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Spring 2019 Provider Workshops
April 1 – MartinsburgApril 2 – WheelingApril 3 – MorgantownApril 4 – ViennaApril 8 – StonewallApril 9 – CharlestonApril 10 – BeckleyApril 11 – Huntington
Sarah Young, Deputy CommissionerCynthia Shelton, Director of Operations & Provider Services
Diana Bossie, Senior Provider Enrollment Specialist
West Virginia Medicaid Enrollment Update
As of March 2019, 510,700 West Virginians received coverage -approximately 29% of West Virginia’s population.
Fee-For-Service (FFS), i.e., traditional/regular Medicaid:o 120,146 members are currently enrolled
Includes children in foster care, Medicaid Waiver recipients, nursing facility residents, elderly/disabled, and those who receive Medicare
Mountain Health Trust (MHT), West Virginia’s Medicaid Managed Care Program:o 390,554 members are currently enrolled
Includes eligible children, pregnant women, adult expansion, parents and caretaker relatives, and Supplemental Security Income (SSI) recipients
1
Managed Care Update
What benefits are NOT included in the Managed Care Organizations’ (MCOs) Plans? Transplants Nursing Facility Services Medicaid Waiver Serviceso Aged and Disabled Waiver (ADW)o Intellectual and Developmental Disabilities Waiver (IDDW)o Traumatic Brain Injury Waiver (TBIW)
Non-Emergency Medical Transportation (NEMT)* Personal Care Services Pharmacy Substance Use Disorder (SUD) Waiver Services o Beginning July 1, 2019, certain SUD Waiver services will be provided by
the MCOs
For these services, providers will continue to send claims to DXC for all members (FFS and Managed Care).
*NEMT services are managed and paid for by the broker, LogistiCare.
2
Managed Care Update: Contacts
Managed Care Organization (MCO) Contact Information: Aetna Better Health of West Virginia (formerly CoventryCares)
Sarah White, Manager of Provider Relations, phone: 304-348-2089, email: [email protected] Carpenter, Chief Operating Officer, phone: 304-348-2017,email: [email protected]
The Health PlanChristy Donohue, Assistant Vice President of Medicaid, phone: 304-720-4923, email: [email protected]
UniCare Health Plan of West VirginiaTerri Roush, Director, Network Relations, phone: 304-989-5471,email: [email protected]
West Virginia Family HealthJean Kranz, Director, Medicaid Operations, phone: 304-347-7682,email: [email protected]
3
Non-Emergency Medical Transportation (NEMT)
Effective September 1, 2018:
All NEMT services for West Virginia Medicaid members are coordinated by LogistiCare.
Toll-Free Reservation: 844-549-8353Toll-Free Ride Assistance: 844-889-1939
Toll-Free Hearing Impaired (TTY): 866-288-3133Hours: 7 a.m. to 6 p.m., Monday through Friday
www.logisticarewv.net
4
Coordinated Care Management (CCM) Update
5
Beginning January 1, 2020, CCM will transition Medicaid, Residential, and Socially Necessary Services for children in foster care and post-adoptive children from FFS to statewide managed care services and create a care management portfolio for vulnerable youth populations.
DHHR’s goals for CCM: Enhance coordination of care and access to services Improve health outcomes for youth and families Develop and utilize information technology (IT) supports to
improve data sharing Help reduce number of children removed from the home
CCM Update (cont.)
6
A single MCO will be selected to oversee and coordinate health and social services.
MCO Requirements: Contract with currently enrolled Medicaid FFS providers and all
providers contracted with DHHR’s Bureau for Children and Families (BCF) for socially necessary services
Provide initial and ongoing training for advocates, providers, and other stakeholders
Serious Emotional Disturbance (SED) Waiver
DHHR’s Bureau for Medical Services (BMS) has sponsored an initiative to develop a waiver under the Home and Community-Based Services (HCBS) program authorized under§1915(c) of the Social Security Act for Children with Serious Emotional Disturbance (SED).
SED is defined as a condition exhibiting the following characteristics over a period of time and to a degree that adversely affects a child’s performance causing:
o An inability to learn that cannot be explained by intellectual, sensory, or health factors
o An inability to build or maintain satisfactory interpersonal relationships with peers, caregivers, and teachers
o Inappropriate types of behavior or feelings under normal circumstances
o A general pervasive mood of unhappiness or depression
o A tendency to develop physical symptoms or fears associated with personal or school problems
7
Medicaid 1115 Waiver: SUD Services
West Virginia Medicaid implemented a Section 1115 waiver to address the substance use disorder (SUD) epidemic. Medicaid benefit expansions under the waiver:
Statewide adoption of the screening, brief intervention, and referral to treatment (SBIRT)
Comprehensive Naloxone initiative and referral to treatment by EMS Coverage of methadone and methadone administration Expanded coverage of withdrawal management Coverage includes clinical and peer recovery support services and
recovery housing supports Short-term, residential substance abuse treatment Enhanced access to outpatient treatment, as appropriate, when
residential treatment is not required
These services are currently provided via FFS. Beginning July 1 2019, certain services will be transitioned to the MCOs.
8
Provider Enrollment Update: Prescriber Edit
In 2018, West Virginia Medicaid implemented a phased-in approach for remaining unenrolled prescribers to mirror Medicare’s approach. All impacted members and unenrolled prescribers were notified in advance of the change.
July 18, 2018: West Virginia Medicaid began denying prescriptions for opioid pain medications written by unenrolled prescribers.
October 17, 2018: West Virginia Medicaid began denying all prescriptions not written by an enrolled provider.
Any prescription (new or refill) written by a provider who is not enrolled with West Virginia Medicaid will be denied.
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Provider Enrollment Update: RevalidationProvider Revalidation is required at least every five years for Medicaid providers under 2011 federal regulations for Provider Screening and Enrollment.
Revalidation started in the Fall of 2018
Who has to revalidate?
o All providers (FFS and MCO providers) will need to revalidate.
When will you need to revalidate?
o Revalidation is based on your enrollment effective date.
What if I’m already enrolled within Medicare?
o Good news: If you are enrolled with Medicare and have already revalidated
with Medicare, CMS has given us the approval to use that revalidation as
our own.
Medicare data and enrollment?10
Electronic Funds Transfer (EFT) Initiative Initiative to reduce the number of paper checks due to cost and administrative burden:
Providers will be placed on PAYHOLD if a bad EFT is returned until a corrected EFT is submitted.
If you currently receive a paper check, please submit your EFT information immediately. Medicaid will stop sending paper checks in the future.
Reminder:
New EFT forms are available on the State Auditor’s Website (https://www.wvsao.gov/) to be completed with new provider enrollment and maintenance.
11
340B Physician Administered Drugs
340B Drugs billed with HCPCS codes:
Must be identified with the modifier UD to ensure the drug claim will not be submitted to the manufacturer for rebate; and
Must be billed at the Actual Acquisition Cost (AAC)
This includes:
Drugs used in out-patient surgery and infusion centers (sometimes referred to as mixed use drugs)
Drugs administered in physician office settings
12
Policy Update
December 2018: Chapter 508 - Home Health Services Chapter 700 - West Virginia Clearance for Access: Registry &
Employment Screening (WV CARES)
January 2019: Chapter 512 - Traumatic Brain Injury Waiver (TBIW) Chapter 501 - Aged and Disabled Waiver (ADW)
February 2019: Chapter 503, Appendix F - Children’s Residential Services
Upcoming Changes: Chapter 528.4 - Mammography Services Chapter 528.5 - Portable X-Ray Services Chapter 524 - Transportation Chapter 538 - School-Based Health Services Chapter 509 - Hospice Services Chapter 532 - Private Duty Nursing Chapter 519.23 - Applied Behavior Analysis (ABA) Chapter 400 - Member Eligibility 13
Policy Update (cont.)
14
https://dhhr.wv.gov/bms/Pages/Manuals.aspx
BMS Fee Schedule Updates
Implementation timeframe for the following fee schedules has been changed from January 1, 2019 to April 1, 2019:
Physician’s Fee Schedule (RBRVS)
Clinical Lab Fee Schedule
Durable Medical Equipment (DME)
Home Health Agencies
Ambulatory Surgery Centers
Ambulance
New codes released December 2018 for the upcoming year were opened effective January 1, 2019, and paid using RVUs from CMS with the prior year’s conversion factor through March 31, 2019.
Acute Care Hospital DRGs will now be updated annually on October 1.15
Presumptive Eligibility (PE)
Since August 2015, certain West Virginia Medicaid enrolled providers have the
opportunity to determine presumptive eligibility:
Hospitals
Federally Qualified Health Centers and Rural Health Clinics
Comprehensive community behavioral health centers
Free clinics
Interested entities must:
Be a West Virginia Medicaid enrolled provider
Submit a presumptive eligibility enrollment package to BMS
Complete an online training course
More information is available at: https://dhhr.wv.gov/bms/Provider/HBPE/Pages/default.aspx
Coming in Fall 2019: Enrolled PE providers will be notified of changes to the PE portal and their log in requirements as part of the IES updates. 16
Payment Error Rate Measurement (PERM)
PERM Record Requests:
CMS conducts a medical record review of FFS payments to determine the appropriateness of the payment.
Not every provider will be contacted to provide medical documentation, only those that provided services for the random sample of FFS claims selected. The random sample is pulled from all West Virginia Medicaid and West Virginia Children’s Health Insurance Program (WVCHIP) FFS payments made in a fiscal year.
Medical records are requested from the provider by the PERM Review Contractor for all FFS claims in the sample.
If there are issues with provider records, claims payment may be affected.
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PERM (cont.)
Request for records:
Letter from Advance Med
Timely responses
Staff education
Audit findings:
Clerical errors
o Date of service
o Member number
o Service or diagnosis code
Documentation not thorough or documented timely
o Service units
o Coding and billing
o Completeness and accuracy
PERM Audit Resource: https://www.cms.gov/Research-Statistics-Data-and-Systems/Monitoring-Programs/Medicaid-and-CHIP-Compliance/PERM/Providers.html 18
BMS Resources
WV Department of Health and Human Resources (DHHR), BMS (WV Medicaid)Mailing address: 350 Capitol Street, Room 251, Charleston, WV 25301Telephone: 304-558-1700 Website: http://www.dhhr.wv.gov/bms
Medicaid Fee-for-Service (FFS)DXC (formerly Molina) – Fiscal Agent: https://www.wvmmis.com/default.aspxKEPRO (formerly APS Healthcare) – UM Contractor: http://wvaso.kepro.comHMS – TPL Contractor: http://www.wvrecovery.com
Medicaid Managed Care (Mountain Health Trust)Maximus – Enrollment Broker: https://www.mountainhealthtrust.comMCOs – Aetna Better Health of WV, The Health Plan, UniCare, and WV Family Health Skygen (formerly Scion Dental) – MCO Dental Benefits Manager: www.sciondental.com
FFS and Managed CareLogistiCare – NEMT Broker: www.logisticarewv.netPhone: 844-549-8353 TTY: 866-288-3133
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Contacts
Sarah Young, Deputy CommissionerCynthia Shelton, Director of Operations and Provider Services
Diana Bossie, Senior Provider Enrollment Specialist
West Virginia Department of Health and Human ResourcesBureau for Medical Services
350 Capitol Street, Room 251Charleston, West Virginia 25301
304-558-1700
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Office of Management Information Services (MIS)
Updates
Brandon LewisDirector of Health Information Technology
WV Integrated Eligibility Solution (IES)
The WV IES will support the eligibility, enrollment, and administration of the West Virginia Department of Health and Human Resources (DHHR) human services programs including West Virginia Medicaid and the West Virginia Children’s Health Insurance Program (WVCHIP).
What this means to providers:
DHHR has implemented a phased approach for the IES with user experience via the public portal (currently inROADS) being the first release. Community Partners and Presumptive Eligibility providers will see a new portal and receive new log-in information prior to the release.
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Electronic Visit Verification (EVV) System
Section 12006 of the 21st Century Cures Act requires states to implement an EVV system for: Personal Care Services (PCS), which are defined as any
hands-on direct care services, such as those provided in the following programs: • Aged and Disabled Waiver (ADW)• Intellectual/Developmental Disabilities Waiver (IDDW)• Traumatic Brain Injury Waiver (TBIW)• State Plan Personal Care Program
Home Health Care Services
EVV applies to services rendered in the home and in the community under Activities of Daily Living (ADL) and Instrumental Activities of Daily Living (IADL).
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EVV Key UpdatesDeadline:
H.R. 6042 extends the PCS deadline to January 1, 2020.
Request for Proposal process:
DHHR has started the request for proposal process (RFP) to select a solution and vendor based on the open/hybrid model
Release date for the RFP has not been finalized
Stakeholder Engagement:
The next EVV stakeholder engagement session is planned for Wednesday, May 29, 2019 at the Bureau of Senior Services’ office in Charleston, WV
For more information, see the EVV website: https://dhhr.wv.gov/bms/Programs/WaiverPrograms/EVV/Pages/default.aspx
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Data Exchange with Provider Boards
The Medicaid Management Information System (MMIS) is the primary solution for paying West Virginia Medicaid claims, as well as, other Medicaid services.
A key service is enrollment and revalidation of more than 36,000 providers.
Licensure verification is a requirement.
The process to verify licensure data is manual and lengthy.
Currently, MIS and BMS are working together with DXC to automate the verification process with the various licensure boards, i.e. Medicine, Osteopathic Medicine, Nursing, and Pharmacy. (PA’s are included in both M.D. and D.O. data).
Successful data exchange with Board of Medicine has greatly streamlined the process for M.D., P.D., and P.A..
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Health Information Exchange (HIE)
The West Virginia Health Information Network (WVHIN) is West Virginia’s designated HIE transforming health care through the use of health information technology.
WVHIN offers services which enable the secure electronic exchange of patient health information among health care providers.
Getting this information to providers when and where it is needed offers numerous benefits to health care providers, health care systems, patients, and others.
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Contact
Brandon Lewis, Director of Health Information Technology West Virginia Department of Health and Human Resources
Office of Management Information Services One Davis Square
Charleston, WV 25301Phone: 304-558-2419
Email: [email protected]
27
West Virginia Children’s Health Insurance Program
(WVCHIP)
Crystal Fox Benefit and Eligibility Specialist
Provider WorkshopSpring 2019
Income Guidelines for WVCHIP
1
Family Size
WVCHIP Gold
WVCHIP Blue
WVCHIP Premium
Per Month Annual
Per Month Annual
Per Month Annual
2 $2,114 $25,365 $2,974 $35,681 $4,228 $50, 730
3 $2,667 $31,995 $3,751 $45,007 $5,333 $63,990
4 $3,219 $38,625 $4,528 $54,333 $6,438 $77,250
5 $3,772 $45,255 $5,305 $63,659 $7,543 $90,510
6 $4,324 $51,885 $6,083 $72,985 $8,648 $103,770
Coverage
30
Medical Services and Prescription Benefits
WVCHIP Gold WVCHIP Blue WVCHIP Premium
Generic Prescriptions No Copay No Copay No CopayListed Brand Prescriptions $5 $10 $15
Non-listed Brand Prescriptions
Full Retail Cost Full Retail Cost Full Retail Cost
Multisource Prescriptions No Copay $10 $15Medical Home Physician Visit
No Copay No Copay No Copay
Physician Visit (non-medical home)
$5 $15 $20
Preventive Services No Copay No Copay No CopayImmunizations No Copay No Copay No Copay
Inpatient Hospital Admissions
No Copay $25 $25
Outpatient Surgical Services
No Copay $25 $25
Emergency Department(is waived if admitted)
No Copay $35 $35
Vision Services No Copay No Copay No CopayDental Benefit No Copay No Copay $25 Copay for some
non-preventive services
2
PERM Audit
Payment Error Rate Measurement (PERM) measures improper payments in DHHR’s Medicaid Program and WVCHIP, and produces error rates for each program.
Of the errors cited previously, the following are considered provider errors:
No documentation (records not received): 15
Incorrect documents received or missing: 5
Incorrect date of service billed: 4
In the current PERM cycle, we are reviewing WVCHIP payments made July 1, 2018 – June 30, 2019.
Our goal for this review is zero errors!
3
CHIP Transition to Managed Care
WVCHIP plans on moving to Managed Care effective July 1, 2019.
Current members will receive their Welcome Packets from Maximus the week of May 13, 2019. The effective date of their enrollment will be July 1, 2019. New enrollees will remain Fee for Service until they are enrolled with their selected or assigned Managed Care Organization (MCO).
CHIP covered services are not expected to change. MCOs may place their own Prior Authorization requirements on covered services.
Providers will need to use the 11-digit Member ID for MCO billing. This may apply to Fee For Service billings to DXC Technology as well.
WVCHIP will continue to use PEIA fee schedules for medical and Medicaid fee schedules for dental.
4
Eligible Medical Home provider types are General Practice, Family Practice, Internal Medicine, and Pediatricians. Any Physician Assistant (PA) or Nurse Practitioner (NP) practicing under these specialties is considered a “back-up” Medical Home provider and will not be assessed a copay when the supervising physician is the named Medical Home provider.
Please note: the physician group/facility must also select to be a Medical Home provider along with the rendering provider.
To become a Medical Home provider, please contact DXC Technology’s Provider Enrollment Department at 1-888-483-0793.
Encourage your patients to enroll in the Medical Home program; WVCHIP will waive the copay for sick visits and increase your reimbursement by the copay amount!
WVCHIP members who have moved to Managed Care will not need to select a Medical Home; they will select a Primary Care Provider (PCP) that participates in their chosen MCO. 5
Medical Home
Provider Enrollment
The Affordable Care Act requires all providers to enroll or revalidate their enrollment information under new enrollment screening criteria. Enrollment and revalidation is mandatory for both Medicaid and WVCHIP providers. Enrollment in Medicaid does not fully enroll the provider in WVCHIP.
Revalidation for WVCHIP and Medicaid will occur at the same time.
Provisional enrollment has ended. If you are not fully enrolled, you will no longer be eligible to receive payment from WVCHIP.
Providers who are currently enrolled in WVCHIP, Medicaid, and MCOs will not need to re-enroll in WVCHIP with the MCO once the transition to Managed Care is complete.
To enroll in WVCHIP, contact DXC Technology at 1-888-483-0793 or 304-348-3360, or enroll online at www.wvmmis.com.
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Provider Enrollment (cont.)
WVCHIP does not enroll local health departments as rendering providers. We enroll the individual provider under their own specialty.
Example: Dr. Smith, Pediatrician, provides services at Mingo County Health Department. WVCHIP will enroll Dr. Smith, with a pay-to for Mingo County Health Department.
When enrolling, make sure documentation is provided for each specialty if there are multiple specialties. The contract assigned to the provider’s file will be determined by all of their specialties.
7
Out-of-State Providers
WVCHIP will waive the out-of-state Prior Authorization requirement if the provider agrees to accept WVCHIP in-state fees as payment in full with no balance billing to the member.
This agreement can be made during provider enrollment or any time thereafter by calling the provider enrollment department at DXC Technology at 1-888-483-0793.
To review the PEIA fee schedules WVCHIP uses for medical, visit www.peia.wv.gov.
To view the Medicaid fee schedules WVCHIP uses for dental, visit http://www.dhhr.wv.gov/bms/FEES/Pages/default.aspx.
8
Dental Services The 2018 Dental Provider Guide is available for review at
www.chip.wv.gov. This guide contains a complete list of codes covered by WVCHIP, billing and Prior Authorization guidelines, service limits, as well as copay information for WVCHIP Premium Dental services. If you do not see a code listed in the guide, the service is not covered.
Crowns do not require Prior Authorization with WVCHIP. Codes D2390, D2751, D2791, and D2930-D2933 are covered by WVCHIP and do not require review prior to payment.
Frenulectomies, D7960, do not require Prior Authorization with WVCHIP effective January 1, 2016.
Effective January 1, 2018, D1354 was moved to covered services and includes silver diamine fluoride. Silver diamine fluoride is a topical medicament (drug) used to treat and prevent dental caries (cavities) and relieve dental hypersensitivity.
9
Orthodontic Treatment
Comprehensive orthodontic treatment is payable once per lifetime. Coverage is not automatic and must be prior authorized to be
covered. Information should be mailed to:WVCHIP – Orthodontic PA Request350 Capitol Street, Room 251Charleston, WV 25301
Prior Authorizations after July 1, 2019, will be handled by the member’s chosen MCO.
Information required for review: Panoramic film Cephalometric x-ray A standard series of 5 intra and 3 extra oral photographs that meet
the American Board of Orthodontic standards Treatment plan including findings, prognosis, length of treatment,
and phases of treatment10
Therapies
Maintenance Therapy is not covered by WVCHIP.
The initial 20 visits of occupational, physical, vision, and speech therapies do not currently require Prior Authorization but must meet policy guidelines (for example: recent or new diagnosis). All active therapy beyond the initial 20 visits requires Prior Authorization.
Prior Authorization is required for chiropractic therapy for children under the age of 16. Children 16 and older do not currently need Prior Authorization for the initial 20 visits.
The initial 26 visits of mental health therapy currently do not require Prior Authorization but also must meet policy guidelines. All active therapy beyond 26 visits requires Prior Authorization.
Duplication of services or payment for claims for the same services provided in the school system under an IEP (Individualized Educational Program) will not be covered by WVCHIP.
11
Third Party Liability (TPL)
Children who have “creditable” health insurance are not eligible for WVCHIP. Insurance that is “excepted” is not considered “creditable” and does not affect eligibility for WVCHIP.
A full list of types of “excepted” insurance is available in the WVCHIP Summary Plan Description. Some examples are:
Limited scope dental and/or vision
Non-coordinated benefits (cancer-only policy)
When primary medical is added for our member, all CHIP claims will deny. Dental insurance will cause dental claims to deny. Vision insurance will cause vision claims to deny. If WVCHIP is listed as secondary to a dental or vision policy, medical claims will still be paid by WVCHIP.
12
Helpful Reminders
When submitting a claim to DXC Technology that does not require or have Prior Authorization, please do not put anything in the Prior Authorization box; this will cause the claim to be rejected.
Claims must currently be filed within 6 months. Claims not submitted within this time period will not be paid, and WVCHIP will not be responsible for payment.
WVCHIP eligibility ends at the end of the month the child turns 19.
WVCHIP members and providers should be using the web portal to verify eligibility. They can also call DXC Technology and the WVCHIP Help Line for verbal eligibility. Members can print out proof of eligibility prior to their appointment from the portal.
13
Current Provider Resources
Eligibility, application status, renewals and general information: WVCHIP HelpLine at 1-877-982-2447
Claims, benefits, and eligibility: DXC Technology at 1-800-479-3310
Prior Authorizations: HealthSmart at 1-800-356-2392
Prescription drug benefits: CVS at 1-800-241-3260
Prescription drug Prior Authorization: WVU School of Pharmacy (Rational Drug Therapy Program) at 1-800-847-3859
Provider enrollment: DXC Technology at 1-888-483-0793
14
Contact
Crystal FoxBenefits and Eligibility SpecialistWVCHIPWest Virginia Department of Health and Human Resources350 Capitol Street, Room 251Charleston, WV 25301Phone: 304-957-7862Fax: 304-558-2741Email: [email protected]
15
@wv.dhhr @WV_DHHR
DXC Workshop Spring 2019
Presented by KEPRO
• Health Homes
• IDD Waiver Services
• AD Waiver Services
• Personal Care Services
• TBI Waiver Services
• Nursing Home PAS Review
• Behavioral Health Services
• Medical Services
• BCF-Socially Necessary Services
• Substance Use Disorder Waiver
Websites/Direct Data Entry Portals
• Medical Requestshttps://providerportal.kepro.com• Health Homeshttps://providerportal.kepro.com• Behavioral Healthhttps://careconnectionwv.kepro.com• Nursing Home PAShttps://c3.kepro.com• Personal Carehttps://wvltc.kepro.com• Aged & Disabled Waiverhttps://wvltc.kepro.com• IDD Waiverhttps://wvltc.kepro.com
2
Existing KEPRO Scope of Work
What Types of Providers Can Become Part of Health Homes?
• Physicians
• Clinical Practices or Clinical Group Practices
• Rural Health Clinics
• Community Health Centers
• Community Mental Health Centers
• Case Management Agencies
• Community/Behavioral Health Agencies
• Federally Qualified Health Centers (FQHC)
Services Provided by Health Home Providers
• Comprehensive Care Management
• Care Coordination
• Health Promotion
• Comprehensive transitional care from inpatient to other settings
• Individual and family support
• Referral to community and social support services
• Use of health information technology, as feasible and appropriate
Health Homes
3
Who is Needed for a Health Homes Core Team?
• Provider – MD, DO or Advanced Practice Nurse licensed in the state of WV.
• Behavioral Health Specialist – Masters or Doctoral prepared individual, licensed in the state of WV in counseling, psychology or social work.
• Nurse – Registered Nurse licensed in the state of WV.
• Care Manager – Registered Nurse or licensed Behavioral Health Specialist. Must complete an internal credentialing process through a provider designated as a health home.
• Care Coordinator – Bachelor’s Degree in a social science with some applicable patient care or counseling experience. Must complete a care coordination training program through a provider designated as a health home.
Please note that one person can fill multiple roles.
4
Member Eligibility Criteria
Health Homes 3-(Pre-Diabetes/Diabetes/Obesity and/or at risk of Anxiety/Depression)
• Medicaid eligible individuals having:
– Two or more of the following chronic conditions: Diabetes, Anxiety, Depression, BMI > 25 (or)
– One chronic condition and the risk of one of the following: Anxiety or Depression
– Geographic limitations to following 14 counties in WV: Boone, Cabell, Fayette, Kanawha, Lincoln, Logan, Mason, McDowell, Mercer, Mingo, Putnam, Raleigh, Wayne, Wyoming
Health Home Contacts
Terrance Hamm, MSW LGSW
• Director-Health Homes
Beverly Turpin
• Review Assistant-Health Homes
Caroline Duckworth, MSW LCSW
• Director-Socially Necessary Services
KEPRO staff can be contacted by calling:
304-343-9663 or 1-888-571-0262
For additional information: http://dhhr.wv.gov/bms/pages/default.aspx
5
Health Homes
IDD Waiver
Effective 7/01/2018 with anchor dates, a new budget methodology is in use.
• All members continue to participate in Annual Functional Assessments with KEPRO.
• Assessment results are still utilized to determine continued program eligibility and the annual budget used to access services.
• The new budget calculation method includes a base range that is dependent on living arrangement and age, with add-on dollar amounts related to some ICAP domain scores.
6
Helpful ADW Tips
• Special characters should not be keyed on the MNER screen in ADW CC. Special characters on the MNER screen prevent the PAS from submitting correctly for the RN.
• Commas should not be used in the title of attachments in ADW CC because they will not open in Google Chrome, only in IE. Most RNs use Google Chrome for ADW CC because of the offline PAS feature.
• After attaching additional requested information for a pended ADW service level change (SLC), providers need to open the request and then click resubmit in the upper left corner.
• SLC requests submitted prior to the member’s anchor date following a recent annual PAS that resulted in a higher service level, must be faxed or emailed, not keyed directly in the system.– Providers cannot request a SLC utilizing the previous PAS. ADW CC only allows
Service Level Changes to be requested on the most recent PAS which is at a higher service level and will result in a denial.
7
Home Health Update
The Home Health manual was updated 12/21/2018. Provider’s are required to document that a face-to-face encounter occurred.• The face-to-face must occur prior to ordering the provision of Home Health services and no more than 90
days prior to the Home Health start of care date or within 30 days of the start of the Home Health care.• The date of encounter must be included in the certification documentation.• The face-to-face encounter must be conducted by a physician, physician assistant, or an Advanced Practice
Registered Nurse. The face-to-face is the responsibility of the Ordering, Referring, Prescribing (ORP) to perform and document in their record.
• A face-to-face is required for certification any time a new start of care assessment is completed to initiate care for services.
• The non-physician practitioner (PA or APRN) performing the face-to-face encounter, working in collaboration with the certifying physician, must document the clinical findings of that face-to face patient encounter and communicate those findings to the certifying physician.
• The documentation of the face-to-face encounter must be a separate and distinct section of the medical record and must be clearly titled, dated and signed by the certifying physician in accordance with 42 CFR §424.22.
• More information can be found at https://dhhr.wv.gov/bms/pages/manuals.aspx WV Medicaid Provider Manual Section 506.3.
8
Fee-for-Service Members
• Fee for service members can receive up to 20 (combined) visits per calendar year without prior authorization.
• The initial request’s prior authorization number will be all 0’s– Submission of an initial prior
authorization is recommended for benefit tracking.
– This number is not to be used for billing purposes.
• Upon the 21st visit the provider will submit an ESTABLISHED request that will be reviewed for medical necessity.
Alternative Benefit Plan (ABP)
• ABP members require prior authorization from the start of PT/OT services.
• Upon approval of an INITIAL request, the C3 system will generate all 0’s for the authorization number.– This number should not be used for
billing purposes.
• A manual authorization number (WXUTH) will be placed in the notes and annotations section at the bottom of the review request screen.
PT/OT
9
Dental Code Update
10
Deleted Code
DescriptionReplacement
CodesDescription
D1515 Space maintainer-fixed-bilateral D1516 Space Maintainer-fixed-bilateral, maxillaryD1517 Space Maintainer-fixed-bilateral, mandibular
D1525Space maintainer-removable-bilateral D1526 Space Maintainer-Removable-bilateral, maxillary
D1527 Space Maintainer-Removable-bilateral, mandibular
D5281
Removable unilateral partial denture-one piece cast metal (including clasps and teeth) D5282
Removable unilateral partial denture-one piece case metal(including clasps and teeth), maxillary
D5283Removable unilateral partial denture-one piece case metal(including clasps and teeth), mandibular
D9940 Occlusal guard, by report D9944 Occlusal Guard-hard appliance, full archD9945 Occlusal Guard-soft appliance, full archD9946 Occlusal Guard-hard appliance, partial arch
Tips for Successful Medical Authorizations
• Please check Master Code List (MCL) or search by the CPT code when submitting via direct data entry (DDE) or by fax. There are some studies that do not require prior authorization.– The MCL can be found at www.wvaso.kepro.com under Resources then Manuals and Reference
Materials.
• Remember to attach or fax documentation to justify medical necessity.– Also, be sure to include written or electronic orders where applicable.– Dental: X-rays and attachments must contain the member’s name.
• Report conservative treatment history (e.g. physical therapy/duration; home exercise/duration) and NSAIDS history (duration/dosages).– These are the two most commonly omitted items that are required for review. If these
interventions are contraindicated, specify the reasoning in medical justification.
• Update your contact information when submitting via DDE. This should include extensions. – Having the incorrect contact information can result in cases being closed and delaying services
to the member.
• The ORP should select themselves as the referring provider when making a request either by fax or via DDE. The servicing provider is the facility/location of where the member will have the procedure(s)/service(s) performed.
11
Emergency Department, Observation and Inpatient Services
• Emergency Department and Observation services do not require prior authorization;
• Diagnostic services and testing that requires prior authorization in outpatient settings must be prior authorized during an observation stay, if performed;
• Inpatient admissions require prior authorization, except labor and delivery and exclusion noted on the MCL; and
• Direct inpatient admission from observation is encompassed in the inpatient authorization and payment.
12
Medical Case Management
• Medical Case Management (CM) is a collaborative process including member assessment, planning, case coordination, advocating services which meet the needs of the member, and monitoring, and evaluation to meet the member’s comprehensive healthcare needs.
• Individualized goals are developed with the member, healthcare providers, family members, guardians, legal representatives and others who may play a role. Case Management serves to facilitate the following:
– Promotes member participation and accountability in their health care.
– Utilization of cost effective measures while facilitating access to resources.
• WV Medicaid has a very complex and diverse population. Any patient may need Case Management.
13
• Our goal is to help the members by being supportive and resourceful, and advocate on their behalf when necessary. We want to exceed expectations and add value by going above the contract requirements and assist members with their healthcare needs.
• Referrals can be initiated by BMS, staff that are involved in the PA process, hospitals, physicians, and can even be requested by the member and/or their legal guardian.
• Case management services must be proven medically necessary as well as being consistent with the diagnosis, treatment plan, and any applicable criteria such as IQ or BMS.
Areas for Case Management
• Specific review areas trigger an automatic referral of members to medical case management services including the following: – Organ transplant– Bariatric procedures– In-patient medical rehab– Private duty nursing– Hospice– Cardiac and/or pulmonary
rehabilitation– Cases that are classified as high cost
outliers
Please note, Case Management is not restricted to these areas.
14
Medical Case Management (Continued)
Training and Technical Assistance
• We offer training via webinar, phone, and various materials.
– These are offered to make submitting online for Prior Authorization an easier process for providers.
– There are also annual reviews/trainings available to providers.
• Provider training is also offered for various provider groups.
• Each PowerPoint presentation from the provider trainings are posted to the http://www.wvaso.kepro.com in the Manuals and Reference Materials section of our website.
• KEPRO will begin ADW quarterly trainings in 2019.
15
Substance Use Disorder (SUD) Waiver
• After the morning presentations there will be a special training just for the SUD Waiver from 1:30-4:00 pm.
• If you are interested in attending and have not registered, please stop by the KEPRO table to register.
• If you are not able to attend today other trainings will be held at each DXC Workshop location after the morning presentations:
16
April 1st Martinsburg – Holiday Inn
April 2nd Wheeling – Oglebay Resort/Pine Room
April 3rd Morgantown – Waterfront Hotel
April 4th Vienna – Grande Pointe Conf. Center
April 8th Roanoke – Stonewall Jackson Resort
April 9th Charleston – Four Points by Sheraton
April 10th Beckley – Tamarack
April 11th Huntington – Big Sandy Superstore Arena
Behavioral Health
• Local Line: 304.346.6732
• Toll Free: 800.378.0284
• Fax: 866.473.2354
Aged & Disabled Waiver
• Toll Free: 844.723.7811
• Fax: 866.212.5053
• General Email: [email protected]
• Email to submit documentation:
TBI Waiver
• Toll Free: 866.385.8920
• Fax: 866.607.9903
I/DD Waiver• Local Line: 304.380.0617
• Toll Free: 866.385.8920
• Fax: 866.521.6882
• General Email: [email protected]
Nursing Home PAS• Toll Free: 844.723.7811
• Fax: 844.633.8425
• General Email: [email protected]
Personal Care• Toll Free: 844.723.7811
• Fax: 866.212.5053
• General Email: [email protected]
17
KEPRO Contact Information
FQHC• Toll Free: 888.571.0262
• Fax: 866.438.1360
Social Necessity
• Local Line: 304.380.0616
• Toll Free: 800.461.9371
• Fax: 866.473.2354
Medical• Toll Free: 800.346.8272
• General Email: [email protected]
Medical Fax Numbers• 844.633.8426 - Bariatric/Inpatient/Inpatient
Rehab Under 21/ Organ Transplants
• 844.633.8427 - Outpatient Surgery
• 844.633.8428 - Imaging/Radiology/Lab
• 844.633.8429 - Cardiac & Pulmonary Rehab/DME/Orthotics & Prosthetics
• 844.633.8430 - Home Health/Hospice/Private Duty Nursing
• 844.633.8431 -Audiology/Speech/Chiropractic/ Dental/Orthodontic/Podiatry/PT/OT/ Vision
• 866.209.9632 - Modification Requests/EPSDT/ Out of Network
18
KEPRO Contact Information
KEPRO Medical Contact Information
1-800-346-8272MEDICAL SERVICES GENERAL VOICEMAIL- EXT. 7996
MEDICAL SERVICES EMAIL: [email protected]
HELEN SNYDER DIRECTOR [email protected] EXT. 4463
KAREN WILKINSON UM NURSE SUPERVISIOR [email protected] EXT. 4474
ALICIA PERRY OFFICE MANAGER [email protected] EXT. 4452
SIERRA HALL TRAINING SPECIALIST [email protected] EXT. 4454
JASPER SMITH ELIGIBILITY SPECIALIST [email protected] EXT. 4490
ROMEDA HICKS ELIGIBILITY SPECIALIST [email protected] EXT. 4492
JAMI PLANTIN ELIGIBILITY SPECIALIST [email protected] EXT. 4502
GENERAL KEPRO INFORMATION: WWW.WVASO.KEPRO.COMFAX #: 866-209-9632 (REGISTRATION AND TECHNICAL SUPPORT ONLY)WEBSITE FOR SUBMITTING AUTHORIZATIONS: HTTPS://PROVIDERPORTAL.KEPRO.COMWEBSITE FOR ORG MANAGERS TO ADD/MODIFY USERS: HTTPS://C3WV.KEPRO.COM
19
QUESTIONS?
20
© 2019 DXC Technology Company. All rights reserved.
May 3, 2019
2019 Spring Provider Workshop
WV Bureau for Medical Services
WV Children’s Health Insurance Program
DXC Technology
May 3, 2019 65© 2019 DXC Technology Company. All rights reserved. May 3, 2019
DXC Technology
October 1, 2018, Molina Medicaid Solutions was acquired by DXC
Technology. DXC Technology (DXC) is a leading IT services
company serving the Medicaid market and provides health and
human services to state and local agencies across the United
States. DXC will continue to serve our existing WV state partner.
How does this affect providers?
• No requirements will be needed other than recognizing the
name change.
• There are no changes with DXC contact information. Any future
email updates will be communicated to the provider community.
May 3, 2019 66© 2019 DXC Technology Company. All rights reserved. May 3, 2019
Provider Enrollment Updates
The federally required enrollment revalidation effort is currently in
process.
• Providers must complete and submit their revalidation before the 120
day deadline in order to avoid termination with both Medicaid,
WVCHIP, and the Managed Care Organizations (MCO).
• Providers who have successfully revalidated with Medicare (PECOS)
will not be required to complete revalidation for Medicaid. DXC will
use the revalidation date listed with PECOS.
• Each provider not successfully revalidated through PECOS will be
required to complete revalidation through Medicaid.
May 3, 2019 67© 2019 DXC Technology Company. All rights reserved. May 3, 2019
A notification will be sent prior to your assigned revalidation date. The
revalidation option is located at www.wvmmis.com and will be
available 90 days prior to your assigned date.
May 3, 2019 68© 2019 DXC Technology Company. All rights reserved.
Paper Application Process Updates
• When submitting a paper application, DXC will enter the application in
the Provider Electronic Application (PEA) Portal. If the application is
not complete a provider notification will be generated which includes
instructions for completing the enrollment on the PEA Portal.
• When submitting an application please use legible documentation with
light shading. The National Provider Identifier (NPI) and/or Case
Number must be included on each document.
• For Enrollment Questions or Assistance
May 3, 2019 69© 2019 DXC Technology Company. All rights reserved.
Reminders
Electronic Fund Transfer (EFT) Initiative
• DXC has identified the provider population who currently receives
paper checks. EFT setup assistance will be provided as needed.
• EFT forms are available on the State Auditor’s Website and should be
completed for new enrollments and changes to EFT.
https://www.wvsao.gov/
Timely Filing Claims
• When submitting claims for a timely filing review or an appeal please
use address P.O. Box 2002 Charleston, WV 25327.
Pharmacy
• The Unenrolled Prescriber Edit applies to all providers who prescribe
medications to Medicaid Members. Medicaid no longer pays for
prescriptions by unenrolled prescribers.
May 3, 2019 70© 2019 DXC Technology Company. All rights reserved.
www.wvmmis.com
• Web Portal for Medicaid &
WVCHIP
• Information for providers,
trading partners, & the public
• Useful website links &
documents
• Latest news & announcements
• Billing instructions, user &
companion guides
DXC Website
The DXC website & EDI web portal provide many opportunities for the
Medicaid and WVCHIP provider communities.
May 3, 2019 71© 2019 DXC Technology Company. All rights reserved.
DXC website provides
• Contact Information
• Office Hours
• Office Closures
• Secure Messaging
• Call Back Requests
• Web Chats
• Grievance & Appeals (Submit online, mail, or fax)
Contact Us
May 3, 2019 72© 2019 DXC Technology Company. All rights reserved.
WV Provider Associations
WV Dental Association - https://www.wvdental.org
WV State Office Manager Association - http://stateoma.com
WV Hospital Association - http://www.wvha.org
WV Behavioral Healthcare Providers Association -
https://www.wvbehavioralhealth.org
WV Health Care Association - https://www.wvhca.org
WV Independent Pharmacy Association - https://www.wvipa.org
WV Primary Care Association - https://www.wvpca.org
WV State Medical Association - https://www.wvsma.org
WV Nurses Association - https://wvnurses.nursingnetwork.com
May 3, 2019 73© 2019 DXC Technology Company. All rights reserved.
“
Provider Field Representative Map
Region 1 Representatives
Linda Pennington at [email protected]
Camilla Carter at [email protected]
Region 2 Representative
Debbie Rhodes at [email protected]
Region 3 Representatives
Katrena Edens at [email protected]
Michelle Miller at [email protected]
Region 4 Representative
Gloria Hayes at [email protected]
Region 5 Representatives
Whitney Choyce at [email protected]
Brandon Treola at [email protected]
May 3, 2019 74© 2019 DXC Technology Company. All rights reserved.
2019 Fall Provider Workshops Dates & Locations
September 16, 2019 – Holiday Inn, Martinsburg, WV
September 17, 2019 – Oglebay Park, Wheeling, WV
September 18, 2019 – Bridgeport Conference Center, Bridgeport, WV
September 19, 2019 – The Blennerhassett Hotel, Parkersburg, WV
September 23, 2019 – Stonewall Jackson Resort, Roanoke, WV
September 24, 2019 – Four Points by Sheraton, Charleston, WV
September 25, 2019 – Tamarack Conference Center, Beckley, WV
September 26, 2019 – Big Sandy Superstore Arena, Huntington, WV
© 2019 DXC Technology Company. All rights reserved.
77
Agenda
Overview
What is Mountain Health Trust?
Managed Care
Member Enrollment
Provider File
Outreach and Education
78
Managed Care Overview
Managed Care76%
Fee for Service
24%
Managed Care
Fee for Service
As of March 2019, there are approximately 513,710 WV residents covered by Medicaid and WV CHIP.
79
Members who are exempt from
managed care are served through a Fee-for-Service delivery system administered by DXC.technology.
Fee ForService
Managed Care Terminology
Members who are eligible for
managed care are served through the Mountain
Health Trust or WV Health Bridge
programs.
Managed Care
MAXIMUS coordinates and
enrolls all eligible managed care
members into a managed care organization
(MCO).
EnrollmentBroker
An MCO is often referred to as a health plan that coordinates the
provision of health services
through networks and case
management.
Managed CareOrganization
80
What is Mountain Health Trust
Mountain Health Trust is the managed care program for West Virginia. With Mountain Health Trust, a member may choose a:
Managed care organization (MCO)
Primary care provider (PCP)
In addition Mountain Health Trust is not:
an MCO/Health Plan.
able to verify Medicaid eligibility.
able to make exemptions for members.
able to credential providers.
81
The Traditional Benefit plan is the health services provided to non-expansion Medicaid members.
Managed Care Service & Benefits
The Alternative Benefit Plan is the health services provided to Medicaid expansion members.
West Virginia Children’s Health Insurance Program is the health services provided to WV CHIP members.
82
EFFECTIVE ENROLLMENT
The effective enrollment date
will be July 1, 2019.
ENROLLMENT PERIOD
Members can begin enrolling into a Plan of
their choice after May 13, 2019.
WELCOME PACKETS
Members can expect to receive
their Welcome Packets beginning the week of May
13, 2019.
WVCHIP Transition into Managed Care
WVCHIP is transitioning to managed care effective July 1, 2019. WVCHIP members will follow the same cutoff schedule and enrollment process as the Managed Care population. CHIP members must choose an MCO by the June 20th cutoff date in order to be effective July 1st.
83
Managed Care Eligibility
Who must Enroll
Most children,
parents and caretakers
SSI recipients (Disabled)
WVCHIPPregnant women
Medicaid expansion
(Adults)
Medicaid Managed Care Members should provide both their State Medicaid Card and their MCO health plan membership card when receiving healthcare services.
WVCHIP members should provide their MCO health plan membership card when receiving services.
Providers may verify eligibility and enrollment for Fee For Service and MCO members via the DXC Provider Portal.
84
Managed Care Exemptions
Exempt from
Managed Care
Aged/ Disabled Waiver
I/DD Waiver
TBI Waiver
Dual Eligible
Long Term Care
Foster Care
Spend down
Program
Members who are exempt from managed care and are Medicaid Fee-for-Service (Traditional Medicaid) should provide their State Medicaid Card when receiving healthcare services.
Providers may verify Medicaid eligibility and enrollment for Fee For Service and MCO members via the DXC Provider Portal.
85
Member Enrollment – Process
DXC.technology transfers eligible managed care members to MAXIMUS.
Once DHHR determines eligibility, Members are transferred to DXC.technology.
MCOs will provide members with their member identification card.
Members must contact MAXIMUS to enroll in an MCO of their choice.
MAXIMUS mails enrollment packets to all newly eligible
managed care members.
MAXIMUS enrolls members into an MCO.
86
Member Enrollment – 2019 Cutoff Dates
19
Members must enroll prior to the cutoff date in order to have an effective enrollment date on the 1st day of the next month. Also, when a member enrolls into an MCO, they will need to choose a Primary Care Provider. If the individual does not select a PCP, the MCO will assign them one.
January
18March
19April
18May
20June
17February
15July
19August
20September
18October
18November
15December
18
87
Enrollment Prior to Cut-off Date
Eligible members have 30 days to
enroll into an MCO of their choice or they
will be Auto-assigned to an MCO.
30 Days to make a Choice
MemberMCO Choice
Cut-off Date
Effective Coverage Date
A member enrolls into an MCO of their choice beforecutoff date.
Cut-off Date for the Month
Member’s effective coverage date will be the 1st
day of the next month.
88
Enrollment After Cut-off Date
Eligible members have 30 days to
enroll into an MCO of their choice or they
will be Auto-assigned to an MCO.
30 Days to make a Choice
MemberMCO Choice
Effective Coverage DateA member
enrolls into an MCO of their choice aftercutoff date.
Member’s effective coverage date will be the 1st
day of the month after next.
Cut-off Date
Cut-off Date for the Month
89
Managed Care Enrollment Options
Call us at 1-800-449-8466. We are here Monday through Friday from 8:00 a.m. - 6:00 p.m. For hearing impaired (TTY), please call 1-304-344-0015.
You can mail your completed enrollment form to us at: West Virginia Mountain Health Trust, 231 Capitol Street, Suite 310, Charleston, WV 25301.
Visit our website to find answers to your questions, compare health plan options, search for providers, or enroll in a health plan at mountainhealthtrust.com.
90
Provider File
MAXIMUS receives a weekly provider file from each MCO that contains all providers currently in their health plan network. The provider file contains provider name, address, phone number, group or clinic name, PCP indicator, provider type, and specialty. The provider file received from each MCO is compiled into a master file that is used on the mountainhealthtrust.com website and by our call center agents to validate provider information.
If there is an error in your provider information, you may contact our call center at 1-800-449-8466 and we will forward the correction to the appropriate MCO.
91
Outreach and Education
Wetzel
Pleasants
Marshall
Wood
Wirt
Pendleton
Randolph
Hampshire
Mineral
Grant
Hardy
Morgan
Lincoln
Cabell
Boone
Ohio
Nicholas
Greenbrier
Fayette
Jackson
Roane
Lewis
Harrison
Monongalia
Putnam
Kanawha
Logan
Mingo
Summers
Pocahontas
Hancock
Brooke
Preston
Marion
BerkeleyTyler
JeffersonTaylor
Doddridge
RitchieBarbour Tucker
Upshur
Gilmer
Calhoun
MasonBraxton
WebsterClay
Wayne
Raleigh
WyomingMonroe
MercerMcDowell
Region I – Steve Richardson, OES
304-844-6148Region III – Bonnie Harrell, OES
304-663-1642
Region II – Spring Blankenship, OES
304-545-6773
AETNA BETTER HEALTH® OF WEST VIRGINIA
April 2019
Our Core Values
ABH of West Virginia (WV) News• New Provider Manuals are available on our website.• A full list of the new 2019 codes that require authorization
beginning on February 1, 2019 is now available on our website www.Aetnabetterhealth.com/westvirginia.
• Effective January 1, 2019, trigger point injections are allowed up to a maximum of 6 units per 12 months.
• Effective January 1, 2019, all claims for breath alcohol testing are subject to pre-payment review.
• New dental codes are payable for pregnancy and diabetic programs: D0150, D0210, D0180 (diabetic only), and D4346 (diabetic only).
• New readmission policy is effective January 1, 2019:o Initial stay will be paid and the readmission will be
denied.
CVS Acquisition
• CVS acquisition of Aetna was completed in December.
• No operational changes at this point.
BMS Fee Schedule Changes• Implementation timeframe for the following fee schedules
has been changed from January 1, 2019 to April 1, 2019:
• Physician’s Fee Schedule (RBRVS)
• Clinical Lab Fee Schedule
• Durable Medical Equipment
• Home Health Agencies
• Ambulatory Surgery Centers
• Ambulance
• New codes released December 2018 for the upcoming year have been opened effective January 1, 2019 and paid using RVUs from CMS with the prior year’s conversion factor through March 31, 2019.
• Acute Care Hospital DRGs will now be updated annually on October 1st.
Referring Provider Information • All providers who refer members for covered services must
first enroll with DXC as required by our State contract and 42 CFR 455.410(b).
• Referring provider information is required to be billed on claims for
• Durable Medical Equipment• Prosthetics/Orthotics• Laboratory Services• Imaging Services• Home Health• Physical, Speech and Occupational Therapy• Private Duty Nursing• Ambulatory Surgery Center
Referring Provider Information cont’d
• Beginning July 1, 2019, these claim types will be denied if the referring provider information is not present, or the referring provider is not enrolled with DXC.
Provider Webinars
• New Provider Orientation Webinar – the fourth Thursday of every month at 11:00 am.
• Quarterly Existing Provider Education/ Updates Webinars – March 28th, June 27th, Sept 26th, and December 26th at 2:00 pm.
RSVP to your Provider Relations Representative.
ABH of WV Provider Workshops
• Dates/Locations TBD – July 2019
• Representation from all areas of the health plan including:
o Utilization Management
o Appeals
o Member Service
o Provider Relations
o Care Management
Thank you!
Spring [2019] workshop: UniCare
Health Plan of West Virginia, Inc.
(UniCare)
UniCare Health Plan of West Virginia, Inc.
Medicaid Managed Care
Provider Maintenance Form
There is a new electronic process for submitting demographic
changes. Demographic changes are now submitted through the
Provider Maintenance Form and will generate automated email
notices. Demographic changes include the following:
• Address
• Name
• TIN (requires W9 to initiate new contract)
• Provider leaving a practice or location
• Closing a practice or location
• Phone or fax number
2UniCare Health Plan of West Virginia, Inc.
Provider NPI Enrollment
• Provider enrollment and participation: Providers
must enroll with DXC (Molina) prior to credentialing
with UniCare.
• Pay hold: If DXC (Molina) has an NPI on pay hold,
UniCare will also place a pay hold on the NPI.
• Adding a new provider: Reach out to your Network
Education Representative.
3UniCare Health Plan of West Virginia, Inc.
Features of Availity
• Remittance advice
• Eligibility
• Claim status or submission
• Member roster
• Interactive Care Reviewer
4UniCare Health Plan of West Virginia, Inc.
Online Authorization Requests
• The Interactive Care Reviewer (ICR) is a real-time solution that improves
efficiency and timeliness of the prior authorization (PA) process by providing:
o Profile service templates.
o Alerts when a PA status changes.
• Through ICR, you are able to:
o View determination letters.
o Save ordering and servicing provider information to your favorites.
o Inquire about and search historic PA and other related information
and documentation.
The ICR is available at [https://www.availity.com].
5UniCare Health Plan of West Virginia, Inc.
Sports Physicals
UniCare has a new value-added benefit for members. We
will now pay in-network PCPs to perform sports physicals.
[One] sports physical per year will be reimbursed for
members between the ages of [3 and 18].
How do I bill for the physical?
You should use CPT code [99212] with DX code [Z02.5].
You can also bill for both a well visit and a sports physical
by including the modifier [25].
6UniCare Health Plan of West Virginia, Inc.
Educational Webinars
In the coming months, UniCare will have educational webinars on the
following topics:
• Behavioral health
• ICR
• Well-child visits
• HEDIS®
• Utilization management (UM)
• Monthly provider orientations
Dates and times will be posted on [www.unicare.com].
HEDIS is a registered trademark of the National Committee for Quality Assurance (NCQA).
7UniCare Health Plan of West Virginia, Inc.
Provider Updates and
Communications
• Provider bulletins
• Provider manuals
• Newsletters
• UM guidelines for physical and behavioral health
• Forms library
• Precertification Look-Up Tool (PLUTO)
8UniCare Health Plan of West Virginia, Inc.
Coming Soon
• Remittance advice changes
• Provider disputes through Availity
9UniCare Health Plan of West Virginia, Inc.
Thank you!
10UniCare Health Plan of West Virginia, Inc.
www.unicare.comUniCare Health Plan of West Virginia, Inc.
UWVPEC-1030-19 [rDate]
2019 DXC Technology
Spring Provider Workshop
• Jason Landers, Senior Vice President of Administrative Services
• Christy Donohue, Assistant Vice President of Medicaid
• Lisa Hawkins, Director of Medicaid Operations
• Valerie Ogilbee, Director Provider Engagement
Provider Engagement Regional Managers:
• Barbara Good, Charleston
• Rachel Waybright Tignor, Morgantown
• Kayla Shreve, Wheeling
Organizational Structure
2
Regional Representat ive Map
Medicaid Drug Test ing
• Presumptive drug screens (80305, 80306, and 80307) are limited to 24 in
combination per calendar year.
• Definitive drug screens (G0480, G0481, and G0482) are limited to 12 in
combination per calendar year.
• G0483 - definitive drug testing for 22 or more drug classes - requires
pre-authorization from the INITIAL date of service.
• Pre-authorization is required beyond above-stated service limits.
• The Health Plan (THP) prorated limits for urine drug testing (UDS) with
dates of service between 7/1/18 – 12/31/18.
• UDS policy is currently posted on our website healthplan.org. Click
Providers > Provider Solutions > Clinical Drug Testing Prior Authorization
Requirements and Coverage Guideline.
4
J Codes Require Pre-authorization
5
• Effective 4/15/19 drugs that apply to medical benefit instead of
pharmacy benefit will require pre-authorization.
• Predominantly injectable or infusion drugs submitted on a 1500 claim
form.
• Ordering provider is typically responsible for obtaining prior authorization.
• Affects all lines of business:
• Medicaid
• Medicare
• Commercial
• Self-funded
• CPT codes requiring prior authorization are located at:
myplan.healthplan.org.
• The pre-authorization list is not all inclusive and is subject to change.
• Direct questions to THP Pharmacy Department at 1.800.624.6961, ext.
7914.
Pal ladian Partnership
Effective January 14, 2019 THP partnered with Palladian Health Systems to
improve member outcomes for musculoskeletal conditions and spine
pain management.
• Changes have occurred to preauthorization requirements.
• A Palladian pre-authorization is not a guarantee of payment.
• THP continues to administer benefits according to provider contracts.
• Bureau for Medical Services (BMS) and Centers for Medicaid and
Medicare Services (CMS) benefit limits continue to apply.
• View medical pre-authorization currently listed at healthplan.org. Click
Providers > Provider Solutions > Access Pre-authorization Forms. (this will
soon be found on the secure provider site)
• View Palladian webinar presentation by logging into your provider
account at myplan.healthplan.org.
6
Pal ladian Partnership, cont.
Specialties affected by Palladian partnership include:
• Chiropractors
• Physical therapists
• Occupational therapists
• Surgeons
• Orthopedists
• Neurologists
• Neurosurgeons
• Pain management specialists and clinics
• Physiatrists
• Anesthesia pain management specialists
7
Readmiss ions With in 30 Days
• Effective 11/1/18 all hospital readmissions within 30 days became
subject for review.
• Readmissions will be denied when any of the following are determined:
• A patient was prematurely discharged from the same hospital.
• A facility failed to have proper and adequate discharge planning in
place, OR
• If there was a lack of proper coordination between the inpatient
and outpatient healthcare teams.
• Observation beyond 48 hours converts to an inpatient stay and is
eligible for 30 day readmission rule.
• Claims billed with same DRGs within 30 days will be denied.
• Policy currently available at healthplan.org. Click Providers > Provider
Solutions > Notice Readmissions Review Occurring Within-30-days.
8
Hospita l B i l l ing Reminders
• Applicable CPT/HCPCs codes are required for all outpatient services.
• Also applies to both critical access and acute hospitals.
• Failure to submit CPT codes will result in a claim line denial.
• Reminder to bill anesthesia administration time in 15-minute intervals on
claims.
• Billing actual minutes will result in a denial.
• Use appropriate modifiers when billing radiology services.
• Overpayments result when hospitals bill globally and an additional
claim is received for the professional component.
• Use the TC modifier when performing only the technical
component.
9
Medicat ion Reconci l iat ion
• Medication reconciliation is the process of reviewing and comparing
discharge (D/C) medications with the patient’s current medication list.
• Medication reconciliation post-discharge is a quality measure
assessing adults >18 y/o.
• Based on discharges, not members.
• Includes all acute and non-acute inpatient D/C.
• Including: hospitals, skilled nursing facilities and rehab facilities.
• Reconciliation documentation should be present in the outpatient
record and should include:
• Evidence of the review completed within 30 days of each D/C.
• The date when the review was performed.
• Medication Reconciliation CPT codes: 99483, 99495, 99496, 1111F.
10
Coordinat ion of Care
Behavioral health providers should communicate with other providers
involved in a member’s health care.
• Medical conditions can interact to affect an individual’s overall
health.
• Primary care physicians (PCP) and other specialties should be
informed of behavioral health issues and medications to better deliver
quality health care.
• Follow all federal and state confidentiality laws.
• THP recognizes the right to keep progress notes private.
• Consent forms and continuity of care forms currently can be found
on the website at healthplan.org. Click Providers > Knowledge >
Provider Resources > Behavioral Health Forms > Authorization to
Disclose Health Information to PCP or Continuity of Care
Consultation Sheet.
11
Dual -E l ig ible Special
Needs Populat ion (D-SNP)
• DSNP is a THP Medicare advantage plan.
• Members have SecureCare HMO primary.
• WV or OH state Medicaid secondary.
• Member has $0 responsibility.
• Annual training is required by Centers for Medicare and Medicaid
(CMS) of providers serving the DSNP population.
• Training materials and attestation are currently available at:
healthplan.org. Click Providers > Support and Service > Compliance
Fraud Waste Abuse & Cultural Competency. Scroll to THP Medicare
Advantage D-SNP Training or by contacting your provider
engagement representative.
12
Annual Prov ider Survey
Practitioner experience surveys are mailed annually to PCPs, behavioral
health providers and secondary care providers.
• Please take the time to complete and return the survey.
• Information obtained is used to create action plans to improve
interactions and remove potential barriers to care.
• Improve communication and increase understanding between
THP and providers.
• Contributes to planning seminars, newsletter articles, email
blasts and other correspondence.
• Provider engagement reps are available for in office visits and
education.
13
New Websi te Feature
14
Announcing new feature to assist providers in verifying and updating
information on our website.
To ensure you are correctly listed in THP’s directories visit our website:
findadoc.healthplan.org.
• Go to Find a Provider
• Click “Search Online” button
• Enter last name
• Select “All” providers and submit
• Double click on appropriate underlined name
• Click new button “Verify/Update Practice Info”
• Option to “Confirm No Changes” or update erroneous information
• You will need the provider’s tax ID and NPI numbers.
• Submitted directly to provider support department to update THP
system.
Medical Access ib i l i ty Standards
15
Provider accessibility standards for PCPs, OB-GYNs & high volume
specialists are:
Routine non-urgent/preventive care
(Well exams, blood pressure checks, preventive care,
etc.)
≤ 21 Days
Urgent care
(Sprains/strains, minor burns, etc.)
Within 48 hours
Non urgent/sick care
(Symptomatic care for cold/flu, sore throat, etc.)
within 48 hours
Emergent care (requires immediate evaluation &
treatment)
ORChest Pain/heart attack, paralysis/stroke
Same day
Send to ER or call
911
Medical Access ibi l i ty Standards
16
Provider accessibility standards for PCPs, OB-GYNs & high volume
specialists are:
Appointment accessibility standards for OB/GYN (prenatal care)
Within 14 days of date woman is
found to be pregnant
After hours accessibility After hours/weekends/holiday care
accessibility – PCP or a designated
covering practitioner is available to
The Health Plan patients within one
hour after leaving a voice mail
message, contacting the
answering service or other similar
arrangements.
Behavioral Health
Access ib i l i ty Standards
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Provider accessibility standards for behavioral health providers (MD, PA, NP,
psychologist, counselor/therapist) are:
New routine office visit Within 10 working days
Follow-up appointment of initial visit for a
specific condition
Prescribers
Non-prescribers
Within 30 working days
Within 20 working days
Follow-up appointment following inpatient
stay
Within 7 days of D/C
Urgent care Within 48 hours
Non-life threatening emergency Within 6 hours
Emergency services Immediately
Average wait time Within 45 minutes of
scheduled appointment
NPI Enrol lment
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Reminder – claims will deny if a provider has not completed the NPI enrollment process with DXC Technology.
• Continue to receive questions on claim denials from providers for this
reason.
• Claims are subject to timely claims filing and resubmission guidelines.
Prov ider Portal
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Register at myplan.healthplan.org
• View announcements and educational presentations
• View claims status
• Submit professional claims online
• Verify member eligibility
• Download member rosters
• Request pre-authorizations
• View pre-authorization status
• Print payment vouchers
Q&A
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