Claims Processing Update

Transcription

1 PROVIDERNEWS First Quarter TABLE OF CONTENTS 1 Claims Processing Update 2 Addiction and Recovery Treatment Services (ARTS) Program. 3 Verify Member Eligibility 3 ARTS continutes 4 Transportation and Ride Assistance Using LogistiCare 4. New Simplified Member Appeal Form 5 Providers: Medicaid Members Cannot Be Balanced Billed. 6 Formulary Changes Claims Processing Update Claims Processing: We have made significant progress in timely processing of claims and continue our focus on ensuring expeditious and accurate claims payment. We remain committed to improving your claims payment experience; please contact Provider Services at with any claims questions or concerns. Submitting Newborn Claims: For the childbirth claim and/or until a permanent Medicaid ID is issued, use mother s I.D. plus the letter A (if multiples, use A, B, C, etc.). Submit these claims using mother s last name and BB (for baby boy) or BG (for baby girl) for first name. For example, Smith, BB; ID A Once the newborn s permanent I.D. is issued, please use it for all claims submissions for dates of service on or after the permanent I.D. effective date. You can obtain the permanent I.D. on the DMAS website, the Navinet portal, or by calling Provider Services at Claims & Correspondence Submission: Mail all Paper Claims and Correspondence to: P.O. Box Birmingham, AL Submit all Electronic Claims using Payer IDs: Change Healthcare (formerly Emdeon): Emdeon One (formerly Capario): Availity: Gateway (TriZetto): INT01 Pre-Authorization and New CPT Code Changes Effective Jan. 1, 2017 As a reminder, we implemented a pilot program related to prior authorizations. Effective Jan. 1, 2017, we no longer require pre-authorization or notification for many Physical, Speech and Occupational Therapies, Behavioral Health/Psychotherapy services and some Durable Medical Equipment. Please be sure to review s Pre-Authorization Lookup Tool ( intotalhealth.org/content/preauthorization_ lookup) to view changes and to verify codes that require a pre-authorization. Authorization Request forms may also be found on our website and faxed to Call , option 4 for Medical and Pharmacy Authorizations.

2 The Department of Medical Assistance Services (DMAS) has introduced the Addiction and Recovery Treatment Services (ARTS) program beginning April 1, This program is available to all members. What is the ARTS program? The ARTS program is an expansion of substance abuse (SA)- covered services traditionally managed by Magellan that will allow to provide a variety of community-based addiction and recovery treatment services to our members. There are several changes to the program including: The current SA services covered under Magellan will now be managed by for our members. These services include SA day treatment, SA intensive outpatient, opioid treatment, SA case management and residential treatment for pregnant women. Several new services have been added for INTotal Health members, including inpatient/residential SA detox, SA residential for all members and SA peer supports. Rates have been significantly increased for several services. What are the services offered under the ARTS program? Service type Inpatient acute detox Inpatient subacute detox SA residential treatment SA partial day treatment SA Intensive Outpatient Methadone Medication-assisted treatment (opioid treatment) SA case management SA peer support New ARTS Benefit April 1, 2017 Setting Acute medical hospital Psychiatric hospital or residential facility Facility Outpatient facility Outpatient facility or professional provider Professional provider DBHDS licensed OTP clinic or professional provider setting (MDs only Suboxone) Outpatient facility or professional provider Outpatient facility or professional provider What type of treatment do patients receive under the various service categories? Inpatient acute, subacute, and residential treatment services: Offered in a hospital inpatient or community setting where patient is admitted for detox or treatment. Substance abuse partial day/hospitalization treatment services: Typically offered in an outpatient hospital setting where patients receive 20 or more hours of clinically intensive programming per week to obtain stabilization. A planned format of individual and family therapy; doctor consult; direct access to psychiatric, medical and laboratory and toxicology services; and close coordination with appropriate intensive levels of care, comprehensive biopsychosocial assessments and supportive housing services. Provider types that offer the service under this program are a team of credentialed addiction treatment professionals including licensed counselors, social workers, certified addiction registered nurses, psychologists and physicians. Intensive outpatient treatment services: Offered in outpatient professional provider setting to patients receiving counseling and medication management for a minimum of three hours a day (two hours for adolescents) and nine hours a week (six hours for adolescents). Methadone treatment services: Offered in DBHDS-licensed opioid-treatment programs (OTP) including medication and counseling. Medication-assisted treatment services: Treatment with Opioids, e.g. SUBOXONE (buprenophine) may be based in an outpatient clinic or office setting (OBOT) to assist patients with opioid withdrawal or maintenance in a controlled environment. These services can be administered by a clinic contracted as a facility or by a professional provider, usually a medical doctor who has received approval from the Drug Enforcement Agency to offer these services. What are the pre-authorization requirements for these services? Pre-authorizations will be required for ASAM levels of care 2.1 through 4.0 under this program. Pre-authorization forms for ARTS services can be found on s website Fax all requests that require pre-authorization to What clinical review criteria will be used to determine eligibility and approval for specific levels of care? The American Society of Addiction Medicine (ASAM) criteria is a widely used and comprehensive set of guidelines used for placement, continued stay and transfer/discharge of patients with addiction and co-occurring conditions. Continues on Page 3 2

3 Verify Member Eligibility and Correct Payer Please ensure that you verify eligibility prior to each visit with our members. When individuals become a Medicaid member, they receive a blue and white plastic medical assistance card (Virginia Medicaid card) that has their name and I.D. number on the card. members are required to show their Virginia Medicaid card to the provider. In addition to the Virginia Medicaid card, INTotal Health members are required to show their member I.D. card. Frequently, members will present ONLY their Virginia Medicaid Card. To assist in identifying the correct payer and confirm eligibility, please note the following directions on the reverse side of the Virginia Medicaid Card: This card is for identification purposes and does not entitle the cardholder to any benefits under any program administered by the Commonwealth of Virginia. PROVIDER: Confirm current status and other potential payers, electronically or by calling MediCall at You can also confirm eligibility on the NaviNet portal or by calling Provider Services at ARTS continues Level of care General overview of ASAM levels Type of service 1.0 Outpatient services 2.1 Intensive outpatient services 2.5 Partial hospitalization/outpatient managed withdrawal 3.1 Clinically managed, low-intensity residential services 3.3 Clinically managed, population-specific, high-intensity residential services for those with cognitive impairments 3.5 Clinically managed, population-specific, high-intensity residential services 24- hour care 3.7 Medically monitored intensive inpatient services 24-hour nursing care with physician availability 4.0 Medically managed intensive inpatient services 24-hour nursing care and daily physician care, counseling available, severe unstable withdrawal What are the credentialing requirements for providers under the various categories or levels of treatment? will follow their standard credentialing practices for the ARTS program. Providers must attest to the ASAM level(s) of care provided and meet all applicable requirements. Professional provider contracting: opioid treatment services Medical doctors are the only approved provider types who can offer and receive direct reimbursement for opioid withdrawal treatment. Doctors must obtain approval from the Drug Enforcement Agency and receive a designation to offer these services. Doctors must also be credentialed by INTotal Health and sign a participation agreement for the INTotal Health program to treat these members and receive direct reimbursement. How do I bill for ARTS Services? The primary diagnosis code for all ARTS claims must specify a substance use disorder. If billing on a UB, you must include the appropriate revenue and HCPCS code. For additional ARTS billing information, please visit our website: 3

4 Transportation and Ride Assistance Using LogistiCare As part of our members Medicaid benefit, uses a company called LogistiCare to provide ride assistance at no cost to our members. There are three programs that LogistiCare offers. 1. Ride assistance to appointments or medical treatment o When using a van or taxi arranged by LogistiCare, a driver will pick up and drop off our member at their curb. Routine appointments Trip reservations require at least three (3) days in advance. Urgent or same day appointments Members will need to call LogistiCare to request an urgent reservation. LogistiCare will then call the doctor s office and confirm the urgent need. Once the provider s office confirms, LogistiCare will let our members know if the trip is approved and will do their best to secure a driver available to make the urgent trip. Special Needs If our members have special transportation needs such as a stretcher, trips more than 50 miles, or out of state trips, we ask that our members let LogistiCare know as soon as possible. These special needs may require additional approval from INTotal and time to make arrangements. Child safety seats Members must provide their own child safety seats when using LogistiCare. The driver will not supply them and will not let the child ride without a child safety seat. 2. Gas money o LogistiCare offers money for gas, if our members can get their own ride to an appointment. Members will need to call LogistiCare before the trip to receive instructions about this program. Money is paid after the trip. 3. Bus tokens o LogistiCare offers free bus tokens for public transportation if our members travel by bus. Our members will need to call in advance and these tokens are mailed to them. They must allow 7-10 days for mailing. How to Make a Reservation for a Ride Telephone o Members can call LogistiCare at toll free 6 a.m. to 8 p.m., Monday-Friday for all reservations. Urgent requests should be made using the telephone. Online o OR Members can log onto to schedule their own routine transportation. This website is available to members 24 hours a day, 7 days a week and will require them to sign in with personal information and create an account. Pharmacy stop If members need to stop at a pharmacy, they should tell LogistiCare when they call for their reservation. Questions or Problems with a Trip Already Scheduled Trip Help (for an already scheduled trip): o Members should call LogistiCare at to to check on a reservation or if the driver is late. For more information about transportation for INTotal Medicaid and FAMIS members, visit Our new member appeal form can be found on our website: Member_Appeal_Form.pdf. New Simplified Member Appeal Form Medical appeals may be initiated by members or providers on the member s behalf, and must be submitted within 30 calendar days from the date of the notice of the adverse decision. Please note: A provider submitting on behalf of a member must have written consent from the member to file the appeal on their behalf. This is a Department of Medical Assistance Services (DMAS) contractual requirement. Our new form contains a section to document this requirement: I give permission for the above provider/personal representative to file an appeal on my behalf. My signature means that I understand that my personal representative will have access to my health information. Signature of Member: Please Mail Medical Appeals to: Attn: Appeals Dept Fairview Park Drive, Suite 900 Falls Church, VA

5 Providers: Medicaid Members Cannot Be Balanced Billed We have had an increase in member grievances related to providers inappropriately billing members. Please be advised: You may not bill or take recourse against a member for denied or reduced claim payment for services that are within the contracted reimbursement amount, duration, and scope of benefits of the Medicaid program. Please be sure you have identified the correct payer and address for claim submission. Additionally, as an participating provider, these actions are in violation of your agreement with and with the policies and procedures pertaining to balance billing incorporated therein. If you choose to provide a member with services that are not covered by or that have been denied as not medically necessary, you must tell the member before providing the service that the cost of non-covered services will be charged to them. You must also have the member give written consent before providing these services. Providers are not allowed to balance bill a member as a result of: Failure to follow pre-authorization requirement Failure to submit a claim in a timely manner, including claims not received by INTotal Submission of an incomplete or incorrect claim Failure to submit a corrected claim within the timely filing resubmission period Failure to appeal a medical necessity review decision within 30 days of a coverage denial notice Failure to appeal a claim payment with the 90-day administrative payment appeal period Errors made in claims preparation, claim submission, or the appeal process 5 Please refer to the Provider Payment Appeal section and the Billing Members section of the provider manual for further information on this process. The Provider Manual can be viewed and downloaded at: uploads/files/2016_provider_manual.pdf Mail all Paper Claims and Correspondence to: P.O. Box Birmingham, AL Submit all Electronic Claims using Payer IDs: Change Healthcare (formerly Emdeon): Emdeon One (formerly Capario): Availity: Gateway (TriZetto): INT01

6 3190 Fairview Park Drive Suite 900 Falls Church, VA (TTY 711) NON PROFIT U.S. POSTAGE PAID PERMIT #2469 MERRIFIELD, VA 1320 Plantation Road, NE Roanoke, VA (TTY 711) Formulary Changes Effective April 1 We update our formulary quarterly and post changes on our website: intotalhealth.org. To request pre-authorization of any of the drugs on our formulary that require it, fax us a completed Pharmacy Pre-Authorization Form that is located at Changes to Some Pre-Authorization Requirements Effective May 1 Effective 5/1, there will be changes to some of the pre-authorization requirements. Please be sure to check before rendering any services. 6