Provider Workshops April 2013 Martinsburg Morgantown Wheeling Flatwoods Huntington Beckley Charleston
Workshop Agenda Welcome and Introductions Medicaid Automated Health Systems Molina APS HMS WV Health Information Network Q & A BMS/Molina 2013 Provider Workshops 2
General Updates WV Bureau for Medical Services (BMS) aka WV Medicaid > Website at ww.dhhr.wv.gov/bms BMS Relationships > Molina – Fiscal Agent (FA) – claims processing, provider enrollment > APS – Utilization Management Contractor (UMC) – prior authorization, case management > HMS – Recovery Audit Contractor (RAC) & Third Party Liability (TPL) > Medicaid Managed Care Organizations (MCOs) • The Health Plan of the Upper Ohio Valley • Unicare of WV • CoventryCares of WV (formerly Carelink) > Automated Health Systems – Enrollment Broker > Other WV DHHR agencies such as EPSDT, Family Planning, Children with Special Health Care Needs BMS/Molina 2013 Provider Workshops 3
General Updates cont’d. BMS is working with APS to ensure the list of codes that require prior authorization is consistent with information in Molina’s system Changes for Tobacco Cessation CPT Codes 99406, 99407 > Effective February 1, 2013, Medicaid may reimburse physicians and/or APRNs for tobacco cessation counseling to symptomatic members > Counseling sessions must be face-to-face, are time sensitive and must be documented in the member’s medical record. > Sessions are limited to 2 per calendar year Nerve Conduction Studies > Effective May 1, 2013, nerve conduction studies require prior authorization before services are provided > Covered in place of service “11” (office setting) Immunization Code 90474 > Open for each additional vaccine (single or combination vaccine/toxoid) by intranasal or oral route BMS/Molina 2013 Provider Workshops 4
General Updates cont’d. Genetic Testing > Coverage for BRCA1 and BRCA2 genes is limited to members who meet the National Comprehensive Cancer Network (NCCN) criteria. > Prior authorization is required and must be requested by an enrolled OB/GYN, oncologist or medical geneticist. > A list of laboratory codes requiring PA is available on the BMS and APS websites. 2012 ADA Claim Form > Molina evaluating system to accommodate additional fields > Providers must include the following items on the 2012 ADA Claim Form for payment consideration: • Place of Service • Quantity or number of units • Diagnosis codes and diagnosis-to-code pointers • Multiple tooth surfaces All Medicaid covered dental code descriptions have been updated in Chapter 505 - Dental Services to match ADA code descriptions. BMS/Molina 2013 Provider Workshops 5
General Updates cont’d. 2013 CPT Coding Changes for Behavioral Health Providers > Several codes deleted > Significant change was deletion of 90862 – pharmacologic management > Evaluation and Management (E/M) codes must now be billed for some of the services represented by deleted codes > BMS provided training via webinar on 2013 coding changes for behavioral health providers; slides on BMS website > Additional information on national medical association websites • American Psychiatric Association • American Academy of Child & Adolescent Psychiatry Ambulatory Surgery Centers > Effective June 1, 2013, billing form and fee schedule change • ASC services must be billed on CMS 1500 form • ASC fee schedule based on 90% of Medicare ASC fee schedule BMS/Molina 2013 Provider Workshops 6
Enhanced Payments for Primary Care Providers Affordable Care Act (ACA) requires that Medicaid reimburse eligible primary care providers at parity with Medicare rates in CYs 2013 and 2014 for certain E&M and vaccination codes (42 CFR 447.400(a)). Eligible primary care providers include physicians and advanced practice professionals (APPs) in certain specialties/subspecialties that meet specific criteria. > Includes Medicaid and MCO-contracted providers Services provided in Federally Qualified Health Clinics (FQHCs), Rural Health Clinics (RHCs), as well as clinics and Health Departments, to the extent that they are reimbursed on an encounter or visit rate, are not eligible for enhanced payments, nor are services provided in nursing facilities that are reimbursed as part of the per diem rate. Qualifying codes and their rates will be published on the BMS website. BMS/Molina 2013 Provider Workshops 7
Eligibility for Enhanced Payments for Primary Care Eligible providers must meet criteria under #1 and #2 below 1. Self-attest to a specialty designation of Family Medicine, Internal Medicine or Pediatrics, or a related-subspecialty as defined by American Board of Medical Specialties (ABMS), American Osteopathic Association (AOA), American Board of Physician Specialists (ABPS) 2. Be board certified by ABMS, AOA or ABPS in specialty or related subspecialty to which he/she attests OR Have billed E&M and vaccine administration services under the specified codes that equal at least 60% of all codes billed to Medicaid during most recent calendar year Note: If provider has not yet participated in Medicaid for a full year, he/she must self- attest that 60% of services billed in previous 30-day period were specified codes BMS/Molina 2013 Provider Workshops 8
Self-Attestation for Enhanced Payments Qualifying providers will receive retroactive payments dating back to January 1, 2013 as long as the completed Self-Attestation Form is sent to BMS no later than December 31, 2013. Prior to receiving the enhanced rate, eligible physicians and advanced practice registered nurses (APRNs) must complete a Self-Attestation Form. Physician Assistants (PAs) automatically qualify if their supervising physician qualifies and self-attests. A self-attestation form must be completed for 2013 and for 2014. Self-attestation form, Provider Guide and Newsletter will be on BMS website BMS/Molina 2013 Provider Workshops 9
Enhanced Payments for Primary Care Enhanced payments will be retroactively paid when CMS approves WV’s state plan amendment (SPA) Frequency of payments may vary between Medicaid and MCOs > Per claim versus quarterly lump sum May be lag between payments for services submitted on claims that pre- date SPA approval versus those submitted after approval Additional information on CMS website > November 1, 2012, CMS Press Release titled “ Health Care Law Delivers Higher Payments to Primary Care Physicians” > CMS Fact Sheet titled “Increased Medicaid Payment for Primary Care” > http://www.medicaid.gov/AffordableCareAct/Provisions/Provider- Payments.html BMS/Molina 2013 Provider Workshops 10
General Policy Reminders For Early Periodic Screening, Diagnosis and Treatment (EPSDT) services, provider must > Append -EP modifier to CPT/HCPCS code and > Enable EPSDT protocol in APS PA system Maternity Visits > Procedure code 99213 with modifier -TH (obstetrical treatment/services prenatal or postpartum) must be billed for each individual prenatal or postpartum visit. Mastectomy or Related Reconstructive Procedures > Prior authorization is not required for individuals diagnosed with or with history of breast cancer. > The appropriate breast cancer diagnosis code must be documented on the CMS 1500 claim form for payment consideration. BMS/Molina 2013 Provider Workshops 11
Updates to BMS Provider Manual BMS Provider Manual > On BMS website at www.dhhr.wv.gov/bms , under “Providers” section > Proposed changes posted on BMS website for 30-Day Public Comment Period Chapter 514 - Nursing Facility Services > Updated and published on January 1, 2013 > Changes include: • Fingerprint-based Criminal Background Checks • All-inclusive rate services have been defined • Ancillary services have been defined • Clarification of cost-reporting used in creating the Medicaid nursing facility rate • Clarification for dispersing Nurse Aide reimbursement • Requirement to check National Practitioner Data Bank (NPDB) – HOWEVER this requirement was recently removed from BMS policy – Providers must review Federal rules to determine requirements for reporting to/checking NPDB BMS/Molina 2013 Provider Workshops 12
Updates to BMS Provider Manual cont’d. Chapter 517 - Personal Care > Will be released for 30-day comment period within next few months > Proposed changes include: • Fingerprint-based Criminal Background Checks • Prior authorization of all hours – 60 hours/240 units » Submit Pre-Admissions Screening (PAS) tool and a physician certification form to APS HealthCare for approval. – Prior authorization for 61 hours/244 units to 210 hours/840 units will remain the same – Authorizations will be a maximum of 12 months. – Will be phased in for members who are receiving Personal Care services prior to implementation date BMS/Molina 2013 Provider Workshops 13
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