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) • 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 BMS/Molina 2012 Provider Workshops 2
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 BMS/Molina 2012 Provider Workshops 3
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 BMS/Molina 2012 Provider Workshops 4
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 of 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. BMS/Molina 2012 Provider Workshops 5
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 BMS/Molina 2012 Provider Workshops 6
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 BMS/Molina 2012 Provider Workshops 7
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 BMS/Molina 2012 Provider Workshops 8
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/ BMS/Molina 2012 Provider Workshops 9
Medicaid Programs – Health Homes (cont’d) To be eligible, Medicaid member must have 2 conditions among those listed below: > Diabetes > Major depression > Cardiovascular disease > Anxiety > Asthma/COPD > Attention Deficit Hyperactive Disorder > Alzheimer’s Disease > Pervasive Developmental > Serious Mental Illness Disorder > Schizophrenia spectrum > Substance abuse disorder > Bipolar disorder OR one condition listed above and one of the following risk factors: > BMI > 25 > Tobacco use > Living in foster care > High utilization of ED & > Residence in a long term care hospitalization facility BMS/Molina 2012 Provider Workshops 10
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 BMS/Molina 2012 Provider Workshops 11
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 BMS/Molina 2012 Provider Workshops 12
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 BMS/Molina 2012 Provider Workshops 13
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 BMS/Molina 2012 Provider Workshops 14
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 BMS/Molina 2012 Provider Workshops 15
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