Provider Workshops March 2012 Agenda Welcome and Introductions - - PowerPoint PPT Presentation

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Provider Workshops March 2012 Agenda Welcome and Introductions - - PowerPoint PPT Presentation

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Provider Workshops March 2012 Agenda Welcome and Introductions BMS Policy & Program Updates National Correct Coding Initiative (NCCI) Medicaid Programs Health Homes Take Me Home WV (Money Follows the Person)

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Provider Workshops March 2012

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Agenda

  • Welcome and Introductions
  • BMS Policy & Program Updates
  • National Correct Coding Initiative (NCCI)
  • Medicaid Programs
  • Health Homes
  • Take Me Home WV (Money Follows the Person)
  • Traumatic Brain Injury (TBI) Waiver Program
  • Program Integrity
  • Provider Enrollment & Screening
  • Risk Levels & Site Visits
  • Provider Re-Enrollment
  • Web-Based Provider Enrollment Application
  • Provider Application Demonstration

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Agenda (continued)

  • 5010 Electronic Transactions & Updates
  • One NPI to Multiple WV Medicaid Provider IDs (One to Many)
  • WV Health Information Network (WVHIN) –Health Information

Exchange and WVDirect

  • Health Information Technology (HIT)
  • APS Healthcare
  • Eligibility Verification of Prior Authorization (PA) Requests
  • Out-Of-Network Requests
  • Denials and Reconsiderations
  • Provider Registration with APS Healthcare
  • Provider Automated Capabilities
  • Automated Voice Response System
  • Web Portal Electronic Transactions
  • WV Medicaid Training Center

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General Policy Updates

  • Updates to BMS Provider Manual Chapters

> Proposed changes posted on BMS website > 30 Day Public Comment Period > Recent updates to Chapters for Partial Hospitalization Program, PRTF, Pharmacy, Hospice, Nursing Facility

  • Devices – pacemakers, implantable defibrillators,

nerve stimulators

> Policies for coverage; some devices require PA

  • OT, PT, Speech Therapy

> If employed by hospital or CAH, facility may bill for therapist’s services; pay-to must be facility

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General Policy Updates (continued)

  • Transperineal Stereotactic Template-Guided Saturation

Prostate Biopsy

> CPT code 55706 > Coverage limited to specific diagnoses > Requires Prior Authorization

  • CTs, MRIs or PET Scans in Office Setting

> Effective 1/1/2012, CMS requires accreditation by American College

  • f Radiology, Intersocietal Accreditation Commission or Joint

Commission

  • Radiologic Guidance for Needle Placement by Different

Modalities

> Effective 03/01/12, WV Medicaid will allow one unit of service per day for CPT codes 76942, 77002, 77003, 77012 and 77021 regardless of the number of needle placements performed.

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General Policy Updates continued

  • Fluoride Varnish – coverage for children at high

risk of dental caries

> Effective 01/16/12, for children age 6 months to 36 months > Primary care providers (physicians, APRNs, physician assistants) > Limited to 4 applications per year

  • 2 applications by dentist and 2 by medical professional

> Must complete training through WVU School of Dentistry

  • Information about course at www.hsc.wvu.edu/sod/oral-health
  • Reminder: HRSA’s 340 B Program Participants

> For WV Medicaid members provided drugs from 340B inventory, billing must be based on 340B-acquisition cost

  • Reminder: Documentation Retention

> Required by WV Medicaid policy (Chapter 320) to retain all documentation supporting medical necessity for a period of not less than 5 years from date of service

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Coding Updates

  • National Correct Coding Initiative (NCCI)

> Mandated by the Affordable Care Act of 2010 to incorporate NCCI into Medicaid claims processing > All Medicaid NCCI edits with Molina system upgrade > Applies to CMS 1500 and outpatient hospital claims > Testing continues > Changes in claims processing – Column 1, Column 2 Code Pairs – Medically Unlikely Edits > For more information, go to http://www.medicaid.gov/Medicaid- CHIP-Program-Information/By-Topics/Data-and-Systems/Medicaid- Nation-Correct-Coding-Initiative.html

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Coding Updates

  • ICD 10

> Implementation delayed per Centers for Medicare and Medicaid Services

  • Modifiers

> Assistant-at-Surgery

  • Must be billed with appropriate modifier (-80,-81,-82,-AS )
  • Operative report must reflect services provided by assistant–at-

surgery > Transportation

  • Must use modifiers to indicate origin and destination
  • Documentation must support codes billed

> Functional or Bypass

  • Examples: Modifier -25 or -59
  • Documentation must support codes billed

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Medicaid Programs – 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 > WV Health Improvement Institute to develop State Plan Amendment (SPA) > SPA has been reviewed by Substance Abuse and Mental Health Services Administration (SAMHSA) as required by CMS > Draft SPA at http://www.wvhealthimprovement.org/Portals/0/documents/GEN- 001%20WV%20draft%20HH%20SPA%20Template%202-15.pdf > Next stakeholder call – April 12, 2012

  • Register at WV Health Improvement Institute’s website

www.wvhealthimprovement.org/

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Medicaid Programs – Health Homes (cont’d)

  • To be eligible, Medicaid member must have 2 conditions

among those listed below:

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> Diabetes > Cardiovascular disease > Asthma/COPD > Alzheimer’s Disease > Serious Mental Illness > Schizophrenia spectrum disorder > Bipolar disorder > Major depression > Anxiety > Attention Deficit Hyperactive Disorder > Pervasive Developmental Disorder > Substance abuse

  • OR one condition listed above and one of the following risk

factors:

> BMI > 25 > Tobacco use > High utilization of ED & hospitalization > Living in foster care > Residence in a long term care facility

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Medicaid Programs – Health Homes (continued)

  • Provider Infrastructure

> Designated primary care physician or advanced practice nurse providers working with multidisciplinary teams in a variety of possible settings

  • primary care and solo medical practices
  • comprehensive community behavioral health centers with a

primary care service base

  • providers who serve special populations
  • academic medical centers
  • other entities meeting established qualifications
  • Health Homes Team works together to Integrate

Medical and Mental Health

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Medicaid Programs – Health Homes (continued)

  • 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

  • Health Information Technology
  • Standards for Monitoring and Evaluation

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Medicaid Programs – Take Me Home WV

  • Money Follows the Person Rebalancing Demonstration

Project

  • Federal grant to enhance services and supports for Medicaid

members who wish to receive services in a home-based or community setting

  • Will transition at least 600 individuals from institutional to

community living over 5 year grant period

  • Builds on successful Transition Navigator Pilot Program

initiated by WV Olmstead Office

  • Opportunity for improvement of home and community-

based services through quality monitoring via consumer and stakeholder participation

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Medicaid Programs - TBI Waiver Program

  • Traumatic Brain Injury (TBI) Waiver Program

> Started February 1, 2012

  • Available to assist individuals to return home following a

TBI, rather than receiving nursing home care

  • Covered services include:

> Case Management > Personal Attendant Services (direct care support and transportation) > Cognitive Rehabilitation Therapy (CRT) > Participant-Directed Goods and Services

  • Chapter 512 in BMS Provider Manual
  • APS Healthcare serves as the Administrative Services

Organization

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TBI Waiver Program (continued)

  • In order to be determined eligible for the TBI Waiver program, applicants

must: > Be 22 years of age or older > Be a permanent resident of West Virginia > Have a TBI caused by an external force resulting in total or partial functional disability and/or psychosocial impairment > TBI cannot be degenerative or congenital in nature > Be approved as medically eligible for nursing home level of care > Score at a Level VII or below on the Rancho Los Amigos Levels of Cognitive Functioning Scale > Be inpatient in a licensed nursing facility, inpatient hospital or licensed rehabilitation facility to treat TBI at the time of application > Meet Medicaid Waiver financial eligibility requirements, as determined by DHHR or SSA, if they currently receive SSI > Choose to participate in the TBI Waiver Program as an alternative to nursing home care

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Program Integrity

  • CMS visit in May 2012
  • Recovery Audit Contractor (RAC)

> Mandated by Affordable Care Act > Contract to be awarded by late summer 2012 > All claims and provider types open to review > Review methodology

  • Data abstraction
  • Desk review of medical records
  • On-site visits

> RAC will communicate requests/findings to providers > Recovery by BMS > Appeal process via BMS > For more info: http://www.cms.gov/Recovery-Audit-Program/

  • Reminder: Failure to submit medical records for Program

Integrity review may result in payhold by BMS

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Provider Enrollment & Screening

  • Provider enrollment and screening requirements mandated by

ACA

> Additional guidance released December 23, 2011 > Guidance pending on Criminal Background Check and Fingerprinting

  • BMS currently accepting paper enrollment application +

supplemental pages

> Updates to Supplemental Pages Required

  • Practice Location Information
  • All future enrollment will require copy of most recent Medicare

approval letter

  • BMS now has access to information in Medicare’s

Provider Enrollment System (PECOS)

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Provider Enrollment & Screening (continued)

  • Application fee of $523.00 for CY 2012

> Required for institutional providers > Application fee waived if paid to Medicare or another State’s Medicaid program or CHIP > Hardship Exception Request available

  • Form letter and supportive documentation must be submitted with

enrollment application

  • Request for hardship exception is sent to CMS by Medicaid
  • CMS makes decision and notifies Medicaid
  • Enrollment application on hold until CMS decision received
  • Ordering/referring providers

> Required to enroll

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Provider Enrollment & Screening (continued)

  • Risk Levels

> Apply to all providers > Based on risk of fraud, waste or abuse

  • Database Checks

> OIG’s List of Excluded Individuals & Entities (LEIE) > GSA’s Excluded Parties List System (EPLS) > National Practitioner Data Bank (NPDB) > SSA Death Match File (SSA DMF) > State Medicaid Exclusion Lists & centralized MCSIS > State Licensing Boards

  • Provider enrollment site visits to begin soon

> Unannounced > Failure to allow site visit is basis for denial of enrollment or disenrollment

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Provider Re-enrollment

  • All WV Medicaid providers must be re-enrolled by 2015.
  • Phased-in approach by provider type/risk level.
  • Schedule will be placed on the web portal and banner pages.
  • Providers will receive general notice 60 days prior to re-

enrollment start date.

  • Then 30 days prior to re-enrollment start date, providers will

receive letter that includes re-enrollment access code .

  • Provider will have 30 days to complete re-enrollment or

BMS may place provider on pay hold.

  • Re-enrollment for specific provider types will be limited to

paper.

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Web-Based Provider Enrollment Application (PEA)

  • Available in 2012
  • Dependent on Molina system upgrades
  • Will accommodate newly enrolling and re-enrolling providers
  • Need provider volunteers for testing phase
  • Process for web-based re-enrollment

> Phased-in approach by provider type/risk level > Schedule will be placed on the web portal and banner pages > Providers will receive general notice 60 days prior to re-enrollment start date > Then 30 days prior to re-enrollment start date, providers will receive letter that includes re-enrollment access code > Provider will have 30 days to complete re-enrollment or BMS may place provider on pay hold

  • Process for newly enrolling providers

> Must contact Molina for information and access code level, if applicable

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Online Application Demo

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5010 and D.0 Electronic Transactions

  • CMS’s regulatory requirements to convert from HIPAA (ASC)

X12 version 4010A1 to ASC X12 version 5010 effective 1/1/2012.

  • The Centers for Medicare & Medicaid Services (CMS) extended

the HIPAA 5010 deadline for compliance – enforcement will begin June 30, 2012.

  • The new HIPAA 5010 electronic transaction

standard will drive billing, reimbursement, and many administrative functions, as well as accommodate the larger ICD-10 code sets.

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5010 and D.0 Electronic Transactions (cont’d.)

  • Molina became 5010 (Medical & Dental), and D.0

(Pharmacy) capable, and began accepting 5010 electronic transactions on 12/27/2011. > 837 I/P/D Claims Submissions Inbound > 276 (Inbound)/277 (Outbound) – Claim Status > 270 (Inbound)/271 (Outbound) – Member Eligibility > 835 Paid Claims Outbound/Upload File

  • DDE (Direct Data Entry) to the Web portal is not impacted.

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5010 and D.0 Electronic Transactions (cont’d)

  • 72% of WV Medicaid electronic claims submitters have

been production certified to submit claims in the 5010 format. > Electronic Submitters are required to pass testing requirements to become production certified to submit 5010 electronic transactions.

  • 3 Successful test files of not less than 15 transactions per
  • file. All transactions claims must pass!

> WV Medicaid 5010 Companion Guides are available on Molina’s website at: www.wvmmis.com

  • Molina will be refreshing its claims payment system to

expedite claims processing and response times in support of 5010 & ICD10 Federal Requirements.

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One NPI to Multiple WV Medicaid Provider IDs

  • Referred to as ‘One to many’ provider records

> This means one NPI to multiple Medicaid provider ID numbers.

  • Separate NPI number can be obtained by NPESS

https://nppes.cms.hhs.gov/NPPES/NPIRegistryHome.do.

  • CMS expects BMS/Molina to use NPI numbers on all

transactions. Benefits

  • Eliminates the use of taxonomy.
  • Reduces delay of claims processing.
  • Facilitates electronic enrollment.

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Automated Voice Response System (AVRS)

Advantages to using AVRS:

  • Automated response
  • No long hold times – Save Your Time!
  • Can be used at your convenience:

> Available 24 hrs per day 7 days per week Use AVRS for:

  • Member Eligibility
  • Payment Information
  • Claim Status

Access to AVRS: 1-888-483-0793 Providers 1-888-483-0797 Members 1-888-483-0801 Pharmacy

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How To Use AVRS

  • Voice response will prompt caller to press 1 to use

NPI or 2 to use Medicaid Provider ID > Use Rendering NPI/ ID for claim status > Use Pay To NPI / ID for accounts payable It is important to choose the correct option to avoid being transferred or hold times.

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Molina’s Web Portal - www.wvmmis.com

Advantages of Having a Web Portal Account

  • Eliminate paper claim forms
  • Saves time and money
  • Updates and Important Billing Information
  • Bulletins and Forms
  • Molina’s contact information
  • User Guides
  • Access to submit all claims free of charge through DDE (Direct Data Entry)
  • Capability to Upload Multiple Claim(s) in 1 file (837 Transactions)
  • Receipt of Electronic Remit 835 transactions 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 Member Eligibility Requests free of charge
  • Capability of uploading up to 99 members for eligibility verification in 1 file

(270 Transactions) & receive electronic response in 1 file (271 Transactions)

  • Access to Provider’s Medicaid Training Center currently in

development

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Registering For 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. Health PAS Online Registration After receipt of completed TPA forms, Molina’s EDI staff will contact you by email with a link to set up username and password through the Health PAS Online Registration. For assistance, contact EDI at 888-493-0793, Option 4.

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Molina Web Portal Welcome Page

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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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West Virginia Medicaid Training Center

  • The Provider Medicaid Training Center is currently

under revision and development.

  • Registration is required to access WV Medicaid

Training Center.

  • Access Training Center through www.WVMMIS.com

web portal.

  • First time registration use default password as

WV-Provider.

  • Training Center can be used for trainings, webinars, and

scheduled classes provided by Molina.

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Molina Web Portal – WV Provider Medicaid Training Center

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