solutions is pleased to announce the implementation a new web site & EDI Web Portal that will provide significant enhancements and functionality in 2013.
Improved Functionality – Real Time Capabilities
Fully automated Trading Partner registration and administration.
WVMMIS trading partner accounts support multiple users in compliance with HIPAA security regulations.
Multiple billing providers can be linked to one account.
Real-time claims Direct Data Entry (DDE) will include the following:
Edit & correct on non-finalized claims Real-time adjudication of claims Real-time claim adjustments, reversal and reversal/replacement of claims Upload of Electronic claim attachments and documentation
Real time Direct Data Entry of: Claims Submission Eligibility Verification Claim Status Referral Status Prior Authorization Status Payment Status
Improved Patient/Member Roster Set-up and Editing
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Molina’s Web Site - www.wvmmis.com
Advantages of Having a Web Portal Account Eliminate paper claim forms Saves time and money Updates and Important Billing Information Newsletters & Bulletins Forms Contact information User Guides & Training Documentation
Electronic Data Interchange (EDI) Transactions – (Free of Charge) Access to submit all claims through DDE (Direct Data Entry), or batch upload 837 transaction. Receipt of Electronic Remit in an 835 transaction with ability to auto-post payments in provider systems
(dependent on provider’s system capabilities) Receipt of Electronic version of Paper Remittance Advices Access to submit & receive Member Eligibility Requests through DDE, batch upload 270/271 transactions –
5 megabyte file NEW – You can now upload claim status inquiries and receive a response the same day, 276/77
transactions – 5 megabyte file Access to Provider’s Medicaid Training Center currently in development
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Registering For Current Web Portal Account
1. Complete Trading Partner Agreement (TPA) with EDI Transaction form
2. TPA & EDI Transaction form is located on the Molina website, www.wvmmis.com.
3. HealthPAS Online Registration
After receipt of completed TPA forms, Molina’s EDI Helpdesk staff will contact you by email with a link to set up username and password through the HealthPAS Online Registration.
For assistance with registering, contact the EDI Helpdesk at 1-888-483-0793 option 6.
After Molina implements the NEW Website & EDI Portal in 2013 Providers will have the capability of registering themselves for a portal account.
BMS/Molina 2013 Provider Workshops
48
Web Portal Training & Provider Field Representatives
Beth Roach
304-348-3291
Carrie Blankenship
304-348-3292
BMS/Molina 2013 Provider Workshops
49