Provider Workshops April 2013 Martinsburg Morgantown Wheeling - - PowerPoint PPT Presentation

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

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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

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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

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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.

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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

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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.

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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

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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

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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

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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.

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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

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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

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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

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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.

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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.

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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

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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

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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

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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

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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

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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

• n pay hold

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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

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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

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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

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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

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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.

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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: Scott.E.Winterfeld@wv.gov

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Strengthening and Enhancing West Virginia’s Medicaid Program:

• Overview of the 2013

Managed Care Organization (MCO) Program Pharmacy Expansion

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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:

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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

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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

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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

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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

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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

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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

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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: remittance@express-scripts.com
• 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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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 WVRegion1@automated-health.com 304-552-1426 Region II – Debbie Hon WVRegion2@automated-health.com 304-549-9420 Region III – Marjorie Burdick WVRegion3@automated-health.com 304-395-0567 Region IV – Michelle Zierer WVRegion4@automated-health.com 304-395-0566

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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 wv_expansion@lewin.com 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?

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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

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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

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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.

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Web Portal Training & Provider Field Representatives

Beth Roach Beth.Roach@molinahealthcare.com 304-348-3291 Carrie Blankenship Carrie.Blankenship@molinahealthcare.com 304-348-3292

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